Abstract:

This is a national cross-sectional, hospital-based study, which interviewed 23,894 postpartum women in 2011-2012 aiming to estimate the prevalence of alcohol use during pregnancy and identifying more vulnerable groups. Alcohol use during pregnancy was identified using the TWEAK scale, and women with a score of ≥ 2 were classified as having a “presumable diagnosis of inadequate alcohol use”. The national prevalence of alcohol use and the prevalence in subgroups were calculated according to maternal characteristics, with respective 95% confidence intervals (95%CI). Coexistence of smoking, inadequate prenatal consultations, and alcohol use during pregnancy were graphically identified. The prevalence of alcohol use was 14% (95%CI: 13.3-14.7), with 10% (95%CI: 9.3-10.6) of women presenting presumable diagnosis of inadequate alcohol us during pregnancy. Higher prevalence of alcohol use and presumable diagnosis of inadequate alcohol us was observed in black women, aged 12-19 years, with lower educational level, from a lower economic class, without a partner, without paid work, with more than three previous births, who did not want to get pregnant, with inadequate prenatal care, with previous delivery in public services, and who reported smoking during pregnancy. Among the interviewees, 1.2% presented all three risk factors for negative perinatal outcomes at the same time: smoking, alcohol use, and inadequate prenatal care. The results showed a high prevalence of alcohol use during pregnancy and presumable diagnosis of inadequate alcohol us, especially among women with worse social conditions. These data are relevant for the formulation of public policies to prevent alcohol use and provide support services to help this population stop alcohol use during pregnancy.

Keywords:
Pregnancy; Alcoholic Beverages; Surveys and Questionnaires; Prevalence

Introduction

Alcohol use during pregnancy is an important public health problem, and it is associated with negative maternal and fetal outcomes ¹1. World Health Organization. Guidelines for the identification and management of substance use and substance use disorders in pregnancy. Geneva: World Health Organization; 2014.. The effects on maternal health include bleeding during pregnancy, miscarriage, premature birth, and placental abruption ²2. Addila AE, Azale T, Gete YK, Yitayal M. 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 2021; 16:64.^,33. Skagerstróm J, Chang G, Nilsen P. Predictors of drinking during pregnancy: a systematic review. J Womens Health 2011; 20:901-13.^,44. Sundermann AC, Zhao S, Young CL, Lam L, Jones SH, Edwards DRV, et al. Alcohol use in pregnancy and miscarriage: a systematic review and meta-analysis. Alcohol Clin Exp Res 2019; 43:1606-16.. For the fetus, excessive exposure to prenatal alcohol is associated with teratogenic effects and the development of fetal alcohol syndrome (FAS) ⁵5. Popova S, Lange S, Probst C, Gmel G, Rehm J. Estimation of national, regional, and global prevalence of alcohol use during pregnancy and fetal alcohol syndrome: a systematic review and meta-analysis. Lancet Glob Health 2017; 5:e290-e9.. In Brazil, estimates suggest that around 1,500 to 6,000 children are born with FAS every year ⁶6. Rocha AG, Souza PRA, Wachholz EG, Fraga LR, Sanseverino MT, Terra AP, et al. Fetal alcohol spectrum disorders: health needs assessment in Brazil. Alcohol Clin Exp Rev 2020; 44:660-8..

Alcohol consumption is a modifiable risk behavior during pregnancy and, although the scientific evidence on the effects of light and moderate consumption is not conclusive ⁷7. Henderson J, Gray R, Brocklehurst P. Systematic review of effects of low-moderate prenatal alcohol exposure on pregnancy outcome. BJOG 2007; 114:243-52.^,88. Mamluk L, Edwards HB, Savovic J, Leach V, Jones T, Moore THM, et al. Low alcohol consumption and pregnancy and childhood outcomes: time to change guidelines indicating apparently 'safe' levels of alcohol during pregnancy? A systematic review and meta-analyses. BMJ Open 2017; 7:e015410., most guidelines recommend that pregnant women, or those intending to become pregnant, abstain from drinking any amount of alcohol, as it is known to be a teratogenic exposure, and because there is still no consensus on the level of consumption that could be considered safe ¹1. World Health Organization. Guidelines for the identification and management of substance use and substance use disorders in pregnancy. Geneva: World Health Organization; 2014.^,99. Carson G, Cox LV, Crane J, Croteau P, Graves L, Kluka S, et al. Alcohol use and pregnancy consensus clinical guidelines. J Obstet Gynaecol Can 2010; 32(8 Suppl 3):S1-31.^,1010. Departamento de Atenção Básica, Secretaria de Atenção à Saúde, Ministério da Saúde. Atenção ao pré-natal de baixo risco. Brasília: Ministério da Saúde; 2012.^,1111. National Health and Medical Research Council, Australian Government. Australian guidelines to reduce health risks from drinking alcohol. Canberra: National Health and Medical Research Council; 2020..

Despite these recommendations, recent estimates suggest that 9.8% (95% confidence interval - 95%CI: 8.9-11.1) of the global population of pregnant women drink alcohol in the prenatal period ⁵5. Popova S, Lange S, Probst C, Gmel G, Rehm J. Estimation of national, regional, and global prevalence of alcohol use during pregnancy and fetal alcohol syndrome: a systematic review and meta-analysis. Lancet Glob Health 2017; 5:e290-e9.. In Europe, the region with the highest estimate of alcohol use during pregnancy, the point prevalence is 25.2% (95%CI: 21.6-29.6) ⁵5. Popova S, Lange S, Probst C, Gmel G, Rehm J. Estimation of national, regional, and global prevalence of alcohol use during pregnancy and fetal alcohol syndrome: a systematic review and meta-analysis. Lancet Glob Health 2017; 5:e290-e9.. In Central America, South America, and the Caribbean, insufficient data are found about alcohol use by pregnant women. However, estimates indicate excessive exposure, with rates above the average found in other countries in the world, as observed in Grenada, in the Caribbean (23.3%) ¹²12. Lange S, Probst C, Heer N, Roerecke M, Rehm J, Monteiro MG, et al. Actual and predicted prevalence of alcohol consumption during pregnancy in latin america and the Caribbean: systematic literature review and meta-analysis. Rev Panam Salud Pública 2017; 41:89.. In Brazil, national-level estimates of alcohol use during pregnancy are not available, with only local studies estimating the prevalence of alcohol use during pregnancy, which ranged from 1.8% in a maternity hospital in Bahia State to 40.6% in three maternity hospitals analyzed together in the city of Rio de Janeiro ⁵5. Popova S, Lange S, Probst C, Gmel G, Rehm J. Estimation of national, regional, and global prevalence of alcohol use during pregnancy and fetal alcohol syndrome: a systematic review and meta-analysis. Lancet Glob Health 2017; 5:e290-e9..

A complex group of sociodemographic characteristics, clinical and obstetric history, prenatal care, and behavioral data can be associated with alcohol use in pregnancy, such as skin color (a common proxy, although not very accurate for ethnicity) ¹³13. Moraes CL, Reichenheim ME. Rastreamento de uso de álcool por gestantes de serviços públicos de saúde do Rio de Janeiro. Rev Saúde Pública 2007; 41:695-703.^,1414. Baptista FH, Rocha KBB, Martinelli JL, Avó LRS, Ferreira RA, Germano CMR, et al. Prevalence and factors associated with alcohol consumption during pregnancy. Rev Bras Saúde Mater Infant 2017; 17:271-9.^,1515. Fonseca GFM, Padilha PC, Santos MS, Lima TSV, Saunders C. Prevalência e fatores associados ao consumo de álcool em gestantes adultas de uma maternidade pública no Rio de Janeiro. Brazilian Journal of Development 2021; 7:87986-8004., economic class ¹⁶16. Shmulewitz D, Hasin DS. Risk factors for alcohol use among pregnant women, ages 15-44, in the United States, 2002 to 2017. Prev Med 2019; 124:75-83., paid work ¹³13. Moraes CL, Reichenheim ME. Rastreamento de uso de álcool por gestantes de serviços públicos de saúde do Rio de Janeiro. Rev Saúde Pública 2007; 41:695-703., history of chronic disease ¹⁷17. Guimarães VA, Fernandes KS, Lucchese R, Vera I, Martins BCT, Amorim TA, et al. Prevalência e fatores associados ao uso de álcool durante a gestação em uma maternidade de Goiás, Brasil Central. Ciênc Saúde Colet 2018; 23:3413-20., parity ¹⁴14. Baptista FH, Rocha KBB, Martinelli JL, Avó LRS, Ferreira RA, Germano CMR, et al. Prevalence and factors associated with alcohol consumption during pregnancy. Rev Bras Saúde Mater Infant 2017; 17:271-9.^,1515. Fonseca GFM, Padilha PC, Santos MS, Lima TSV, Saunders C. Prevalência e fatores associados ao consumo de álcool em gestantes adultas de uma maternidade pública no Rio de Janeiro. Brazilian Journal of Development 2021; 7:87986-8004., intended pregnancy ¹⁸18. Mekuriaw B, Belayneh Z, Shemelise T, Hussen R. Alcohol use and associated factors among women attending antenatal care in southern Ethiopia: a facility based cross sectional study. BMC Res Notes 2019; 12:690., number of prenatal consultations ¹⁶16. Shmulewitz D, Hasin DS. Risk factors for alcohol use among pregnant women, ages 15-44, in the United States, 2002 to 2017. Prev Med 2019; 124:75-83., and intimate partner violence ¹⁹19. Moraes CL, Viellas EF, Reichenheim ME. Assessing alcohol misuse during pregnancy: evaluating psychometric properties of the CAGE, T-ACE and TWEAK in a Brazilian setting. J Stud Alcohol 2005; 66:165-73.^,2020. Russell BS, Eaton LA, Petersen-Williams P. Intersecting epidemics among pregnant women: alcohol use, interpersonal violence, and HIV infection in South Africa. Curr HIV/AIDS Rep 2013; 10:103-10.. Some of them have well-established associations, such as smoking ²¹21. Lange S, Probst C, Quere M, Rehm J, Popova S. Alcohol use, smoking and their co-occurrence during pregnancy among Canadian women, 2003 to 2011/12. Addict Behav 2015; 50:102-9., while others, like marital status and educational level, show divergence ¹⁴14. Baptista FH, Rocha KBB, Martinelli JL, Avó LRS, Ferreira RA, Germano CMR, et al. Prevalence and factors associated with alcohol consumption during pregnancy. Rev Bras Saúde Mater Infant 2017; 17:271-9.^,1515. Fonseca GFM, Padilha PC, Santos MS, Lima TSV, Saunders C. Prevalência e fatores associados ao consumo de álcool em gestantes adultas de uma maternidade pública no Rio de Janeiro. Brazilian Journal of Development 2021; 7:87986-8004.^,1616. Shmulewitz D, Hasin DS. Risk factors for alcohol use among pregnant women, ages 15-44, in the United States, 2002 to 2017. Prev Med 2019; 124:75-83.^,1717. Guimarães VA, Fernandes KS, Lucchese R, Vera I, Martins BCT, Amorim TA, et al. Prevalência e fatores associados ao uso de álcool durante a gestação em uma maternidade de Goiás, Brasil Central. Ciênc Saúde Colet 2018; 23:3413-20..

Based on these individual variables showing unequal access to policies and services - making them vulnerable subjects ²²22. Carmo ME, Guizardi FL. O conceito de vulnerabilidade e seus sentidos para as políticas públicas de saúde e assistência social. Cad Saúde Pública 2018; 34:e00101417. - we attempted to estimate the prevalence of alcohol use during pregnancy according to maternal characteristics in order to support the development of prevention and control strategies. This study aimed to estimate the national prevalence of alcohol use during pregnancy and identify groups that are more exposed to this problem, according to maternal sociodemographic, obstetric, and behavioral characteristics.

Method

Study design

This is a national, hospital-based study on pregnancy, delivery, and birth care conducted in 2011-2012 and titled Birth in Brazil survey. The sample of the Birth in Brazil survey was calculated considering the proportion of cesarean sections in Brazil in 2007 of 46.6% and a confidence level of 5% to detect differences of 14% between public and mixed hospitals and private hospitals. A 1.3 design effect ²³23. Walter SD, Altman DG. Practical statistics for medical research. Biometrics 1992; 48:656. was used, resulting in a planned sample of 23,940 postpartum women from 266 hospitals in all states of the country.

The sampling process comprised three stages of selection. In the first stage, hospitals with 500 or more annual deliveries were selected, stratified according to the country’s macro regions, location (capital or non-capital), and type of hospital (public, private, or mixed), with a probability of selection proportional to the number of deliveries in each of the strata in 2007. In the second stage, the number of days needed to interview 90 postpartum women in every hospital (minimum of seven days) was defined using an inverse sampling method. In the third and final stage, eligible postpartum women were selected. More information about the sample design is detailed in Vasconcellos et al. ²⁴24. Vasconcellos MTL, Silva PLN, Pereira APE, Schilithz AOC, Souza Junior PRB, Szwarcwald CL. Desenho da amostra Nascer no Brasil: Pesquisa Nacional sobre Parto e Nascimento. Cad Saúde Pública 2014; 30 Suppl:S49-58..

Participants

Postpartum women with hospital live births of any weight and gestational age or stillbirths with birth weight ≥ 500g and/or gestational age ≥ 22 weeks were considered eligible for the study. Women who gave birth at home, on a public street, or at another health institution that was not part of the sample; women with serious psychiatric illness or foreigners who did not understand Portuguese; and women with hearing impairment were considered ineligible for the study.

Data collection

Participants were interviewed during their hospital stay in the immediate postpartum period by a team of trained interviewers. Data from the hospital records of every woman and newborn were extracted after hospital discharge. Prenatal cards were photographed, with subsequent data extraction.

Study variables

To assess alcohol use during pregnancy, the Brazilian version of the Tolerance, Worry, Eye-opener, Amnesia/black-out, and K/Cut Down (TWEAK) ¹⁹19. Moraes CL, Viellas EF, Reichenheim ME. Assessing alcohol misuse during pregnancy: evaluating psychometric properties of the CAGE, T-ACE and TWEAK in a Brazilian setting. J Stud Alcohol 2005; 66:165-73. instrument was used. This instrument consists of five questions: T - tolerance = “how many drinks can you hold?”; W - worried = “have close friends or relatives worried or complained about your drinking in the past year?”; E - eye-opener = “do you sometimes take a drink in the morning when you first get up?”; A - amnesia - stands for blackouts = “has a friend or family member ever told you about things you said or did while you were drinking that you could not remember?”; K - cut down = “do you sometimes feel the need to cut down on your drinking?” ¹⁹19. Moraes CL, Viellas EF, Reichenheim ME. Assessing alcohol misuse during pregnancy: evaluating psychometric properties of the CAGE, T-ACE and TWEAK in a Brazilian setting. J Stud Alcohol 2005; 66:165-73.. A positive response to the “tolerance” question (three or more drinks without falling asleep or passing out) and a positive response to the “worry” question receive two points each, while a positive response to each of the last three questions receives one point each, with scores ranging from zero to seven points. Women who did not report alcohol use during pregnancy were classified as “did not use alcohol during pregnancy”, women with a TWEAK score of less than two points were classified as “no inappropriate alcohol use”, and women with two or more points in the total score were classified as “presumable diagnosis of inappropriate alcohol use”, using the same nomenclature adopted by the authors who validated the scale in Brazil ¹³. This cutoff point, which is suggested by the original scale validation study, has 70%-90% sensitivity and 65%-90% specificity ²⁵25. Russell M. New assessment tools for risk drinking during pregnancy: T-ACE, TWEAK, and others. Alcohol Health Res World 1994; 18:55-61.^,2626. Russell M, Martier SS, Sokol RJ, Mudar P, Jacobson S, Jacobson J. Detecting risk drinking during pregnancy: a comparison of four screening questionnaires. Am J Public Health 1996; 86:1435-9..

The following maternal characteristics were analyzed: (a) demographic and socioeconomic: geographic region of residence of the participant (North, Northeast, Central-West, South, and Southeast); maternal age (12-19, 20-34, and 35 older), self-reported race/skin color (white, black, mixed-race, “yellow” [following IBGE criteria], indigenous); educational level in years (up to 7, 8-10, 11 or more years); marital status (without a partner, with a partner); economic class (D+E, C, A+B, where A/B are the highest classes) ²⁷27. Associação Brasileira de Empresas de Pesquisa. Critério de Classificação Econômica Brasil. Alterações na aplicação do Critério Brasil, válidas a partir de 01/Jun/2021. São Paulo: Associação Brasileira de Empresas de Pesquisa; 2021., paid work (yes or no); type of childbirth procedures funding (public or private); (b) obstetric history: parity (0, 1-2, 3 or more); (c) current pregnancy data: intended pregnancy (I wanted to get pregnant now; I wanted to get pregnant, but not now; I didn’t want to get pregnant); start of prenatal care (first, second, third trimester of pregnancy), adequacy of the number of prenatal consultations for gestational age at delivery (inadequate, partially adequate, adequate, more than adequate); (d) behavioral: smoking during pregnancy (yes or no).

Data about age, education, economic class, marital status, work, childbirth procedures funding, intended pregnancy, smoking, and alcohol use were obtained in the interviews with postpartum women. Data about the obstetric history and prenatal care were obtained mainly from the prenatal card, and data from hospital records and structured interviews with postpartum women were also used when the card was not available.

The adequacy of the number of prenatal consultations was evaluated considering the gestational age at delivery and the schedule of consultations recommended by the Brazilian Prenatal Humanization Program ²⁸28. Secretaria Executiva, Ministério da Saúde. Programa Humanização do Parto: humanização no pré-natal e nascimento. Brasília: Ministério da Saúde; 2002. in effect at the time of the study: one consultation in the first trimester of pregnancy, two in the second trimester of pregnancy, and three in the third trimester of pregnancy, totaling at least six consultations for a full-term pregnancy.

Data analysis

The prevalence of the two categories of alcohol use and their respective 95%CI were estimated in the sample as a whole and in the categories of maternal variables. Statistical analyses were performed using R (version 4.1.2, http://www.r-project.org) and its Survey library, including weighting, calibration, and design effect in all stages of the statistical analysis ²⁸28. Secretaria Executiva, Ministério da Saúde. Programa Humanização do Parto: humanização no pré-natal e nascimento. Brasília: Ministério da Saúde; 2002..

A Venn diagram ²⁹29. Cai H, Chen H, Yi T, Daimon CM, Boyle JP, Peers C, et al. VennPlex - a novel Venn diagram program for comparing and visualizing datasets with differentially regulated datapoints. PLoS One 2013; 8:e53388. was used to assess the coexistence of maternal characteristics that may be associated with a higher risk of negative perinatal outcomes. In addition to alcohol use during pregnancy, smoking during pregnancy and the adequacy of the number of consultations were analyzed. The variable “smoking during pregnancy” was selected due to its known effect on perinatal outcomes, such as low weight, prematurity, and malformations ²¹21. Lange S, Probst C, Quere M, Rehm J, Popova S. Alcohol use, smoking and their co-occurrence during pregnancy among Canadian women, 2003 to 2011/12. Addict Behav 2015; 50:102-9.. The variable “adequacy of the number of prenatal consultations” was selected because it is an important component of such management and care, associated with better perinatal outcomes when in adequate number ³⁰30. Viellas EF, Domingues RMSM, Dias MAB, Gama SGN, Theme Filha MM, Costa JV, et al. Assistência pré-natal no Brasil. Cad Saúde Pública 2014; 30 Suppl:S85-100.. In addition, a higher number of prenatal service consultations can provide greater opportunity for actions to reduce smoking and alcohol use during pregnancy, which are modifiable risk factors with good response to brief interventions ³¹31. Staton CA, Vissoci JRN, El-Gabri D, Adewumi K, Concepcion T, Elliott SA, et al. Patient-level interventions to reduce alcohol-related harms in low-and middle-income countries: a systematic review and meta-summary. PLoS Med 2022; 19:e1003961..

Ethical aspects

This study uses data from the Birth in Brazil survey approved by the Research Ethics Committee of the Sergio Arouca National School of Public Health, Oswaldo Cruz Foundation (ENSP/Fiocruz; CAAE 0096.0.031.000-10/June 10, 2010). All precautions were adopted to ensure the data secrecy and confidentiality. Before conducting every interview, participants signed an informed consent form.

Results

Of all 23,894 postpartum women interviewed in the Birth in Brazil survey, most lived in the Southeast (42.5%) and Northeast (28.9%) regions of Brazil. The mean age was 27 years, with 70.4% of the women in the 20-34 age group. Most interviewees reported mixed race/skin color (56.1%), with a small proportion of women reporting “yellow” (1.1%) and indigenous (0.4%) ethnicity. Almost half (47.8%) of the participants had 11 years or more of education, 52% belonged to the “C” class, 81.4% lived with a partner, 59.7% did not have paid work, and 80.1% gave birth in the public health system. Regarding the current pregnancy, 46.9% were primiparous, 44.3% wanted to get pregnant, 60.6% started prenatal care in the first trimester of pregnancy, and more than half of the total interviewees had an adequate number of prenatal care consultations, considering the number of consultations and their gestational age at delivery. Of the total number of participants, 9.6% reported smoking during pregnancy (Table 1).

Alcohol use during pregnancy was estimated at 14% (95%CI: 13.3-14.7), with 10% (95%CI: 9.4-10.6) of women presenting presumable diagnosis of inappropriate alcohol use during pregnancy (Table 2). A lower prevalence of total alcohol use was observed in pregnant women living in the North and Northeast regions, while a lower presumable diagnosis of inappropriate alcohol use of alcohol was observed only in the North Region. Higher alcohol consumption and presumable diagnosis of inappropriate alcohol use were observed in women under 35 years old, black, with up to ten years of education, from economic classes “C” and “D+E”, without a partner, without paid work, patients of the public health system, with three children or more, who did not want to get pregnant, with prenatal care beginning in the second or third trimester of pregnancy, with an inadequate number of prenatal consultations, and who smoked during pregnancy; smokers presented a prevalence that was over three times the prevalence among non-smokers.

A gradient of prevalence was observed according to age, educational level, economic class, parity, intended pregnancy, beginning of prenatal care, and adequacy of the number of prenatal consultations, both for alcohol use and presumable diagnosis of inappropriate alcohol use during pregnancy, with a higher prevalence in younger women, with lower educational level, from a lower economic class, who did not want to get pregnant, with a later start of prenatal care and inadequate number of consultations.

The Venn diagram graphically represented the coexistence of all maternal factors analyzed in this study. Of the total study population, 7.9% reported only alcohol consumption; 2.2% smoking and alcohol use; 2.3% alcohol use and inadequate number of consultations; and 1.2% presented the three factors (Figure 1).

Discussion

The results of this study show that 14% of pregnant women used different amounts of alcohol during pregnancy, with 10% classified as having presumable diagnosis of inappropriate alcohol use. A higher prevalence of total alcohol use during pregnancy was observed in the South Region, and a lower prevalence in the North and Northeast regions, indicating regional differences in alcohol consumption, in a country with significant regional, demographic, and social diversity ³²32. Instituto Brasileiro de Geografia e Estatística. Pesquisa Nacional por Amostra de Domicílios: síntese de indicadores 2015. Rio de Janeiro: Instituto Brasileiro de Geografia e Estatística; 2016.. Our study shows an even higher frequency of smoking in women who used alcohol during pregnancy, exposing pregnant women and fetuses to the harmful effects of alcohol and tobacco. Higher prevalence of total alcohol use and presumable diagnosis of inappropriate alcohol use was also observed in women presenting greater social vulnerability, including women with lower educational level, from lower economic classes, non-whites, without a partner during pregnancy, without paid work, with a higher number of previous deliveries, with unintended pregnancies, treated in the public health system, with a late start of prenatal care and an inadequate number of consultations.

A comparison of our results with those of other studies must be performed with caution, as a wide variety of terms are used in the literature to refer to alcohol use during pregnancy ³³33. Chagas C, Paula TCS, Galduróz JCF. A Linguagem e o estigma: Os termos utilizados na área de álcool e outras drogas. Epidemiol Serv Saúde 2021; 30:e2020921., making it difficult to identify and standardize scientific studies on the subject. In addition to varied terms, different scales have been used to measure alcohol consumption during pregnancy, since there is no universal recommendation regarding the scale to be used. The use of different scales also makes it difficult to compare the estimates and is one of the possible explanations for different prevalence rates observed in studies using distinct scales.

This estimates obtained in our study for total alcohol consumption are higher than global estimates, but lower than those observed in European countries, which show the highest prevalence in the world ⁵5. Popova S, Lange S, Probst C, Gmel G, Rehm J. Estimation of national, regional, and global prevalence of alcohol use during pregnancy and fetal alcohol syndrome: a systematic review and meta-analysis. Lancet Glob Health 2017; 5:e290-e9.. In Latin America and the Caribbean, a meta-analysis of studies conducted in 1984-2014 to assess any alcohol consumption during pregnancy identified 24 studies, obtaining a combined prevalence of alcohol consumption during pregnancy in two countries: Brazil (15.2%, 95% CI: 10.4-20.8) and Mexico (1.2%; 95%CI: 0.0-2.7). For another 31 countries in Latin America and the Caribbean, the prevalence of alcohol consumption during pregnancy ranged from 4.8% (95%CI: 4.2-5.4) in Cuba to 23.3% (95%CI: 20.1-26.5) in Grenada ¹²12. Lange S, Probst C, Heer N, Roerecke M, Rehm J, Monteiro MG, et al. Actual and predicted prevalence of alcohol consumption during pregnancy in latin america and the Caribbean: systematic literature review and meta-analysis. Rev Panam Salud Pública 2017; 41:89.. Regarding the methods of the studies included in the meta-analysis, 88% used non-probability sampling and only 13% used a validated instrument to investigate alcohol use. Of 19 studies conducted in Brazil, only five used a scale to measure alcohol consumption, and only one study used TWEAK ¹³13. Moraes CL, Reichenheim ME. Rastreamento de uso de álcool por gestantes de serviços públicos de saúde do Rio de Janeiro. Rev Saúde Pública 2007; 41:695-703.. An explanation for the high prevalence of alcohol use during pregnancy in some countries in Latin America and the Caribbean is the marketing campaigns advertising alcohol consumption, promoting existing alcohol industries, and the failure to adopt important public policies supported by organizations such as the World Health Organization (WHO) ³⁴34. De Boni RB, Mota JC, Coutinho C, Bastos FI. Would the Brazilian population support the alcohol policies recommended by the World Health Organization? Rev Saúde Pública 2022; 56:66..

The estimate of 10% presumable diagnosis of inappropriate alcohol use found in our study is close to values reported in the literature, such as in Rio de Janeiro, Brazil, in 2007 (7.3%; 95%CI: 5.1-9.5) ¹³13. Moraes CL, Reichenheim ME. Rastreamento de uso de álcool por gestantes de serviços públicos de saúde do Rio de Janeiro. Rev Saúde Pública 2007; 41:695-703., in Rio Grande do Sul State, Brazil, in 2007/2008 ³⁵35. Silva I, Quevedo LA, Silva RA, Oliveira SS, Pinheiro RT. Associação entre abuso de álcool durante a gestação e o peso ao nascer. Rev Saúde Pública 2011; 45:864-9. (2.1%, 95%CI not reported), and Goiás State, Brazil, in 2014/2015 (17.7%; 95%CI: 14.1-22.0) ¹⁷17. Guimarães VA, Fernandes KS, Lucchese R, Vera I, Martins BCT, Amorim TA, et al. Prevalência e fatores associados ao uso de álcool durante a gestação em uma maternidade de Goiás, Brasil Central. Ciênc Saúde Colet 2018; 23:3413-20.. In studies with small samples that used the TWEAK scale, the estimated prevalence of inadequate alcohol use in the world ranged from 13.6% in Italy in 2017 ³⁶36. Ferraguti G, Merlino L, Battagliese G, Piccioni MG, Barbaro G, Carito V, et al. Fetus morphology changes by second-trimester ultrasound in pregnant women drinking alcohol. Addict Biol 2020; 25:e12724. to 54% in Canada in 2006 and 2007 ³⁷37. Sarkar M, Einarson T, Koren G. Comparing the effectiveness of TWEAK and T-ACE in determining problem drinkers in pregnancy. Alcohol Alcohol 2010; 45:356-60., probably due to the specific characteristics of studied populations. A study with 11,909 pregnant women in Western Ukraine estimated the prevalence of 10.9% of harmful use of alcohol from 2007 to 2012 ³⁸38. Chambers CD, Yevtushok L, Zymak-Zakutnya N, Korzhynskyy Y, Ostapchuk L, Akhmedzhanova D, et al. Prevalence and predictors of maternal alcohol consumption in 2 regions of Ukraine. Alcohol Clin Exp Res 2014; 38:1012-9., a similar rate to that found in our study. However, the cutoff point used for “tolerance” in the questionnaire was different - six or more drinks without falling asleep or passing out. If the two studies in question had used three drinks or more as the cutoff point, 52.2% of women in Western Ukraine would have presented presumable diagnosis of inappropriate alcohol use during pregnancy.

The prevalence of presumable diagnosis of inappropriate alcohol use during pregnancy was higher in subgroups already identified in the literature: young women ¹⁷17. Guimarães VA, Fernandes KS, Lucchese R, Vera I, Martins BCT, Amorim TA, et al. Prevalência e fatores associados ao uso de álcool durante a gestação em uma maternidade de Goiás, Brasil Central. Ciênc Saúde Colet 2018; 23:3413-20. of lower educational level ¹⁶16. Shmulewitz D, Hasin DS. Risk factors for alcohol use among pregnant women, ages 15-44, in the United States, 2002 to 2017. Prev Med 2019; 124:75-83., low economic class ¹³13. Moraes CL, Reichenheim ME. Rastreamento de uso de álcool por gestantes de serviços públicos de saúde do Rio de Janeiro. Rev Saúde Pública 2007; 41:695-703.^,1414. Baptista FH, Rocha KBB, Martinelli JL, Avó LRS, Ferreira RA, Germano CMR, et al. Prevalence and factors associated with alcohol consumption during pregnancy. Rev Bras Saúde Mater Infant 2017; 17:271-9., non-whites ¹³13. Moraes CL, Reichenheim ME. Rastreamento de uso de álcool por gestantes de serviços públicos de saúde do Rio de Janeiro. Rev Saúde Pública 2007; 41:695-703., without a partner ¹³13. Moraes CL, Reichenheim ME. Rastreamento de uso de álcool por gestantes de serviços públicos de saúde do Rio de Janeiro. Rev Saúde Pública 2007; 41:695-703., with unintended pregnancy ¹³13. Moraes CL, Reichenheim ME. Rastreamento de uso de álcool por gestantes de serviços públicos de saúde do Rio de Janeiro. Rev Saúde Pública 2007; 41:695-703.^,1818. Mekuriaw B, Belayneh Z, Shemelise T, Hussen R. Alcohol use and associated factors among women attending antenatal care in southern Ethiopia: a facility based cross sectional study. BMC Res Notes 2019; 12:690.^,3939. Iversen ML, Sørensen NO, Broberg L, Damm P, Hedegaard M, Tabor A, et al. Alcohol consumption and binge drinking in early pregnancy. a cross-sectional study with data from the copenhagen pregnancy cohort. BMC Pregnancy Childbirth 2015; 15:327. and multiparity ⁴⁰40. Tesfaye G, Demlew D, G/Tsadik M, Habte F, Molla G, Kifle Y, et al. The prevalence and associated factors of alcohol use among pregnant women attending antenatal care at public hospitals Addis Ababa, Ethiopia, 2019. BMC Psychiatry 2020; 20:337., without paid work ¹³13. Moraes CL, Reichenheim ME. Rastreamento de uso de álcool por gestantes de serviços públicos de saúde do Rio de Janeiro. Rev Saúde Pública 2007; 41:695-703., with inadequate prenatal care ¹⁵15. Fonseca GFM, Padilha PC, Santos MS, Lima TSV, Saunders C. Prevalência e fatores associados ao consumo de álcool em gestantes adultas de uma maternidade pública no Rio de Janeiro. Brazilian Journal of Development 2021; 7:87986-8004., and who reported smoking during pregnancy ¹⁵15. Fonseca GFM, Padilha PC, Santos MS, Lima TSV, Saunders C. Prevalência e fatores associados ao consumo de álcool em gestantes adultas de uma maternidade pública no Rio de Janeiro. Brazilian Journal of Development 2021; 7:87986-8004.^,1717. Guimarães VA, Fernandes KS, Lucchese R, Vera I, Martins BCT, Amorim TA, et al. Prevalência e fatores associados ao uso de álcool durante a gestação em uma maternidade de Goiás, Brasil Central. Ciênc Saúde Colet 2018; 23:3413-20..

Indigenous women had a higher prevalence rate of alcohol use when compared to white women, but no significant difference was observed in relation to mixed-race and “yellow” women, probably due to the small sample size of indigenous people in the study. This finding should be explored in future studies with this specific population, as the excessive use of alcohol has been reported in other studies and institutional documents, especially among indigenous people living outside the village, in urban peripheries ⁴¹41. Secretaria Nacional de Políticas sobre Drogas, Ministério da Justiça e Cidadania. O uso de substâncias psicoativas no Brasil: módulo 1. 11th Ed. Brasília: Secretaria Nacional de Políticas sobre Drogas; 2017..

A higher prevalence of alcohol consumption in pregnant women living in the South Region and a lower prevalence in pregnant women living in the North Region are consistent with national studies assessing the general population ⁴²42. Bastos FIP, Vasconcellos MTL, De Boni RB, Reis NL, Coutinho CFS, organizadores. III levantamento nacional sobre o uso de drogas pela população brasileira. http://clinicaquintadosol.com.br/projeto-juntos/documentos/relato-rio-do-iii-lnud-v2018-07-05-final.pdf (accessed on 31/Jul/2019).
http://clinicaquintadosol.com.br/projeto... . In a study conducted by Bastos et al. ⁴²42. Bastos FIP, Vasconcellos MTL, De Boni RB, Reis NL, Coutinho CFS, organizadores. III levantamento nacional sobre o uso de drogas pela população brasileira. http://clinicaquintadosol.com.br/projeto-juntos/documentos/relato-rio-do-iii-lnud-v2018-07-05-final.pdf (accessed on 31/Jul/2019).
http://clinicaquintadosol.com.br/projeto... , which assessed a population aged over 12 years, the prevalence of alcohol consumption was 22.2% in the North Region and 32.5% in the South Region. In 2019, in the Brazilian National Health Survey (PNS), which evaluated the population aged 18 years and older, point prevalence rates for these regions were 20.5% and 35.6%, respectively. These data suggest that a regional pattern of alcohol use in adults that is reproduced during pregnancy.

On the other hand, when analyzing the prevalence of alcohol use according to educational level, our findings do not agree with national studies that assessed adolescents and/or adults outside the gestational period. While in our study the prevalence was higher in women with lower educational level, national studies assessing participants outside the gestational period indicate that higher educational levels are linked with higher use of alcohol ⁴²42. Bastos FIP, Vasconcellos MTL, De Boni RB, Reis NL, Coutinho CFS, organizadores. III levantamento nacional sobre o uso de drogas pela população brasileira. http://clinicaquintadosol.com.br/projeto-juntos/documentos/relato-rio-do-iii-lnud-v2018-07-05-final.pdf (accessed on 31/Jul/2019).
http://clinicaquintadosol.com.br/projeto... ^,4343. Instituto Brasileiro de Geografia e Estatística. Pesquisa Nacional de Saúde, 2013. Percepção do estado de saúde, estilos de vida e doenças crônicas: Brasil, grandes regiões e Unidades da Federação. https://biblioteca.ibge.gov.br/index.php/biblioteca-catalogo?view=detalhes&id=291110 (accessed on 16/Mar/2023).
https://biblioteca.ibge.gov.br/index.php... ^,4444. Instituto Brasileiro de Geografia e Estatística. Pesquisa Nacional de Saúde 2019. Percepção do estado de saúde, estilos de vida, doenças crônicas e saúde bucal: Brasil e grandes regiões. https://biblioteca.ibge.gov.br/index.php/biblioteca-catalogo?view=detalhes&id=2101764 (accessed on 16/Mar/2023).
https://biblioteca.ibge.gov.br/index.php... . This pattern is observed both in men and in non-pregnant women. Regarding the consumption of four drinks or more on a single occasion (binge drinking), the most recent Brazilian telephone survey ⁴⁵45. Departamento de Análise em Saúde e Vigilância de Doenças Não Transmissíveis, Secretaria de Vigilância em Saúde, Ministério da Saúde. Vigitel Brasil 2019: vigilância de fatores de risco e proteção para doenças crônicas por inquérito telefônico: estimativas sobre frequência e distribuição sociodemográfica de fatores de risco e proteção para doenças crônicas nas capitais dos 26 estados brasileiros e no Distrito Federal em 2019. Brasília: Ministério da Saúde; 2020. showed that, among women, alcohol consumption increased with the educational level. In Denmark, a higher occurrence of binge drinking was also observed in women with higher educational level before the diagnosis of pregnancy ⁴⁶46. Strandberg-Larsen K, Poulsen G, Bech BH, Chatzi L, Cordier S, Dale MTG, et al. Association of light-to-moderate alcohol drinking in pregnancy with preterm birth and birth weight: elucidating bias by pooling data from nine European cohorts. Eur J Epidemiol 2017; 32:751-64..

One hypothesis for the higher consumption of alcohol during pregnancy among women with lower educational level in Brazil is the poor access to information about the harmful effects of alcohol use during pregnancy. Studies in Africa reporting a higher prevalence of alcohol consumption during pregnancy, including binge drinking, in pregnant women with fewer years of education ⁴⁷47. Bitew MS, Zewde MF, Wubetu M, Alemu AA. Consumption of alcohol and binge drinking among pregnant women in Addis Ababa, Ethiopia: prevalence and determinant factors. PLoS One 2020; 15:e0243784., or among residents in communities with lower educational level ⁴⁸48. Addila AE, Azale T, Gete YK, Yitayal M. Individual and community-level predictors of maternal alcohol consumption during pregnancy in Gondar town, Northwest Ethiopia: a multilevel logistic regression analysis. BMC Pregnancy Childbirth 2021; 21:419., found a much higher chance of these women not being aware of the risks of alcohol use during pregnancy ⁴⁷47. Bitew MS, Zewde MF, Wubetu M, Alemu AA. Consumption of alcohol and binge drinking among pregnant women in Addis Ababa, Ethiopia: prevalence and determinant factors. PLoS One 2020; 15:e0243784. and considering alcohol use during pregnancy as socially or culturally accepted, than that observed in women with higher educational level ⁴⁸48. Addila AE, Azale T, Gete YK, Yitayal M. Individual and community-level predictors of maternal alcohol consumption during pregnancy in Gondar town, Northwest Ethiopia: a multilevel logistic regression analysis. BMC Pregnancy Childbirth 2021; 21:419..

The difference observed in alcohol consumption between women of higher and lower educational levels suggests that different strategies are required, with actions for the general population, focused on women of higher educational levels, and prenatal care actions especially for women of lower educational levels.

A higher prevalence of alcohol use was observed in women with inadequate number of prenatal consultations. Insufficient consultations offer fewer opportunities for counseling about the importance of not using alcohol during pregnancy, whether in individual consultations or educational activities related to the subject. Lower use of prenatal services by women who use alcohol may be due to different reasons, including higher social vulnerability, obstacles to visiting health services, and low adherence to health promotion activities, such as prenatal care.

Increased use of alcohol and smoking and the inadequate number of prenatal consultations associated with negative outcomes for the newborn reinforces the importance of further expanding access to prenatal care for the most vulnerable women. These three factors can be an alert for efforts to prevent and monitor this population of pregnant women who present these risk factors. The identification of a higher prevalence of alcohol use in women with late beginning of prenatal care also highlights the need for strategies to promote an early diagnosis of pregnancy, avoiding exposure to alcohol when the woman does not know she is pregnant. Data from the Birth in Brazil survey show that 46.6% of women with late beginning of prenatal care mentioned challenges in pregnancy diagnosis as a reason for not having started prenatal care earlier ³⁰30. Viellas EF, Domingues RMSM, Dias MAB, Gama SGN, Theme Filha MM, Costa JV, et al. Assistência pré-natal no Brasil. Cad Saúde Pública 2014; 30 Suppl:S85-100..

The results of this study must be interpreted considering its limitations and strengths. Study limitations include the fact that estimates cannot be extrapolated to women who gave birth at home, on public roads, in hospitals with less than 500 births a year, and pregnant women whose pregnancy miscarriage, since they were not eligible for the study. Another possible limitation was the method to measure the inappropriate use of alcohol through self-report and retrospectively. Retrospective data collection may underestimate the use of alcohol in early pregnancy, when the woman does not know she is pregnant ⁴⁹49. Kaup ZOL, Merighi MAB, Tsunechiro MA. Avaliação do consumo de bebida alcoólica durante a gravidez. Rev Bras Ginecol Obstet 2001; 23:575-80.. Self-report, on the other hand, may underestimate the use of alcohol during pregnancy due to the embarrassment of women in admitting its use, given the concern about the harmful effects of alcohol during pregnancy for the fetus and newborn ⁵⁰50. Clift-Matthews V. Alcohol in pregnancy: what is a safe amount? Br J Midwifery 2008; 16:208.^,5151. Muggli E, Cook B, O'Leary C, Forster D, Halliday J. Increasing accurate self-report in surveys of pregnancy alcohol use. Midwifery 2015; 31:e23-8.. However, using the TWEAK questionnaire may have mitigated these limitations, as it is a scale developed for use in obstetrics and gynecology clinics and in primary care ¹, ensuring high sensitivity and specificity in identifying the inappropriate use of alcohol during pregnancy in different ethnic groups ²⁶26. Russell M, Martier SS, Sokol RJ, Mudar P, Jacobson S, Jacobson J. Detecting risk drinking during pregnancy: a comparison of four screening questionnaires. Am J Public Health 1996; 86:1435-9.^,5151. Muggli E, Cook B, O'Leary C, Forster D, Halliday J. Increasing accurate self-report in surveys of pregnancy alcohol use. Midwifery 2015; 31:e23-8.. The absence of information about gestational age in the diagnosis of pregnancy, social support during pregnancy, and guidance received during pregnancy regarding the use of alcohol during pregnancy and its harmful effects also limit the understanding of the importance of these factors related to alcohol consumption during pregnancy. A study conducted in Australia showed a low proportion of counseling received by pregnant women, despite existing care guidelines ⁵²52. Doherty E, Wiggers J, Wolfenden L, Anderson AE, Crooks K, Tsang TW, et al. Antenatal care for alcohol consumption during pregnancy: pregnant women's reported receipt of care and associated characteristics. BMC Pregnancy Childbirth 2019; 19:299.. In Brazil, two studies assessed prenatal counseling ⁵³53. Bianchini BV, Maroneze MC, Timm MS, Dos Santos BZ, Dotto PP. Prevalence of alcohol and tobacco use and perceptions regarding prenatal care among pregnant Brazilian women, 2017 to 2018: a mixed-methods study. Matern Child Health J 2020; 24:1438-45.^,5454. Martinelli JL, Germano CMR, de Avó LRDS, Fontanella BJB, Melo DG. Motivation for alcohol consumption or abstinence during pregnancy: a clinical-qualitative study in Brazil. PLoS One 2019; 14:e0223351. and reported that women consider it is important to be informed about the dangers of consuming alcohol during pregnancy, but they received little information about that, sometimes incorrectly, and not always easy to understand. A relationship full of conflict with the partner has also been reported as one of the factors associated with higher alcohol consumption during pregnancy ⁵⁵55. Esper LH, Furtado EF. Stressful life events and alcohol consumption in pregnant women: A cross-sectional survey. Midwifery 2019; 71:27-32.^,5656. Erdenetuya B, Kwon D, Choi S, Choe SA. Alcohol use during pregnancy: findings from a gender-based violence survey in Mongolia. Arch Womens Ment Health 2022; 25:789-95., as well as social reasons for drinking during pregnancy ⁵⁴54. Martinelli JL, Germano CMR, de Avó LRDS, Fontanella BJB, Melo DG. Motivation for alcohol consumption or abstinence during pregnancy: a clinical-qualitative study in Brazil. PLoS One 2019; 14:e0223351.^,5757. Watson D, Clark LA, Tellegen A. Development and validation of brief measures of positive and negative affect: the PANAS scales. J Pers Soc Psychol 1988; 54:1063-70.. Finally, contextual factors have also been evaluated, such as living in an environment that does not encourage physical activity ⁵⁸58. Boing AF, Boing AC, Wagner KJP, Saraiva SS, Tomasi YT. Individual and contextual variables associated with smoking and alcohol consumption during pregnancy. Rev Bras Enferm 2021; 74 Suppl 4:e20200804.. None of these factors was available in our study and should be explored in future investigations.

In terms of study strengths, this is the first study that estimated the prevalence of alcohol use and presumable diagnostic of inapproriate alcohol use during pregnancy that used a comprehensive and representative sample of the country and all its regions. Although data refer to 2011-2012 and may not reflect current prevalence, they present a national scenario of alcohol use during pregnancy, and regional and social inequalities that can support the formulation of health policies, which must be updated with new studies. Specific policies on alcohol consumption during pregnancy have not been implemented since then, and it is unlikely that changes have been made in service routines. Regarding the inequalities observed in alcohol consumption, data from the PNS conducted in 2013 and 2019 ⁴³43. Instituto Brasileiro de Geografia e Estatística. Pesquisa Nacional de Saúde, 2013. Percepção do estado de saúde, estilos de vida e doenças crônicas: Brasil, grandes regiões e Unidades da Federação. https://biblioteca.ibge.gov.br/index.php/biblioteca-catalogo?view=detalhes&id=291110 (accessed on 16/Mar/2023).
https://biblioteca.ibge.gov.br/index.php... ^,4444. Instituto Brasileiro de Geografia e Estatística. Pesquisa Nacional de Saúde 2019. Percepção do estado de saúde, estilos de vida, doenças crônicas e saúde bucal: Brasil e grandes regiões. https://biblioteca.ibge.gov.br/index.php/biblioteca-catalogo?view=detalhes&id=2101764 (accessed on 16/Mar/2023).
https://biblioteca.ibge.gov.br/index.php... estimate an increase in alcohol consumption of once or more per week in women, residents in the Southeast region, and people presenting higher educational level. However, these changes cannot be extrapolated to the population of pregnant women and the assessment of inequalities in consumption among pregnant women depends on further specific studies.

Conclusion

Around 14% of Brazilian pregnant women reported alcohol use during pregnancy and 10% presented presumable diagnosis of inadequate alcohol use during pregnancy, with higher prevalence of alcohol use among women in higher social vulnerability and among smokers. These results may be relevant for the development of public policies and care guidelines that include actions to improve prenatal care, prevent alcohol use, and offer support services to stop alcohol use during pregnancy. Screening and counseling on alcohol consumption during pregnancy - actions recommended by the WHO ¹1. World Health Organization. Guidelines for the identification and management of substance use and substance use disorders in pregnancy. Geneva: World Health Organization; 2014. - should be implemented in all prenatal services, as well as educational actions addressing the risk of alcohol use, with a focus on all pregnant women, especially those who are more vulnerable.

Acknowledgements

We would like to thank the Birth in Brazil research group, headed by Dr. Maria do Carmo Leal and under the general coordination of Sergio Arouca National School of Public Health, Oswaldo Cruz Foundation (ENSP/Fiocruz), for the support in this study. F. I. Bastos is supported by Rio de Janeiro State Research Foundation (FAPERJ) grant Health Network Program E-26/010.002428/2019 and Brazilian National Research Council (CNPq) career grant.

References

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