Heavy prenatal alcohol exposure and increased risk of stillbirth

The perinatal and childhood outcomes of children born to Indigenous women with mental health problems: A scoping review

OBJECTIVE

Maternal mental health problems are common during the perinatal period and have been associated with several negative outcomes in children. However, few studies have examined the associations between maternal mental health problems and offspring outcomes among Indigenous people, and the findings across these studies have been inconsistent. This scoping review examined the birth and childhood (≤12 years) health and development outcomes of the children of Indigenous women with mental health problems.

METHODS

A scoping review was conducted following the methodological framework developed by Arksey and O'Malley and based on the PRISMA-ScR guidelines. Eight databases were searched electronically for studies examining the associations between any perinatal maternal mental health problems and birth and childhood outcomes among the Indigenous populations of Australia, Canada, New Zealand, and the USA. Two authors reviewed studies for inclusion. A narrative synthesis approach was adopted.

RESULTS

Of 2,836 records identified, 10 were eligible. One of three studies evaluating maternal depression and anxiety problems found a negative (adverse) association with birth and childhood behavioural outcomes. Six of seven studies that examined the associations between maternal substance use disorder (mainly alcohol use disorder) and several birth and childhood outcomes found at least one negative association.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

Maternal substance use disorder appears to be associated with adverse birth and childhood outcomes among some Indigenous populations. However, there is preliminary evidence for the other common maternal mental health problems. Further research is critically required to draw definitive conclusions regarding the impact of maternal mental health problems on the birth and childhood outcomes.

Practice change intervention to improve antenatal care addressing alcohol consumption during pregnancy: a randomised stepped-wedge controlled trial

Background

Clinical guideline recommendations for addressing alcohol consumption during pregnancy are sub-optimally implemented and limited evidence exists to inform practice improvements. The aim of this study was to estimate the effectiveness of a practice change intervention in improving the provision of antenatal care addressing alcohol consumption during pregnancy in public maternity services.

Methods

A randomised stepped-wedge controlled trial was undertaken with all public maternity services in three sectors (one urban, two regional/rural) of a single local health district in New South Wales, Australia. All antenatal care providers were subject to a seven-month multi-strategy intervention to support the introduction of a recommended model of care. For 35 months (July 2017 – May 2020) outcome data were collected from randomly selected women post an initial, 27–28 weeks and 35–36 weeks gestation antenatal visit. Logistic regression models assessed intervention effectiveness.

Results

Five thousand six hundred ninety-four interviews/online questionnaires were completed by pregnant women. The intervention was effective in increasing women’s reported receipt of: assessment of alcohol consumption (OR: 2.63; 95% CI: 2.26–3.05; p < 0.001), advice not to consume alcohol during pregnancy and of potential risks (OR: 2.07; 95% CI: 1.78–2.41; p < 0.001), complete care relevant to alcohol risk level (advice and referral) (OR: 2.10; 95% CI: 1.80–2.44; p < 0.001) and all guideline elements relevant to alcohol risk level (assessment, advice and referral) (OR: 2.32; 95% CI: 1.94–2.76; p < 0.001). Greater intervention effects were found at the 27–28 and 35–36 weeks gestation visits compared with the initial antenatal visit. No differences by sector were found. Almost all women (98.8%) reported that the model of care was acceptable.

Conclusions

The practice change intervention improved the provision of antenatal care addressing alcohol consumption during pregnancy in public maternity services. Future research could explore the characteristics of pregnant women and maternity services associated with intervention effectiveness as well as the sustainment of care practices over time to inform the need for, and development of, further tailored practice change support.

Trial registration

Australian and New Zealand Clinical Trials Registry (Registration number: ACTRN12617000882325; Registration date: 16/06/2017) https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=372985&isReview=true

Sex- and tissue-specific effects of binge-level prenatal alcohol consumption on DNA methylation at birth

Background: Binge-level prenatal alcohol exposure (PAE) causes developmental abnormalities, which may be mediated in part by epigenetic mechanisms. Despite this, few studies have characterised the association of binge PAE with DNA methylation in offspring. Methods: We investigated the association between binge PAE and genome-wide DNA methylation profiles in a sex-specific manner in neonatal buccal and placental samples. Results: We identified no differentially methylated CpGs or differentially methylated regions (DMRs) at false discovery rate <0.05. However, using a sum-of-ranks approach, we identified a DMR in each tissue of female offspring. The DMR identified in buccal samples is located near regions with previously-reported associations to fetal alcohol spectrum disorder (FASD) and binge PAE. Conclusion: Our findings warrant further replication and highlight a potential epigenetic link between binge PAE and FASD.

Maternal alcohol consumption and risk of offspring with congenital malformation: the Japan Environment and Children's Study

BACKGROUND

The association between fetal exposure to alcohol and congenital structural disorders remains inconclusive. The present study searched for relationships between maternal alcohol consumption during pregnancy and the risk of congenital malformations.

METHODS

We evaluated the fixed dataset of a large national birth cohort study including 73,595 mothers with a singleton live birth. Information regarding the alcohol consumption of mothers was obtained from self-reported questionnaires. Physicians assessed for 6 major congenital malformations (congenital heart defects [CHDs], male genital abnormalities, limb defects, cleft lip and/or cleft palate [orofacial clefts (OFC)], severe brain abnormalities, and gastrointestinal obstructions) up to 1 month after birth. Multiple logistic regression analysis was performed to identify associations between maternal alcohol consumption during pregnancy and each malformation.

RESULTS

The prevalence of maternal drinking in early pregnancy and until the second/third trimester was 46.6% and 2.8%, respectively. The onset of CHD was inversely associated with mothers who quit drinking during early pregnancy (OR 0.85, 95% CI 0.74-0.98). There was no remarkable impact of maternal drinking habit status on the other congenital malformations after adjustment for covariates.

CONCLUSIONS

Maternal alcohol consumption during pregnancy, even in early pregnancy, displayed no significant adverse impact on congenital malformations of interest.

IMPACT

This large-scale Japanese cohort study revealed that no teratogenic associations were found between maternal retrospective reports of periconceptional alcohol consumption and congenital malformations after adjustment for covariates. This is the first nationwide birth cohort study in Japan to assess the effect of maternal alcohol consumption during pregnancy on major congenital malformations. Our finding indicated that maternal low-to-moderate alcohol consumption during pregnancy, even in early pregnancy, displayed no significant adverse impact on congenital heart defects, male genital abnormalities, limb defects, orofacial clefts, severe brain abnormalities, or gastrointestinal obstructions.

Community Priority setting for Fetal Alcohol Spectrum Disorder Research in Australia

INTRODUCTION

Fetal Alcohol Spectrum Disorder (FASD) is a neurodevelopmental disorder caused by prenatal alcohol exposure (PAE). FASD research is a rapidly growing field that crosses multiple disciplines. To ensure research is relevant and meaningful for people living with FASD, their families, and the broader public there is a need to engage community members in setting priorities for research.

OBJECTIVES

Our primary objective was to formally identify the views of people living with FASD, their parents/caregivers, service providers, and the general community on the research priorities for FASD and alcohol use in pregnancy in Australia. Our secondary objective was to provide an overview of current research in the highest priority areas identified.

METHODS

The approach for this study involved two community surveys and a consensus workshop, followed by a rapid literature review. Survey responses (n = 146) were collected and grouped using qualitative thematic analysis. The themes identified were then ranked in a second survey (n = 45). The 22 highest ranked themes were considered in a workshop with 21 community members, and consensus on the top ten priority areas was sought. The priority areas were grouped into conceptually similar topics and rapid literature reviews were undertaken on each.

RESULTS

A diverse range of priorities was identified within key areas of prevention, diagnosis, and therapy. On request from participants, separate priority lists were developed by Aboriginal and non-Aboriginal participants.

CONCLUSION

There is need for a national network of researchers to take forward the research commenced by the Centre of Research Excellence, FASD Research Australia, in addressing community priorities.

KEY WORDS

Community, priorities, FASD, rapid review, Australia.

Maternal Alcohol-Use Disorder and Child Outcomes

OBJECTIVES

Investigate the relationship between maternal alcohol-use disorder and multiple biological and social child outcomes, including birth outcomes, child protection, justice contact, and academic outcomes for both Indigenous and non-Indigenous children.

METHODS

Women with a birth recorded on the Western Australian Midwives Notification System (1983-2007) and their offspring were in scope. The exposed cohort were mothers with an alcohol-related diagnosis (International Classification of Diseases, Ninth Revision and International Classification of Diseases, 10th Revision) recorded in an administrative data set and their offspring (non-Indigenous: n = 13 969; Indigenous: n = 9635). The exposed cohort was frequency matched with mothers with no record of an alcohol-related diagnosis and their offspring (comparison cohort; non-Indigenous: n = 40 302; Indigenous: n = 20 533).

RESULTS

Over half of exposed non-Indigenous children (55%) and 84% of exposed Indigenous children experienced ≥1 negative outcome. The likelihood of any negative outcome was significantly higher for the exposed than the comparison cohort (non-Indigenous: odds ratio [OR] = 2.67 [95% confidence interval (CI) = 2.56-2.78]; Indigenous: OR = 2.67 [95% CI = 2.50-2.85]). The odds were greatest for children whose mothers received a diagnosis during pregnancy (non-Indigenous: OR = 4.65 [95% CI = 3.87-5.59]; Indigenous: OR = 5.18 [95% CI = 4.10-6.55]); however, numbers were small.

CONCLUSIONS

The effects of maternal alcohol-use disorder are experienced by the majority of exposed children rather than a vulnerable subgroup of this population. These findings highlight the need for universal prevention strategies to reduce harmful alcohol use and targeted interventions to support at-risk women and children.

Co-use of alcohol, tobacco, and licit and illicit controlled substances among pregnant and non-pregnant women in the United States: Findings from 2006 to 2014 National Survey on Drug Use and Health (NSDUH) data

BACKGROUND

The use, misuse and co-use of alcohol, cannabis, tobacco, and other licit and illicit controlled substances has increased in past decades leading to higher rates of morbidity, overdose, and mortality in women of reproductive age. Co-use compounds the adverse health effects of substance use compared to single-use of similar substances. Little is known about the full range of substance combinations used by pregnant and non-pregnant women. We sought to describe patterns of co-use of alcohol, tobacco, and controlled substances, and examine correlates of co-use in a nationally-representative sample of women.

METHODS

Cross-sectional study using self-reported survey data from 2006 to 2014 for women ages 18-49 years (N = 160,371) in National Survey on Drug Use and Health data. We use weighted proportions and 95% confidence intervals (CI) to report differences in substance use patterns in pregnant and non-pregnant women. Multivariate logistic regression models assessed association between characteristics and type of substance use pattern.

RESULTS

Prevalence of substance co-use among pregnant women is 5.1% and among non-pregnant women is 23.6%. Nearly all of the most frequent co-use patterns included alcohol, cannabis, or tobacco. Determinants of co-use among pregnant women included: younger age (18-25 years) compared to ≥ 26 years [AOR (95% CI): 1.81 (1.18, 2.80)]; and past year history of substance use [AOR 5.42 (3.59, 8.20)].

CONCLUSIONS

Co-use of several substances, including and especially of tobacco, alcohol and cannabis, persists among pregnant women in the United States. Efforts that aim to improve maternal and child health should address the complexity of substance use during pregnancy, including and beyond opioids.

Investigating Mechanisms of Stillbirth in the Setting of Prenatal Substance Use

Introduction

Intrauterine fetal demise affects between 0.4-0.8% of pregnancies worldwide. This significant adverse pregnancy outcome continues to be poorly understood. In utero exposure to substances increases the risk of stillbirth to varying degrees according to the type of substance and degree of exposure. The aim of this qualitative narrative review is to investigate common biologic relationships between stillbirth and maternal substance use.

Methods

A PubMed literature search was conducted to query the most commonly used substances and biologic mechanisms of stillbirth. Search terms included "stillbirth," "intrauterine fetal demise," "placenta," "cocaine," "tobacco," "alcohol," "methamphetamines," "opioids/ opiates," and "cannabis."

Results

There are very few studies identifying a direct link between substance use and stillbirth. Several studies demonstrate associations with placental lesions of insufficiency including poor invasion, vasoconstriction, and sequestration of toxic substances that inhibit nutrient transport. Restricted fetal growth is the most common finding in pregnancies complicated by all types of substance use.

Discussion

More research is needed to understand the biologic mechanisms of stillbirth. Such knowledge will be foundational to understanding how to prevent and treat the adverse effects of substances during pregnancy.

Time- and sex-dependent associations between prenatal alcohol exposure and placental global DNA methylation

AIM

Epigenetic changes, in particular in the placenta, may mediate the effects of prenatal alcohol exposure (PAE) on children's health. We examined the relationship between PAE patterns, based on dose and timing, and placental global DNA methylation.

METHODS

Using linear regression analysis, we examined the association between different PAE categories and placental global DNA methylation (n = 187), using the proxy measure of Alu-interspersed repeats.

RESULTS

Following adjustment for important covariates, we found no evidence of an association between PAE and placental global DNA methylation overall. However, when stratifying by newborn sex, PAE throughout pregnancy was associated with higher placental global DNA methylation (1.5%; p = 0.01) of male newborns.

CONCLUSION

PAE may have sex-specific effects on placental global DNA methylation if alcohol is consumed throughout pregnancy.

Substance use in pregnancy: The medical challenge

Substance use contributes significantly to the global burden of disease. Growing numbers of women use nicotine, alcohol, and illicit substances. Women are the most vulnerable to problematic substance use in their reproductive years. The first 1000 days of life, starting at conception, have been established as a critical window of time for long-term health and development. Substance use in pregnancy is associated with negative pregnancy and child health outcomes. The impact of antenatal substance use on these outcomes needs to be considered within a challenging and complex context. This review provides an overview of the current literature on the impact of substances on pregnancy and child outcomes as well as the evidence and guidelines on screening and interventions for women using substances during pregnancy.

Exploring factors impacting early childhood health among Aboriginal and Torres Strait Islander families and communities: protocol for a population-based cohort study using data linkage (the 'Defying the Odds' study)

INTRODUCTION

Empirical evidence on family and community risk and protective factors influencing the comparatively high rates of potentially preventable hospitalisations and deaths among Aboriginal and Torres Strait Islander infants and children is limited. As is evidence on geographical variation in these risks. The 'Defying the Odds' study aims to explore the impact of perinatal outcomes, maternal social and health outcomes and level of culturally secure service availability on the health outcomes of Western Australian (WA) Aboriginal infants and children aged 0-5 years.

METHODS AND ANALYSIS

The study combines a retrospective cohort study that uses state-wide linked health and administrative data from 12 data sources for multiple generations within Aboriginal families in WA, with specifically collected survey data from health and social services supporting Aboriginal families in regions of WA. Data sources include perinatal/birth registration, hospital, emergency department, mental health services, drug and alcohol service use, mortality, infectious disease notifications, and child protection and family services. Multilevel regression models will be used to examine the intensity of admissions and presentations, mortality, intensity of long stays and morbidity-free survival (no admissions) for Aboriginal children born in WA in 2000-2013. Relationships between maternal (and grand-maternal) health and social factors and child health outcomes will be quantified. Community-level variation in outcomes for Aboriginal children and factors contributing to this variation will be examined, including the availability of culturally secure services. Online surveys were sent to staff members at relevant services to explore the scope, reach and cultural security of services available to support Aboriginal families across selected regions of WA.

ETHICS AND DISSEMINATION

Ethics approvals have been granted for the study. Interpretation and dissemination are guided by the study team's Aboriginal leadership and reference groups. Dissemination will be through direct feedback and reports to health services in the study and via scientific publications and policy recommendations.

Human Brain Abnormalities Associated With Prenatal Alcohol Exposure and Fetal Alcohol Spectrum Disorder

Fetal alcohol spectrum disorder (FASD) is a common neurodevelopmental problem, but neuropathologic descriptions are rare and focused on the extreme abnormalities. We conducted a retrospective survey (1980–2016) of autopsies on 174 individuals with prenatal alcohol exposure or an FASD diagnosis. Epidemiologic details and neuropathologic findings were categorized into 5 age groups. Alcohol exposure was difficult to quantify. When documented, almost all mothers smoked tobacco, many abused other substances, and prenatal care was poor or nonexistent. Placental abnormalities were common (68%) in fetal cases. We identified micrencephaly (brain weight <5th percentile) in 31, neural tube defects in 5, isolated hydrocephalus in 6, corpus callosum defects in 6 (including some with complex anomalies), probable prenatal ischemic lesions in 5 (excluding complications of prematurity), minor subarachnoid heterotopias in 4, holoprosencephaly in 1, lissencephaly in 1, and cardiac anomalies in 26 cases. The brain abnormalities associated with prenatal alcohol exposure are varied; cause–effect relationships cannot be determined. FASD is likely not a monotoxic disorder. The animal experimental literature, which emphasizes controlled exposure to ethanol alone, is therefore inadequate. Prevention must be the main societal goal, however, a clear understanding of the neuropathology is necessary for provision of care to individuals already affected.

Maternal Alcohol Use Disorder and Risk of Child Contact with the Justice System in Western Australia: A Population Cohort Record Linkage Study

BACKGROUND

Early contact with the justice system is associated with a multitude of negative outcomes across the life course. This includes an increased risk of ongoing justice contact, social disadvantage and marginalization, and mental health and substance use issues. Children whose mothers have an alcohol use disorder may be at risk of early justice system contact, and we sought to quantify this relationship in a Western Australian cohort.

METHODS

This population cohort study made use of linked administrative data. Those in-scope for the study were women who had a birth recorded on the Midwives Notification System (1983 to 2007). The exposed cohort were mothers who had an alcohol-related diagnosis (ICD9/10), recorded on administrative data. This included mental and behavioral disorders which were alcohol related, diseases which could be entirely attributed to alcohol and other ICD alcohol codes. These women were considered to have an alcohol use disorder, which was a proxy for heavy drinking. The comparison cohort was frequency-matched sample with no alcohol-related diagnosis identified on administrative data sets.

RESULTS

After adjusting for potential confounders, children whose mothers had a maternal alcohol use disorder had a significantly increased odds of justice contact when compared to those whose mothers had no diagnosis (odds ratio [OR] = 1.79, 95% confidence interval [CI] = 1.60 to 1.99). Additional significant maternal factors associated with child justice contact included being Indigenous (OR = 5.14, 95% CI = 4.54 to 5.81), low maternal age, low socioeconomic status, being unmarried, and a history of a mental health problems. Significant child-level factors, which were associated with increased odds of justice contact, included being male, a mental health diagnosis, child protection contact, parity, and academic failure.

CONCLUSIONS

Children who were exposed to a maternal alcohol use disorder had significantly increased odds of contact with the justice system. Additional risk was associated with being Indigenous and with markers of social disadvantage. These results suggest that prevention and early intervention services should span across agencies in an effort to reduce risk.

The Stillbirth Classification System for the Safe Passage Study

Objective Describe the classification system for assigning the cause of stillbirth in the Safe Passage Study, an international, multi-institutional, prospective analysis conducted by the NIAAA/NICHD-funded Prenatal Alcohol in SIDS and Stillbirth (PASS) Research Network. The study mission is to determine the role of prenatal alcohol and/or cigarette smoke exposure in adverse pregnancy outcomes, including stillbirth, in a high-risk cohort of 12,000 maternal/fetal dyads. Methods The PASS Network classification system is based upon 5 "sites of origin" for cause of stillbirth, further subdivided into mechanism subcategories; both are employed to assign an ultimate cause of death. Each PASS stillbirth was assigned a cause of death and status of sporadic versus recurrent. Adjudication involved review of maternal and obstetrical records; fetal autopsy and placental findings; and required complete consensus in each case. Two published classification systems, ie, INCODE and ReCoDe, were used for comparison. Results Causes of stillbirth classified were fetal (26%), placental (53%), external (5%), and undetermined (16%). Nine cases (47%) had placental causes of death due to maternal disorders that carry recurrence risks. There was full agreement for cause of death across the 3 classification systems in 26% of cases and partial agreement among them in 42% of cases. Conclusions The proposed PASS schema employs a user-friendly classification that provides comparable information to previously published systems. Advantages include its simplicity, mechanistic formulations, tight clinicopathologic integration, provision for an undetermined category, and its wide applicability to perinatal mortality review boards with access to information routinely collected during clinicopathologic evaluations.

Causes of stillbirth in a socioeconomically disadvantaged urban Australian population - a comprehensive analysis

INTRODUCTION

The aim of this paper was to provide an in-depth analysis of all stillbirth causation over a period of 10 years in a busy maternity unit located in a socioeconomically disadvantaged urban area, with an emphasis on overlapping pathology.

MATERIALS AND METHODS

A retrospective analysis of all structurally normal stillbirths in singleton pregnancies born during 2002-2012. The PSANZ stillbirth classification was used; per stillbirth subgroup main risk factors were evaluated.

RESULTS

Out of 130 cases, 43% showed overlapping pathologies. In the remaining 74 (56%) cases, the following single pathologies were found: IUGR 20 (15%), infection 12 (9%), abruption 8 (6%), placental thrombotic pathology 8 (6%), miscellaneous 6 stillbirths (5%), and 20 cases (15%) unexplained. Smoking was a risk factor for stillbirth associated with abruption (OR 3.639), infection (OR 2.271), and thrombotic pathology (OR 2.168). Drug use had an association with (placental) infection (OR 3.598). Obesity showed a significant association with IUGR (OR 3.782) and abruption (OR 9.040). Thrombophilia risk analysis for the overall group of stillbirths showed significant results for Protein S (OR 8.889) and homocysteine >90th centile (OR 2.087).

CONCLUSIONS

Overlapping pathology was identified in 43% of stillbirths. Infection, IUGR, and abruption were the most important single cause of stillbirth.

Serotonin Receptors in the Medulla Oblongata of the Human Fetus and Infant: The Analytic Approach of the International Safe Passage Study

The Safe Passage Study is an international, prospective study of approximately 12 000 pregnancies to determine the effects of prenatal alcohol exposure (PAE) upon stillbirth and the sudden infant death syndrome (SIDS). A key objective of the study is to elucidate adverse effects of PAE upon binding to serotonin (5-HT) 1A receptors in brainstem homeostatic networks postulated to be abnormal in unexplained stillbirth and/or SIDS. We undertook a feasibility assessment of 5-HT_1A receptor binding using autoradiography in the medulla oblongata (6 nuclei in 27 cases). 5-HT_1A binding was compared to a reference dataset from the San Diego medical examiner’s system. There was no adverse effect of postmortem interval ≤100 h. The distribution and quantitated values of 5-HT_1A binding in Safe Passage Study cases were essentially identical to those in the reference dataset, and virtually identical between stillbirths and live born fetal cases in grossly non-macerated tissues. The pattern of binding was present at mid-gestation with dramatic changes in binding levels in the medullary 5-HT nuclei over the second half of gestation; there was a plateau at lower levels in the neonatal period and into infancy. This study demonstrates feasibility of 5-HT_1A binding analysis in the medulla in the Safe Passage Study.

Impact of fetal alcohol exposure on body systems: A systematic review

Review of published manuscripts on fetal alcohol exposure on several body systems.

METHOD

Articles in this review were found online using databases such as Medline, Medline Complete, PubMed, and Health Source: Nursing/Academic Edition. The following terms were searched: fetal alcohol spectrum disorders, fetal alcohol syndrome, prenatal alcohol exposure, and alcohol related birth defects.

RESULTS

Thirteen articles were gathered, five original investigations and eight reviews. This review identified several abnormalities in the body systems discussed and their associations to fetal alcohol syndrome.

CONCLUSIONS

Evidence shows that the brain was the most severely impacted organ of the body systems discussed. However, prenatal alcohol exposure causes several abnormalities within the heart, kidney, liver, gastrointestinal tract, and the endocrine systems. In addition, preventative measures need to be taken by mothers during pregnancy. Birth Defects Research (Part C), 2016. © 2016 Wiley Periodicals, Inc. Birth Defects Research (Part C) 108:174-180, 2016. © 2016 Wiley Periodicals, Inc.

Substance use during pregnancy

Prenatal substance use is a critical public health concern that is linked with several harmful maternal and fetal consequences. The most frequently used substance in pregnancy is tobacco, followed by alcohol, cannabis and other illicit substances. Unfortunately, polysubstance use in pregnancy is common, as well as psychiatric comorbidity, environmental stressors, and limited and disrupted parental care, all of which can compound deleterious maternal and fetal outcomes. There are few existing treatments for prenatal substance use and these mainly comprise behavioral and psychosocial interventions. Contingency management has been shown to be the most efficacious of these. The purpose of this review is to examine the recent literature on the prenatal use of tobacco, alcohol, cannabis, stimulants, and opioids, including the effects of these on maternal and fetal health and the current therapeutic options.

Pregnancy outcomes of mothers with an alcohol-related diagnosis: a population-based cohort study for the period 1983-2007

OBJECTIVE

To examine fetal outcomes of mothers with an alcohol-related diagnosis.

DESIGN

Population-based cohort.

SETTING

Western Australia (WA).

POPULATION

Births on the WA Midwives Notification System (1983-2007).

METHODS

Infants of mothers with an alcohol-related diagnosis [International Classification of Disease (ICD), 9th/10th revisions] recorded on WA health data sets (non-Aboriginal n = 13 807; Aboriginal n = 9766) were identified through the WA data linkage system. A comparison cohort of infants born to mothers without an alcohol diagnosis was frequency matched on maternal age, year of birth of the offspring, and Aboriginal status (non-Aboriginal n = 40 148; Aboriginal n = 20 643).

MAIN OUTCOME MEASURES

Poisson regression-generated adjusted relative risk (aRR) and 95% confidence intervals (95% CIs) for small for gestational age (SGA), preterm birth, and low-Apgar score, calculated separately for non-Aboriginal and Aboriginal infants of mothers with an alcohol diagnosis recorded during pregnancy and any alcohol diagnosis. Population-attributable fractions were calculated.

RESULTS

The aRR for non-Aboriginal infants when a maternal alcohol diagnosis was recorded during pregnancy ranged from 1.79 (95% CI 1.42-2.16) for SGA to 2.57 (95% CI 1.69-4.27) for preterm birth <32 weeks of gestation, and for Aboriginal infants ranged from 2.69 (95% CI 2.28-3.16) to 1.99 (95% CI 1.40-2.84), respectively. The highest population-attributable fractions were for any alcohol diagnosis and for Aboriginal infants. For Aboriginal births, approximately 9% (95% CI 4.74-12.97) and 10.1% (95% CI 5.50-14.49) of moderate and very preterm births, respectively, and 24.4% (95% CI 13.5-21.2%) of SGAs were attributable to having a mother with any alcohol-related diagnosis.

CONCLUSIONS

Mothers with an alcohol diagnosis are at increased risk of poor pregnancy outcomes. The public health impact of maternal alcohol-use disorders on fetal outcomes is significant.

Midwives' knowledge, attitudes and practice about alcohol exposure and the risk of fetal alcohol spectrum disorder

Background

Midwives are an influential profession and a key group in informing women about alcohol consumption in pregnancy and its consequences. There are no current quantitative Australian data on midwives’ knowledge, attitudes and practice in relation to alcohol consumption during pregnancy and Fetal Alcohol Spectrum Disorder. We aimed to reduce this knowledge gap by understanding midwives’ perceptions of their practice in addressing alcohol consumption during pregnancy.

Methods

This cross-sectional study was conducted at 19 maternity sites across the seven health regions of country Western Australia. A questionnaire was designed following review of the literature and other relevant surveys. Midwifery managers of the maternity sites distributed questionnaires to all midwives working in their line of management. A total of 334 midwives were invited to participate in the research and (n = 245, 73.4%) of these were eligible.

Results

The response fraction was (n = 166, 67.8%). Nearly all (n = 151, 93.2%) midwives asked pregnant women about their alcohol consumption during pregnancy and (n = 164, 99.4%) offered advice about alcohol consumption in accordance with the Australian Alcohol Guideline, which states “For women who are pregnant or planning a pregnancy, not drinking is the safest option”. Nearly two thirds (n = 104, 64.2%) of the midwives informed pregnant women about the effects of alcohol consumption in pregnancy, they did not always use the recommended AUDIT screening tool (n = 66, 47.5%) to assess alcohol consumption during pregnancy, nor conduct brief intervention when indicated (n = 107, 70.4%). Most midwives endorsed professional development about screening tools (n = 145, 93.5%), brief intervention (n = 144, 92.9%), and alcohol consumption during pregnancy and FASD (n = 144, 92.9%).

Conclusion

Nearly all midwives in this study asked and advised about alcohol consumption in pregnancy and around two thirds provided information about the effects of alcohol in pregnancy. Our findings support the need for further professional development for midwives on screening and brief intervention. Policy should support midwives’ practice to screen for alcohol consumption in pregnancy and offer brief intervention when indicated.

Validity and reliability of stillbirth data using linked self-reported and administrative datasets

Background

A high rate of stillbirth was previously observed in the Australian Longitudinal Study of Women’s Health (ALSWH). Our primary objective was to test the validity and reliability of self-reported stillbirth data linked to state-based administrative datasets.

Methods

Self-reported data, collected as part of the ALSWH cohort born in 1973–1978, were linked to three administrative datasets for women in New South Wales, Australia (n = 4374): the Midwives Data Collection; Admitted Patient Data Collection; and Perinatal Death Review Database. Linkages were obtained from the Centre for Health Record Linkage for the period 1996–2009. True cases of stillbirth were defined by being consistently recorded in two or more independent data sources. Sensitivity, specificity, positive predictive value, negative predictive value, percent agreement, and kappa statistics were calculated for each dataset.

Results

Forty-nine women reported 53 stillbirths. No dataset was 100% accurate. The administrative datasets performed better than self-reported data, with high accuracy and agreement. Self-reported data showed high sensitivity (100%) but low specificity (30%), meaning women who had a stillbirth always reported it, but there was also over-reporting of stillbirths. About half of the misreported cases in the ALSWH were able to be removed by identifying inconsistencies in longitudinal data.

Conclusions

Data linkage provides great opportunity to assess the validity and reliability of self-reported study data. Conversely, self-reported study data can help to resolve inconsistencies in administrative datasets. Quantifying the strengths and limitations of both self-reported and administrative data can improve epidemiological research, especially by guiding methods and interpretation of findings.

Low-to-moderate prenatal alcohol consumption and the risk of selected birth outcomes: a prospective cohort study

PURPOSE

To estimate whether low-to-moderate prenatal alcohol exposure is associated with selected birth outcomes.

METHODS

Low-to-moderate prenatal alcohol drinking and effects on low birthweight, preterm delivery, intrauterine growth restriction, and selected neonatal outcomes were evaluated among 4496 women and singleton infants. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated using multivariable logistic regression, controlling for confounding variables.

RESULTS

Early pregnancy drinking was associated with reduced odds of low birthweight, OR, 0.66 (95% CI, 0.46-0.96) and birth length less than 10th percentile, OR, 0.74 (95% CI, 0.56-0.97). Drinking during the first 3 months showed lower odds for birth length and head circumference less than 10th percentile, OR, 0.56 (95% CI, 0.36-0.87) and OR, 0.69 (95% CI, 0.50-0.96), respectively. Third trimester drinking was associated with lower odds for low birthweight, OR, 0.56 (95% CI, 0.34-0.94) and preterm delivery, OR, 0.60 (95% CI, 0.42-0.87).

CONCLUSIONS

Our results suggest low-to-moderate alcohol exposure during early and late gestation is not associated with increased risk of low birthweight, preterm delivery, intrauterine growth restriction, and most selected perinatal outcomes.

Alcohol-use disorders during and within one year of pregnancy: a population-based cohort study 1985-2006

OBJECTIVES

To examine alcohol-use disorders in pregnant women and the extent of under-reporting.

DESIGN

Population-based cohort study.

SETTING

Western Australia.

POPULATION

Women with a birth recorded on the Western Australian Midwives Notification System (1985-2006).

METHODS

Mothers with an International Classification of Diseases 9/10 alcohol-related diagnosis, indicating heavy alcohol consumption, recorded on population-based health datasets (non-Aboriginal n=5,839; Aboriginal n=2,583) were identified through the Western Australian data-linkage system. This 'exposed' cohort was frequency matched (on maternal age, year of birth of offspring, Aboriginal status) with comparison mothers without an alcohol-related diagnosis (non-Aboriginal n=33,979; Aboriginal n=8,005).

MAIN OUTCOME MEASURES

Trends in maternal alcohol diagnoses in relation to pregnancy for non-Aboriginal and Aboriginal women. The proportion of children diagnosed with fetal alcohol syndrome (FAS) who had a mother with an alcohol diagnosis recorded during pregnancy.

RESULTS

The proportion of Aboriginal mothers in Western Australia with an alcohol diagnosis (23.1%) is ten times greater than for non-Aboriginal mothers (2.3%). There has been a six-fold increase in the percentage of non-Aboriginal births with a maternal alcohol diagnosis recorded during pregnancy and a 100-fold increase for Aboriginal births. Around 70% of the mothers of children diagnosed with FAS did not have an alcohol diagnosis recorded during pregnancy and 18% of the mothers had no record of an alcohol diagnosis.

CONCLUSIONS

Maternal alcohol exposure during pregnancy is significantly under-ascertained. Given the severe risks to the fetus from heavy prenatal alcohol exposure, assessment and recording of alcohol use should be routinely undertaken in maternity and other health settings.

Maternal alcohol use and sudden infant death syndrome and infant mortality excluding SIDS

BACKGROUND

Improvements in the rate of infant mortality (death in first year of life) have not occurred in recent years. This study investigates the association between maternal alcohol-use disorder and sudden infant death syndrome (SIDS) and infant mortality not classified as SIDS using linked, population-based health and mortality data.

METHODS

Exposed mothers were identified through the presence of an International Classification of Diseases 9/10 alcohol diagnosis, a proxy for alcohol-use disorder, recorded on health, mental health, and/or drug and alcohol datasets (1983-2005). Comparison mothers without an alcohol diagnosis were frequency matched to exposed mothers on maternal age within maternal race and year of birth of their children. All offspring with their birth recorded on the Midwives Notification System compose the exposed (n = 21 841) and comparison (n = 56 054) cohorts. Cases of SIDS (n = 303) and infant mortality excluding SIDS (n = 598) were identified through linkage with the Western Australian Mortality Register. Analyses were conducted by using Cox regression and results presented as adjusted hazard ratios (aHRs) and 95% confidence intervals (CIs).

RESULTS

The highest risk of SIDS occurred when a maternal alcohol diagnosis was recorded during pregnancy (aHR 6.92, 95% CI 4.02-11.90) or within 1 year postpregnancy (aHR 8.61, 95% CI 5.04-14.69). An alcohol diagnosis recorded during pregnancy more than doubled the risk of infant deaths (excluding SIDS) (aHR 2.35, 95% CI 1.45-3.83). Maternal alcohol-use disorder is attributable for at least 16.41% (95% CI 9.73%-23.69%) of SIDS and 3.40% (95% CI 2.28%-4.67%) of infant deaths not classified as SIDS.

CONCLUSIONS

Maternal alcohol-use disorder is a significant risk factor for SIDS and infant mortality excluding SIDS.