Preconception interventions to reduce the risk of alcohol-exposed pregnancies: A systematic review

The burden of generational harm due to alcohol use in Tanzania: A mixed method study of pregnant women

BACKGROUND

Rates of prenatal alcohol use in Sub-Saharan Africa (SSA) are increasing despite regulatory bodies urging pregnant women to abstain from alcohol. Tanzania has minimal policies, interventions, and educational programs addressing prenatal alcohol exposure. Consequently, a considerable number of mothers and their fetuses are exposed to alcohol, leading to serious health consequences like fetal alcohol spectrum disorder (FASD). Our study aims to understand the alcohol use practices of pregnant women, the knowledge and attitudes related to prenatal alcohol exposure among different genders and generations, and how these may be influenced by community perceptions and cultural beliefs among patients at Kilimanjaro Christian Medical Center (KCMC).

METHODS

A total of 676 individuals seeking care at the KCMC Emergency Department (ED) or Reproductive Health Center (RHC) met our inclusion criteria, were approached for participation using a systematic random sampling method, and were enrolled. Of those, 541 women and 114 men completed the survey. The quantitative analysis focused exclusively on survey data from 533 women who reported their pregnancy status and age. Descriptive frequencies were used to compare sociodemographic factors and alcohol use practices across three female groups stratified by pregnancy status and age. Nineteen survey participants-both men and women-were purposively selected for qualitative semi-structured in-depth interviews (IDIs) exploring knowledge, attitudes, and cultural beliefs surrounding alcohol use during pregnancy. A grounded theory approach was used to analyze IDIs in NVivo.

RESULTS

A large percentage of pregnant women reported consuming alcohol at least once per week (42.2%). Older non-pregnant women exhibited the highest rate of alcohol use per week (66.0%). Many older non-pregnant women (28.7%) perceived alcohol use as acceptable during pregnancy. Younger non-pregnant women had the highest prevalence of harmful or hazardous drinking (HHD) at 16.4%. This group also reported the highest weekly alcohol expenses, with 18.1% spending over 10,000 Tanzanian shillings (TZS) per week. Median [IQR] DrInC scores were 0 [0-0] for pregnant women, 0 [0-7] for younger non-pregnant women, and 0 [0-1] for older non-pregnant women. Older non-pregnant women exhibited the highest prevalence of depression (31.4%). Median [IQR] PHQ-9 scores were 4 [3-6.25] for pregnant women, 5 [2-8] for younger non-pregnant women, and 6 [3-10] for older non-pregnant women. Qualitative analyses demonstrated that (1) cultural beliefs are intricately tied to perceived benefits of prenatal alcohol exposure, (2) a history of alcohol use preceding pregnancy largely influences prenatal alcohol use, and (3) community views of PWCA are negative.

CONCLUSIONS

Our findings demonstrate high rates of prenatal alcohol use in Moshi, Tanzania, with pre-pregnancy alcohol use as a significant predictor. Despite generally negative views of pregnant women who consume alcohol (PWCA), some sociocultural beliefs and limited knowledge about the dangers of prenatal alcohol exposure encouraged alcohol use during pregnancy. To improve health outcomes and reduce alcohol-related pregnancy complications for current and future generations, community-wide health messaging and pre-pregnancy interventions may prove beneficial for pregnant women and women of reproductive age who consume alcohol.

Magnitude and risk factors of khat, alcohol and cigarettes use among pregnant women in Africa: a systematic review and meta-analysis

BACKGROUND

The use of khat, alcohol, and cigarettes during pregnancy is a serious public health problem associated with harmful outcomes for the fetus and the mother's health. Studies that investigated khat, alcohol, and cigarettes usage during pregnancy yielded varied and contradictory results. This study used a systematic review and meta-analysis to estimate the pooled prevalence and associated factors of khat, alcohol, and cigarettes use among pregnant women in Africa.

METHODS

A review of eligible studies was conducted using Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. This review has been registered in PROSPERO with protocol ID CRD42021289074. Literature published in English from January 1, 2002 to November 30, 2021 was retrieved from PubMed, Google Scholar, Cochrane, HINARI, African Journal Online, and Science Direct databases. The quality of included articles was assessed using the Joanna Briggs Institute's (JBI) critical appraisal checklist. The I2 statistic and Cochran's Q test were used to assess the presence of heterogeneity between studies. To assess publication bias, a funnel plot and Egger's regression test were utilized. The random effect model was used to estimate the summary prevalence and the corresponding 95% confidence interval (CI) of risk factors for khat, alcohol, and cigarettes use.

RESULTS

Out of the 1509 studies identified, 71 met the inclusion criteria. The pooled prevalence of khat chewing, alcohol drinking, active smoking, and secondhand smoke exposure during pregnancy was 18.93%, 22.20%, 11.85%, and 43.45%, respectively. The subgroup analysis by UN sub-region showed the highest pooled prevalence of alcohol use during pregnancy in Middle Africa (25.69%) and the lowest in Northern Africa (1.10%). Several factors were identified as risk factors for alcohol use, including low educational level, younger age women, pre-pregnancy alcohol use, unplanned pregnancy, history of abortion, poor social support, mental distress, poor knowledge on alcohol risks, and partner alcohol use.

CONCLUSION

This review indicated that the pooled magnitude of khat, alcohol and cigarette use during pregnancy was higher in Africa. Substance use screening and brief interventions (SBI) should be routinely delivered in antenatal care settings to reduce pregnant women's substance use.

Participatory Modeling for High Complexity, Multi-System Issues: Challenges and Recommendations for Balancing Qualitative Understanding and Quantitative Questions

Community stakeholder participation can be incredibly valuable for the qualitative model development process. However, modelers often encounter challenges for participatory modeling projects focusing on high-complexity, synergistic interactions between multiple issues, systems, and granularity. The diverse stakeholder perspectives and volumes of information necessary for developing such models can yield qualitative models that are difficult to translate into quantitative simulation or clear insight for informed decision-making. There are few reccomended best practices for developing high-complexity, participatory models. We use an ongoing project as a case study to highlight three practical challenges for tackling high-complexity, multi-system issues with system dynamics tools. These challenges include balanced and respectful stakeholder engagement, defining boundaries and levels of variable aggregation, and timing and processes for qualitative/quantitative model integration. Our five recommendations to address these challenges serve as a foundation for further research on methods for developing translatable qualitative multi-system models for informing actions for systemic change.

Fetal alcohol spectrum disorder and Aboriginal and Torres Strait Islander men: A discussion to be had

Fetal alcohol spectrum disorder (FASD) is a lifelong disability of varying severity that occurs among individuals prenatally exposed to alcohol. Among Aboriginal and Torres Strait Islander (Indigenous) Australians, the effects of colonisation and ongoing racism could increase the risk of alcohol consumption during pregnancy. Much of the research and the effort towards prevention of and caring for people with FASD in Indigenous communities has been targeted towards women and children. More support and effort towards prevention of FASD is needed across the whole Indigenous community. In this paper, we discuss several areas for increased involvement by Indigenous men in future FASD research, prevention, care and support.

Prenatal Alcohol Counseling Among American Indian and Alaska Native Women and Non-Hispanic White Women in the Pregnancy Risk Assessment Monitoring System

OBJECTIVE

Universal screening and counseling are recommended for alcohol use during pregnancy, but no prior study has examined differences in prenatal counseling by race or ethnicity. We used Pregnancy Risk Assessment Monitoring System (PRAMS) data to assess differences in provision of counseling on prenatal alcohol use between American Indian/Alaska Native (AI/AN) and non-Hispanic White (NHW) women during prenatal care.

METHODS

We analyzed data from 2014-2015 from the four PRAMS states with the highest number of births to AI/AN women: Alaska, New Mexico, Oklahoma, and Washington. We estimated the prevalence of prenatal alcohol use, associated risk factors, and prenatal alcohol prevention counseling for AI/AN (n = 1,805) and NHW (n = 5,641) women. We then conducted multivariable logistic regression modeling stratified by race to estimate factors associated with receipt of prenatal alcohol prevention counseling. All analyses were weighted and accounted for the complex sampling design of PRAMS.

RESULTS

Results showed that AI/AN women were counseled on prenatal alcohol use more often than NHW women (77% vs. 67%, p < .05), although the likelihood of any prenatal alcohol use was the same in both groups. The likelihood of prenatal drinking increased with age, education, and income in both groups. Higher education levels were significantly associated with lower risk of prenatal alcohol counseling receipt among AI/AN women. Compared with those with less than a high school diploma, AI/AN women with a college degree or more had 39% reduced risk of receiving counseling (adjusted risk ratio [aRR] = 0.61; 95% confidence interval [CI]: 0.45-0.83). Among NHW women, living at 100% to 199% of the Federal Poverty Level was associated with lower risk (aRR = 0.88; 95% CI: 0.79-0.98) of counseling receipt compared with women living below the federal poverty line. Higher parity was significantly associated with lower risk of counseling for both groups of women.

CONCLUSION

Although race was not associated with prenatal alcohol use, AI/AN women were more likely than NHW women to be counseled about prenatal alcohol exposure. Factors associated with counseling receipt differed between the two groups. These findings suggest that receipt of counseling is associated with sociodemographic characteristics, and that counseling is not universally provided. More efforts to provide universal counseling are warranted.

Fetal alcohol spectrum disorders

Alcohol readily crosses the placenta and may disrupt fetal development. Harm from prenatal alcohol exposure (PAE) is determined by the dose, pattern, timing and duration of exposure, fetal and maternal genetics, maternal nutrition, concurrent substance use, and epigenetic responses. A safe dose of alcohol use during pregnancy has not been established. PAE can cause fetal alcohol spectrum disorders (FASD), which are characterized by neurodevelopmental impairment with or without facial dysmorphology, congenital anomalies and poor growth. FASD are a leading preventable cause of birth defects and developmental disability. The prevalence of FASD in 76 countries is >1% and is high in individuals living in out-of-home care or engaged in justice and mental health systems. The social and economic effects of FASD are profound, but the diagnosis is often missed or delayed and receives little public recognition. Future research should be informed by people living with FASD and be guided by cultural context, seek consensus on diagnostic criteria and evidence-based treatments, and describe the pathophysiology and lifelong effects of FASD. Imperatives include reducing stigma, equitable access to services, improved quality of life for people with FASD and FASD prevention in future generations.

Reducing Prenatal Alcohol Exposure and the Incidence of FASD: Is the Past Prologue?

PURPOSE

This narrative review summarizes and synthesizes the clinical trials and randomized clinical trials that evaluated selected and targeted approaches to reducing preconception and prenatal alcohol exposure (PAE) and alcohol-exposed pregnancy (AEP) since 2011.

SEARCH METHODS

A professional hospital librarian completed the primary search using strategies specified within this review, resulting in 94 records returned in PubMed, Ovid MEDLINE, Clinical Key, the World Health Organization International Clinical Trials Registry Platform, and ClinicalTrials.gov. The author completed two supplementary literature searches.

SEARCH RESULTS

From the total of 238 records returned from the three searches, 217 records were eliminated. Elimination reasons included other medical problem (119); duplicate entry (34); no content/results (23); secondary analysis (16); focus on effects of PAE (9); treatment of childhood fetal alcohol spectrum disorders (FASD) (6); maternal risk factors (3); and other (7). The remaining 21 studies were included with four overarching themes: (1) case management efforts (n = 4); (2) preconception efforts to reduce AEP (n = 5); (3) motivational interviewing and screening, brief intervention, and referral to treatment (n = 2); and (4) use of technology to deliver the intervention (n = 10).

DISCUSSION AND CONCLUSIONS

Case management and home visits did not appear to have strong current empirical support. Study limitations included small sample sizes and no comparison groups, whereas larger efforts did not demonstrate definitive advantages to justify this intensive approach. The studies of preconception efforts, all based on the Project CHOICES approach, had similar outcomes, with the reduction in AEP risk largely due to improved contraception in women of childbearing age who were sexually active and drank alcohol but were not pregnant. It is unknown whether these women refrained from alcohol use when they became pregnant. Two studies of motivational interviewing to reduce prenatal alcohol use did not demonstrate the efficacy of the intervention. Both were small, with less than 200 pregnant women combined; moreover, the study samples had low baseline levels of alcohol use, allowing little opportunity for improvement. Finally, studies evaluating the impact of technological approaches to reducing AEP were reviewed. These exploratory investigations had small sample sizes and provided preliminary evaluations of techniques such as text messages, telephone contact, computer-based screening, and motivational interviewing. The potentially promising findings may inform future research and clinical efforts. Future directions may include research to address the limitations of the evidence to date and should reflect the complexities of FASD that include the biological and social context associated with prenatal alcohol use.

Prevention of alcohol related harm though preconception care: A scoping review of barriers and enablers

Objective

To understand the perspectives of healthcare practitioners and women of reproductive age regarding addressing prevention of an alcohol exposed pregnancy before conception.

Methods

A scoping review of mixed methods, qualitative and quantitative research was conducted. Medline, CINAHL, EMBASE and PsychInfo databases were searched for literature published by March 2022. Data were extracted and synthesized.

Results

Twenty-three studies were included. Views varied between healthcare practitioners and women about addressing alcohol with women before pregnancy. Healthcare practitioners agreed prevention was important but believed they were ill-prepared to provide support, and that it might be intrusive if women were not contemplating pregnancy. Whereas women would welcome advice from healthcare practitioners, particularly if offered during appointments or visits for services related to reproductive health. A knowledge deficit about pregnancy and fetal harms from alcohol was expressed by both healthcare practitioners and women.

Conclusions

Investment in alcohol education and skills training for healthcare professionals is required to ensure a coherent message is communicated across services, and that shared decision making about healthcare between service users and health professionals is facilitated. Future research should explore implementation of interventions to prevent alcohol exposed pregnancy in settings where women are seeking reproductive health support.

Self-reported alcohol consumption of pregnant women and their partners correlates both before and during pregnancy: A cohort study with 21,472 singleton pregnancies

Background

The partners’ role in determining the alcohol consumption behavior of pregnant women is not well studied. We measured alcohol use before and during pregnancy in pregnant women and their partners to evaluate the correlation in their levels of consumption.

Methods

We evaluated the self‐reported alcohol use of 14,822 women and their partners during 21,472 singleton pregnancies delivered in Kuopio University Hospital, Finland during the period 2009‒2018. The information was gathered during pregnancy and at the time of childbirth and recorded in two databases that were merged to yield a single cohort. Missing data were accounted for by multiple imputation using the predictive mean matching method.

Results

In 86% of the pregnancies, women reported alcohol use before pregnancy, whereas in 4.5% of the pregnancies women reported alcohol use during pregnancy. In contrast, no decrease was detected in their partners’ alcohol use before or during pregnancy. In 26% of the pregnancies, the woman reported stopping alcohol use only after recognizing that she was pregnant. Before pregnancy, there were strong correlations between the pregnant women and their partners in the total Alcohol Use Disorders Identification Test score (r_s = 0.69, p < 0.0001) and the self‐reported average weekly amount of alcohol consumed (r_s = 0.56, p < 0.0001). During pregnancy, there were weak correlations between the pregnant women and their partners in the frequency of drinking (r_s = 0.20, p < 0.0001) and the average weekly amount of alcohol consumed (r_s = 0.18, p < 0.0001).

Conclusions

The self‐reported alcohol consumption of pregnant women and their partners was positively correlated both before and during pregnancy, though the correlation declined substantially during pregnancy. Evaluating the alcohol consumption of both parents before pregnancy could assist in identifying women at risk of prenatal alcohol exposure. Supporting a reduction in partners' alcohol use could help to reduce pregnant women's alcohol consumption and prevent its associated harms.