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Consumption of alcohol and binge drinking among pregnant women in Addis Ababa, Ethiopia: Prevalence and determinant factors

  • Mezinew Sintayehu Bitew ,

    Roles Conceptualization, Formal analysis, Methodology, Project administration, Software, Supervision, Writing – original draft, Writing – review & editing

    sintayehume@gmail.com

    Affiliation Department of Mental Health, Debre Markos University, Debre Markos, Amhara, Ethiopia

  • Maereg Fekade Zewde,

    Roles Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Software, Supervision, Validation, Visualization, Writing – original draft

    Affiliation Department of Maternal and Child Health, Addis Ababa City Administration Health Bureau, Addis Ababa, Ethiopia

  • Muluken Wubetu,

    Roles Data curation, Formal analysis, Methodology, Resources, Software, Supervision

    Affiliation Department of Pharmacy, Debre Markos University, Debre Markos, Amhara, Ethiopia

  • Addisu Alehegn Alemu

    Roles Formal analysis, Methodology, Resources, Software, Supervision

    Affiliation Department of Midwifery, Debre Markos University, Debre Markos, Amhara, Ethiopia

Consumption of alcohol and binge drinking among pregnant women in Addis Ababa, Ethiopia: Prevalence and determinant factors

  • Mezinew Sintayehu Bitew, 
  • Maereg Fekade Zewde, 
  • Muluken Wubetu, 
  • Addisu Alehegn Alemu
PLOS
x

Abstract

Introduction

People in Ethiopia, including pregnant women, highly consume both home-made and manufactured alcohol beverages due to lack of awareness about the harmful effect of risky alcohol use, and cultural acceptance of alcohol consumption. Alcohol consumption and other hazardous patterns of use like binge drinking have tremendous adverse effects on fetus and mothers. Therefore, this study aimed to assess the magnitude of alcohol consumption, binge drinking and its determinants among pregnant women residing in Kolfe sub-city, Addis Ababa, Ethiopia.

Methods

Institutional based cross-sectional study was conducted among a total of 367 pregnant women. The participants were selected using a systematic random sampling method. Data were collected through a structured questionnaire. A binary logistic regression was conducted using SPSS version 20 software to identify determinants of alcohol consumption and binge drinking. A p-value < 0.05 was used to declare a statistical significance in multiple logistic regression. The results were described using adjusted odds ratio with a 95% confidence interval.

Results

This study revealed that the prevalence of alcohol consumption, binge drinking, and weekly alcohol consumption of four or more units among pregnant women was 39.78%, 3.54% and 4.9%, respectively. Not having formal education [AOR 95% CI = 8.47 (2.42, 29.62), having primary education [AOR 95% CI = 4.26 (1.23, 14.74), being a housewife [AOR 95% CI = 4.18 (2.13, 8.22), having an unplanned pregnancy [AOR 95% CI = 2.47(1.33, 4.60), having a history of abortion [AOR 95% CI = 3.33 (1.33, 6.05)], not having awareness about the harmful effect of alcohol consumption [AOR 95% CI = 4.66 (2.53, 8.61)], and not having family social support [AOR 95% CI = 2(1.14,3.53) were determinants of alcohol consumption among pregnant women.

Conclusions

This study found a high level of alcohol consumption among pregnant women. Interventions to create awareness on the harmful effects of alcohol are needed. Moreover, strengthening social support during pregnancy and family planning services to reduce unplanned pregnancy and abortion should be considered.

Introduction

Globally, use of substances such as alcohol, tobacco and other illicit substances, in a way that could harm the users’ health, have escalated through time in all segments of the population and has become one of the growing public health and socioeconomic concerns. Alcohol shares the highest-burden that accounts for 3.8% of all global deaths and 4.6% of the global burden of diseases and neuropsychiatric disorders [13]. Risky use of alcohol causes significant morbidity and mortality (particularly from injuries) and societal harm such as social disruption from crime, unemployment and marital disharmony [2, 3].

The negative health consequences of alcohol consumption are more profound for pregnant women and their fetuses. Alcohol consumption during pregnancy has also shown to be one of the leading causes of preventable birth defects and developmental problems comprising language and motor delays and deprived academic achievement [46].

New studies indicate that even low levels of prenatal alcohol exposure could adversely affect the developing fetus. Cognitive and socio-emotional deficits, among children exposed to even small amounts of alcohol, are found [7]. Consumption of 2 or more standard drink of alcohol/day in early pregnancy is associated with significant problems on the fetus. It can cause miscarriage, preterm birth and low birth weight compared to children born from non-drinkers. In addition, other studies reported that women who consumed more than three drinks per week during the first trimester had a significant harmful health effect on their pregnancy. The consequence would be five folds more if they took five or more units of alcohol per week [812]. Furthermore, binge‐drinking (commonly defined as consuming 4 or more units of alcohol at one occasion for women) during pregnancy is more harmful because of its serious toxic effects on fetal neurodevelopment crossing the placenta [13, 14].

The adverse effects of prenatal alcohol exposure can range from subtle developmental problems, or fetal alcohol effects, to full-blown fetal alcohol spectrum syndrome (FASS). However, it is not limited to infancy and childhood; prenatal exposure to alcohol, particularly in early pregnancy, has also been found to increase the likelihood of developing an alcohol disorder in adulthood [15, 16]. Given these consequences and the belief that there is no safe time or amount to consume alcohol in pregnancy, the CDC recommends complete abstinence [17, 18].

Studies have reported alcohol consumption among pregnant women ranging from 19.5% in South Africa to 59% in Nigeria [1926].

Similarly, studies conducted on the prevalence of binge drinking among pregnant women showed between 3% in Canada and 25% in Congo [3, 2731]. A study in New Zealand also revealed 10% of pregnant women drank seven and more units of alcohol per week which is the other clinically significant patterns of alcohol use [30].

According to studies from different countries showed that socio-demographic factors (age, marital status, educational status, and occupation), obstetric history (gestational age, unplanned pregnancy, gravidity, and history of abortion), social support and behavioral issues like use of Khat and cigarette smoking were determinants of alcohol consumption during pregnancy [3237]. Additionally, studies reported that awareness about the harmful effect of alcohol on fetus, attitude and culture of the population were determinants of alcohol consumption [36, 3840].

Alcohol consumption and its associated problems among pregnant women increased globally [41]. In low-income countries including Ethiopia, the rapid increase of the consumption of alcohol has also been indicated for decades, especially reproductive-age women are affected [1, 42]. Both traditional and commercially produced alcohol beverages are widely spread more than ever which are also an important contributing factors for increased alcohol consumption in Ethiopia [1, 38].

People in Ethiopia that include pregnant women highly consume alcohol beverages, especially the traditionally prepared alcohol beverages like Areki, Teje, Tella that have higher percentages of alcohol amount [4345]. Thus, locally made alcohols are being used excessively without control in different holidays, religious festivals, parties, and almost in daily family meals and day to day life [4345].

Despite the adverse health effects of alcohol consumption is profound, its assessment with determinants among pregnant women is limited. In particular, there is a scarcity of information on binge drinking of alcohol by measuring or calculating the amount consumed. Addis Ababa, the capital city of Ethiopia where the current study was conducted, is heavily affected with consumption of alcohol [1]. Therefore, this study was intended to assess the magnitude of alcohol consumption and binge drinking among pregnant women, and its determinants in Kolfe sub city, Addis Ababa, Ethiopia. The finding of this study will have significant contributions for health program managers, policymakers, clinicians and researchers.

Materials and methods

Study design, sample size and sampling technique

An institutional-based quantitative cross-sectional study was conducted based on the guidelines of strengthening the Report of Observational Studies in Epidemiology (STROBE) for observational research [46]. It was conducted at Kolfe Keranio sub-city, Addis Ababa, Ethiopia. The sub-city covers an area of 61.25 sq.km and has a total population of 546, 219 (235, 360 females). Around 2.33% (9,531) of females were pregnant. The sub-city has 15 districts and 11 Health Centers (HCs) [47].

A total of 397 pregnant women were included in this study. Single population proportion formula was considered to calculate the sample size. Taking 34% prevalence (p) of alcohol consumption among pregnant women [48], 5% margin of error (d), 95% confidence interval (CI) and 15% non-response rate. Systematic random sampling was carried out after the sample was proportionally allocated to each of the 11 health centers. All pregnant women, regardless of the gestational age, attended the health centers during the study period were included. However, pregnant women who were seriously ill and unable to respond were excluded. The study was conducted from May to June 2017.

Data collection instrument and procedure

Data regarding on participants’ socio-demographic, obstetric characteristics, alcohol consumption, awareness about the harmful effect of alcohol and the use of other substances (i.e. Khat chewing and cigarette smoking) were collected using a structured questionnaire developed from previous literature.

However, family social support was assessed through the Multidimensional Scale of Perceived Social Support (MSPSSf). MSPSS has three subscales (family, friends and significant others), with a total of 12 items each scaled from 1 (very strongly disagree) to 7 (very strongly agree) [49, 50]. Respondents scored higher than 14 from a multidimensional scale of perceived family social support (MSPSSF) 7 Likert scale were recognized as having family social support, those who scored less than or equal to 14 were not having social support.

Likewise, the amount and frequency of alcohol consumption per day, week and month during the time of pregnancy were adapted from AUDIT and other articles [13, 21, 51]. In Ethiopian, both traditional (e.g. Tella, Araki, Teje) and manufactured (Beer, Wine) alcohol beverages are widely produced and consumed. People used local equipment’s called Tella Birecheko, Melekia, and Birelie to drink traditional alcohols that can measure around 340 ml, 40 ml and 270 ml, respectively. Pregnant women were asked to estimate the average number of drinks they consumed. Finally, the data were standardized using the percentage and volume of alcohol in each ml of beverages. And drinking four more units of alcohol on one occasion was considered binge drinking.

Six questions were developed to assess the awareness of the harmful effect of alcohol on fetus, and those who answered the six questions correctly identified as having awareness about the consequences of alcohol. Furthermore, any amount of khat use and cigarette smoking even at once during the current pregnancy is known as pregnant women who chew khat and smoke cigarette, respectively. The questionnaire was prepared initially in English and translated to Amharic then back to English to check the consistency of the questions.

Eleven BSc nurses as a data collector and two public health officers as supervisor participated during data collection. Ethical clearance was obtained from Addis Ababa University, public health school ethical review committee. The right participants were systematically selected by data collectors when pregnant women came to maternal care. Data collectors explained the objective and procedures of the study, and their right to refuse or discontinue the interview at any time to participants. And, they knew that the questionnaire was anonymous and their privacy kept confidential. Also, Participants were aware of as the study has not any risk or direct benefit like incentives for them; it was only conducted for the achievement of objectives, and ultimately for improving health services of pregnant women and the community as a whole. After participants heard and understood all the necessary information and consent statement, they have been asked about their willingness to be interviewed, which was verbal consent. Those volunteers were again asked to write their name and put their signature with the date of interview in a prepared blank space found below the information sheet and statement of consent, which was written consent. For participants under 18 years old, informed consent was also obtained from their parents.

After that, data collectors interviewed the selected participant in the face to face manner by using a structured questionnaire at the waiting room of the maternal care clinic that took around 15 minutes. Those who found risky of alcohol consumption has been linked to substance abuse clinic, and responsible leaders in selected health centers and maternal care clinics were recommended and noticed to initiate and strengthen prevention of alcohol consumption among pregnant women.

Data quality, processing and analysis

To assure the data quality training was given to the data collectors and supervisors for three days about the data collection tool, way of interview, and the ethical principles of confidentiality before their involvement to the data collection. The collected data were checked for its completeness and consistency daily. Then, the collected data were checked, cleaned and entered into Epi. DATA 3.1 version and exported to Statistical Package for the Social Sciences (SPSS) version 20 for analysis. Descriptive statistics were summarized using frequencies, percentage, graphs, the mean and standard deviation. Binary logistic regression was employed to assess the association of each independent variables with the outcome variable. All variables with p-value < 0.2 during binary logistic regression were considered in the multiple logistic regression. The findings were presented using Odds ratio (crude and adjusted) with its 95%CIs. Moreover, a p-value < 0.05 was considered to declare the variable was statistically significant during the final multiple logistic regression analysis.

Results and discussion

Results

Description of socio-demographic characteristics.

A total of 367 pregnant women were interviewed that made 92.44% response rate. This study revealed almost three fourth (74.7%) of participants were married. Seven out of ten (70.8%) participants were non-educated, whereas women who completed secondary education and above were 26 (7.1%). The age of participants ranged between 15 and 49 with mean age 27.43 (SD ± 4.77) years. Regarding ethnicity, Amhara and Oromo comprise the majority, 114 (31.1%) and 107(29.2%) respectively. Nearly half of the participants (48.2%) were followers of orthodox religion followed by Muslims (35.7%). The majority (42.5%) of pregnant women were housewives. Similarly, one-third of participants’ monthly average income was between1001-2000 ETB (Table 1).

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Table 1. Socio-demographic characteristics of pregnant women in Kolfe Keranio sub city (n = 367), Addis Ababa, Ethiopia.

https://doi.org/10.1371/journal.pone.0243784.t001

Assessment of obstetric history of respondents.

As shown in Table 2 below, the majority of pregnant women (40.3%) were in the second trimester. Almost three quarters (73%) of pregnant women had a planned pregnancy. Three or more out of ten (31.6%) of pregnant women had a history of abortion.

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Table 2. Obstetric history of the pregnant women in kolfe Keranio sub city (n = 367) Addis Ababa, Ethiopia.

https://doi.org/10.1371/journal.pone.0243784.t002

Though most of the participants were in the second and third trimester, the proportion of alcohol consumption value was high among first trimester 21 (55.26%) (Fig 1).

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Fig 1. Alcohol consumption among pregnant women respected to trimesters of pregnancy in Kolfe Keranio sub city (n = 367), Addis Ababa, Ethiopia.

https://doi.org/10.1371/journal.pone.0243784.g001

Alcohol consumption, binge drinking and other substances during pregnancy.

As illustrated in (Table 3) below, 146(39.8%) of pregnant women drank alcohol. The majority (44.4%) of participants predominately drank Tella. Fifty-four (14.71%) of participants consumed alcohol 2–4 times per month, while 15 (4.09%) of pregnant women drank four and above times per week. On the other hand, 13 (3.54%) of women had the experience of binge drinking during their pregnancy.

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Table 3. Alcohol consumption and binge drinking among pregnant women in kolfe sub city (n = 367), Addis Ababa, Ethiopia.

https://doi.org/10.1371/journal.pone.0243784.t003

Awareness about the harmful effect of alcohol use.

As demonstrated in Fig 2, Two hundred forty-four (66.5%) pregnant women have awareness, answered all six questions correctly regarding the harmful effect of alcohol consumption. Among those who have awareness, only 69 (28.28%) consumed alcohol. Whereas, of those who answered the awareness questions incorrectly, 76 (62.6%) drank alcohol.

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Fig 2. Magnitude of alcohol consumption among pregnant women respected to awareness about the harmful effect of alcohol on fetus in Kolfe Keranio sub city (n = 367), Addis Ababa, Ethiopia.

https://doi.org/10.1371/journal.pone.0243784.g002

Factors associated with alcohol consumption among pregnant women.

As shown in Table 4, educational status, occupation, plan of pregnancy, history of abortion, awareness about the harmful effect of alcohol, and family social support of pregnant women were significant predictors of alcohol consumption among pregnant women. The higher odds alcohol consumption was observed among non-educated and attained primary education pregnant women with (AOR 95% CI = 8.47 (2.42, 29.62) and AOR 95% CI = 4.26 (1.23, 14.74), respectively compared to those completed secondary education and above.

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Table 4. Determinants of alcohol consumption among pregnant women in Kolfe Keranio sub city Addis Ababa, Ethiopia (n = 367).

https://doi.org/10.1371/journal.pone.0243784.t004

Pregnant women who were housewives had a fourfold risk of alcohol consumption (AOR 95% CI = 4.18 (2.13, 8.22) compared to employed women. Women whose last pregnancy was unplanned had a two folds risk of alcohol consumption than their counters (AOR 95% CI = 2.47(1.33, 4.60). Likewise, pregnant women who had a history of abortion were prone to three-fold risk for alcohol consumption compared to pregnant women who hadn’t [AOR 95% CI = 3.33 (1.33, 6.05)]. Women who had awareness about the effect of alcohol on fetus and them found to be a protective factor for alcohol consumption compared to those who had no awareness [AOR 95% CI 4.66 (2.53, 8.61)]. Moreover, in assessment family social support, more than half (66.5%) of them scored greater than or equal to 14 from the total score of MSPSSf. This study also found pregnant women who hadn’t family social support had a two-fold risk for alcohol consumption [AOR 95% CI = 2 (1.14, 3.53) compared to those who had family social support.

Discussion

The overall prevalence of alcohol consumption among pregnant women was 39.78% (34.74, 44.99). The finding from this study is lower than Ethiopia Demographic and Health Survey (45%) [52]. However, the prevalence of alcohol consumption reported in this study was higher than research conducted in Jimma hospital and Bahir Dar dwellers which are 31.3% and 34%, respectively [48, 53]. The possible reason could be the time of the study; population difference, and study design. A study conducted in Bahir Dar was community-based, unlike the current study which was institution-based.

This study’s alcohol consumption prevalence was also higher than the findings from some of the African countries such as 16% in Uganda [54], 19.6% in South Africa [21], 25% in Uganda [22], 32.5% in Congo [23], 20.4% in Ghana [55] and 22.6% in South Nigeria [38].

Similarly, the magnitude from this study was higher compared to some studies in western countries like the United Kingdom (28.5%), Russia (26.5%) and Switzerland (20.9%) [19]. However, it is in line with a study conducted in Geneva that showed around 36.3% of the women drank at least one glass of alcohol during pregnancy [20]. In contrast to the above, alcohol consumption in this study was far lower compared to the results in Nigeria (59.3%) [26], Ghana (48%) [24], and Australia (56%) [25]. The observed discrepancy might be due to the type of alcohol consumed, study period, awareness and perception about the effect of alcohol on the fetus, and socio-cultural difference among the participants.

The magnitude of binge drinking, which is known for its hazardous effect on the fetus, was 3.54% (1.89, 5.98). It was similar to the findings to the studies in America (3.1%) [28], Canada (3%) [27], and South Africa (4.6%) [29]. However, it was much lower than the findings from studies in New Zealand (9%) [30], Uganda (10%), Congo (20.16%) [31], and Congo (25.42%) [23].

Another pattern of alcohol consumption, hazardous drinking which is found as a risk factor for abortion and miscarriage, was also determined in this study. It has still an immense negative health effect on the fetus. Of those pregnant women who consumed alcohol, 4.9% (2.03, 6.65) of them drank four or more unit of alcohol per week. Similarly, 11.7% of pregnant women in this study reported as they drank 2 to 3 unit of alcohol per week. Around 14% of participants were drinking 2 to 3 units of alcohol per month. A similar study conducted in New Zealand revealed 10% of pregnant women drank 7 units or more of alcohol within a week which was higher than the current study [30]. The discrepancy of the magnitude of binge drinking and amount of alcohol taken per week observed might be due to socio-demographic difference, study design, year of study, and awareness and perception about the effect of alcohol on the fetus.

This study also showed a significant association between not having formal education and alcohol consumption. It is in line with findings from previous studies [38, 53, 56]. It could be due to non-educated women might not have awareness on the harmful effect of alcohol consumption. However, another study showed that highly educated pregnant women were more likely to consume alcohol [32].

The occupation was also significantly associated with alcohol consumption. Being a housewife was shown as risky for alcohol consumption compared to being employed and working their businesses. This finding is supported by other studies [48, 57]. It could be explained by housewives dependent behavior on their spouse that could create distress and their usual engagement in a routine home activity that includes preparing traditional alcohol beverages. Whereas, studies in European countries revealed that employed pregnant women are more likely prone to alcohol consumption [32]. Again, pregnant women lacking awareness about the harmful effect of alcohol on the fetus were more likely to consume higher levels of alcohol than pregnant women who have the awareness. This finding is supported by other similar studies [36, 38, 55]. The other important factor significantly associated with alcohol consumption is family social support. According to the current study, pregnant women who had not family social support had higher odds of alcohol consumption which is consistent with other studies [33, 34]. But, a study conducted in Boston, Massachusetts revealed that social support is not a factor for alcohol consumption [58].

Moreover, a woman whose pregnancy was unplanned and had abortion history had a higher chance of consuming alcohol. This finding is also in line with the result of other studies [3537, 48]. The possible reason could be that grief due to the previous abortion, psychological and physiological effect of abortion that might eventually cause distress and alcohol consumption.

Unlike some previous studies [35, 38, 59, 60], the current study didn’t show a significant association between women age, gestational age, gravidity, ethnicity, number of alive children, religion, average monthly income, previous alcohol use, chat use, and cigarette smoking with alcohol consumption of pregnant women. Even though alcohol consumption is culturally accepted, the amount and frequency of alcohol drinking may be under-reported by pregnant women because of the possible perceived stigma and recall bias during the interview. Likewise, estimating the amount of alcohol drank by participants and changing the different type of alcohol into the standard unit was challenging and may not be accurate. It is also a real challenge and considered as a limitation for alcohol and other substances study across the world that includes the current research.

Conclusions

This study revealed a higher magnitude of alcohol consumption among pregnant women. The prevalence of binge drinking and the amount and frequency of drinking per week among pregnant women was also higher. Factors such as not being educated, being housewife, having unplanned current pregnancy, having a history of abortion, not having awareness about the effect of alcohol on the fetus and not having family social support were significantly associated with alcohol consumption. Interventions focused on creating awareness about the harmful effects of alcohol on pregnancy; strengthening social support, and family planning services have to be developed and implemented. Moreover, we recommend to future researchers to conduct longitudinal study considering devices that help to measure the amount of alcohol in the blood.

Acknowledgments

We would like to acknowledge Addis Ababa University, School of public health for their courage to begin this program and keep it to be continued. We also thank the staffs, and plan and program officers of Kolfe Keranio sub-city health centers for providing the necessary information, and their permission and support to conduct this research.

References

  1. 1. Odejide AO. Status of drug use/abuse in Africa: A review. Int J Ment Health Addict. 2006;4(2):87–102.
  2. 2. Organization WH. Atlas on substance use (2010): resources for the prevention and treatment of substance use disorders. Geneva: World Health Organization; 2010.
  3. 3. Poznyak V. The impact of alcohol consumption on global health. Tackling Harmful Alcohol Use. 2015;81.
  4. 4. McGee CL, Bjorkquist OA, Riley EP, Mattson SN. Impaired language performance in young children with heavy prenatal alcohol exposure. Neurotoxicol Teratol. 2009;31(2):71–5. pmid:18938239
  5. 5. Kalberg WO, Provost B, Tollison SJ, Tabachnick BG, Robinson LK, Eugene Hoyme H, et al. Comparison of motor delays in young children with fetal alcohol syndrome to those with prenatal alcohol exposure and with no prenatal alcohol exposure. Alcohol Clin Exp Res. 2006;30(12):2037–45. pmid:17117969
  6. 6. Goldschmidt L, Richardson GA, Cornelius MD, Day NL. Prenatal marijuana and alcohol exposure and academic achievement at age 10. Neurotoxicol Teratol. 2004;26(4):521–32. pmid:15203174
  7. 7. Linell A, Richardson MX, Wamala S. The Swedish national public health policy report 2010. Scand J Public Health. 2013;41(10_suppl):3–56. pmid:23341365
  8. 8. Kesmodel U, Wisborg K, Olsen SF, Brink Henriksen T, Jørgen Secher N. Moderate alcohol intake in pregnancy and the risk of spontaneous abortion. Alcohol Alcohol. 2002;37(1):87–92. pmid:11825863
  9. 9. Harlap S, Shiono PH. Alcohol, smoking, and incidence of spontaneous abortions in the first and second trimester. Lancet. 1980;316(8187):173–6.
  10. 10. Rasch V. Cigarette, alcohol, and caffeine consumption: risk factors for spontaneous abortion. Acta Obstet Gynecol Scand. 2003;82(2):182–8. pmid:12648183
  11. 11. Kesmodel U, Wisborg K, Olsen SF, Henriksen TB, Secher NJ. Moderate alcohol intake during pregnancy and the risk of stillbirth and death in the first year of life. Am J Epidemiol. 2002;155(4):305–12. pmid:11836194
  12. 12. Nykjaer C, Alwan NA, Greenwood DC, Simpson NAB, Hay AWM, White KLM, et al. Maternal alcohol intake prior to and during pregnancy and risk of adverse birth outcomes: evidence from a British cohort. J Epidemiol Community Heal. 2014;68(6):542–9. pmid:24616351
  13. 13. Kesmodel U. Binge drinking in pregnancy—frequency and methodology. Am J Epidemiol. 2001;154(8):777–82. pmid:11590091
  14. 14. Bailey BN, Delaney-Black V, Covington CY, Ager J, Janisse J, Hannigan JH, et al. Prenatal exposure to binge drinking and cognitive and behavioral outcomes at age 7 years. Am J Obstet Gynecol. 2004;191(3):1037–43. pmid:15467586
  15. 15. Alati R, Al Mamun A, Williams GM, O’Callaghan M, Najman JM, Bor W. In utero alcohol exposure and prediction of alcohol disorders in early adulthood: a birth cohort study. Arch Gen Psychiatry. 2006;63(9):1009–16. pmid:16953003
  16. 16. Manning MA, Hoyme HE. Fetal alcohol spectrum disorders: a practical clinical approach to diagnosis. Neurosci Biobehav Rev. 2007;31(2):230–8. pmid:16962173
  17. 17. Seiler NK. Alcohol and pregnancy: CDC’s health advice and the legal rights of pregnant women. Public Health Rep. 2016;131(4):623–7. pmid:27453609
  18. 18. Butt P, Beirness D, Gliksman L, Paradis C, Stockwell T. Alcohol and health in Canada: a summary of evidence and guidelines for low-risk drinking. Ottawa, Can Cent Subst Abus. 2011;
  19. 19. Mårdby A-C, Lupattelli A, Hensing G, Nordeng H. Consumption of alcohol during pregnancy—A multinational European study. Women and Birth. 2017;30(4):e207–13. pmid:28111037
  20. 20. Dupraz J, Graff V, Barasche J, Etter J-F, Boulvain M. Tobacco and alcohol during pregnancy: prevalence and determinants in Geneva in 2008. Swiss Med Wkly. 2013;143(2122). pmid:23740290
  21. 21. Petersen Williams P, Jordaan E, Mathews C, Lombard C, Parry CDH. Alcohol and other drug use during pregnancy among women attending midwife obstetric units in the Cape Metropole, South Africa. Adv Prev Med. 2014;2014. pmid:24639899
  22. 22. Namagembe I, Jackson LW, Zullo MD, Frank SH, Byamugisha JK, Sethi AK. Consumption of alcoholic beverages among pregnant urban Ugandan women. Matern Child Health J. 2010;14(4):492–500. pmid:19629663
  23. 23. Barthélémy T, Andy M, Roger M. Effect of maternal alcohol consumption on gestational diabetes detection and mother-infant’s outcomes in Kinshasa, DR Congo. Open J Obs Gynecol. 2011;1(4):208–12.
  24. 24. Lekettey JDP, Dako-Gyeke P, Agyemang SA, Aikins M. Alcohol consumption among pregnant women in James Town Community, Accra, Ghana. Reprod Health. 2017;14(1):120. pmid:28950877
  25. 25. Alcohol | Australian Government Department of Health [Internet]. [cited 2020 Jun 17]. https://www.health.gov.au/resources/pregnancy-care-guidelines/part-c-lifestyle-considerations/alcohol
  26. 26. Ordinioha B, Brisibe S. Alcohol consumption among pregnant women attending the ante. natal clinic of a tertiary hospital in South. South Nigeria. Niger J Clin Pract. 2015;18(1):13–7. pmid:25511337
  27. 27. Popova S, Lange S, Probst C, Parunashvili N, Rehm J. Prevalence of alcohol consumption during pregnancy and Fetal Alcohol Spectrum Disorders among the general and Aboriginal populations in Canada and the United States. Eur J Med Genet. 2017;60(1):32–48. pmid:27638329
  28. 28. Tan CH, Denny CH, Cheal NE, Sniezek JE, Kanny D. Alcohol use and binge drinking among women of childbearing age—United States, 2011–2013. Morb Mortal Wkly Rep. 2015;64(37):1042–6. pmid:26401713
  29. 29. Popova S, Lange S, Probst C, Shield K, Kraicer‐Melamed H, Ferreira‐Borges C, et al. Actual and predicted prevalence of alcohol consumption during pregnancy in the WHO African Region. Trop Med Int Heal. 2016;21(10):1209–39. pmid:27429168
  30. 30. Ho R, Jacquemard R. Maternal alcohol use before and during pregnancy among women in Taranaki, New Zealand. New Zeal Med J. 2009;122(1306).
  31. 31. Williams AD, Nkombo Y, Nkodia G, Leonardson G, Burd L. Prenatal alcohol exposure in the Republic of the Congo: prevalence and screening strategies. Birth Defects Res Part A Clin Mol Teratol. 2013;97(7):489–96. pmid:23670862
  32. 32. Alcohol and Pregnancy: Attitudes Around the Globe [Internet]. [cited 2020 Jun 17]. https://womensmentalhealth.org/posts/alcohol-pregnancy-attitudes-around-globe/
  33. 33. Haynes G, Dunnagan T, Christopher S. Determinants of alcohol use in pregnant women at risk for alcohol consumption. Neurotoxicol Teratol. 2003;25(6):659–66. pmid:14624964
  34. 34. Barnet B, Duggan AK, Wilson MD, Joffe A. Association between postpartum substance use and depressive symptoms, stress, and social support in adolescent mothers. Pediatrics. 1995;96(4):659–66.
  35. 35. Isaksen AB, Østbye T, Mmbaga BT, Daltveit AK. Alcohol consumption among pregnant women in Northern Tanzania 2000–2010: a registry-based study. BMC Pregnancy Childbirth. 2015;15(1):205. pmid:26337194
  36. 36. Sedgh G, Singh S, Hussain R. Intended and unintended pregnancies worldwide in 2012 and recent trends. Stud Fam Plann. 2014;45(3):301–14. pmid:25207494
  37. 37. Coleman PK, Reardon DC, Cougle JR. Substance use among pregnant women in the context of previous reproductive loss and desire for current pregnancy. Br J Health Psychol. 2005;10(2):255–68. pmid:15969853
  38. 38. Onwuka CI, Ugwu EO, Dim CC, Menuba IE, Iloghalu EI, Onwuka CI. Prevalence and predictors of alcohol consumption during pregnancy in South-Eastern Nigeria. J Clin diagnostic Res JCDR. 2016;10(9):QC10. pmid:27790525
  39. 39. Demaio AR, Dugee O, De Courten M, Bygbjerg IC, Enkhtuya P, Meyrowitsch DW. Exploring knowledge, attitudes, and practices related to alcohol in Mongolia: a national population-based survey. BMC Public Health. 2013;13(1):1–7.
  40. 40. Sudhinaraset M, Wigglesworth C, Takeuchi DT. Social and cultural contexts of alcohol use: Influences in a social–ecological framework. Alcohol Res Curr Rev. 2016;
  41. 41. Coles CD, Black MM. Introduction to the special issue: impact of prenatal substance exposure on children’s health, development, school performance, and risk behavior. J Pediatr Psychol. 2006;31(1):1–4. pmid:22282638
  42. 42. Seyoum G, Gebre A. Rapid assessment of the situation of drug and substance abuse in selected urban areas in Ethiopia. Addis Ababa, AAU. 1995;9–55.
  43. 43. Wedajo Lemi B. Microbiology of Ethiopian traditionally fermented beverages and condiments. Int J Microbiol. 2020;2020. pmid:32148508
  44. 44. Narcotic Manual final—EFDA [Internet]. [cited 2020 Jun 18]. http://www.fmhaca.gov.et/publication/narcotic-manual-final/
  45. 45. Abebe H. Isolation and Characterization of the Dominant Yeast in the Traditional beverages of Ethiopia; Tella and Tej. Addis Ababa Universty; 2011.
  46. 46. Von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. Ann Intern Med. 2007;147(8):573–7. pmid:17938396
  47. 47. Kolfe Keranio Sub City—aaca [Internet]. [cited 2020 Jun 15]. http://www.addisababa.gov.et/de/web/guest/kolfe-keranio-sub-city
  48. 48. Anteab K, Demtsu B, Megra M. Assessment of Prevalence and Associated Factors of Alcohol Use during Pregnancy among the dwellers of Bahir-Dar City, Northwest Ethiopia, 2014. 2014;
  49. 49. Zimet GD, Dahlem NW, Zimet SG, Farley GK. The multidimensional scale of perceived social support. J Pers Assess. 1988;52(1):30–41.
  50. 50. Nakigudde J, Musisi S, Ehnvall A, Airaksinen E, Agren H. Adaptation of the multidimensional scale of perceived social support in a Ugandan setting. Afr Health Sci. 2009;9(2).
  51. 51. Saunders JB, Aasland OG, Babor TF, De la Fuente JR, Grant M. Development of the alcohol use disorders identification test (AUDIT): WHO collaborative project on early detection of persons with harmful alcohol consumption‐II. Addiction. 1993;88(6):791–804. pmid:8329970
  52. 52. Statistical Agency C, International I. Ethiopia 2011 Demographic and Health Survey.
  53. 53. Mohammed MA, Ahmed JH, Bushra AW, Aljadhey HS. Medications use among pregnant women in Ethiopia: a cross sectional study. J Appl Pharm Sci. 2013;3(4):116.
  54. 54. English L, Mugyenyi GR, Ngonzi J, Kiwanuka G, Nightingale I, Koren G, et al. Prevalence of Ethanol Use Among Pregnant Women in Southwestern Uganda. J Obstet Gynaecol Canada JOGC = J d’obstetrique Gynecol du Canada JOGC. 2015;37(10):901–2. pmid:26606706
  55. 55. Adusi-Poku Y, Edusei AK, Bonney AA, Tagbor H, Nakua E, Otupiri E. Pregnant women and alcohol use in the Bosomtwe district of the Ashanti region-Ghana. Afr J Reprod Health. 2012;16(1). pmid:22783668
  56. 56. Demographic N. Health Survey 2011. Addis Ababa, Ethiop. 2012;
  57. 57. Onah MN, Field S, van Heyningen T, Honikman S. Predictors of alcohol and other drug use among pregnant women in a peri-urban South African setting. Int J Ment Health Syst. 2016;10(1):38.
  58. 58. McNAMARA TAYK, Orav EJ, Wilkins-Haug L, Chang G. Social support and prenatal alcohol use. J Women’s Heal. 2006;15(1):70–6. pmid:16417421
  59. 59. Muckle G, Laflamme D, Gagnon J, Boucher O, Jacobson JL, Jacobson SW. Alcohol, smoking, and drug use among Inuit women of childbearing age during pregnancy and the risk to children. Alcohol Clin Exp Res. 2011;35(6):1081–91. pmid:21332531
  60. 60. Skeen S, Lund C, Kleintjes S, Flisher A, Consortium MhRP. Meeting the millennium development goals in Sub-saharan Africa: what about mental health? Int Rev Psychiatry. 2010;22(6):624–31. pmid:21226650