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Factors predictive of alcohol use during pregnancy in three rural states

Factors predictive of alcohol use during pregnancy in three rural states Background: A substance use screening instrument was used to determine factors predictive of drinking during pregnancy. Alcohol consumption during pregnancy can lead to negative birth outcomes. Methods: The participants (n = 4,828) for the study were sampled from pregnant women attending prenatal clinics in Montana, South Dakota, and North Dakota. Clinic sites for the administration of the screening instrument were selected in each state, based on geographic and known population characteristics. Univariate and multivariate statistical procedures were used to determine factors predictive of drinking during pregnancy. Results: Women who drank tended to: be single, be between 21–25 years old, have had fewer children, have had abortions, and be unemployed. Demographic factors that were protective of drinking when pregnant were married and full-time housewife status. Other variables associated with maternal alcohol use were: past sexual abuse, current or past physical abuse, tobacco use, other drug use, lived with substance users, and had mates who were substance users. Other contributing factors for alcohol use included: feeling sad, believing that drinking any amount of alcohol while pregnant was acceptable, had been in treatment, could use treatment now, and were able to hold four or more drinks. Conclusion: Because drinking rates were high and factors correlated with drinking are known, alcohol screening for this population is essential. reduce maternal alcohol use during pregnancy to 6 per- Background Alcohol is the most commonly used teratogen in the west- cent [4]. ern world [1]. Of all the substances (e.g., cocaine, heroin, marijuana, etc.) of abuse, alcohol produces the most seri- Screening for alcohol use among pregnant women is ous neurobehavioral effects to the fetus [2]. Prenatal expo- becoming increasingly important in view of new studies sure to alcohol is the leading preventable cause of mental that show that even low levels of prenatal alcohol expo- retardation in the United States [3]. Additionally, one of sure can have deleterious impacts on the fetus [5]. Even the major health objects for Healthy People 2010 is to though approximately 20 percent of the pregnant women Page 1 of 6 (page number not for citation purposes) Behavioral and Brain Functions 2007, 3:8 http://www.behavioralandbrainfunctions.com/content/3/1/8 drink at some point in the pregnancy, maternal drinking included in the PNQ queries the extent of alcohol use can be difficult to measure and detect [5]. before and during pregnancy, along with the potential risk factors and demographic information. The psychometric It is estimated that about 60 percent of adult American properties of the SAQ (e.g., sensitivity = 76.6, specificity = women drink at least occasionally [2]. Most women are 92.8, positive predictive value = 92.4) were found to be light to moderate drinkers who have few problems related adequate [14,22]. The PNQ includes fifteen dichotomous to their drinking [2]. In a national study of women con- risk factor items, based on past research and items from ducted in 1991 [6] it was found that 44 percent were con- the original questionnaire [14,22], along with modified sidered light drinkers, 12 percent were moderate drinkers, TACE and TWEAK questions. The changes made in the and 3 percent were classified as heavy drinkers. In the SAQ for the PNQ were minimal and it is believed that the same study, 73 percent of the women in their 20s and 69 psychometric properties would be similar, since the drink- percent in their 30s used alcohol in the past year. Drinking ing questions are the same. We are currently validating the rates were the highest among young women and tended PNQ in another study. to decline with age [2]. The proportion of women drink- ing increased between the 1940s and the 1980s [7]. The Drinking on the PNQ was assessed in two ways: 1) by ask- drinking rates among women have been relatively stable ing the amount and frequency of drinking during this with slight increases in the 1970s and modest declines pregnancy; and, 2) by comparing time of last drink with since the 1980s [6,8,9] along with slight declines noted normal menstrual cycle as per the validation of the SAQ for women aged 18–44 in the 1990s [10]. [22]. Physical abuse was assessed by the question, "Has anyone physically abused (hit, kicked, slapped, etc.) you Estimates on the rate of pregnant women drinking ranged during the last year." Sexual abuse was measured by the from 13.2 percent to over 50 percent [11-16]. The Institute question, "Have you ever had sex without giving your con- of Medicine (IOM) suggests that approximately 20 per- sent?" The amount of alcohol a person can 'hold' was cent of pregnant women drink at least some alcohol [2]. assessed by two questions: 1) "If you drink, how many However, the majority of the children born to these drinks can you hold?" and, 2) "If you drink, how many women have no deleterious damage [2]. drinks can you drink before passing out or falling asleep?" Women who have had a previous child with Fetal Alcohol Sampling strategy Spectrum Disorders (FASD) are at high risk for drinking Medical clinics providing prenatal care were selected to during subsequent pregnancies [17]. Alcohol use before participate in the study based on sampling procedures pregnancy is another risk factor for alcohol use during and willingness to participate in the survey. The sampling pregnancy [10,18,19]. Marital status is a significant pre- design for each state was stratified, based on geographic dictor of drinking during pregnancy. Single women have area or population densities and types (e.g., urban, rural, a greater likelihood of drinking during pregnancy than do frontier, reservation). Clinics were randomly selected married persons [14]. Married women may be less likely within these stratifications. Clinic personnel collected the to use alcohol during pregnancy because of the following completed questionnaires and returned them to the protective factors: superior social and financial support, Center for Disabilities at the University of South Dakota. and greater possibility of wanted pregnancies [14,18,20]. Smoking is a risk factor [14-16,18] for maternal substance Women accessing prenatal care were asked to complete use, as is having experienced physical and sexual abuse the PNQ anonymously by nurses or receptionists at their [14,19,21,22]. Partner's use and/or drinking by the first prenatal care visit. All the women completing the sur- woman's mother [2,14,19] have been correlated with veys were pregnant, although it was not known if the preg- maternal drinking. Additional correlates of drinking dur- nancies were planned. If the pregnant persons decided to ing pregnancy include limited or no transportation [14], participate, they were given packets containing general and any reported past physical or emotional abuse [14]. information on the study and contact information in the The purpose of this study was to examine risk factors for event that they would like more information, along with drinking during pregnancies for women living in three the PNQ, and an unsealed envelope. The women were rural states. instructed to read the general information sheet and instructions, complete the PNQ, seal the completed PNQ Methods in the envelope, and return it to the nurses or reception- Questionnaire ists. The pregnant women were given small incentive gift The Prenatal Questionnaire (PNQ) was adapted from the certificates upon finishing the questionnaires. Since par- Self-Administered Questionnaire (SAQ) developed ticipation was voluntary and 99 sites participated, it was within the Indian Health Service in 1997 [14] to meet the not possible to assess exact response or refusal rates, special needs of the Northern Plains Indians. The 36 items although state supervisors estimated that more than 90 Page 2 of 6 (page number not for citation purposes) Behavioral and Brain Functions 2007, 3:8 http://www.behavioralandbrainfunctions.com/content/3/1/8 percent of the prenatal patients participated. IRB approval Significant dichotomous factors – univariate analysis for the project was obtained from the University of North The significance of factors predictive of drinking was Dakota, the University of South Dakota, Montana State determined by univariate and multivariate factors with chi University, and the Indian Health Service Area Office in square and logistic procedures, respectively. Univariate Aberdeen, South Dakota. statistics were used to determine the total number of sig- nificant factors, and multivariate procedures were used to Results determine a smaller set of questions that retain predictive Basic demographic information validity. Probability values equal to or less than .05 were The information presented in this study was based on considered statistically significant. Probabilities were 4,828 questionnaires, collected at the first prenatal visit. adjusted, as noted, to accommodate multiple compari- Most (58.5%) of the respondents were in their first trimes- sons. ter, some (26.2%) in the second, and a few (15.2%) in their third trimester. The surveys were collected from sites Based on all persons in the sample (n = 4,828), some in North Dakota (n = 1,688), South Dakota (n = 1,638), demographic factors were found statistically significantly and Montana (n = 1,502). The average age of the pregnant related to drinking status, although group differences were women completing the PNQ was 26.7 (sd = 5.8) years modest and have limited clinical utility. The drinkers had with age ranging from 14 to 47. Women completing the more abortions (means were .16 and .09, t = -5.03, p = PNQ averaged 13.4 (sd = 2.5) years of education. The .001) and fewer children (means were .94 and 1.09, t = women had a mean of 1.1 (sd = 1.1) children with 3.62, p = .001) than the comparison (non-drinking) responses ranging from zero to fifteen. The survey partici- group. pants reported an average of 1.7 (sd = 1.7) pregnancies, which was consistent across states. Of those responding, Income was significantly (χ = 16.2, p = .03) related to 8.6 percent had a previous abortion and 24.6 percent drinking classification. In examining the percent drinking reported a miscarriage from a prior pregnancy. by income category, it was noted that those with low ($0– $20,000) income and high income ($50,000 or more) As would be expected based on population values for had the highest drinking rates. Also, survey respondents these three rural states, a vast majority (88.7%) of the who were younger (ages 21–25) were more likely to drink respondents were 'White,' and 8.9 percent were Native than were all other age groups (χ = 14.67, p < .001). Americans (Table 1). The total percent by 'Race/Ethnicity' Unemployment (χ = 9.3, p < .04) was another demo- equals more than 100 percent because respondents were graphic factor predictive of drinking status. able to select multiple 'Race/Ethnicity' categories. Most (65.7%) were 'Married,' some were 'Single' (19.0%) or Factors found to be protective of drinking included: mar- 2 2 'Living Together' (13.4%), and a few (2.7%) were ried (χ = 26.1, p < .001), full-time housewife status (χ = 'Divorced' or 'Separated.' Some persons had multiple 27.4, p < 001), and employed (χ = 9.3, p <.002). Married responses to these categories. Also, a majority (69.4%) of women had the lowest drinking rate (χ = 26.1, p < .001) survey participants declared themselves as employed with of the marital status categories, and the single women had 15.8 percent indicating 'A full-time house wife and not the highest (χ = 15.3, p < .001) rate, suggesting that mar- looking for employment,' and 10.4 percent identified riage is a protective factor for maternal substance use and χ = 27.1, p < .001) themselves as unemployed. Finally, more than one-half being single a risk factor. Sexual abuse ( (54.1%) reported total family income over $30,000, and and physical abuse in the past year (χ = 35.3, p < .001) some (14.7%) reported annual family incomes less than were significant risk factors. Amount of alcohol consump- $10,000. tion was another category of risk factors. Women, who believed any amount of alcohol was safe for pregnant Nearly all who responded to the health question felt that women to drink (χ = 67.7, p < .001) or felt that they could they had 'Good', 'Very Good' or 'Excellent' health. Almost hold more than four drinks (χ = 169.0, p < .001), had ele- one-half (45.1%) of those completing the survey indi- vated risk levels. cated that their health was 'Very Good' and 3.0 percent reported their health status as 'Fair' or 'Poor.' About one- The concurrent and past use of other drugs (χ = 255.7, p fifth (18.9%) reported at least some feelings of discour- < .001) and tobacco (χ = 31.2, p < .001) were related to agement and hopelessness in the last month. Most of the drinking or risk status. Additionally, being around others respondents from each state reported that in the last who used substances was correlated with risk status. Part- month they did not have feelings of sadness, hopeless- ners or mates using substances (χ = 172.9, p < .001) and ness, discouragement, or had so many problems that they persons in household drinking or using drugs (χ = 100.3, wondered if everything was worthwhile. p < .001) were two factors related to drinking when preg- nant. If partner or mate substance use was viewed as a Page 3 of 6 (page number not for citation purposes) Behavioral and Brain Functions 2007, 3:8 http://www.behavioralandbrainfunctions.com/content/3/1/8 Table 1: Demographic Factors: Overall and by State – Frequencies Overall MT ND SD N = 4828 N = 1502 N = 1688 N = 1638 Race/Ethnicity American Indian 8.9% 12.4% 7.9% 6.7% Asian 0.8% 0.4% 1.0% 0.9% Black 0.5% 0.1% 0.6% 0.7% Pacific Islander 0.4% 0.4% 0.3% 0.4% White 88.7% 86.3% 88.9% 90.7% Hispanic 3.2% 4.3% 3.0% 2.4% Other 1.1% 1.6% 0.8% 0.8% Marital Status Single 19.0% 20.0% 17.1% 20.1% Married 65.7% 59.3% 71.7% 65.4% Living together 13.4% 18.3% 10.0% 12.5% Separated 1.3% 2.1% 0.7% 1.1% Divorced 1.4% 1.6% 1.2% 1.6% Employment Unemployed 10.4% 14.2% 9.1% 8.2% Full-time housewife 15.8% 18.9% 15.5% 13.2% Employed 69.4% 61.7% 70.7% 75.0% Income $0–$10,000 14.7% 20.7% 10.5% 13.7% $10,001–$20,000 15.5% 20.2% 13.1% 13.8% $20,001–$30,000 15.7% 16.9% 14.4% 16.0% $30,001–$50,000 27.0% 23.1% 28.7% 28.7% Over $50,000 27.1% 19.0% 33.3% 27.7% Overall Health Excellent 15.6% 15.1% 16.5% 15.1% Very good 45.1% 41.2% 49.5% 44.1% Good 36.3% 39.4% 32.0% 37.9% Fair 2.9% 4.1% 2.0% 2.8% Poor 0.1% 0.2% 0.0% 0.2% Felt Sad, Discouraged, Hopeless, etc., in Last Month Extremely 1.0% 1.6% 0.7% 0.8% Very much 2.6% 4.1% 1.6% 2.2% Quite a bit 4.4% 5.0% 3.2% 5.1% Some 10.9% 13.9% 9.0% 10.1% A little bit 26.5% 25.6% 26.2% 27.8% Not at all 54.6% 49.8% 59.3% 54.0% problem by the pregnant women, the drinking risk was related risk factors in predicting drinking and to establish increased (χ = 4.4, p = .04). a smaller number of questions, using a backward stepwise procedure (e.g., backward likelihood ratio). Significant Other factors found to be predictive of drinking status factors were determined for blocks (i.e., demographic, were: being sad or discouraged in the last month (χ = social-psychological, and past substance use and TACE- 32.1, p < .001), could use treatment at present time (χ = type questions) of related questions. The significant fac- 15.0, p < .001), and had previous participation in sub- tors for each block were used in the final regression anal- stance abuse treatment programs (χ = 22.2, p < .001). ysis phase. With this procedure, only factors that added predictive information were included in the final regres- Multivariate analysis sion model. In the final logistic regression model, eleven Logistic regression was used to assess the significance of factors (Table 2) were retained. These demographic, the dichotomous demographic and social-psychological social-psychological and related factors accounted for a Page 4 of 6 (page number not for citation purposes) Behavioral and Brain Functions 2007, 3:8 http://www.behavioralandbrainfunctions.com/content/3/1/8 modest amount (Nagelkerke R Square = .13) of the predict- with other research [2,14,19,21]. Our study indicated that ability of the binary dependent measure, indicating that about 19 percent of those drinking had a history of sexual there are many other psychological, social, or demo- or physical abuse. Abuse questions need to be asked in a graphic factors that are related to substance use during sensitive, non-obtrusive manner. A self-administered pregnancy. instrument, like the PNQ, may provide such an avenue. The final factors in the logistic regression model were: pre- A general area with potential opportunity for the amelio- vious abortion, full-time housewife, physical abuse, per- ration of risk factors is the amount of alcohol that individ- ception of how many drinks a person can hold, need to uals reported drinking. Pregnant women, indicating any cut down on drinking, mate was user of alcohol, used daily alcohol use (question: "How much alcohol can a drugs before this pregnancy, believed that some alcohol pregnant woman safely drink each day?"), were at risk for use while pregnant was acceptable, and had experienced maternal alcohol use. Nearly one-half (47.6%) of those difficulty remembering events after drinking. believing that any amount of daily drinking was accepta- ble were found to be drinking. Additionally, many Discussion (38.0%) survey participants who felt they are able to hold This study examined risk factors for maternal drinking, 4 or more drinks were drinking during this pregnancy. using a prenatal questionnaire that included substance- Education and brief intervention programs that stress zero screening questions with a large sample of pregnant drinking, while pregnant, and limiting the number of women. The samples were systematically drawn from drinks per occasion, while non-pregnant, could result in medical clinics from three states with large geographic reduced drinking behavior and better birth outcomes. (e.g., rural, frontier) areas, along with some urban sites. Pregnant women were invited to complete the question- Limitations naire anonymously during the first prenatal visit. The This article did not discuss the overall drinking rate, which study results indicate that there are a number of risk fac- was higher than many reported results, because the topic tors present. The identification of the risk factors is para- will be addressed in another paper. Refusal rates at the mount in targeting high-risk women for appropriate clinics were unknown, because participants self-selected intervention programs. themselves and the state project directors did not have direct oversight of the clinics or the patients. The partici- Marital status was related to risk status. Consistent with pants should have been asked if the pregnancy was other studies [14,16], being single was found to be a risk planned. Physical and sexual abuse questions were asked factor for alcohol use during pregnancy. Being married as general questions without much specificity. A valida- and a full-time housewife were protective factors in this tion of a short version of the PNQ is currently being con- study. It may be that these two later factors are indicative ducted by the FAS Consortium. of a stable home environment with adequate social and economic support. Social support has been found to be an Conclusion important ingredient in reducing or curtailing alcohol use Knowing the risk factors for women who will likely use in women [21]. alcohol during pregnancy is vitally important to health care providers so that intervention procedures can be tar- Physical and sexual abuses were identified as risk factors geted for the appropriate persons. The use of an instru- for maternal alcohol use. These findings are consistent ment like the PNQ is essential in screening women at Table 2: Logistic Regression Results-Risk Factors Significant Factors Multivariate Analysis B Coefficient Wald Statistic Probability Ever had an abortion -.48 15.95 .001 Full-time housewife .28 6.34 .01 Physical abuse in last year -.63 9.40 .002 Physical abuse this pregnancy .93 7.61 .006 How many drinks can you hold -.43 30.00 .001 Need to cut down on drinking -.85 31.85 .001 Don't remember events -.37 12.56 .001 Partner uses -.67 76.82 .001 Safely drink -.76 30.09 .001 Past drug use -.26 7.45 .006 Page 5 of 6 (page number not for citation purposes) Behavioral and Brain Functions 2007, 3:8 http://www.behavioralandbrainfunctions.com/content/3/1/8 prenatal clinics so that the immediate attention can be References 1. Barr HM, Streissguth AP: Identifying maternal self-reported given to women who are drinking. One of the goals of the alcohol use associated with fetal alcohol spectrum disorders. regression analysis was to establish fewer questions while Alcohol Clin Exp Res 2001, 25:283-287. maintaining predictive validity. 2. Stratton K, Howe C, Battaglia F: Fetal alcohol syndrome: diag- nosis, epidemiology, prevention and treatment. Washington, DC, National Academy Press; 1996. The screening instrument should be administered as early 3. Abel EL, Sokol RJ: Incidence of fetal alcohol syndrome and eco- nomic impact of FAS-related anomalies. Drug Alcohol Depend as possible in the pregnancy to maximize the timing at 1987, 19:51-70. which counseling or other intervention could be imple- 4. U.S. Department of Health and Human Services: Healthy People mented. Once the extent and severity of alcohol use or 2010. In With Understanding and Improving Health and Objectives for Improving Health. 2 vols 2nd edition. Washington, DC: U.S. Govern- misuse has been determined, the Institute of Medicine ment Printing Office; 2000. recommends that the clients be treated or managed with 5. Chang G: Alcohol-screening instruments for pregnant brief intervention by trained personnel [2]. A number of women. Alcohol Res Health 2001, 25:204-209. 6. Wilsnack S, Wilsnack R, Hiller-Sturmhofel S: How women drink: controlled studies have demonstrated the viability of brief epidemiology of women's drinking and problem drinking. intervention with pregnant women [23]. Alcohol Res Health 1994, 18:173-181. 7. Halliday A, Bush B, Cleary P: Alcohol use in women seeking gynecologic care. Obstet Gynecol 1986, 68:322-326. Pregnancy offers a unique opportunity to positively 8. Midanik L, Clark W: The demographic distribution of US drink- impact women's lives, resulting in the reduction of harm- ing patterns in 1990: description and trends from 1984. Am J Public Health 1994, 84:1218-1222. ful substances such as alcohol, cigarettes, and other drugs. 9. Williams G, Debakey S: Changes in levels of alcohol consump- There is evidence that pregnancies provide increased tion: United States, 1983-1988. Addiction 1992, 87:643-648. motivation to reduce or eliminate unhealthy habits such 10. Ebrahim S, Luman E, Floyd L, Murphy C, Bennett E, Boyle C: Alcohol consumption by pregnant women in the United States dur- as smoking and drinking [24]. ing 1988-1995. Obstet Gynecol 1998, 92:187-192. 11. Centers for Disease Control: Surveillance for fetal alcohol syn- drome using multiple sources. Morb Mortal Wkly Rep Surveill Prevention programs for pregnant women who are drink- Summ 1997, 46:1118-1120. ing should consider providing a range of services such as, 12. Centers for Disease Control: Surveillance for fetal alcohol syn- transportation, brief intervention, counseling, social sup- drome, Alaska, Arizona, Colorado, and New York, 1995- 1997. Morb Mortal Wkly Rep Surveill Summ 2002, 51:433-435. port, prenatal classes, parenting and family functioning 13. Floyd R, David M, Martin M, Hungerford D, Hymbaugh K: Fetal alco- classes, and mental health services. A promising interven- hol syndrome: from data to action. CDC Maternal and Child tion program that targets multiple domains was devel- Health Monograph 1994:343-350. 14. Kvigne VL, Bad Heart Bull L, Welty TK, Leonardson GR, Lacina L: oped for pregnant women by other programs included in Relationship of prenatal alcohol use with maternal and pre- this Center for Substance Abuse Prevention (CSAP) grant natal factors in American Indian women. Soc Biol 1998, 45:215-222. [25]. Programs that provide support to prenatal patients, 15. Serdula M, Williamson D, Kendrick L, Anda R, Byers T: Trends in who are drinking, need to be prioritized and imple- alcohol consumption by pregnant women: 1985 through mented [14]. 1988. J Am Med Assoc 1991, 265:876-879. 16. Centers for Disease Control: Alcohol use among women of childbearing age - United States, 1991-1999. Morb Mortal Wkly Competing interests Rep Surveill Summ 2002, 51:273-276. 17. Kvigne VL, Leonardson GR, Borzelleca J, Brock E, Neff-Smith M, The author(s) declare that they have no competing inter- Welty TK: Characteristics of mothers who have children with ests. fetal alcohol syndrome or some characteristics of fetal alco- hol syndrome. J Am Board Fam Pract 2003, 16:296-303. 18. Bagheri M, Burd L, Martsolf J, Klug M: Fetal alcohol syndrome: Authors' contributions maternal and neonatal characteristics. J Perinat Med 1998, GL and RL developed the design of the study and analysis 26:263-269. and interpretation of data. 19. Hayes M, Brown E, Hofmaster P, Davare A, Parker K, Raczek J: Pre- natal alcohol intake in a rural, Caucasian clinic. Fam Med 2002, 34:120-125. RL and JS were involved in the acquisition of the data. 20. Westphal L: Prenatal alcohol use among urban American Indi- ans/Alaska Native women. Am Indian Alsk Native Ment Health Res 2000, 9:38-48. All authors were involved in drafting the manuscript and 21. Astley SJ, Clarren SK: Diagnosing the full spectrum of fetal alco- have given final approval of the version to be published. hol exposed individuals: introducing the 4-digit diagnostic code. Alcohol Alcohol 2000, 35:400-410. 22. Bad Heart Bull L, Kvigne VL, Leonardson GR, Lacina L, Welty TK: Acknowledgements Validation of a self-administered questionnaire to screen for The data for this article came from the PNQ developed by the FAS Con- prenatal alcohol use in northern plains Indian women. Am J Prev Med 1999, 16:240-243. sortium from funding (SP10421) provided by CSAP. The opinions 23. Edwards G, Orford J, Egert S, Guthrie S, Hawker A, Hensman C, expressed in this paper are those of the authors and do not necessarily Mitcheson M, Oppenhimer E, Taylor C: Alcoholism: a controlled reflect the views of the FAS Consortium or the Center for Substance trial of treatment an advice. J Stud Alcohol 1977, 38:1004-1031. Abuse Prevention. 24. Hankin J, McCaul M, Heussner J: Pregnant, alcohol-abusing women. Alcohol Clin Exp Res 2000, 24:1276-1286. 25. Loudenburg RA, Leonardson GR: A multifaceted intervention strategy for reducing substance use in high-risk women. Neu- rotoxicol Teratol 2003, 25:737-744. Page 6 of 6 (page number not for citation purposes) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Behavioral and Brain Functions Springer Journals

Factors predictive of alcohol use during pregnancy in three rural states

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Springer Journals
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Copyright © 2007 by Leonardson et al; licensee BioMed Central Ltd.
Subject
Biomedicine; Neurosciences; Neurology; Behavioral Therapy; Psychiatry
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1744-9081
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Abstract

Background: A substance use screening instrument was used to determine factors predictive of drinking during pregnancy. Alcohol consumption during pregnancy can lead to negative birth outcomes. Methods: The participants (n = 4,828) for the study were sampled from pregnant women attending prenatal clinics in Montana, South Dakota, and North Dakota. Clinic sites for the administration of the screening instrument were selected in each state, based on geographic and known population characteristics. Univariate and multivariate statistical procedures were used to determine factors predictive of drinking during pregnancy. Results: Women who drank tended to: be single, be between 21–25 years old, have had fewer children, have had abortions, and be unemployed. Demographic factors that were protective of drinking when pregnant were married and full-time housewife status. Other variables associated with maternal alcohol use were: past sexual abuse, current or past physical abuse, tobacco use, other drug use, lived with substance users, and had mates who were substance users. Other contributing factors for alcohol use included: feeling sad, believing that drinking any amount of alcohol while pregnant was acceptable, had been in treatment, could use treatment now, and were able to hold four or more drinks. Conclusion: Because drinking rates were high and factors correlated with drinking are known, alcohol screening for this population is essential. reduce maternal alcohol use during pregnancy to 6 per- Background Alcohol is the most commonly used teratogen in the west- cent [4]. ern world [1]. Of all the substances (e.g., cocaine, heroin, marijuana, etc.) of abuse, alcohol produces the most seri- Screening for alcohol use among pregnant women is ous neurobehavioral effects to the fetus [2]. Prenatal expo- becoming increasingly important in view of new studies sure to alcohol is the leading preventable cause of mental that show that even low levels of prenatal alcohol expo- retardation in the United States [3]. Additionally, one of sure can have deleterious impacts on the fetus [5]. Even the major health objects for Healthy People 2010 is to though approximately 20 percent of the pregnant women Page 1 of 6 (page number not for citation purposes) Behavioral and Brain Functions 2007, 3:8 http://www.behavioralandbrainfunctions.com/content/3/1/8 drink at some point in the pregnancy, maternal drinking included in the PNQ queries the extent of alcohol use can be difficult to measure and detect [5]. before and during pregnancy, along with the potential risk factors and demographic information. The psychometric It is estimated that about 60 percent of adult American properties of the SAQ (e.g., sensitivity = 76.6, specificity = women drink at least occasionally [2]. Most women are 92.8, positive predictive value = 92.4) were found to be light to moderate drinkers who have few problems related adequate [14,22]. The PNQ includes fifteen dichotomous to their drinking [2]. In a national study of women con- risk factor items, based on past research and items from ducted in 1991 [6] it was found that 44 percent were con- the original questionnaire [14,22], along with modified sidered light drinkers, 12 percent were moderate drinkers, TACE and TWEAK questions. The changes made in the and 3 percent were classified as heavy drinkers. In the SAQ for the PNQ were minimal and it is believed that the same study, 73 percent of the women in their 20s and 69 psychometric properties would be similar, since the drink- percent in their 30s used alcohol in the past year. Drinking ing questions are the same. We are currently validating the rates were the highest among young women and tended PNQ in another study. to decline with age [2]. The proportion of women drink- ing increased between the 1940s and the 1980s [7]. The Drinking on the PNQ was assessed in two ways: 1) by ask- drinking rates among women have been relatively stable ing the amount and frequency of drinking during this with slight increases in the 1970s and modest declines pregnancy; and, 2) by comparing time of last drink with since the 1980s [6,8,9] along with slight declines noted normal menstrual cycle as per the validation of the SAQ for women aged 18–44 in the 1990s [10]. [22]. Physical abuse was assessed by the question, "Has anyone physically abused (hit, kicked, slapped, etc.) you Estimates on the rate of pregnant women drinking ranged during the last year." Sexual abuse was measured by the from 13.2 percent to over 50 percent [11-16]. The Institute question, "Have you ever had sex without giving your con- of Medicine (IOM) suggests that approximately 20 per- sent?" The amount of alcohol a person can 'hold' was cent of pregnant women drink at least some alcohol [2]. assessed by two questions: 1) "If you drink, how many However, the majority of the children born to these drinks can you hold?" and, 2) "If you drink, how many women have no deleterious damage [2]. drinks can you drink before passing out or falling asleep?" Women who have had a previous child with Fetal Alcohol Sampling strategy Spectrum Disorders (FASD) are at high risk for drinking Medical clinics providing prenatal care were selected to during subsequent pregnancies [17]. Alcohol use before participate in the study based on sampling procedures pregnancy is another risk factor for alcohol use during and willingness to participate in the survey. The sampling pregnancy [10,18,19]. Marital status is a significant pre- design for each state was stratified, based on geographic dictor of drinking during pregnancy. Single women have area or population densities and types (e.g., urban, rural, a greater likelihood of drinking during pregnancy than do frontier, reservation). Clinics were randomly selected married persons [14]. Married women may be less likely within these stratifications. Clinic personnel collected the to use alcohol during pregnancy because of the following completed questionnaires and returned them to the protective factors: superior social and financial support, Center for Disabilities at the University of South Dakota. and greater possibility of wanted pregnancies [14,18,20]. Smoking is a risk factor [14-16,18] for maternal substance Women accessing prenatal care were asked to complete use, as is having experienced physical and sexual abuse the PNQ anonymously by nurses or receptionists at their [14,19,21,22]. Partner's use and/or drinking by the first prenatal care visit. All the women completing the sur- woman's mother [2,14,19] have been correlated with veys were pregnant, although it was not known if the preg- maternal drinking. Additional correlates of drinking dur- nancies were planned. If the pregnant persons decided to ing pregnancy include limited or no transportation [14], participate, they were given packets containing general and any reported past physical or emotional abuse [14]. information on the study and contact information in the The purpose of this study was to examine risk factors for event that they would like more information, along with drinking during pregnancies for women living in three the PNQ, and an unsealed envelope. The women were rural states. instructed to read the general information sheet and instructions, complete the PNQ, seal the completed PNQ Methods in the envelope, and return it to the nurses or reception- Questionnaire ists. The pregnant women were given small incentive gift The Prenatal Questionnaire (PNQ) was adapted from the certificates upon finishing the questionnaires. Since par- Self-Administered Questionnaire (SAQ) developed ticipation was voluntary and 99 sites participated, it was within the Indian Health Service in 1997 [14] to meet the not possible to assess exact response or refusal rates, special needs of the Northern Plains Indians. The 36 items although state supervisors estimated that more than 90 Page 2 of 6 (page number not for citation purposes) Behavioral and Brain Functions 2007, 3:8 http://www.behavioralandbrainfunctions.com/content/3/1/8 percent of the prenatal patients participated. IRB approval Significant dichotomous factors – univariate analysis for the project was obtained from the University of North The significance of factors predictive of drinking was Dakota, the University of South Dakota, Montana State determined by univariate and multivariate factors with chi University, and the Indian Health Service Area Office in square and logistic procedures, respectively. Univariate Aberdeen, South Dakota. statistics were used to determine the total number of sig- nificant factors, and multivariate procedures were used to Results determine a smaller set of questions that retain predictive Basic demographic information validity. Probability values equal to or less than .05 were The information presented in this study was based on considered statistically significant. Probabilities were 4,828 questionnaires, collected at the first prenatal visit. adjusted, as noted, to accommodate multiple compari- Most (58.5%) of the respondents were in their first trimes- sons. ter, some (26.2%) in the second, and a few (15.2%) in their third trimester. The surveys were collected from sites Based on all persons in the sample (n = 4,828), some in North Dakota (n = 1,688), South Dakota (n = 1,638), demographic factors were found statistically significantly and Montana (n = 1,502). The average age of the pregnant related to drinking status, although group differences were women completing the PNQ was 26.7 (sd = 5.8) years modest and have limited clinical utility. The drinkers had with age ranging from 14 to 47. Women completing the more abortions (means were .16 and .09, t = -5.03, p = PNQ averaged 13.4 (sd = 2.5) years of education. The .001) and fewer children (means were .94 and 1.09, t = women had a mean of 1.1 (sd = 1.1) children with 3.62, p = .001) than the comparison (non-drinking) responses ranging from zero to fifteen. The survey partici- group. pants reported an average of 1.7 (sd = 1.7) pregnancies, which was consistent across states. Of those responding, Income was significantly (χ = 16.2, p = .03) related to 8.6 percent had a previous abortion and 24.6 percent drinking classification. In examining the percent drinking reported a miscarriage from a prior pregnancy. by income category, it was noted that those with low ($0– $20,000) income and high income ($50,000 or more) As would be expected based on population values for had the highest drinking rates. Also, survey respondents these three rural states, a vast majority (88.7%) of the who were younger (ages 21–25) were more likely to drink respondents were 'White,' and 8.9 percent were Native than were all other age groups (χ = 14.67, p < .001). Americans (Table 1). The total percent by 'Race/Ethnicity' Unemployment (χ = 9.3, p < .04) was another demo- equals more than 100 percent because respondents were graphic factor predictive of drinking status. able to select multiple 'Race/Ethnicity' categories. Most (65.7%) were 'Married,' some were 'Single' (19.0%) or Factors found to be protective of drinking included: mar- 2 2 'Living Together' (13.4%), and a few (2.7%) were ried (χ = 26.1, p < .001), full-time housewife status (χ = 'Divorced' or 'Separated.' Some persons had multiple 27.4, p < 001), and employed (χ = 9.3, p <.002). Married responses to these categories. Also, a majority (69.4%) of women had the lowest drinking rate (χ = 26.1, p < .001) survey participants declared themselves as employed with of the marital status categories, and the single women had 15.8 percent indicating 'A full-time house wife and not the highest (χ = 15.3, p < .001) rate, suggesting that mar- looking for employment,' and 10.4 percent identified riage is a protective factor for maternal substance use and χ = 27.1, p < .001) themselves as unemployed. Finally, more than one-half being single a risk factor. Sexual abuse ( (54.1%) reported total family income over $30,000, and and physical abuse in the past year (χ = 35.3, p < .001) some (14.7%) reported annual family incomes less than were significant risk factors. Amount of alcohol consump- $10,000. tion was another category of risk factors. Women, who believed any amount of alcohol was safe for pregnant Nearly all who responded to the health question felt that women to drink (χ = 67.7, p < .001) or felt that they could they had 'Good', 'Very Good' or 'Excellent' health. Almost hold more than four drinks (χ = 169.0, p < .001), had ele- one-half (45.1%) of those completing the survey indi- vated risk levels. cated that their health was 'Very Good' and 3.0 percent reported their health status as 'Fair' or 'Poor.' About one- The concurrent and past use of other drugs (χ = 255.7, p fifth (18.9%) reported at least some feelings of discour- < .001) and tobacco (χ = 31.2, p < .001) were related to agement and hopelessness in the last month. Most of the drinking or risk status. Additionally, being around others respondents from each state reported that in the last who used substances was correlated with risk status. Part- month they did not have feelings of sadness, hopeless- ners or mates using substances (χ = 172.9, p < .001) and ness, discouragement, or had so many problems that they persons in household drinking or using drugs (χ = 100.3, wondered if everything was worthwhile. p < .001) were two factors related to drinking when preg- nant. If partner or mate substance use was viewed as a Page 3 of 6 (page number not for citation purposes) Behavioral and Brain Functions 2007, 3:8 http://www.behavioralandbrainfunctions.com/content/3/1/8 Table 1: Demographic Factors: Overall and by State – Frequencies Overall MT ND SD N = 4828 N = 1502 N = 1688 N = 1638 Race/Ethnicity American Indian 8.9% 12.4% 7.9% 6.7% Asian 0.8% 0.4% 1.0% 0.9% Black 0.5% 0.1% 0.6% 0.7% Pacific Islander 0.4% 0.4% 0.3% 0.4% White 88.7% 86.3% 88.9% 90.7% Hispanic 3.2% 4.3% 3.0% 2.4% Other 1.1% 1.6% 0.8% 0.8% Marital Status Single 19.0% 20.0% 17.1% 20.1% Married 65.7% 59.3% 71.7% 65.4% Living together 13.4% 18.3% 10.0% 12.5% Separated 1.3% 2.1% 0.7% 1.1% Divorced 1.4% 1.6% 1.2% 1.6% Employment Unemployed 10.4% 14.2% 9.1% 8.2% Full-time housewife 15.8% 18.9% 15.5% 13.2% Employed 69.4% 61.7% 70.7% 75.0% Income $0–$10,000 14.7% 20.7% 10.5% 13.7% $10,001–$20,000 15.5% 20.2% 13.1% 13.8% $20,001–$30,000 15.7% 16.9% 14.4% 16.0% $30,001–$50,000 27.0% 23.1% 28.7% 28.7% Over $50,000 27.1% 19.0% 33.3% 27.7% Overall Health Excellent 15.6% 15.1% 16.5% 15.1% Very good 45.1% 41.2% 49.5% 44.1% Good 36.3% 39.4% 32.0% 37.9% Fair 2.9% 4.1% 2.0% 2.8% Poor 0.1% 0.2% 0.0% 0.2% Felt Sad, Discouraged, Hopeless, etc., in Last Month Extremely 1.0% 1.6% 0.7% 0.8% Very much 2.6% 4.1% 1.6% 2.2% Quite a bit 4.4% 5.0% 3.2% 5.1% Some 10.9% 13.9% 9.0% 10.1% A little bit 26.5% 25.6% 26.2% 27.8% Not at all 54.6% 49.8% 59.3% 54.0% problem by the pregnant women, the drinking risk was related risk factors in predicting drinking and to establish increased (χ = 4.4, p = .04). a smaller number of questions, using a backward stepwise procedure (e.g., backward likelihood ratio). Significant Other factors found to be predictive of drinking status factors were determined for blocks (i.e., demographic, were: being sad or discouraged in the last month (χ = social-psychological, and past substance use and TACE- 32.1, p < .001), could use treatment at present time (χ = type questions) of related questions. The significant fac- 15.0, p < .001), and had previous participation in sub- tors for each block were used in the final regression anal- stance abuse treatment programs (χ = 22.2, p < .001). ysis phase. With this procedure, only factors that added predictive information were included in the final regres- Multivariate analysis sion model. In the final logistic regression model, eleven Logistic regression was used to assess the significance of factors (Table 2) were retained. These demographic, the dichotomous demographic and social-psychological social-psychological and related factors accounted for a Page 4 of 6 (page number not for citation purposes) Behavioral and Brain Functions 2007, 3:8 http://www.behavioralandbrainfunctions.com/content/3/1/8 modest amount (Nagelkerke R Square = .13) of the predict- with other research [2,14,19,21]. Our study indicated that ability of the binary dependent measure, indicating that about 19 percent of those drinking had a history of sexual there are many other psychological, social, or demo- or physical abuse. Abuse questions need to be asked in a graphic factors that are related to substance use during sensitive, non-obtrusive manner. A self-administered pregnancy. instrument, like the PNQ, may provide such an avenue. The final factors in the logistic regression model were: pre- A general area with potential opportunity for the amelio- vious abortion, full-time housewife, physical abuse, per- ration of risk factors is the amount of alcohol that individ- ception of how many drinks a person can hold, need to uals reported drinking. Pregnant women, indicating any cut down on drinking, mate was user of alcohol, used daily alcohol use (question: "How much alcohol can a drugs before this pregnancy, believed that some alcohol pregnant woman safely drink each day?"), were at risk for use while pregnant was acceptable, and had experienced maternal alcohol use. Nearly one-half (47.6%) of those difficulty remembering events after drinking. believing that any amount of daily drinking was accepta- ble were found to be drinking. Additionally, many Discussion (38.0%) survey participants who felt they are able to hold This study examined risk factors for maternal drinking, 4 or more drinks were drinking during this pregnancy. using a prenatal questionnaire that included substance- Education and brief intervention programs that stress zero screening questions with a large sample of pregnant drinking, while pregnant, and limiting the number of women. The samples were systematically drawn from drinks per occasion, while non-pregnant, could result in medical clinics from three states with large geographic reduced drinking behavior and better birth outcomes. (e.g., rural, frontier) areas, along with some urban sites. Pregnant women were invited to complete the question- Limitations naire anonymously during the first prenatal visit. The This article did not discuss the overall drinking rate, which study results indicate that there are a number of risk fac- was higher than many reported results, because the topic tors present. The identification of the risk factors is para- will be addressed in another paper. Refusal rates at the mount in targeting high-risk women for appropriate clinics were unknown, because participants self-selected intervention programs. themselves and the state project directors did not have direct oversight of the clinics or the patients. The partici- Marital status was related to risk status. Consistent with pants should have been asked if the pregnancy was other studies [14,16], being single was found to be a risk planned. Physical and sexual abuse questions were asked factor for alcohol use during pregnancy. Being married as general questions without much specificity. A valida- and a full-time housewife were protective factors in this tion of a short version of the PNQ is currently being con- study. It may be that these two later factors are indicative ducted by the FAS Consortium. of a stable home environment with adequate social and economic support. Social support has been found to be an Conclusion important ingredient in reducing or curtailing alcohol use Knowing the risk factors for women who will likely use in women [21]. alcohol during pregnancy is vitally important to health care providers so that intervention procedures can be tar- Physical and sexual abuses were identified as risk factors geted for the appropriate persons. The use of an instru- for maternal alcohol use. These findings are consistent ment like the PNQ is essential in screening women at Table 2: Logistic Regression Results-Risk Factors Significant Factors Multivariate Analysis B Coefficient Wald Statistic Probability Ever had an abortion -.48 15.95 .001 Full-time housewife .28 6.34 .01 Physical abuse in last year -.63 9.40 .002 Physical abuse this pregnancy .93 7.61 .006 How many drinks can you hold -.43 30.00 .001 Need to cut down on drinking -.85 31.85 .001 Don't remember events -.37 12.56 .001 Partner uses -.67 76.82 .001 Safely drink -.76 30.09 .001 Past drug use -.26 7.45 .006 Page 5 of 6 (page number not for citation purposes) Behavioral and Brain Functions 2007, 3:8 http://www.behavioralandbrainfunctions.com/content/3/1/8 prenatal clinics so that the immediate attention can be References 1. Barr HM, Streissguth AP: Identifying maternal self-reported given to women who are drinking. 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Behavioral and Brain Functions – Springer Journals

Published: Feb 9, 2007

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