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PEDIATRICS Vol. 111 No. 2 February 2003, pp. 443-444

Maternal Report of Prenatal Alcohol Use

We read with great interest the paper of Jacobson et al¹ wherein the validity of maternal reports of alcohol usage during pregnancy was investigated by comparing the antenatal and postpartum (13- month) interviews. The authors concluded that the antenatal interview provides more valid information in relation to infant outcome while the postpartum interview is unreliable. In the study by our team,² 2477 women who gave birth at Rabin Medical Center in Israel from November 1999 to April 2000 were asked about alcohol use and smoking using a direct technique. We found that 8.8% reported smoking but only 1.13% reported drinking alcohol during pregnancy, and only 0.84% reported drinking by a family member. Our sample included new immigrants from the former Soviet Union and Ethiopia and women of Indian origin (all origins found to be related to alcohol abuse in Israel), as well as Israeli-born orthodox Jewish women (who are expected to drink at least small quantities in religious ceremonies). These findings, combined with the fact that a related study reported a 33.5% rate of alcohol use in the month before the study in the general population of Jewish Israeli women,³ prompted us to conclude that direct-oriented questions lead to underreporting. This might be explained by fear of stigmatization (especially among new immigrants); denial, which might be triggered by direct questions and feelings of guilt; and the general reluctance of Israeli women to admit to alcohol use to an unfamiliar hospital staff.

Our data agree with the findings of Jacobson et al,¹ even though we performed the interview in the first days after birth, during maternal hospitalization, and not after 13 months. Because pregnant Israeli women have little incentive to report alcohol use, we suggest that alternative methods and locations of questioning be used.

For example, the study could be conducted in the calmer, more familiar atmosphere of the prenatal clinic using both direct and indirect techniques. We also recommend combining the results with biological-based assessments as well as information provided by family members and friends.

Paul Merlob, MD
Haviva Sharan, PhD
Department of Neonatology
Rabin Medical Center, Beilinson Campus
Petah Tikva, 49100 Israel

Shoshana Weiss, DSC
Israel Society for the Prevention of Alcoholism
Ramat Gan, Israel

REFERENCES

1. Jacobson SA, Chiodo LM, Sokol RJ, Jacobson JL. Validity of maternal report of prenatal alcohol, cocaine, and smoking in relation to neurobehavioral outcome. Pediatrics.2002; 109 :815 –825[Abstract/Free Full Text]
2. Weiss S, Sharan H, Merlob P. Self-reported alcohol use among pregnant women in the center of Israel. Int J Risk Safety Med.2000; 13 :225 –232
3. Neumark YD, Rahav G, Teichman M, Hasin D. Alcohol drinking patterns among Jewish and Arab men and women in Israel. J Stud Alcohol.2001; 62 :443 –447[Web of Science][Medline]

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In Reply.—

We wish to thank Drs. Merlob, Sharan, and Weiss for their interest in our article and their thoughtful comments. They suggest that direct questioning about alcohol can sometimes lead to underreporting. Indeed, denial is a substantial problem in obtaining adequate and accurate alcohol histories and has led to the development of screening tools, which assess drinking-related problems indirectly, for use in the clinical setting.¹ The use of quantitative measures of alcohol exposure, however, is very important in research evaluating the impact of prenatal exposure on infant and child neurobehavioral outcomes. In our current study, presented in Pediatrics,² alcohol histories were uniformly collected by individuals highly trained in obtaining accurate alcohol histories, using timeline follow-back methods to determine incidence and amount of drinking on a day-by-day basis during the preceding 2 weeks.³ Recall was linked to specific times of day and activities. Using this methodology, pregnancy drinking was found to be predictive of growth and aberrant neurobehavioral development,^4–8 thus providing support for the accuracy, precision, and predictive validity of our methods.

We concur and, indeed, our findings support the importance of obtaining alcohol histories prospectively in the prenatal clinic. This type of research is particularly difficult in populations, such as the Israeli immigrant groups described by Merlob et al. Nonetheless, our research shows that prenatal clinic interviews by trained, noncritical examiners in such diverse cultures and cohorts as inner-city Detroit,^4–8 the Inuit mothers in Northern Quebec,⁹ and the Cape Coloured community in Cape Town, South Africa¹⁰ can generate valid measures of alcohol use during pregnancy. Moreover, these measures are sensitive to subtle deficits in infants that would most likely not have been detected retrospectively or by indirect screening techniques. Thus, our data suggest that direct but sensitive interviewing in the prenatal clinic can reduce denial and provide an accurate quantitative ascertainment of pregnancy drinking.

Research on prenatal exposure to cocaine and other illicit drugs as well as various environmental contaminants, such as polychlorinated biphenyls, mercury, and lead, has made use of biological markers, including meconium, hair, and maternal and cord sera. Unfortunately, given the short half-life of alcohol, it has been difficult to identify biomarkers of alcohol use during pregnancy, which reflect exposure beyond the 1 to 2 days detected in urine samples. A few groups are currently working on developing such biomarkers of prenatal alcohol exposure using meconium,¹¹ but their validity and utility are still under investigation.

Sandra W. Jacobson, PhD^*
a Department of Psychiatry and Behavioral Neuroscience
Wayne State University School of Medicine
Detroit, MI, USA

Robert J. Sokol, MD
Department of Obstetrics and Gynecology
Wayne State University School of Medicine
Detroit, MI, USA

Joseph L. Jacobson, PhD
Department of Psychology
Wayne State University
Detroit, MI, USA

REFERENCES

1. Russell M, Martier SS, Sokol RJ, Mudar P, Bottoms S, Jacobson S, Jacobson J. Brief screens for risk drinking during pregnancy. Am J Public Health.1996; 86 :1435 –1439[Abstract/Free Full Text]
2. Jacobson SW, Chiodo LM, Jacobson JL, Sokol RJ. Validity of maternal report of alcohol, cocaine, and smoking during pregnancy in relation to infant neurobehavioral outcome. Pediatrics.2002; 109 :815 –825
3. Sokol RJ, Martier S, Ernhart C. Identification of alcohol abuse in the prenatal clinic. In: Chang NC, Chao HM, eds. Early Identification of Alcohol Abuse. Research Monograph No. 17. Rockville, MD: Alcohol, Drug Abuse, and Mental Health Administration, 1983
4. Jacobson JL, Jacobson SW, Sokol RJ, Martier SS, Ager JW, Shankaran S. Effects of alcohol use, smoking, and illicit drug use on fetal growth in black infants. J Pediatr.1994; 124 :757 –764[CrossRef][Web of Science][Medline]
5. Jacobson SW, Jacobson JL, Sokol RJ, Martier SS, Ager JW. Prenatal alcohol exposure and infant information processing ability. Child Dev.1993; 64 :1706 –1721[CrossRef][Web of Science][Medline]
6. Jacobson SW, Jacobson JL, Sokol RJ. Effects of fetal alcohol exposure on infant reaction time. Alcohol Clin Exp Res.1994; 18 :1125 –1132[CrossRef][Web of Science][Medline]
7. Jacobson JL, Jacobson SW, Sokol RJ, Martier SS, Ager JW, Kaplan-Estrin M. Teratogenic effects of alcohol on infant development. Alcohol Clin Exp Res.1993; 17 :174 –183[CrossRef][Web of Science][Medline]
8. Jacobson SW, Bihun JT, Chiodo LM. Effects of prenatal alcohol and cocaine exposure on infant cortisol levels. Dev Psychopathol.1999; 11 :195 –208
9. Muckle G, Jacobson SW, Dewailly E, Jacobson JL. The relation of alcohol and domestic violence to psychological distress in Inuit mothers. Alcohol Clin Exp Res.2000; 24 :60A
10. Jacobson SW, Hay A, Molteno C, et al. FAS and neurobehavioral deficits in alcohol-exposed South African infants. Alcohol Clin Exp Res.2002; 26 :175A
11. Bearer CF, Lee S, Salvator AE, et al. Ethyl linoleate in meconium: a biomarker for prenatal ethanol exposure. Alcohol Clin Exp Res.1999; 23 :487 –493[CrossRef][Web of Science][Medline]

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PEDIATRICS (ISSN 1098-4275). ©2003 by the American Academy of Pediatrics

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This Article Extract Full Text (PDF) Submit a response Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Services E-mail this article to a friend Similar articles in this journal Similar articles in Web of Science Similar articles in PubMed Alert me to new issues of the journal Add to My File Cabinet Download to citation manager Request Permissions Citing Articles Citing Articles via CrossRef Citing Articles via Google Scholar Google Scholar Articles by Merlob, P. Articles by Jacobson, J. L. Search for Related Content PubMed PubMed Citation Articles by Merlob, P. Articles by Jacobson, J. L. Social Bookmarking                         What's this?