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The effects of maternal alcohol consumption during pregnancy on adverse fetal outcomes among pregnant women attending antenatal care at public health facilities in Gondar town, Northwest Ethiopia: a prospective cohort study

Substance Abuse Treatment, Prevention, and Policy volume 16, Article number: 64 (2021) Cite this article

Abstract

Background

The teratogenic effect of fetal alcohol exposure may lead to actual and potential problems, instantly after birth, at infancy; or even later, and mental impairment in life. This study aimed to investigate the effects of maternal alcohol consumption during pregnancy on adverse fetal outcomes at Gondar town public health facilities, Northwest Ethiopia.

Methods

A facility-based prospective cohort study was performed among 1778 pregnant women who were booked for antenatal care in selected public health facilities from 29 October 2019 to 7 May 2020 in Gondar town. We used a two-stage random sampling technique to recruit and include participants in the cohort. Data were collected using the Alcohol Use Disorders Identification Test – Consumption (AUDIT-C) standardized and pre-tested questionnaire. Multivariable analysis was performed to examine the association between reported prenatal alcohol exposure (non-hazardous and hazardous) and interested adverse birth outcomes using log-binomial regression modeling. The burden of outcomes was reported using the adjusted risk ratio and population-attributable risk (PAR).

Results

A total of 1686 pregnant women were included in the analysis, which revealed that the incidences of low birth weight, preterm, and stillbirth were 12.63% (95% CI: 11.12, 14.31), 6.05% (95% CI: 5.00, 7.29) and 4.27% (95% CI: 3.4, 5.35), respectively. Non-hazardous and hazardous alcohol consumption during pregnancy was significantly associated with low birth weight (ARR = 1.50; 95% CI: 1.31, 1.98) and (ARR = 2.34; 95% CI: 1.66, 3.30), respectively. Hazardous alcohol consumption during pregnancy was also significantly associated with preterm birth (ARR = 2.06; 95% CI: 1.21, 3.52). The adjusted PAR of low birth weight related to non-hazardous and hazardous alcohol drinking during pregnancy was 11.72 and 8.44%, respectively. The adjusted PAR of hazardous alcohol consumption was 6.80% for preterm.

Conclusions

Our findings suggest that there is an increasing risk of adverse birth outcomes, particularly preterm delivery and low birth weight, with increasing levels of alcohol intake. This result showed that the prevention of maternal alcohol use during pregnancy has the potential to reduce low birth weight and preterm birth. Hence, screening women for alcohol use during antenatal care visits and providing advice with rigorous follow-up of women who used alcohol may save the fetus from the potential risks of adverse birth outcomes.

Background

Alcohol consumption during pregnancy may have adverse effects not only on the incidence of diseases, injuries, and other health conditions to the women but also on the infants and children [1]. Pregnant women may consume alcohol without fully understanding the ill effects of alcohol consuming [2]. Since alcohol passes through the placental, fetal blood may have the same blood alcohol concentration or higher than that of the mother that can result in various adverse effects on the fetus besides the risk of harm to the mother [3]. The body of the fetus during the developmental stage does not similarly process alcohol an adult does; the alcohol is more concentrated in the body of the fetus, and it can prevent the passage of adequate amount of nutrition and oxygen to the vital organs of the fetus [4]. Subsequently, the teratogenic effects of fetal alcohol exposure may lead to actual and potential problems, instantly after birth, at infancy, or even later, leading to anatomical abnormalities, behavioral problems, and mental impairment in life [5]. On the other hand, a wide range of birth defects termed fetal alcohol spectrum disorder (FASD) has been associated with alcohol use during pregnancy [6,7,8].

The degree of effects of alcohol use during pregnancy may vary depending on the frequency of exposure to alcohol, dose, duration, genetic factors, maternal nutrition, and developmental stage of the fetus at exposure [3, 9,10,11,12]. Due to genetic and lifestyle factors, there may also have different outcomes from the same exposure [13, 14]. However, there is no currently assured exact dose-response relationship between the amount of alcohol consumed during the pregnancy and the degree of the problem or a risk threshold caused by alcohol in the infant [15]. According to different studies, nobody knows the exact amount of alcohol that is potentially harmful to the developing baby in any trimester. Hence, researchers and health professionals recommend not drinking any amount of alcohol for pregnant women as well as women who are trying to get pregnant [16,17,18,19,20,21,22,23]. The consequences and safety of low-to-moderate alcohol consumption during pregnancy on the fetus is still inconclusive and discordant [9, 15, 24, 25].It is argued that the lack of agreement between studies might be due to heterogeneity of the study participants, methodological differences, low statistical power, potential confounding factors, and the difference in detecting tools used or biased information on maternal alcohol consumption [23, 26]. On the other hand, multiple adverse birth outcomes have been correlated with hazardous alcohol use during pregnancy, including low birth weight, preterm birth, intrauterine growth retardation (IUGR), having low weight for head circumferences, and small for gestational age (SGA) [9, 25, 27].

Despite many guidelines that advise that women should avoid drinking any alcoholic beverages during any stage of pregnancy to save future generations from alcohol-associated mental, physical, and behavioral abnormalities, numerous studies have shown that a significant number of pregnant women continue to drink alcohol in Ethiopia [28,29,30,31]. Regardless of a high proportion of pregnant women consume alcoholic beverages; policies have paid little attention to risks associated with alcohol consumption during pregnancy.

In Ethiopia, due to the rapid expansion of industrially-manufactured newly branded alcoholic beverages over time and the rising purchasing power of the society [32], a great proportion of pregnant mothers consume alcoholic beverages [28,29,30,31]. Moreover, homemade indigenous alcoholic beverages such as Tella (traditional Ethiopian beer fermented from mostly barley but also with wheat, maize, sorghum, and mixed with ‘Gesho’ [Rhamnusprinioides]) [33], Areki (a whiskey-like drink distilled from fermented barley or maize and mixed with [Rhamnusprinioides]), and Tej (a honey wine), Borde, and Korofe are generally common in Ethiopia and everyone drinks without any confinement of official body [34].

Previously conducted studies in different parts of the world had an inconsistent association between prenatal alcohol exposure and adverse fetal outcomes to take appropriate interventions [9, 35,36,37,38,39]. Therefore, this study focused on determining the effects of alcohol use during pregnancy on adverse fetal outcomes such as preterm, stillbirth, and low birth weight, as they are one of the major causes of neonatal morbidity and mortality in low- and middle-income countries [40], including Ethiopia [41,42,43]. By investigating the effects of alcohol consumption during pregnancy, the present study could make a novel share to help fill the gaps in the current literature and update future guidelines concerning alcohol consumption during pregnancy.

Materials and methods

Study design, period, and study setting

We carried out a facility-based prospective cohort study among pregnant women who were booked for antenatal care in selected public health facilities from 29 October 2019 to 7 May 2020 in Gondar town. The included health facilities were one hospital (University of Gondar Comprehensive Specialized Hospital) and three health centers (Gondar polyclinic, Azezo, and Maraki). Gondar town is located about 727 km far from Addis Ababa, the capital city of Ethiopia. According to the Gondar town Finance and Economic Development branch Office report in 2018, the total population of Gondar town was approximately 338, 646 (165, 937 males and 172, 709 females). Of these females, 7454 were estimated to be pregnant. In the town, there are eight health centers and one comprehensive specialized hospital [44].

Sample size determination and sampling procedure

The sample size was determined by using EPI INFO version 7.2.1.0 STAT CALC software cohort study as described by Fleiss with continuity correction to estimate the sample size (https://silo.tips/download/statcalc-calculating-a-sample-size-with-epi-info) [45]. We used the following assumptions: two-sided 95% confidence level, power of 80%, the ratio of sample size 2:1 to detect the odds ratio of 1.9 by considering 6.4% of low birth weight in the unexposed group and 11.7% in the exposed group to bring a difference in two population based on the research conducted in Brazil [46]. These rates were taken from a study conducted in another country because we did not find similar studies in Ethiopia or other similar situations. Finally, 1778 study participants (593 exposed and 1185 unexposed to alcohol use) were enrolled using a design effect of 1.5 and 10% withdrawn or attrition rate from the cohort for a variety of reasons. We used a two-stage random sampling technique to recruit pregnant women and include them in the cohort. In the first stage, we applied simple random sampling to select three health centers. In addition to these three health centers, one hospital was purposively included in the study. In the second stage, pregnant mothers who fulfilled the inclusion criteria were chosen using a systematic sampling technique. The sample size was proportionally allocated to each health facility based on previous client-flow information. A flow diagram of the study participants was presented in (Fig. 1).

Fig. 1
figure 1

Flowchart of the study participants at Gondar town public health facilities, Northwest Ethiopia, 2020

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Study variables

The outcome of interest

Information on birth outcomes was obtained from health facilities’ maternity records and interviewing the mothers. The outcome interest variables of the study were preterm, stillbirth, and low birth weight which were categorized as a dichotomous variable (yes/no); we used the World Health Organization (WHO) recommended definition for international comparisons for the outcomes. Birth weight was obtained from the delivery logbook to categorize infants as low birth weight (< 2500 g) regardless of gestational age. The estimated time of conception and subsequent gestational age at delivery was calculated based on the first day of the last menstrual period (LMP) or an ultrasound estimated result. Preterm delivery and stillbirth were defined as babies born before 37 weeks of pregnancy and a baby born with no signs of life at or after 28 weeks of gestation, respectively. Alcohol consumption during pregnancy was the main independent variable.

Potential confounding variables

Data were collected at baseline and postnatal on various risk factors through the pregnancy, including comprehensive maternal characteristics and potential confounding variables. Besides, detailed pregnancy history was gathered, including pre-existing medical conditions. Some of the included potential confounding variables were socio-demographic characteristics: maternal age, religion, ethnicity, household wealth status, education of respondents, education of husband, marital status and occupation; obstetrics and some medical factors: parity, history of abortion (bleeding during pregnancy), history of preterm birth, history of stillbirth, unwanted pregnancy, hypertensive disorders in pregnancy [47](chronic hypertension, preeclampsia-eclampsia, preeclampsia superimposed on chronic hypertension, and gestational hypertension), gestational diabetes, Mid-Upper Arm Circumference (MUAC), and sex of infant and behavioral variables: cigarette smoking, coffee intake, khat chewing were evaluated.

Participant selection and recruitment

Women were enrolled and a baseline interview was executed if they were in the first 2 weeks of the third trimester or 28th weeks of gestational age. Because if the baseline data were collected and study participants were advised to stop alcohol intake in the first or/and second trimesters, they might not give the right information about alcohol use in the next interview that may underestimate and lead to false-negative outcomes. The postpartum interview was carried out following delivery, typically in the health facility during the postpartum stay or within 48 h of delivery. All mother-newborns pairs in Gondar town were a source population, and pregnant women who were sampled in the selected health facilities were the study participants. Medical health facility documents or log booklets for infants and mothers were reviewed to collect necessary information related to delivery, selected medical risk factors, and some potential confounders. The eligible study participants in the follow-up were restricted to a singleton pregnancy and aged 18 years or above. If the birth outcomes were not well known due to giving birth at their home or incomplete registration, they were excluded from the study. If a woman was uncertain in remembering the first day of the last menstrual period, the cycle was irregular or there was a difference of more than 7 days, and a booking ultrasound scan estimate was not preferred, they were also excluded from the study.

Exposure ascertainment and alcohol use measures

To ascertain fetal alcohol exposure, we used maternal self-reporting that is the most common clinical instrument and standard in detecting alcohol exposure [48]. Information on alcohol intake during pregnancy was collected for specific trimesters of pregnancy during baseline prenatal and postpartum interviews. During the baseline interview, study participants were asked in detail about alcohol use information during the first and second trimesters, including the type and quantity of alcoholic beverages. Drinking information of the third trimester was collected in the postpartum interview. For each type of alcoholic beverage, pregnant women were asked how often they consumed alcohol and the number of drinks they drank during the specific trimester based on the AUDIT-C questionnaire [49,50,51].AUDIT-C is the most popular shortened version of the 10-item AUDIT that comprises three items to assess alcohol consumption cross-culturally and identify hazardous drinkers [49, 52]. The tool had shown to be a valid instrument for alcohol consumption since pregnancy recognition based on self-report [53]. The questionnaire was adjusted by considering the local context of alcoholic beverages of alcohol content and drinking containers. The amount of alcohol content in a standard drink varies from country to country; we used the WHO’s standard for this study since Ethiopia has no national alcohol policy defining standard alcohol drinks [54]. Based on this, for a standard drink, 12 g of absolute alcohol was assumed which was considered as alcohol consumption. A standard drink was determined by converting local drinks to grams of pure alcohol, and then we specified the amount of pure alcohol per local drink and using local units of measure.

For this study, participants were categorized as abstainers or non-drinkers if women reported that they have never drunk any alcoholic beverages entirely throughout pregnancy, (AUDIT-C score = 0), low-risk drinkers, or non-hazardous drinkers if they reported 1 or 2 scores in AUDIT-C for the period of pregnancy) [55], and hazardous drinkers if they consumed a pattern or quantity of alcohol with an AUDIT-C score of three or more [56,57,58]. Different receptacles were used to measure local drinks, such as ‘tassa’, malekia’ and ‘birille’ for drinks Tella (traditional Ethiopian beer fermented from mostly barley but also with wheat, maize, sorghum, and mixed with ‘Gesho’ [Rhamnusprinioides]) [33], Areki (a whiskey-like drink distilled from fermented barley or maize and mixed with ‘[Rhamnusprinioides]) and Tej (a honey wine), respectively. The amount of each drink consumed in ml was then calculated. This value was converted to grams of absolute alcohol by applying a conversion factor and taking into account the percentage of absolute alcohol present in each drink. Accordingly, a standard drink equivalent to 1 bottle beer (330 ml) at 5% x (strength) 0.79 (conversion factor) = 13 g of ethanol; 1 glass wine (140 ml) at 12% × 0.79 = 13.3 g of ethanol; 1 shot (‘malekia’) Areki(40 ml) at 40% × 0.79 = 12.6 g of ethanol, alcoholic content (30–50%); 1 ‘birille’ Tej (200 ml) at 8% × 0.79 = 12.64 g of ethanol, alcoholic content (7–11%);and 1 “tassa” Tella/Korofe (330-500 ml) at 4.5% × 0.79 = 11.73 g of ethanol of alcoholic content (4–6%) [59,60,61].

Data collection methods and tools

This data collection tool was similar to a previous article, a nested case-control study, which was part of this project published elsewhere [62]. The questionnaire was prepared first in English and then translated into Amharic (local language) to suit local applicability and then back to English to ensure its consistency. The tool was developed by reviewing different previous studies of similar objectives [2, 50, 51, 63,64,65,66], and then experts’ consultation was sought to ascertain its validity by considering the local situation of the study participants and clinical relevance. Data were collected using a standardized interviewer-administered questionnaire and reviewing maternal care logbooks at the health facilities. A detailed interview was done for each woman in private with a nurse or a midwife at the baseline using a pre-tested interviewer administrated questionnaire. Data collectors and supervisors trained on data collection tools, procedures during data collection, obtaining consent from participants, and not missing any questions in the questionnaire. The Amharic version questionnaire was pre-tested for clarity through a pilot study on 67 respondents in Bahir Dar town, which is 180 km away from the actual study area. The tool was checked for its reliability and validity before actual data collection. To assure data truthfulness, weekly meetings and daily supervision were conducted with supervisors and data collectors to observe the quality, status, and issues in collecting data. In addition to AUDIT-C, the tool also included the Edinburgh Postnatal Depression Scale (EPDS), which has 10 items scored on a scale of 0–3; the score ranging from 0 to 30, and we used a cut-off point of 13 and above on the scale to identify women with depressive symptoms [67].

The socio-economic status of the households (wealth index) was assessed using 16 variables extracted from Ethiopia Demographic and Health Survey 2016, and Principal Component Analysis was computed to determine it. The MUAC of the left arm with no clothing was measured in the third trimester using a flexible non-stretchable standard tape measure. Pregnant women having MUAC< 22 cm were considered undernourished and ≥ 22 cm normal [68]. When the hemoglobin level was less than 11.0 g/dl during the first or third trimester, the presence of anemia was considered [69].

Statistical analysis

The data were entered using into EpiData 3.1.version and exported to STATA version 14. We computed bivariable log-binomial regression model analysis to see the association of selected maternal characteristics and prenatal alcohol use (non-hazardous and hazardous) with primary outcomes of interest using the chi-square test statistic. All variables significantly associated with outcomes of interest in bivariable analysis at p-value ≤0.2 were considered as candidates for the multivariable log-binomial regression model. In the final model, multivariable analysis was performed to examine the association between reported prenatal alcohol exposure (non-hazardous and hazardous) and interested adverse birth outcomes. The strength of associations of the regression model was reported using an adjusted risk ratio (ARR) with a corresponding 95% confidence interval (CI) and the p-value < 0.05 to declare the statistical significance threshold. The occurrence of multicollinearity among explanatory variables was ensured using the Variance Inflation Factor (VIF) at a cut-off point of 10 [70]. Complete case analyses were carried out by taking out any cases with a missing covariate. We used the adjusted PAR to determine the proportion of adverse birth outcomes that would not occur in a population if alcohol consumption were eliminated in the entire cohort after adjustment for potential confounders. This method first estimates the risk ratio for the alcohol consumption and for potential confounders and then estimates the number of events expected if the exposure of interest were eliminated to derive the percentage of outcomes attributable to alcohol consumption. The proportion of LBW, preterm birth, and stillbirth outcomes that could be attributed to maternal pregnancy alcohol consumption was estimated using Levin’s formula: PAR % = P*(ARR–1) / [P*(ARR–1) + 1] *100, where P was the proportion of women who used alcohol (hazardous or non-hazardous drinkers) during pregnancy, and ARR was the adjusted risk ratio of the adverse birth outcomes associated with the alcohol consumption [71, 72].

Ethical considerations

Ethical clearance was obtained from the Institutional Ethical Review Board of the University of Gondar (R. No.-O/V/P/RCS/05/747/2019), and permission was received from Amhara Public Health Institute and Gondar town health department before the start of the study. Before enrolment of the participants, all respondents were informed about the importance of the study, its objective, effects, and the significance of participation. Verbal informed consent was also obtained before conducting data collection and all information was completed to maintain confidentiality. After taking the necessary information, all participants were counseled about the risks of alcohol drinking during pregnancy and advised not to drink any alcohol during pregnancy or while trying to get pregnant. Besides, women who engaged in hazardous drinking were referred to healthcare providers and proper linkage was established to get possible treatment options in their respective health facilities.

Results

Socio-demographic characteristics of the participants

A total of 1778 pregnant women were enrolled in the study, and of these, 1686 had data available on birth outcomes. We excluded 92 mother-infant pairs from the analysis due to missing appropriate birth outcome data (Fig. 1).

The mean maternal age at the baseline was 26.47 ± 4.58 years. Nearly two-thirds (60.8%) of the study participants were between the ages 25 and 34 years. Most of the women were married (97.4%) and were orthodox (88.2%). Three hundred sixty-six (21.7%) of them had no formal education, and only 510(30.2%) had tertiary education (Table 1).

Table 1 Socio-demographic and economic characteristics of study participants in Gondar town, Northwest Ethiopia, 2020 (n = 1686)
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Reproductive and medical history related characteristics of the study participants

Almost half, (49.23%) of the study participants had one or two children. Concerning birth intervals, the majority (81.91%) of pregnant women had 24 months and above birth intervals. More than half, (60.50%) of the women had experienced at least one previous birth (multiparous). Two hundred ten (12.46%) of the respondents had experienced a history of abortion. Among the study participants who were tested for hemoglobin level, 248(14.86%) of the pregnant women had anemia (Table 2).

Table 2 Reproductive and medical history related characteristics of study participants attending ANC at public health facilities in Gondar town, Northwest Ethiopia, (n = 1686)
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Alcohol consumption during pregnancy

Among women who used alcohol of the study participants, approximately one-fifth (20.57%) reported taking hazardous alcohol during their current pregnancy. Five hundred thirty-eight (95.39%) of the alcohol drinkers used alcoholic beverages in the first trimester, 548(97.16%) and 539(95.57%) consumed in the second and third trimesters, respectively.

Regarding the amount of alcohol consumption, 98(17.38%) of the respondents used six or more drinks on one occasion during their current pregnancy. Likewise, most pregnant women (68.62%) consumed one or two standard drinks, 21.10% had three or four drinks, and 10.28% of the participants had five or more standard drinks on a typical day. Concerning the types of alcoholic beverages that were consumed by respondents, the most commonly used alcoholic beverage in the first trimester was Tella(56.03%), followed by beer/draft (19.15%). In the second trimester, 39.18, 31.74, 3.55, 2.30, and 20.39% of the respondents consumed beer/draft, Tella, wine, Areki/Tej/Korofe, and two or more types of drinks, respectively. Finally, types of alcoholic beverages which were consumed in the third trimester were beer/draft (35.64%), Tella (31.21%), Areki/Korofe/Tej/wine (5.33%), and two or more types of drinks (23.94%) (Table 3).

Table 3 Alcohol intake during pregnancy using Alcohol Use Disorders Identification Test- Consumption (AUDIT-C)
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Birth outcomes

The mean birth weight of newborns who were delivered from singleton pregnancies was 2994.68 ± 433.02 g, and the gestational age of newborns was 38.84 ± 1.66 weeks. The incidence of low birth weight in the whole cohort (weighed less than the 2500 g) was 12.63% (95% CI: 11.12, 14.31). Likewise, the incidence of preterm (< 37 weeks gestation) and stillbirth were 6.05% (95% CI: 5.00, 7.29) and 4.27% (95% CI: 3.4, 5.35), respectively.

Relationship between the level of alcohol intake and birth outcomes

Overall, there was some difference between the adverse birth outcomes for infants of mothers who drank any levels of alcohol during pregnancy and women who were abstinent during pregnancy. Alcohol consumption during pregnancy had dose-response relationship with the risk of low birth weight (10.25% for no consumption, 15.18% for non-hazardous, and 25.86% for hazardous consumption at chi-square = 26.80, P < 0.001) and preterm delivery (5.53% for no consumption, 5.58% for non-hazardous, 12.93% for hazardous consumption at chi-square = 10.38, P < 0.001). On the other hand, there was an inconsistency of dose-response relationship for stillbirth between babies born to mothers of alcohol-consuming and women who did not (4.28% for no consumption, 3.13% for non-hazardous, 8.62% for hazardous consumption at chi-square = 6.81, P = 0.033).

Women who reported a hazardous pattern of alcohol intake during pregnancy were 2.34 times (ARR = 2.34; 95% CI: 1.66, 3.30) increased the risk of low birth weight when compared to women who abstained entirely throughout pregnancy. Similarly, the risk of LBW was 50% (ARR = 1.50; 95% CI: 1.31, 1.98) higher for non-hazardous alcohol drinker pregnant women when compared to women who did not consume any alcohol. Analysis of the hazardous level of alcohol consumption during pregnancy yielded 2.06 times (ARR = 2.06; 95% CI: 1.21, 3.52) increased the risk of preterm birth compared to abstinent during pregnancy, but the association was not observed at non-hazardous levels of alcohol use during pregnancy (Table 4). The adjusted PAR of low birth weight related to non-hazardous and hazardous alcohol drinking during pregnancy was 11.72 and 8.44%, respectively, while the adjusted PAR of hazardous alcohol consumption was 6.80% for preterm.

Table 4 Associations between alcohol consumption during pregnancy, and some maternal characteristics and adverse fetal outcomes at public health facilities in Gondar town, Northwest, Ethiopia, 2020
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Before adjusting for potential confounders, the association between stillbirth and the hazardous level of alcohol consumption was found to be two-fold (RR = 2.01; 95% CI: 1.05, 3.88) higher than abstinent during pregnancy. However, there was no evidence of an increased likelihood of stillbirth at any levels of alcohol consumption during pregnancy after adjustment for other covariates (Table 5).

Table 5 Associations between alcohol consumption during pregnancy, and some maternal characteristics and stillbirth at public health facilities in Gondar town, Northwest, Ethiopia, 2020
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Discussion

To the best of our knowledge, this is the first prospective cohort study regarding maternal alcohol consumption in Ethiopia that looked at hazardous and non-hazardous alcohol exposures during pregnancy separately and their association with adverse birth outcomes. Maternal alcohol consumption during pregnancy in many countries continues to be the single most important modifiable risk factor for adverse birth outcomes. This study examined the potential effects of alcohol (hazardous and non-hazardous) consumption during pregnancy on adverse birth outcomes. In the present study, we found the risk of low birth weight significantly increased among newborns of mothers who drank both hazardous and non-hazardous alcohol during pregnancy. Likewise, there was a statistically significant association between hazardous alcohol intake and preterm birth. However, there was no evidence of the association between alcohol consumption during pregnancy and stillbirth had been observed after taking into account other covariates. In addition to alcohol consumption, other risk factors associated with low birth weight: education level, household wealth status, family size, anemia in pregnancy, and MUAC; and preterm birth: occupation, hypertensive disorder of pregnancy, and sex of the newborn. Stillbirth was associated with family size, anemia, and preterm birth.

Findings from our study showed that an increasing trend in the risk of low birth weight with increasing levels of alcohol exposure was statistically significant. In this cohort study, prenatal hazardous and non-hazardous alcohol exposures were 2.34 times and 50% more likely to increase the risk of low birth weight compared to abstainers, respectively. On the other hand, the analyses of adjusted PAR percent also showed that 8.44and 11.72% of low birth weight cases might be attributed to hazardous and non-hazardous alcohol consumption, respectively. Some studies have concordantly found that maternal prenatal alcohol exposure was negatively associated with the weight of newborns [37, 73, 74]. Similarly, our study is consistent with several studies examining higher levels of prenatal alcohol consumption that have been linked with low birth weight [1, 9, 39]. Simultaneously, non-hazardous or light to moderate alcohol consumption during pregnancy had a positive significant association with the risk of low birth weight. This finding agreed with previous results of other studies that found low weight in newborns that were prenatally exposed to low to moderate maternal drinking [75,76,77]. The reason for this association could be justified that alcohol consumption during pregnancy impairs placental growth, lead to vasoconstriction, and interferes placental transmission of necessary nutrients and sufficient oxygen to the fetus [78]. On the contrary, some studies conducted in various areas detected no association between non-hazardous alcohol consumption and low birth weight [1, 26]. The possible explanation for this disagreement might be the difference in genetic material or biological variation for alcohol absorption and metabolism in the mothers and their fetus, data collection tools or methods, a cut-off value for low to a moderate level, characteristics of the study participants, lack of consistent definition for non-hazardous or low to moderate alcohol use and timing of consumption [79, 80]. Another potential reason for variation could be the heterogeneity of the quality of alcohol consumed; in our study, the majority of alcoholic drinks were locally prepared or homemade, which are prone to contamination with methanol and has high alcohol-related harm [12, 81]. Also, there might be the failure to adjust appropriately or differences in adjustment for possible confounding covariates between the studies, and residual confounding might have been a problem in some studies because of incorrectness in measuring confounders.

Similarly, based on our analysis, alcohol consumption during pregnancy has a dose-response relationship with preterm birth. We have attempted to provide the public health burden of hazardous alcohol consumption for preterm by quantifying PAR percent. We also found an association of hazardous prenatal alcohol drinking with preterm delivery compared to abstainers during pregnancy after adjusting for possible confounding factors. The finding showed that preterm birth was higher among women who reported hazardous alcohol consumption (AUDIT-C score ≥ 3) implies that exposure to excess alcohol during pregnancy has the potential to premature delivery. This result is consistent with the findings of other earlier studies that found preterm birth in neonates who were prenatally exposed to hazardous or heavy maternal drinking [38, 82]. The possible clarification for this link could be due to the association of prenatal alcohol exposure with placental dysfunction, diminished placental size, impaired blood flow and important nutrient transportation, and endocrine changes, any of which could play a role in the alcohol exposure effects on preterm birth [78]. On the other hand, the present finding is not in line with the result of other studies [76]. Our study could not find the effect of non-hazardous alcohol consumption on the risk for preterm delivery. This finding is consistent with previous studies of low to moderate alcohol exposure [83,84,85] and a systematic review of low-to-moderate alcohol consumption [26]. However, our result lacked the concordance with a prospective cohort study among mother-child pairs that demonstrated a light and mild level of maternal alcohol intake during pregnancy was positively associated with the risk of preterm birth [86]. The possible explanations for the discrepancy of our finding with earlier studies could be methods of assessment of maternal alcohol intake during pregnancy and variation in classifications of alcohol consumption (e.g. we categorized as non-drinker or abstainer, non-hazardous and hazardous based on AUDIT-C score, but others might not be similar to this). On the other hand, our study participants were not identical to the study participants of the previous studies with respect to biology and other characteristics that might cause the difference in susceptibility to adverse effects of alcohol use.

On the other analysis, there was no statistically significant association between any levels of alcohol consumption during pregnancy and stillbirth. This finding is consistent with the studies conducted in various parts of the world [87]. However, there are some controversial findings in the relationship between alcohol consumption during pregnancy and stillbirth; they confirmed that there was a positive link between higher threshold prenatal alcohol exposure and stillbirth [88,89,90]. This lack of relationship might be due to the limited information received about dose and frequency of alcohol consumption, unobserved heterogeneity among the study participants, and differences in exposure ascertainment that make it difficult to compare our results with those of findings. Generally, the variations between our findings and other studies could be to some extent due to heterogeneity between studies related to the method of alcohol assessments and inconsistent choice of potential confounders. Furthermore, the discrepancy in findings between nations may be a reflection of differences in alcoholic beverages and drinking patterns. Lastly, differences might also be due to genetic variations linked to the metabolism of alcohol that may differ between populations [91].

Strengths and limitations of the study

One of the strengths of this study is the clarification of a dose-response relationship between maternal prenatal alcohol consumption and adverse birth outcomes, including locally brewed alcohols. It is important that only limited evidence exists on the effect of non-hazardous alcohol levels of prenatal alcohol exposure on adverse birth outcomes. Another strength of this study is determining population attributable risk, which allows public health programmers to address what percent of adverse birth outcomes could be prevented if alcohol consumption during pregnancy were to be taken out from the pregnant women.

Despite these strengths, due to the presence of some limitations, the findings of this study should be interpreted with caution. Alcohol consumption information was collected based on maternal self-report and hence is subject to recall bias. Women who consumed alcohol were more likely to either falsely refuse the alcohol use or significantly underreport the actual level that they drank and then could be categorized as non-drinker because drinking alcohol during pregnancy is considered socially unacceptable [92]. Thus, the reported amounts of alcoholic beverages consumed may be considerably lower than the real value biasing the study results due to misclassification and would under-estimate the true link between drinking and adverse birth outcomes, leading to a type II error. Nevertheless, self-report has been found to be more precise than other methods [93]. Most of the alcohol used was locally homemade brews; therefore, the exact volume of containers of alcohol was not well understood by the respondents, so it was difficult to get the factual standard drink during conversion.

Conclusions and recommendations

Our findings suggest that there is an increasing risk of adverse birth outcomes, particularly preterm delivery and low birth weight, with increasing the level of alcohol intake. This result showed that the prevention of maternal alcohol use during pregnancy has the potential to reduce low birth weight and preterm. Hence, screening women for alcohol use during ANC visits and provide advice with rigorous follow-up of women who used alcohol may save the fetus from the potential risks of adverse birth outcomes. Healthcare workers have maintained strong and consistent messages of alcohol abstinence for pregnant women. Healthcare professionals should always be supported by comprehensive and up-to-date information on prenatal alcohol use and incorporate such information to prevent alcohol use among women before they become pregnant [94]. The lack of an association between prenatal alcohol exposure and stillbirth in this study needs further investigation.

Availability of data and materials

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Abbreviations

ANC:

Antenatal Care

AUDIT:

Alcohol Use Disorders Identification Test

AUDIT-C:

Alcohol Use Disorder Identification Test-Consumption

EPDS:

Edinburgh Postnatal Depression Scale

FASD:

Fetal Alcohol Spectrum Disorder

LAMP:

Last Menstrual Period

MUAC:

Mid-Upper Arm Circumference

PAR:

Population-Attributable Risk

VIF:

Variance Inflation Factor

WHO:

World Health Organization

References

  1. Chen J-HJA. Maternal alcohol use during pregnancy, birth weight and early behavioral outcomes. Alcohol Alcohol. 2012;47(6):649–56.

    Article  CAS  PubMed  Google Scholar 

  2. Peadon E, Payne J, Henley N, D'antoine H, Bartu A, O'Leary C, et al. Women’s knowledge and attitudes regarding alcohol consumption in pregnancy: a national survey. BMC Public Health. 2010;10(1):510.

    Article  PubMed  PubMed Central  Google Scholar 

  3. O'Neil E. Developmental timeline of alcohol-induced birth defects. In: Embryo Project Encyclopedia; 2012.

    Google Scholar 

  4. Hox JJ, Moerbeek M, Van de Schoot R. Multilevel analysis: techniques and applications. New York: Routledge; 2010.

  5. O'Brien J, Mattson SN, Astley S, O'Connor MJ, Chasnoff IJ, Kodituwakku PW, et al. Fetal alcohol spectrum disorders; 2011.

    Google Scholar 

  6. Rothwell PM, Howard SC, Dolan E, O'Brien E, Dobson JE, Dahlöf B, et al. Prognostic significance of visit-to-visit variability, maximum systolic blood pressure, and episodic hypertension. Lancet. 2010;375(9718):895–905. https://doi.org/10.1016/S0140-6736(10)60308-X.

    Article  PubMed  Google Scholar 

  7. Streissguth A, Landesman-Dwyer S, Martin JC, Smith DW. Teratogenic effects of alcohol in humans and laboratory animals. Science. 1980;209(4454):353–61.

    Article  CAS  PubMed  Google Scholar 

  8. Webster W, Walsh D, McEWEN SE, Lipson A. Some teratogenic properties of ethanol and acetaldehyde in C57BL/6J mice: implications for the study of the fetal alcohol syndrome. Teratology. 1983;27(2):231–43. https://doi.org/10.1002/tera.1420270211.

    Article  CAS  PubMed  Google Scholar 

  9. Patra J, Bakker R, Irving H, Jaddoe VW, Malini S, Rehm J. Dose–response relationship between alcohol consumption before and during pregnancy and the risks of low birthweight, preterm birth and small for gestational age (SGA)—a systematic review and meta-analyses. BJOG Int J Obstet Gynaecol. 2011;118(12):1411–21. https://doi.org/10.1111/j.1471-0528.2011.03050.x.

    Article  CAS  Google Scholar 

  10. Ornoy A, Ergaz Z. Alcohol abuse in pregnant women: effects on the fetus and newborn, mode of action and maternal treatment. Int J Environ Res Public Health. 2010;7(2):364–79. https://doi.org/10.3390/ijerph7020364.

    Article  PubMed  PubMed Central  Google Scholar 

  11. Warren KR, Li TK. Genetic polymorphisms: impact on the risk of fetal alcohol spectrum disorders. Birth Defects Res A Clin Mol Teratol. 2005;73(4):195–203. https://doi.org/10.1002/bdra.20125.

    Article  CAS  PubMed  Google Scholar 

  12. Riley EP, Infante MA, Warren KR. Fetal alcohol spectrum disorders: an overview. Neuropsychol Rev. 2011;21(2):73–80. https://doi.org/10.1007/s11065-011-9166-x.

    Article  PubMed  PubMed Central  Google Scholar 

  13. McQuire C, Daniel R, Hurt L, Kemp A, Paranjothy S. The causal web of foetal alcohol spectrum disorders: a review and causal diagram. Eur Child Adolesc Psychiatry. 2019;29:1–20.

    Google Scholar 

  14. Eberhart JK, Parnell SE. The genetics of fetal alcohol spectrum disorders. Alcohol Clin Exp Res. 2016;40(6):1154–65.

    Article  PubMed  PubMed Central  Google Scholar 

  15. Flak AL, Su S, Bertrand J, Denny CH, Kesmodel US, Cogswell ME. The association of mild, moderate, and binge prenatal alcohol exposure and child neuropsychological outcomes: a meta-analysis. Alcohol Clin Exp Res. 2014;38(1):214–26.

    Article  PubMed  Google Scholar 

  16. BabyCenter Medical Advisory Board. How much alcohol is too much during pregnancy?. 2016.

    Google Scholar 

  17. CDC: Center for Diseases Control and prevention. Fetal alcohol spectrum Disorders (FASDs). https://www.cdc.gov/ncbddd/fasd/facts.html.

  18. U. J: Alcohol and Pregnancy: Is 'A Little Bit' Safe? https://www.webmd.com/baby/features/drinking-alcohol-during-pregnancy.

  19. NHS: NHS Foundation Trust. Alcohol and pregnancy. https://www.nicswell.co.uk/health-news/no-change-to-alcohol-guidelines-for-pregnancy.

  20. Pereira PP, Mata FA, Figueiredo AC, Silva RB, Pereira MG. Maternal exposure to alcohol and low birthweight: a systematic review and meta-analysis. Rev Bras Ginecol Obstet. 2019;41(5):333–47.

    Article  PubMed  Google Scholar 

  21. Unit drinking alcohol while pregnant - NHS.UK. https://www.nhs.uk/conditions/pregnancy-and-baby/alcohol-medicines-drugs-pregnant/. Last reviewed: 14 Jan 2017.

  22. O’Leary CM, Bower C. Guidelines for pregnancy: what's an acceptable risk, and how is the evidence (finally) shaping up? Drug Alcohol Rev. 2012;31(2):170–83. https://doi.org/10.1111/j.1465-3362.2011.00331.x.

    Article  PubMed  Google Scholar 

  23. Williams JF, Smith VC. Abuse CoS: fetal alcohol spectrum disorders. Pediatrics. 2015;136(5):e1395–406. https://doi.org/10.1542/peds.2015-3113.

    Article  PubMed  Google Scholar 

  24. Gray R, Mukherjee RA, Rutter M. Alcohol consumption during pregnancy and its effects on neurodevelopment: what is known and what remains uncertain. Addiction. 2009;104(8):1270–3. https://doi.org/10.1111/j.1360-0443.2008.02441.x.

    Article  PubMed  Google Scholar 

  25. Pfinder M, Kunst AE, Feldmann R, van Eijsden M, Vrijkotte TG. Preterm birth and small for gestational age in relation to alcohol consumption during pregnancy: stronger associations among vulnerable women? Results from two large Western-European studies. BMC Pregnancy Childbirth. 2013;13(1):49. https://doi.org/10.1186/1471-2393-13-49.

    Article  PubMed  PubMed Central  Google Scholar 

  26. Henderson J, Gray R, Brocklehurst P. Systematic review of effects of low–moderate prenatal alcohol exposure on pregnancy outcome. BJOG Int J Obstet Gynaecol. 2007;114(3):243–52. https://doi.org/10.1111/j.1471-0528.2006.01163.x.

    Article  CAS  Google Scholar 

  27. Mullally A, Cleary BJ, Barry J, Fahey TP, Murphy DJ. Prevalence, predictors and perinatal outcomes of peri-conceptional alcohol exposure-retrospective cohort study in an urban obstetric population in Ireland. BMC Pregnancy Childbirth. 2011;11(1):27. https://doi.org/10.1186/1471-2393-11-27.

    Article  PubMed  PubMed Central  Google Scholar 

  28. Anteab K, Demtsu B, Megra M. Assessment of prevalence and associated factors of alcohol use during pregnancy among the dwellers of Bahir-Dar City, Northwest Ethiopia, 2014; 2014.

    Google Scholar 

  29. Mekuriaw B, Belayneh Z, Shemelise T, Hussen RJ. Alcohol use and associated factors among women attending antenatal care in Southern Ethiopia: a facility based cross sectional study. BMC Res Notes. 2019;12(1):690.

    Article  PubMed  PubMed Central  Google Scholar 

  30. Wubetu AD, Habte S, Dagne KJ. Prevalence of risky alcohol use behavior and associated factors in pregnant antenatal care attendees in Debre Berhan, Ethiopia, 2018. BMC Psychiatry. 2019;19(1):250.

    Article  PubMed  PubMed Central  Google Scholar 

  31. Addila AE, Bisetegn TA, Gete YK, Mengistu MY, Beyene GM. Alcohol consumption and its associated factors among pregnant women in Sub-Saharan Africa: a systematic review and meta-analysis' as given in the submission system. Subst Abuse Treat Prev Policy. 2020;15:1–14.

    Google Scholar 

  32. AddisBiz: Alcohol supplier companies and businesses in ethiopia, list of alcohol suppliers in Ethiopia https://addisbiz.Com/business-directory/food-beverages/alcohol. 2020.

    Google Scholar 

  33. Lee M, Regu M, Seleshe S. Uniqueness of Ethiopian traditional alcoholic beverage of plant origin, tella. J Ethnic Foods. 2015;2(3):110–4. https://doi.org/10.1016/j.jef.2015.08.002.

    Article  Google Scholar 

  34. Teshome DA, Rainer M, Noel J-C, Schüßler G, Fuchs D, Bliem HR, et al. Chemical compositions of traditional alcoholic beverages and consumers characteristics, Ethiopa. Afr J Food Sci. 2017;11(7):234–45.

    CAS  Google Scholar 

  35. Mamluk L, Jones T, Ijaz S, Edwards HB, Savović J, Leach V, et al. Evidence of detrimental effects of prenatal alcohol exposure on offspring birthweight and neurodevelopment from a systematic review of quasi-experimental studies. Int J Epidemiol. 2020;49(6):1972–95.

    Article  PubMed Central  Google Scholar 

  36. Popova S, Dozet D, O’Hanlon G, Temple V, Rehm J. Maternal alcohol use, adverse neonatal outcomes and pregnancy complications in British Columbia, Canada: a population-based study. BMC Pregnancy Childbirth. 2021;21(1):1–13.

    Article  Google Scholar 

  37. Nykjaer C, Alwan NA, Greenwood DC, Simpson NA, Hay AW, White KL, et al. Maternal alcohol intake prior to and during pregnancy and risk of adverse birth outcomes: evidence from a British cohort. J Epidemiol Community Health. 2014;68(6):542–9.

    Article  PubMed  Google Scholar 

  38. Ikehara S, Kimura T, Kakigano A, Sato T, Iso H, Group JECsS, et al. Association between maternal alcohol consumption during pregnancy and risk of preterm delivery: the Japan Environment and Children’s Study. BJOG. 2019;126(12):1448–54.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  39. Virji SJ. The relationship between alcohol consumption during pregnancy and infant birthweight: an epidemiologic study. Acta Obstet Gynecol Scand. 1991;70(4–5):303–8.

    Article  CAS  PubMed  Google Scholar 

  40. Goldenberg RL, McClure EM, Saleem S. Improving pregnancy outcomes in low-and middle-income countries. Reprod Health. 2018;15(1):7–14.

    Google Scholar 

  41. Muhe LM, McClure EM, Nigussie AK, Mekasha A, Worku B, Worku A, et al. Major causes of death in preterm infants in selected hospitals in Ethiopia (SIP): a prospective, cross-sectional, observational study. Lancet Glob Health. 2019;7(8):e1130–8. https://doi.org/10.1016/S2214-109X(19)30220-7.

    Article  PubMed  PubMed Central  Google Scholar 

  42. Mengesha HG, Sahle BW. Cause of neonatal deaths in northern Ethiopia: a prospective cohort study. BMC Public Health. 2017;17(1):62. https://doi.org/10.1186/s12889-016-3979-8.

    Article  PubMed  PubMed Central  Google Scholar 

  43. Abate MG, Angaw DA, Shaweno T. Proximate determinants of infant mortality in Ethiopia, 2016 Ethiopian demographic and health surveys: results from a survival analysis. Arch Public Health. 2020;78(1):1–10.

    Article  Google Scholar 

  44. Total population of the Gondar town. Gondar town finance and economic development branch office 2018.

    Google Scholar 

  45. Fahim NK, Negida A. Sample size calculation guide-part 2: how to calculate the sample size for an independent cohort study. Front Emerg Med. 2019;3(1):e12.

    Google Scholar 

  46. Sbrana M, Grandi C, Brazan M, Junquera N, Nascimento MS, Barbieri MA, et al. Alcohol consumption during pregnancy and perinatal results: a cohort study. Sao Paulo Med J. 2016;134(2):146–52.

    Article  PubMed  Google Scholar 

  47. Mammaro A, Carrara S, Cavaliere A, Ermito S, Dinatale A, Pappalardo EM, et al. Hypertensive disorders of pregnancy. J Prenat Med. 2009;3(1):1.

    PubMed  PubMed Central  Google Scholar 

  48. Bager H, Christensen LP, Husby S, Bjerregaard L. Biomarkers for the detection of prenatal alcohol exposure: a review. Alcohol Clin Exp Res. 2017;41(2):251–61. https://doi.org/10.1111/acer.13309.

    Article  CAS  PubMed  Google Scholar 

  49. López MB, Lichtenberger A, Conde K, Cremonte M. Psychometric properties of brief screening tests for alcohol use disorders during pregnancy in Argentina. Rev Bras Ginecol Obstet. 2017;39(07):322–9.

    Article  PubMed  Google Scholar 

  50. Fletcher OV, May PA, Seedat S, Sikkema KJ, Watt MH. Attitudes toward alcohol use during pregnancy among women recruited from alcohol-serving venues in Cape Town, South Africa: a mixed-methods study. Soc Sci Med. 2018;215:98–106. https://doi.org/10.1016/j.socscimed.2018.09.008.

    Article  PubMed  Google Scholar 

  51. Bush K, Kivlahan DR, McDonell MB, Fihn SD, Bradley KA. The AUDIT alcohol consumption questions (AUDIT-C): an effective brief screening test for problem drinking. Arch Intern Med. 1998;158(16):1789–95. https://doi.org/10.1001/archinte.158.16.1789.

    Article  CAS  PubMed  Google Scholar 

  52. Babor TF, de la Fuente JR, Saunders J, Grant M. The alcohol use disorders identification test: guidelines for use in primary care; 2011.

    Google Scholar 

  53. Burns E, Gray R, Smith LA. Brief screening questionnaires to identify problem drinking during pregnancy: a systematic review. Addiction. 2010;105(4):601–14. https://doi.org/10.1111/j.1360-0443.2009.02842.x.

    Article  PubMed  Google Scholar 

  54. Organization WH. Global status report on alcohol and health 2018. Switzerland: World Health Organization; 2019.

  55. Kingsland M, Doherty E, Anderson AE, Crooks K, Tully B, Tremain D, et al. A practice change intervention to improve antenatal care addressing alcohol consumption by women during pregnancy: research protocol for a randomised stepped-wedge cluster trial. Implement Sci. 2018;13(1):112. https://doi.org/10.1186/s13012-018-0806-x.

    Article  PubMed  PubMed Central  Google Scholar 

  56. Smith L, Savory J, Couves J, Burns E. Alcohol consumption during pregnancy: cross-sectional survey. Midwifery. 2014;30(12):1173–8. https://doi.org/10.1016/j.midw.2014.04.002.

    Article  PubMed  Google Scholar 

  57. Brittain K, Remien RH, Phillips T, Zerbe A, Abrams EJ, Myer L, et al. Factors associated with alcohol use prior to and during pregnancy among HIV-infected pregnant women in Cape Town, South Africa. Drug Alcohol Depend. 2017;173:69–77. https://doi.org/10.1016/j.drugalcdep.2016.12.017.

    Article  PubMed  PubMed Central  Google Scholar 

  58. Fitzpatrick JP, Latimer J, Ferreira ML, Carter M, Oscar J, Martiniuk AL, et al. Prevalence and patterns of alcohol use in pregnancy in remote W estern a ustralian communities: the L ililwan P roject. Drug Alcohol Rev. 2015;34(3):329–39. https://doi.org/10.1111/dar.12232.

    Article  PubMed  Google Scholar 

  59. Tafere G. A review on traditional fermented beverages of Ethiopian. J Nat Sci Res. 2015;5:94–102.

    Google Scholar 

  60. Organization WH. International guide for monitoring alcohol consumption and related harm. Geneva: World Health Organization; 2000.

    Google Scholar 

  61. Fekadu A, Alem A, Hanlon C. Alcohol and drug abuse in Ethiopia: past, present and future. Afr J Drug Alcohol Stud. 2007;6(1):40–53.

    Google Scholar 

  62. Addila AE, Azale T, Gete YK, Yitayal M. Determinants of hazardous alcohol use among pregnant women attending antenatal care at public health facilities in Gondar town, Northwest Ethiopia: a nested case-control study. PLoS One. 2021;16(7):e0253162. https://doi.org/10.1371/journal.pone.0253162.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  63. Anteab K, Demtsu B, Megra M. Assessment of prevalence and associated factors of alcohol use during pregnancy among the dwellers of Bahir-Dar City; 2014.

    Google Scholar 

  64. Raymond N, Beer C, Glazebrook C, Sayal K. Pregnant women's attitudes towards alcohol consumption. BMC Public Health. 2009;9(1):175. https://doi.org/10.1186/1471-2458-9-175.

    Article  PubMed  PubMed Central  Google Scholar 

  65. Webster J, Linnane JW, Dibley LM, Hinson JK, Starrenburg SE, Roberts JA. Measuring social support in pregnancy: can it be simple and meaningful? Birth. 2000;27(2):97–101. https://doi.org/10.1046/j.1523-536x.2000.00097.x.

    Article  CAS  PubMed  Google Scholar 

  66. Chang G, McNamara TK, Orav EJ, Wilkins-Haug L. Alcohol use by pregnant women: partners, knowledge, and other predictors. J Stud Alcohol. 2006;67(2):245–51. https://doi.org/10.15288/jsa.2006.67.245.

    Article  PubMed  PubMed Central  Google Scholar 

  67. Dibaba Y, Fantahun M, Hindin MJ. The association of unwanted pregnancy and social support with depressive symptoms in pregnancy: evidence from rural southwestern Ethiopia. BMC Pregnancy Childbirth. 2013;13(1):135. https://doi.org/10.1186/1471-2393-13-135.

    Article  PubMed  PubMed Central  Google Scholar 

  68. Dadi AF, Desyibelew HD. Undernutrition and its associated factors among pregnant mothers in Gondar town, Northwest Ethiopia. PLoS One. 2019;14(4):e0215305.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  69. Kumera G, Gedle D, Alebel A, Feyera F, Eshetie SJ. Undernutrition and its association with socio-demographic, anemia and intestinal parasitic infection among pregnant women attending antenatal care at the University of Gondar Hospital, Northwest Ethiopia. Matern Health Neonatol Perinatol. 2018;4(1):18.

    Article  PubMed  PubMed Central  Google Scholar 

  70. Craney TA, Surles JG. Model-dependent variance inflation factor cutoff values. Qual Eng. 2002;14(3):391–403. https://doi.org/10.1081/QEN-120001878.

    Article  Google Scholar 

  71. Northridge ME. Public health methods--attributable risk as a link between causality and public health action. Am J Public Health. 1995;85(9):1202–4.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  72. Levin ML. The occurrence of lung cancer in man. Acta Unio Int Contra Cancrum. 1953;9(3):531–41.

    CAS  PubMed  Google Scholar 

  73. Shu XO, Hatch MC, Mills J, Clemens J, Susser MJ. Maternal smoking, alcohol drinking, caffeine consumption, and fetal growth: results from a prospective study. Epidemiology. 1995;6:115–20.

    Article  CAS  PubMed  Google Scholar 

  74. Lake EA, Olana Fite RJ. Low birth weight and its associated factors among newborns delivered at wolaita sodo university teaching and referral hospital, southern Ethiopia, 2018. Int J Pediatr. 2019;2019:4628301.

    Article  PubMed  PubMed Central  Google Scholar 

  75. Windham GC, Fenster L, Hopkins B, Swan SH. The association of moderate maternal and paternal alcohol consumption with birthweight and gestational age. Epidemiology. 1995;6:591–7.

    Article  CAS  PubMed  Google Scholar 

  76. Meyer-Leu Y, Lemola S, Daeppen JB, Deriaz O, Gerber SJ. Association of moderate alcohol use and binge drinking during pregnancy with neonatal health. Alcohol Clin Exp Res. 2011;35(9):1669–77.

    PubMed  Google Scholar 

  77. Guardian T. 2020. https://www.theguardian.com/lifeandstyle/2020/sep/16/plans-to-record-pregnant-womens-alcohol-consumption-in-england-criticised. Accessed 16 Sept 2020.

  78. Burd L, Roberts D, Olson M, Odendaal HJ, Medicine N. Ethanol and the placenta: a review. J Matern Fetal Neonatal Med. 2007;20(5):361–75.

    Article  CAS  PubMed  Google Scholar 

  79. Wall TL, Luczak SE, Hiller-Sturmhöfel SJ. Biology, genetics, and environment: underlying factors influencing alcohol metabolism. Alcohol Res. 2016;38(1):59.

    PubMed  PubMed Central  Google Scholar 

  80. Stang PE, Ryan PB, Overhage JM, Schuemie MJ, Hartzema AG, Welebob EJ. Variation in choice of study design: findings from the Epidemiology Design Decision Inventory and Evaluation (EDDIE) survey. Drug Saf. 2013;36(1):15–25.

    Article  Google Scholar 

  81. WHO. Global status report on alcohol and health. WHO; 2014. www.who.intsubstance_abusepublicationsglobal_alcohol_reportprofileseth.pdfeth.

  82. O’Leary CM, Nassar N, Kurinczuk JJ, Bower CJ. The effect of maternal alcohol consumption on fetal growth and preterm birth. BJOG. 2009;116(3):390–400.

    Article  PubMed  Google Scholar 

  83. Bakker R, Pluimgraaff LE, Steegers EA, Raat H, Tiemeier H, Hofman A, et al. Associations of light and moderate maternal alcohol consumption with fetal growth characteristics in different periods of pregnancy: the Generation R Study. Int J Epidemiol. 2010;39(3):777–89.

    Article  PubMed  Google Scholar 

  84. Shiono PH, Klebanoff MA, Rhoads GG. Smoking and drinking during pregnancy: their effects on preterm birth. JAMA. 1986;255(1):82–4.

    Article  CAS  PubMed  Google Scholar 

  85. Lundsberg LS, Illuzzi JL, Belanger K, Triche EW, Bracken MB. Low-to-moderate prenatal alcohol consumption and the risk of selected birth outcomes: a prospective cohort study. Ann Epidemiol. 2015;25(1):46–54. e43.

    Article  PubMed  Google Scholar 

  86. Lundsberg LS, Bracken MB, Saftlas AF. Low-to-moderate gestational alcohol use and intrauterine growth retardation, low birthweight, and preterm delivery. Ann Epidemiol. 1997;7(7):498–508.

    Article  CAS  PubMed  Google Scholar 

  87. Andersen A-MN, Andersen PK, Olsen J, Grønbæk M, Strandberg-Larsen KJ. Moderate alcohol intake during pregnancy and risk of fetal death. Int J Epidemiol. 2012;41(2):405–13.

    Article  PubMed  Google Scholar 

  88. Kesmodel U, Wisborg K, Olsen SF, Henriksen TB, Secher NJ. Moderate alcohol intake during pregnancy and the risk of stillbirth and death in the first year of life. Am J Epidemiol. 2002;155(4):305–12.

    Article  PubMed  Google Scholar 

  89. Bailey BA, Sokol RJ. Prenatal alcohol exposure and miscarriage, stillbirth, preterm delivery, and sudden infant death syndrome. Alcohol Res Health. 2011;34(1):86.

    PubMed  PubMed Central  Google Scholar 

  90. O’Leary C, Jacoby P, D’Antoine H, Bartu A, Bower CJ. Heavy prenatal alcohol exposure and increased risk of stillbirth. J Matern Fetal Neonatal Med. 2012;119(8):945–52.

    Google Scholar 

  91. Abel EL, Hannigan JH. Maternal risk factors in fetal alcohol syndrome: provocative and permissive influences. Neurotoxicol Teratol. 1995;17(4):445–62.

    Article  CAS  PubMed  Google Scholar 

  92. Poikolainen K, Kärkkäinen PJ. Diary gives more accurate information about alcohol consumption than questionnaire. Drug Alcohol Depend. 1983;11(2):209–16.

    Article  CAS  PubMed  Google Scholar 

  93. McNamara TK, Orav EJ, Wilkins-Haug L, Chang GJ. Risk during pregnancy—Self-report versus medical record. Am J Obstet Gynecol. 2005;193(6):1981–5.

    Article  PubMed  PubMed Central  Google Scholar 

  94. France K, Henley N, Payne J, D'Antoine H, Bartu A, O’Leary C, et al. Health professionals addressing alcohol use with pregnant women in Western Australia: barriers and strategies for communication. Subst Use Misuse. 2010;45(10):1474–90.

    Article  PubMed  Google Scholar 

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Acknowledgments

We thank the Gondar town health department, University of Gondar Comprehensive Specialized Hospital and, health centers for their provision of necessary information and support during data collection. Our genuine thanks also go to the study participants, data collectors, and supervisors who took part in the study.

Funding

This study was funded by the University of Gondar and Wachemo University. The universities are following whether findings are presented and published. The universities have no role in the design, data collection, analysis and interpretation of the findings and in writing the manuscript. All the statements and findings are the responsibility of the investigators.

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Authors and Affiliations

  1. Department of Public Health, College of Medicine and Health Sciences, Wachemo University, Hossana, Ethiopia

    Alemu Earsido Addila

  2. Department of Epidemiology and Biostatistics, College of Medicine and Health Sciences, Institute of Public Health, University of Gondar, Gondar, Ethiopia

    Alemu Earsido Addila & Yigzaw Kebede Gete

  3. Department of Health Education and Behavioral Sciences, College of Medicine and Health Sciences, Institute of Public Health, University of Gondar, Gondar, Ethiopia

    Telake Azale

  4. Department of Health Systems and Policy, College of Medicine and Health Sciences, Institute of Public Health, University of Gondar, Gondar, Ethiopia

    Mezgebu Yitayal

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  1. Alemu Earsido Addila
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Contributions

A.E conceptualized, designed, coordinated data collection, analyzed the data, and drafted the manuscript. T.A, Y.K, and M.Y designed the study and critically revised the manuscript. All authors read and approved the final manuscript.

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Correspondence to Alemu Earsido Addila.

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Ethics approval and consent to participate

Ethical approval was taken from the University of Gondar Institutional Ethical Review Board (R. No.-O/V/P/RCS/05/747/2019) and a permission letter was also obtained from the Gondar town health department. All the study participants were above 18 years. They were notified about the objective and verbal informed consent was obtained before conducting data collection. They were also informed that they had the full right to withdraw or refuse to participate in the study. No financial incentive was given to participants for their participation in the study. Data obtained from study participants were held anonymously and confidentially.

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The authors declare that they have no competing interests.

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Addila, A.E., Azale, T., Gete, Y.K. et al. The effects of maternal alcohol consumption during pregnancy on adverse fetal outcomes among pregnant women attending antenatal care at public health facilities in Gondar town, Northwest Ethiopia: a prospective cohort study. Subst Abuse Treat Prev Policy 16, 64 (2021). https://doi.org/10.1186/s13011-021-00401-x

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Substance Abuse Treatment, Prevention, and Policy

ISSN: 1747-597X