Prevalence of risky alcohol use behavior and associated factors in pregnant antenatal care attendees in Debre Berhan, Ethiopia, 2018

Debre Berhan town is located in North Shoa Administrative Zone, Amhara National Regional State, Ethiopia. It is found at 130 km North of Addis Ababa; the capital city of Ethiopia and 695 km from Bahir-Dar; the capital of Amhara regional state. The town is founded by Emperor Zara Yakob on 7 March 1456. The town has 9 administrative Kebele. In the town, there is one public referral hospital and one private general hospital, 3 health centers, 9 health posts, 5 private specialty clinics, which render health services for the community. These public health institutions expected to serve 2.8 million peoples per year and has Adult and pediatric outpatient, Immunization room, Emergency room, labor and delivery room, laboratory and antenatal care unit rooms. The above health institutions have the same national standard and private specialty clinics were not included in the study.

Institutional based cross-sectional study was conducted from April–May 2018.

The sample size was calculated using the general formula for single population proportion and by considering 5% margin of error, Z = 1.96 (95% confidence level) and proportion = 34% of respondents consumed alcohol during pregnancy in a similar study [14]. By adding a 10% non-response rate the final sample size of the study became (n = 380). The Preliminary assessment study was done among all pregnant women who had antenatal care follow up at all public health institutions. Based on the assessment 685 pregnant mothers’ use any amount of alcoholic beverage at least once during the current pregnancy were included in the study. Based on the baseline information, pregnant mothers (current users) were further interviewed for risky alcohol use behavior by using systematic random sampling technique (k = 2).

Risk drinking/ Problem drinking: pregnant Mothers who scored 2 or more on “CAGE” alcohol use screening tool (CAGE: C- Cut down, A- annoyed, G-guilty feeling, and E-Eye opener).

Depression and anxiety: - According to patient’s health questionnaire (PHQ-4), individuals for depression and anxiety were rated as normal (0–2), mild [3‐5], moderate [6‐8], and severe [9‐12]. Total score ≥ 3 for the first 2 questions suggests anxiety. And total score ≥ 3 for the last 2 questions suggests depression.

Poor support:-Mothers who score 3–8 on the OSLO-3 social support scale during pregnancy.

Moderate support:-Mothers who score 9–11 on OSLO-3 social support scale during pregnancy.

Strong support:-Mothers who score 11–14 on the OSLO-3 social support scale during pregnancy.

Violence: - According to Abuse Assessment Screen (AAS) for use in Pregnancy, at least a response of one “yes” for physical or sexual abuse from three questions.

Stressful Life event: according to the list of threatening events questionnaire (LTE-Q), individuals who reported no “yes” for all items considered as no trauma, one “yes” as exposed to single trauma and two or more “yes” considered as exposed to multiple trauma.

The questionnaires were translated into the local language (Amharic) and back to English; and was checked for consistency. Study subjects were informed on questions included in the questionnaires, purpose of the study, importance of privacy, and confidentiality issues. Before conducting the main study, a pretest was carried out in another health institution before two weeks of the main data collection period on 38 (10%) individuals who were attending antenatal care unit and the pretest data was not included in the analysis.

Data were collected by using pretested semi-structured data-collection tools for some associated factors. Standardized tools were used to assess the outcome variable and some explanatory variables. All the data’s required were quantitative and was collected by interviewer-administered questionnaire. The CAGE questionnaire was used to assess risky alcohol use behavior during pregnancy. The patient’s health questionnaire (PHQ-4) was used to assess the level of anxiety and depression, Oslo-3 to assess social support level, Abuse Assessment Screen (AAS) to assess the status of physical emotional and sexual abuse status and list of threatening events questionnaire (LTE-Q) to assess pregnant women level of exposure to life-threatening events.

Data was entered into Epi-data version 3.1 statistical software after coding and checking of the questionnaires. The entered data were exported to SPSS version 20 for analysis. Then data were categorized and sorted to facilitate its analysis. Descriptive statistics were used to describe the frequency and percentages of the respondents by socio-demographic characteristics, obstetric factors, Psychosocial Factors, and Clinical Factors. Bivariate and multivariate Binary logistic regression models were used to identify factors associated with risky alcohol use behavior.

The descriptive results were presented in text and tables as based on the types of data. All explanatory variables which were associated with the outcome variable during bivariate analysis with a p-value of 0.2 or less were exported to multivariate analysis. The crude and adjusted odds ratio together with their 95% confidence intervals were computed. During multivariate binary logistic regression, P-value < 0.05 was considered to declare as statistically significant associated factors. Assumption tests of logistic regression were managed. The value of VIF (variance inflation factor) was above 1 and below 5 for multicollinear variables. The Model goodness of fit was done by using the Hosmer Lemeshow test and its p-value was 0.54.

Ethical clearance was obtained from the Institutional Health Research Review Committee (Ref. No. IHRERCB-569/2018) of the College of Health and Medicine, Debre Berhan University. Official permission was taken from each health institution administrators and verbal consent was taken from the study participants. All pregnant women who use alcohol were informed about the effect of alcohol.

A total of 380 respondents participated in the study, yielding a response rate of 100%. A total of 380 pregnant women were interviewed in the study; of them, almost 82% (n = 310) were found between the age of 25–45 years old (mean age = 29.6 ± 5.7 years). The majority, 275(72.4%) were married and 51(13.4%) were single. Regarding occupation, the higher proportion of the study subjects, 133(35%) were a private employee. As it would be expected based on population values of the study area, a vast majority 244 (64%) of the respondents’ were Amhara in ethnicity, and 262 (66%) of the study subjects were Orthodox by religion (see Table 1).

From all pregnant women, 271(71%) of mothers reported that the intention of the current pregnancy was wanted and 251(66%) of the pregnancies were planned. Almost half, 186 (48.9%) of the mothers were in the third trimester of pregnancy. Twenty-eight percent (n = 108) of the study subjects had no child. History of abortion was experienced by 68 (17.9%) of respondents. Though, 17.6, 46.1, 25.3 and 11.1% of participants reported to have ANC follow up in first, second, third and fourth visit respectively; 233(61%) of them were not informed about the risks of drinking alcohol by their health care providers (see Table 2).

Of 380 respondents, 23 (6.1%) had known psychiatric illness and 45(11.8%) of the respondent’s family had known mental health problem. Self-reported diagnosed medical illness (pregnancy-related or previously diagnosed) was found among 54(14.2%) of pregnant women.

Study subjects social support status was screened by using the OSLO-3 social support scale. Among all study subjects, 171 (45%) had moderate social support and almost half of the study participants had moderate husband support during their pregnancy. Almost 56% (n = 193) of the study subjects didn’t experience any anxiety and depression symptoms. (See Table 3).

The prevalence of risky alcohol use behavior during pregnancy was screened by using the CAGE questionnaire, and mothers who reported two or more yes were considered as having risky alcohol use behavior. The overall prevalence of risky alcohol use was 16.1% (95% CI: 12.1, 19.7) (Fig. 1).

Having Poor social support were associated with risky alcohol use behavior during pregnancy. The odds of having risky alcohol use behavior were four times higher in odds among mothers who had poor social support as compared with who had strong social support (AOR = 4.06, 95% CI = 1.56,10.5).

Having diagnosed with family psychiatric history was higher in odds to use alcohol in a risky way. The odds of having risky alcohol use behavior during pregnancy were two times higher among mothers who had diagnosed family psychiatric history as compared with those who had no family psychiatric history (AOR = 2.20, 95% CI = 1.03,5.41). In a similar dimension, being suffered moderate to severe anxiety and depression during pregnancy was also significantly associated with risky alcohol use behavior during pregnancy (AOR = 1.91, 95% CI = 1.01, 4.50). Among obstetric factors, having a history of abortion in previous pregnancies were associated with risky alcohol use behavior as compared with those mother without a history of abortion; AOR = 1.94, 95% CI = 1.23, 4.41 (see Table 4).

The current study attempted to determine the prevalence of risky alcohol use behavior during pregnancy and its associated factor. The overall prevalence of risky alcohol use behavior in the current study was 16.1% (95% CI: 12.1, 19.7).

The current study finding shows that the prevalence of risky alcohol use behavior was consistent with studies done in the world health organization’s survey report among Africa countries’ i.e. Cameron (12.6%), Uganda (20.5%), Namibia (14.2%), Sierra Leone (14.8%) [15], Ghana 20.4% [16] and Korea 16.4% [17].

The prevalence of risky alcohol use behavior during pregnancy in this study was higher than those studies conducted in equatorial guinea (2.2%), Seychelles (3.4%), Botswana (5.7%), Eastern Mediterranean (0.2%) [13], and united states national survey 7.6% [18], united states 10% [19], South Africa 5.4% [20] and Nigeria [21]. The higher prevalence of risky alcohol use behavior during pregnancy in the current study might be due to the difference in perceived seriousness of alcohol use during pregnancy. And also the studies in African countries described above were used random-effects meta-analysis to determine alcohol use during pregnancy in some WHO Africa regions. The studies done in the United States [18, 19] were used a national survey and the perceived risk of using alcohol during pregnancy might be well understood (better health literacy) in developed countries.

But, the prevalence of risky alcohol use behavior during pregnancy in the current study was lower than the studies done in Ireland 60% [13], Belarus 47% [22], Denmark 46% [20], United Kingdom and Northern Ireland 41% [20], Russian Federation 37% [20], northern Tanzania 34.1% [23] and Bahir Dar; Ethiopia 34% [24]. The lower prevalence in the current study might be due to, the current study focuses on risky alcohol use than any amount of alcohol consumption.

This study result showed that prevalence of risky alcohol use behavior was higher among pregnant women who had a history of abortion in a previous pregnancy, poor social support, diagnosed family psychiatric history and suffered moderate to severe depression and anxiety. The association of having moderate to severe depression and anxiety with problematic alcohol use in the current study was in agreement with the study done in Australia [25]. The association might be due to the fact that individuals who had poor mental health are prone to use alcohol for self-treatment.

Having a history of abortion in a previous pregnancy, having poor social support and having diagnosed family psychiatric history were also associated with the prevalence of risky alcohol use behavior in the current study. The association might be due to women who had pregnancy-related complications and poor social support are at greater risk to use alcohol to suppress stressful feelings.

Having diagnosed with family psychiatric history including depression will also make individuals prone to have poor mental health and concurrently may use alcohol for stress management.

World health organization report on alcohol drinking during pregnancy recommended that there is no safe amount and time of alcohol drinking, especially for the growing fetus. But, the Current study authors use “CAGE” questionnaire to assess risky alcohol use for both the mother and the growing fetus. The CAGE screening tool was used for this study opposed to alternate single question screening tools due to the authors hypothesize that since local drinks are easily available at the study area in addition to modern drinks pregnant mothers may use alcohol at least once in the current pregnancy by ignoring an unfavorable outcome. And the authors aimed to determine the proportions of risky alcohol drinkers to herself and the fetus than using the single question asking about alcohol use during pregnancy. But, the authors had no additional reason for using CAGE screening tool than other standardized tools like T-ACE and AUDIT.