Overall, 618 eligible women attending antenatal clinic were approached over eighteen clinic days, of whom 610 (98.7%) agreed to participate. Almost all women lived in either Kampala District (N=395; 66.2%) or encircling Wakiso District (N=192; 32.2%). The median (interquartile range; IQR) age was 22(18
) years with 20.2% of women between 14 and 17 years of age. Overall, 71.6% were formally or customarily married, about half attended secondary school or higher, and almost one -third had a job that generated income. Fifty-seven percent of women reported having one or more previous pregnancies and 8.9%. of women were HIV-infected.
Alcohol consumption prior to recognition of pregnancy
Prior to learning of pregnancy, 29.5% of women reported regular consumption of alcoholic beverages and were assumed to have an AEP, 4.3% reported non-regular drinking, and 66.2% never drank alcohol(). Alcohol consumption was associated with older age (p<0.001), being married (p=0.005), having a job that generated income ( p=0.023), belonging to a religion that does not restrict alcohol (p<0.001), having a previous pregnancy or live birth (p<0.001) and being HIV-infected (p=0.006).
Prevalence of alcohol consumption before recognition of pregnancy by sociodemographic, clinical, and reproductive factors and substance use, among 610 women seeking antenatal at Mulago Hospital, Kampala, Uganda, June – August 2006.
Few women (3.1%) had ever smoked cigarettes and only 1.0% currently smoked; nevertheless, these women tended to drink regularly prior to pregnancy. Women who drank regularly were more likely to have male partners (p<0.001) and friends ( p<0.001) who also drank alcohol. Women who reported that alcohol consumption during pregnancy was harmful to their baby’s health were less likely to regularly consume alcohol (26.9%) compared to women who believed otherwise (49.3%; p=0.001).
Among regular drinkers, most (92.8%) drank commercial alcoholic beverages ()with beer (4–6% ABV) consumed most commonly (98.2%). Twelve women drank wine (12.5% ABV), 7 drank fortified wine (20% ABV), and 11 drank spirits (40% ABV). Although 94 women (52.2%) drank traditional alcoholic beverages, only 7.2% drank them solely. Fifty-eight women drank tonto (banana wine; 6–11% ABV) (23
), 50 drank local waragi (banana gin; 35–45% ABV; unpublished data), 36 drank malwa (fermented millet; 6–8% ABV) (13
), 15 drank kweete (fermented maize and millet; ABV unknown), 15 drank munanansi (fermented pineapple; ABV unknown), 3 drank omuramba (fermented sorghum; ABV unknown), and 6 drank other varieties. Overall, 52.2% of regular drinkers reported drinking two or more beverage types.
Types and frequency of alcoholic beverages consumed by 180 women who drank regularly before learning of pregnancy, Mulago Hospital, Kampala, Uganda, June to August 2006.
Women reported drinking most alcoholic beverages weekly or less (). However, almost one-quarter of women who drank commercial beer or local waragi reported consuming these beverages on two or more days per week. Women who drank beer and tonto, both of which are usually 0.5 liters per serving, reported drinking on average an equivalent of 3.5 and 5.0 standard U.S. drinks during an episode, respectively. Overall, 55 women (9.0%) reported drinking usual quantities of a single beverage that equaled levels considered binging for women(4 or more standard U.S. drinks in one occasion )(24
), and 48 women (7.9%) averaged more than one drink per day, considered to be a “risky” level of consumption for women by the U.S. Department of Agriculture (USDA) (25
). Sixteen women (2.6%) reported consuming an average of at least 7 drinks of a given beverage in a single occasion, a quantity which the USDA recommends women not to exceed in an entire week(25
Alcohol consumption after recognition of pregnancy
Among the 180 women who drank regularly prior to pregnancy, 33 (18.3%)stopped drinking alcohol altogether, 123 (68.3%)decreased consumption of all alcoholic beverages, 8 (4.4%) reported no change in drinking, and 20 (11.1%) reported an increase in consumption of at least one alcoholic beverage type after recognition of pregnancy.
Pattern of alcohol consumption was strongly associated with age (). Regular drinking prior to learning of pregnancy increased with age (15.5%, 28.0%, 38.9% among women ≤17, 18–24, and ≥25 years, respectively; p<0.001, χ2test for linear trend). However, older women were more likely to stop drinking after learning of pregnancy as compared to younger women (5.3%, 16.4%, and 22.7% among women ≤17, 18–24, and ≥25 years, respectively; p<0.001, χ2test for linear trend).
Alcohol before and after learning of pregnancy according to age among 610 women attending antenatal care, Mulago Hospital, Kampala, Uganda, June to August 2006.
Among the 404 women who had not previously consumed alcohol, 4 (1.0%) initiated drinking after learning of pregnancy. These women ranged from 16 to 20 year sin age, all had friends who drank, two had male partners who drank, one was married, none were previously pregnant, and one had previously attended antenatal care. Two women reported not knowing that alcohol consumption was harmful during pregnancy. When probed for reasons why they began drinking for the first time during pregnancy, one woman reported being told that “drinking waragi relieves heartburn” and “drinking beer will make [the] baby grow big.” Two women believed that drinking waragi would make their baby lighter in reference to their preference to deliver vaginally. The fourth woman began drinking half a bottle of vodka per week, but did not reveal why.
CAGE scores of women who stopped drinking (n=33) were similar to those of women who continued to drink (n=147) after learning of their pregnancy: 81.8% and82.3% had a CAGE. ≥1 (p=0.946); 48.5% and 42.2% had a CAGE. ≥2 (p=0.509 ), respectively. Continued drinkers were more likely to answer in the affirmative to the fourth item of the CAGE (“Do you ever feel the need to have a drink first thing in the morning?”) compared to women who stopped (19.7% vs. 9.1%), but the difference was not statistically significant ( p=0.149).
Predictors of alcohol consumption
In unadjusted analysis, per year increase in age was associated with 4% higher prevalence of regular drinking before learning of pregnancy (PR=1.04; 95% CI:1.02, 1.05; ). Higher prevalence of regular drinking was also significantly associated with several characteristics correlated with older age: 1) being married; 2) having a job that generated income; 3) previously being pregnant; and 4) previously having a live birth. HIV-infected women had a 51% higher prevalence of regular drinking before learning of pregnancy compared to uninfected women (PR=1.51; 95% CI:1.08, 2.11).
Unadjusted log-binomial regression of factors associated with alcohol consumption before and after learning of pregnancy among 610 women attending antenatal care, Mulago Hospital, Kampala, Uganda, June to August 2006.
Women smokers were over twice as likely to drink regularly before learning of their pregnancy (PR=2.29; 95% CI: 1.28, 4.09)and 23% more likely to continue after learning of their pregnancy (PR=1.23; 95% CI: 1.15, 1.32)compared to non -smokers. Women whose male partners or friends drank alcohol were over twice as likely (PR=2.47; 95% CI: 1.95, 3.12) or three times as likely (PR=3.16; 95% CI: 2.36, 4.24), respectively, to drink regularly before pregnancy compared to those whose partners and friends did not drink. These women were also more likely to continue to drink after learning of pregnancy.
Women whose religion explicitly prohibited alcohol were 50% less likely to drink regularly before learning of pregnancy compared to women whose religion did not have an explicit restriction (PR=0.49; 95% CI: 0.36, 0.66). On average, these women were 19% less likely to continue drinking after learning of their pregnancy (PR=0.81; 95% CI: 0.65, 1.00). Women who believed that alcohol consumed during pregnancy was harmful to the baby’s health were 45% less likely to report regular drinking before learning of pregnancy (PR=0.55; 95% CI: 0.42, 0.72). Binge drinking prior to learning of pregnancy was not predictive of continued drinking after learning of pregnancy (PR=1.04; 95% CI: 0.73, 1.47).
Several factors remained associated with regular drinking before learning of pregnancy in the adjusted model: having a male partner who drinks alcohol (PR=1.56; 95% CI: 1.21, 2.02), having friends who drink alcohol (PR=2.36; 95% CI:1.72, 3.23), belonging to a religion that prohibits alcohol (PR=0.61; 95% CI:0.45, 0.81), and per year increase in age (PR=1.03; 95% CI: 1.01, 1.04).
Overall, 151 of 610 women (24.8%) consumed alcoholic beverages after knowing they had become pregnant. This included 147 women who drank regularly before and 4 who newly started after learning of their pregnancy. We developed a two-step algorithm to screen for alcohol consumption during pregnancy using questions that would not elicit socially desirable responses ().
Proposed algorithm to screen for drinking alcohol during pregnancy based on consumption reported among 610 women attending antenatal care, Mulago Hospital, Kampala, Uganda, June to August 2006.
In the first step, a provider asks a woman about her religion and whether any of her friends or male partner drinks alcohol. Based on our observed data, 135 women (22.1%) belonged to a religion that prohibits alcohol consumption and did not have friends and male partners who drank alcohol, of whom only 5 drank during pregnancy (NPV=96.3%). There were 475 women (77.9%) who belonged to religions that do not prohibit alcohol or had friends or male partners who drank alcohol, of whom 146 drank during pregnancy (PPV=30.7%). If the woman was predicted by the first step to be drinking during pregnancy, then the provider would ask whether she has ever had a drink containing alcohol. Based on the observed data, 278 women (58.5%) never and 197 women (41.5%) previously drank alcohol. Of the former, none drank during pregnancy as expected (NPV=100%); of the latter, 146 drank during pregnancy (PPV=74.1%).
Step 1 of the algorithm had 96.7% sensitivity but only 28.3% specificity in correctly identifying women who drank and did not drink during pregnancy, respectively. Step 2 maintained the overall sensitivity at 96.7% but improved the overall specificity to 88.9%. The AUC for the algorithm was 0.928, and drinking during pregnancy was correctly classified for 90.2% of women. If at random 5% (n=23), 10% (n=46), or 15% (n=69) of the 459 women who reported not drinking during pregnancy (404 never, 26 non-regular, and 19 regular drinkers before learning of pregnancy) actually did drink, Monte Carlo simulations demonstrated that the algorithm was still able to classify correctly drinking during pregnancy for 87.9%, 85.0%, and 82.1% of women, respectively.