Research Article: Effect of Hazardous Alcohol Use During Pregnancy on Growth Outcomes at Birth: Findings from a South African Cohort Study

Date Published: December 28, 2017

Publisher: John Wiley and Sons Inc.

Author(s): Bronwyn Myers, Nastassja Koen, Kirsten A. Donald, Raymond T. Nhapi, Lesley Workman, Whitney Barnett, Nadia Hoffman, Sheri Koopowitz, Heather J. Zar, Dan J. Stein.


Cohort studies have noted associations between hazardous alcohol use during pregnancy and infant growth outcomes, but many have not controlled for potential psychosocial confounders. To assess the unique contribution of hazardous alcohol use, we examined its effect on infant growth outcomes while controlling for maternal psychosocial stressors and hazardous tobacco and drug use in a cohort of 986 pregnant South African women enrolled into the Drakenstein Child Health Study between 2012 and 2015.

Data on psychosocial stressors and maternal risk behaviors were collected between 28 and 32 weeks of gestation. Participants were categorized as hazardous alcohol users if they obtained moderate or high scores (>10) on the Alcohol, Smoking and Substance Involvement Screening Test at this assessment or retrospectively reported drinking at least 2 drinks weekly during any trimester of pregnancy. Infant growth outcomes were recorded at delivery. Multivariable regression models examined correlates of hazardous alcohol use and associations between hazardous alcohol use and birth outcomes.

Overall, 13% of mothers reported hazardous alcohol use. Recent exposure to intimate partner violence (adjusted odds ratio (aOR) = 2.08; 95% confidence interval (CI): 1.37, 3.18) and hazardous tobacco use (aOR = 5.03; 95% CI: 2.97, 8.52) were significant correlates of hazardous alcohol use. After controlling for potential psychosocial confounders, hazardous alcohol use remained associated with lower infant weight‐for‐age (B = −0.35, 95% CI: −0.56, −0.14), height‐for‐age (B = −0.46, 95% CI: −0.76, −0.17), and head‐circumference‐for‐age z‐scores (B = −0.43, 95% CI: −0.69, −0.17).

Interventions to reduce hazardous alcohol use among pregnant women in South Africa are needed to prevent alcohol‐related infant growth restrictions. As these growth deficits may lead to neurodevelopmental consequences, it is critical to identify alcohol‐related growth restrictions at birth and link exposed infants to early interventions for neurodevelopment.

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This study presents data from the Drakenstein Child Health Study (DCHS), a longitudinal birth cohort study that examines biological, environmental, and psychosocial determinants of maternal, paternal, and child health within the Drakenstein subdistrict of the Western Cape Province, South Africa (Stein et al., 2015). The Faculty of Health Sciences’ Human Research Ethics Committee at the University of Cape Town (401/2009), Stellenbosch University (N12/02/0002), and the Western Cape Provincial Health Research Committee (2011RP45) approved this study.

This study examined associations of hazardous alcohol use, psychosocial stressors, and hazardous tobacco and illicit drug use with adverse birth outcomes in a cohort of pregnant South African women. Study findings build on those of previous cohort studies (e.g., Carter et al., 2012; Sania et al., 2017) by revealing the unique contribution that hazardous alcohol use makes to adverse birth outcomes after controlling for the potential confounding effects of maternal psychosocial stressors and other maternal risk behaviors. The main findings were that (i) a sizable proportion of women reported hazardous alcohol use during pregnancy; (ii) hazardous alcohol use was associated with infant growth restriction at birth, even after controlling for maternal BMI, psychosocial stressors, and hazardous tobacco and drug use; and (iii) hazardous tobacco use and experiences of IPV were associated with hazardous alcohol use during pregnancy.

Despite some limitations, study findings have implications for the development of health services aimed at promoting maternal and infant well‐being. First, findings of high levels of hazardous alcohol use point to the need for ongoing community‐based education around the risks associated with hazardous alcohol use during pregnancy. Second, findings suggest that universal screening of pregnant women for hazardous alcohol use (as well as tobacco use and exposure to IPV) is required to identify and link pregnant women with these risks to appropriate interventions. Third, findings indicate that alcohol‐reduction interventions should target not only hazardous alcohol use but also potential exposure to IPV and co‐occurring tobacco use. Given the exceptionally high rates of IPV and other forms of trauma in South African society (Choi et al., 2014), trauma‐informed interventions that address alcohol and tobacco use in an integrated manner may be particularly effective for reducing hazardous alcohol use among pregnant women in South Africa. Randomized controlled trials of trauma‐informed interventions for maternal alcohol use must still confirm this hypothesis. Fourth, our findings of alcohol‐associated infant growth restrictions have implications for the early identification of infants with potential exposure to hazardous alcohol use. We recommend retrospective screening of all infants with growth restrictions for hazardous alcohol exposure and their linkage, if required, to early childhood development programs to address potential developmental problems.

This study was funded by the Bill and Melinda Gates Foundation (OPP 1017641). BM, DJS, HJZ, NK, and WB are supported by the South African Medical Research Council.

The authors have no conflict of interest to declare.




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