alcohol consumption behavior of pregnant women in japan
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Preventive Medicine 47 (2008) 544–549
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Alcohol consumption behavior of pregnant women in Japan
Tetsuo Tamaki a, Yoshitaka Kaneita a,⁎, Takashi Ohida a, Satoru Harano a, Eise Yokoyama a, Yoneatsu Osaki b,Shinji Takemura c, Kenji Hayashi d
a Department of Public Health, Nihon University School of Medicine, Tokyo 173-8610, Japanb Division of Enviromental and Preventive Medicine, Department of Social Medicine, Tottori University Faculty of Medicine, Tottori, Japanc Department of public Health Policy, National Institute of Public Health, Wako, Japand National Institute of Public Health, Wako, Japan
⁎ Corresponding author. Fax: +81 3 3972 5878.E-mail address: [email protected] (Y. Kane
0091-7435/$ – see front matter © 2008 Elsevier Inc. Aldoi:10.1016/j.ypmed.2008.07.013
a b s t r a c t
a r t i c l e i n f oArticle history:
Objective. This study wa Available online 29 July 2008Keywords:Alcohol consumptionPregnant womenJapan
s conducted to clarify the prevalence of alcohol consumption among pregnantwomen in Japan and its associated factors.
Method. 344 institutions participated in the survey which was conducted in February 2006. Each subjectwas requested to fill out a self-administered anonymous questionnaire. Factors associated with alcoholconsumption during pregnancy were examined using the chi-squared test and logistic regression analysis.
Results. The number of effective responses was 18,965. The prevalence of alcohol consumption before theconfirmation of pregnancy and during pregnancy was 44.6% and 4.6% respectively. The following items wererecognized as being associated with promoting alcohol consumption during pregnancy: greater number ofweeks of pregnancy, more pregnancies, fewer years of schooling, being employed, an alcohol consumptionbefore the confirmation of pregnancy, smoking during pregnancy, ignorance about the effects of alcoholconsumption on fetuses, receiving advice regarding alcohol abstention, difficulty maintaining sleep, anddaytime sleepiness.
Conclusion. It is important to have a more comprehensive understanding of the factors associated withthe alcohol consumption behavior of pregnant women, as revealed in the present study, in order to developfuture policies for preventing alcohol consumption among pregnant women.
© 2008 Elsevier Inc. All rights reserved.
Introduction
It is well known that alcohol consumption during pregnancyincreases the risk of fetal alcohol syndrome (FAS) (Centers forDisease Control and Prevention, 1995; Mattson and Riley, 1998;American Academy of Pediatrics, 2000). The incidence of FAS is race-dependent (Warren et al., 2001); in western countries, this is esti-mated to be within the range of 0.2 to 1.5 per 1000 births (Centersfor Disease Control and Prevention, 2008, compared with 1 per10,000–20,000 births in Japan (Tanaka, 1995).
It is also known that alcohol consumption during pregnancyinduces various fetal disorders, including FAS. For example, consump-tion of large amounts of alcohol during pregnancy is reported to be arisk factor for low infant birth weight (Mariscal et al., 2006), as well ascausing folic acid deficiency, which induces neurological disorders infetuses (Centers for Disease Control and Prevention, 1992; TheMinistry of Health, Labour and Welfare, Japan, 2000; Anderson etal., 2006).
ita).
l rights reserved.
In 2000, the Japanese Ministry of Health, Labour and Welfareconducted a nationwide survey of pregnancy, childbirth, and infantgrowth for mothers of children aged between 14 days and 6 years (TheMinistry of Health, Labour and Welfare, Japan, 2001). The datarevealed that 4% of women had consumed alcohol at least once perweek during pregnancy. A survey conducted by a health center inTokyo in 2005 revealed that the prevalence of alcohol consumptionduring pregnancy was 8.1% (Sawa, 2005). In our survey of the lifestylebehaviors of pregnant Japanese women in 2001, we found that theprevalence of alcohol consumption was 11% (Ohida, 2001). Althoughthese studies were significant nationwide surveys, they had someserious limitations. The results of the survey on baby's body growthmay have had a recall bias because the mothers were retrospectivelyquestioned about their alcohol consumption behavior after they hadgiven birth. In our 2001 survey and the survey of Tokyo, the motherswere asked whether or not they regularly consumed alcohol, andtherefore the evaluation of their alcohol consumption might not havebeen accurate. The present study was planned in order to resolve thelimitations of these previous studies by clarifying the prevalence ofalcohol consumption among pregnant women, and to identify itsassociated factors. It was anticipated that the data obtained from thisstudy would be extremely important for improving maternal andchild health.
Table 1Background of the survey subjects among Japanese pregnant women
Number %
Age (year) (N=18,965)Under 20 263 1.420–24 2267 12.025–29 5877 31.030–34 7316 38.635–39 2874 15.240 or above 368 1.9
Schooling (years) (N=18,945)12≧ 7014 37.012b 11,931 63.0
Current employment status (N=18,831)Not employed 13,686 72.7Employed 5145 27.3
Pregnancy trimester (N=18,965)First trimester (∼13 weeks) 1248 6.6Second trimester (14 weeks–27 weeks) 6774 35.7Third trimester (28 weeks∼) 10,943 57.7
Number of pregnancies (N=18,921)First 9146 48.2Second 6602 34.8Third 2349 12.4Fourth or more 824 4.3
Data were collected in February in 2006.For each item, the subjects who did not answer the related questions were excluded.
545T. Tamaki et al. / Preventive Medicine 47 (2008) 544–549
Methods
Sample and procedures
The studywas approved by the Ethics Committee of the institution.Among the 940 survey points which were the medical institutionsthat Japan Association of Obstetricians and Gynecologists specified fora survey of an infectious disease and statistics in all over Japan, 344institutions that provided maternity services eventually participatedin the survey. We distributed questionnaires, envelopes, and writingmaterial to the medical institutions that were willing to cooperatewith the survey at the end of January 2006. The number of question-naires distributed was 24,000, while 19,650 completed questionnaireswere collected (collection rate, 82%). The subjects of the study werewomen with confirmed pregnancies who had had a 2nd or subse-quent prenatal consultation at one of these institutions. Each subjectwas requested to fill out a self-administered anonymous question-naire while waiting at the institution. Completed questionnaires wereenclosed in the envelopes provided, sealed, and handed over to thestaff at the institutions.
The following survey items were included in the questionnaire: age,years of schooling completed, pregnancy status, employment status,smoking status before and after the confirmation of pregnancy, alcoholconsumption status before and after the confirmation of pregnancy,items regarding sleep (subjective assessment of sleep; sleep duration;and whether or not the subjects had difficulty initiating sleep,maintaining sleep, or showed early morning awakening), daytimesleepiness, and a diagnosis of restless leg syndrome. The EpworthSleepiness Scale (Johns, 1991) was used for evaluation of daytimesleepiness. Total scores of 0–10 indicated absence of daytime sleepiness,and total scores of 11 or more indicated presence of daytime sleepiness.
The questions regarding alcohol consumption status after theconfirmation of pregnancy were as follows:
1. Do you currently consume alcoholic beverages? [Yes/No]For those who answered “Yes”: What amount of alcoholicbeverages do you consume at one session? [when converted tothe equivalent quantity of beer, ca. one glass (less than 350 ml)/one500-ml bottle/two 500-ml bottles/three or more 500-ml bottles]
2. Are you aware of the effects of alcohol consumption on fetuses?[Yes/No]
3. Were you advised to quit alcohol consumption after yourpregnancy had been confirmed? [Yes/No]If Yes, who advised you? [Spouse/parents/friends, acquaintances/physicians, nursing staff/others]
4. Do you use alcoholic beverages to induce sleep? [Never/seldom/sometimes/often/always]
In this study, those who answered “yes” to the question “Do youcurrently consume alcoholic beverages?” and consumed the alcoholequivalence of one or more glasses of beer were classified as “drinkersduring pregnancy.”
The survey was conducted for 2 weeks in February 2006. Of the19,650 collected questionnaires, 227 were excluded because theweeks of pregnancy were not known,125 because the estimated datesof delivery were not stated, 18 because the dates when the ques-tionnaires were completed were not stated, and 315 because they didnot contain responses to the questions regarding alcohol consump-tion. Data from the remaining 18,965 questionnaireswere analyzed, asthey had complete data.
Statistical analyses
First, the prevalence of alcohol consumption before the confirma-tion of pregnancy and during pregnancy was calculated. Then, amongthose who consumed alcohol before the confirmation of pregnancy,the percentage of those who quit drinking during pregnancy was
calculated. Finally, using the chi-squared test and multiple logisticregression analysis, the factors associated with alcohol consumptionduring pregnancy were examined. In the multiple logistic regressionanalysis, alcohol consumption during pregnancy was used as thedependent variable, and the following items were used as covariates:age, weeks of pregnancy, number of pregnancies, years of schoolingcompleted, employment status, smoking during pregnancy, alcoholconsumption before the confirmation of pregnancy, awarenessregarding the effects of alcohol consumption on fetuses, whether ornot the participants had been advised to quit alcohol consumption,sleep duration, difficulty initiating sleep, difficulty maintaining sleep,early morning awakening, and daytime sleepiness. All the analyseswere performed using SPSS for Windows Version 11.5.
Results
Attributes of the survey participants
Participants aged 25 years or more and less than 35 yearsaccounted for approximately 70% of all the analyzed cases. Themean agewas 30.0 years [Standard Deviation (SD) 4.7]. With regard tothe years of schooling completed, those with more than 12 years ofschooling accounted for 63% of the cases. A considerable number ofparticipants were not employed; moreover, a considerable numberwere in the 28th or later weeks of pregnancy (Table 1).
The data of this study and those of the Vital Statistics of Japan(2006) were very similar with regard to the age distribution ofpregnant women and the number of live births in each of the 6 zonesinto which the country was divided. Furthermore, the number ofpregnancies reported in this study and the percentage of births bybirth order obtained from the study Vital Statistics of Japan are verysimilar (Table 2).
Prevalence of alcohol consumption before the confirmation of pregnancyand during pregnancy
The prevalence of alcohol consumption before the confirmationof pregnancy was 44.6% [95%confidence interval (CI) 43.9%, 45.3%]and that during pregnancy was 4.6% [95%CI 4.3%, 4.9%]. Approxi-mately 0.3% [95%CI 0.2%, 0.4%] of the pregnant women startedconsuming alcohol during pregnancy, although they had not
Table 2Comparison of this study in Japan and Vital Statistics of Japan regarding “age distribution”, “number of live births”, and “births by birth order”
This study Number % Vital statistics in 2006 Number %
Age class (year)Under 20 263 1.4 15,974 1.520–24 2267 12.0 130,230 11.925–29 5877 31.0 335,771 30.730–34 7316 38.6 417,776 38.235–39 2874 15.2 170,775 15.640 or above 368 1.9 22,139 2.0Total 18,965 100.0 1,092,665 100.0
Number of live birthsHokkaido/Tohoku 1571 8.3 117,802 10.8Kanto/Tokai 8721 46.0 456,495 41.8Zyousinetsu 1450 7.6 89,470 8.2Kinki 3367 17.8 197,182 18.0Chugoku/Shikoku 1980 10.4 98,186 9.0Kyushu 1876 9.9 133,363 12.2Foreign country 176 0.0Total 18,965 100.0 1,092,674 100.0
Number of pregnancies Births by order of birthFirst 9146 48.2 First 522,785 47.8Second 6602 34.8 Second 407,783 37.3Third 2349 12.4 Third 130,796 12.0Fourth or more 824 4.3 Fourth or more 31,301 2.9Unknown 44 0.2Total 18,965 100.0 1,092,665 100.0
Data of this study were collected in February in 2006.Due to rounding, the percentages may not equal 100%.
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consumed it before the confirmation of pregnancy. Among thewomen who had consumed alcohol before the confirmation ofpregnancy, those who quit drinking in pregnancy accounted for90.3% [95%CI 89.7%, 90.9%] of the cases (Table 3). With regard toalcohol consumption during pregnancy, the majority of women(90.8% [95% CI 88%, 92.8%]) reported drinking the equivalent of oneglass of beer at one session (Table 4).
The prevalence of alcohol consumption during pregnancy areshown in Table 5.
Factors associated with alcohol consumption during pregnancy
The results of the logistic regression analysis using alcohol con-sumption during pregnancy as a response variable are shown in Table6. The adjusted odds ratios for alcohol consumption duringpregnancy were significantly high among women in the greaternumber of weeks of pregnancy, those who had more pregnancies,those who had completed fewer years of schooling, those who wereemployed, those who smoked during pregnancy, those whoconsumed alcohol before the confirmation of pregnancy, those whowere ignorant about the effects of alcohol consumption on fetuses,those who had been advised to quit alcohol consumption, those whohad difficulty maintaining sleep, and those who experienced daytimesleepiness.
Table 3Alcohol consumption statuses of the women before the confirmation of pregnancy andduring pregnancy among Japanese women
Before pregnancy During pregnancy Total
Not drinking Drinking
Not drinking 10,448 58 10,506 (55.4%)Drinking 7639 820 8459 (44.6%)Total 18,087 (95.4%) 878 (4.6%) 18,965 (100%)
Data were collected in February in 2006.
Discussion
One of the strengths of this epidemiological study is that theresults generalize to large portion of childbearing women in thecountry because this study was conducted on a nationwide scale witha relatively high response rate. We have already demonstratedelsewhere that the age structure of the sample used for this studywas similar to that of mothers of neonates nationwide, as obtainedfrom the results of Vital Statistics of Japan (Ohida et al., 2007). Thissuggests that the study sample represented pregnant women in Japan.The second strength is that the amount of alcohol consumed wasobtained. The third strength is that the precision of this statisticalanalysis was ensured by using large-scale data, i.e., approximately19,000 questionnaires.
In this study, womenwho had consumed alcohol once or more perweek before the confirmation of pregnancy accounted for 44.6% of thesubjects. During pregnancy, the prevalence of alcohol consumptiondecreased to 4.6%. The prevalence of alcohol consumption once ormore per week during pregnancy was 4.0% as revealed by the surveyconducted by the Ministry of Health, Labour andWelfare in 2000 (TheMinistry of Health, Labour and Welfare, Japan, 2001). Although thedefinitions of alcohol consumption during pregnancy were slightlydifferent for these surveys, our result was markedly similar to the
Table 4Amount of alcohol during pregnancy among Japanese pregnant women
Alcoholic quantity Number %
A glass of beer ≦17.5 g 753 90.8A bottle of beer 25 g 66 8.02 bottles of beer 50 g 8 1.03 bottles of beer or more 75 g≦ 2 0.2Total 829 100.0
Data were collected in February in 2006.Among 878 who drank during pregnancy, 49 did not answer the related question.The quantity of “a glass” and “one bottle” defined as less than 350 ml and 500 mlrespectively.We calculated alcoholic level at 5%.
Table 5Prevalence of alcohol consumption among Japanese pregnant women
Number % 95% CI
Total 18,965 4.6 4.3–4.9Age (year) (N=18,965)Under 20 263 1.9 0.2–3.620–24 2267 4.4 3.6–5.225–29 5877 4.1 3.6–4.630–34 7316 4.7 4.2–5.235–39 2874 6.1 5.2–7.040 or above 368 4.3 2.2–6.4
Pregnancy trimester (N=18,965)First trimester (∼13 weeks) 1248 3.0 2.1–3.9Second trimester (14 weeks–27 weeks) 6774 4.6 4.1–5.1Third trimester (28 weeks∼) 10,943 4.8 4.4–5.2
Number of pregnancies (N=18,921)First 9146 3.0 2.7–3.3Second 6602 5.4 4.9–5.9Third 2349 7.7 6.6–8.8Fourth or more 824 7.9 6.1–9.7
Schooling (years) (N=18,945)12≧ 7014 5.5 5.0–6.012b 11,931 4.1 3.7–4.5
Current employment status (N=18,831)Not employed 13,686 4.4 4.1–4.7Employed 5145 5.1 4.5–5.7
Smoking during pregnancy (N=18,933)Not employed not smoking 17,503 4.2 3.9–4.5Employed 1430 9.9 8.4–11.4
Drinking frequency before pregnancy (N=8,163)1–2 times per week 4866 7.0 6.3–7.73–4 times per week 1401 12.1 10.4–13.8Almost everyday 1896 15.5 13.9–17.1
Amount of drinking before pregnancy (N=13,522)A glass of beer 7,504 4.2 3.7–4.7A bottle of beer 4,022 8.2 7.4–9.02 bottles of beer 1,398 10.6 9.0–12.23 bottles of beer or more 598 11.9 9.3–14.5
About the effects of drinking on fetuses (N=18,879)Unknown 4233 4.7 4.1–5.3Known 14,646 4.6 4.3–4.9
Advised to quit drinking (N=8,077)No 4490 9.0 8.2–9.8Yes 3587 10.8 9.8–11.8
Have a nightcap (N=18,328)No 18,222 4.7 4.4–5.0Yes 106 19.8 12.2–27.4
Sleep duration (hours) (N=18,796)7N 4545 5.5 4.8–6.27≦ 14,251 4.4 4.1–4.7
Difficulty in initiating sleep (N=18,949)No 16,129 4.5 4.2–4.8Yes 2820 4.4–6.0
Difficulty maintaining sleep (N=18,946)No 11,588 4.1 3.7–4.5Yes 7358 5.5 5.0–6.0
Early morning awakening (N=18,951)No 17,261 4.5 4.2–4.8Yes 1690 6.0 4.9–7.1
Daytime sleepiness (`=17,687)No 16,583 4.5 4.2–4.8Yes 1104 6.2 4.8–7.6
Awakening for snoring (N=18,880)No 18,378 4.6 4.3–4.9Yes 502 7.0 4.8–9.2
Restless legs syndrome (N=18,879)No 18,190 4.6 4.3–4.9Yes 689 6.1 4.3–7.9
Data were collected in February in 2006.For each item, the subjects who did not answer the related questions were excluded.
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result obtained by the ministry. The prevalence of alcohol consump-tion during pregnancy in the U.S. in recent years was reported to be inthe range of 10–16% (Ebrahim et al., 1998; Centers for Disease Controland Prevention, 2002; Centers for Disease Control and Prevention,2004), and that in Perth, Australia, was 35% (Giglia and Binns, 2007).
The prevalence of alcohol consumption among general reproductive-age women in both the U.S. and Japan exceeded 50% (The Ministry ofHealth, Labour and Welfare, Japan, 2004; Centers for Disease Controland Prevention, 2005) and each of the rates was very similar. There-fore, the reason for the difference in the prevalence of alcohol con-sumption during pregnancy between these countries could not beexplained by alcohol consumption behavior before the confirmationof pregnancy. In Japan, it is mandatory for women to report theirpregnancy to the municipal government, following which, a maternaland child health handbook is issued to them. This handbook providesguidance on lifestyle habits during pregnancy, which could lower theprevalence of alcohol consumption during pregnancy in Japan.
Since the prevalence of alcohol consumption during pregnancydecreased by a factor of approximately 10, it was revealed that mostpregnant women modified their alcohol consumption behavior whenthey became aware of their pregnancy. However, in particular groups,such as pluriparas and those who had completed fewer years ofschooling, the prevalence of alcohol consumption during pregnancywas significantly high. Among pluriparas, familiarization withpregnancy could lead to downplaying the risk of the effects of alcoholconsumption on fetuses in subsequent pregnancies.
In this study, it was indicated that the adjusted odds ratio withregard to alcohol consumption increased as the weeks of pregnancyincreased. The first trimester of pregnancy is the organogenesis stage;at this stage, the embryo is most susceptible to external influences.Thus, the risk of developing congenital abnormalities is especiallyhigh at this stage (Shiota et al, 2001). Moreover, in the first trimester,the course is unstable and there is a greater risk of miscarriage(Sagawa and Matsumoto, 1998). Hyperemesis gravidarum also easilyoccurs in this trimester, which may restrict alcohol consumption. It isinferred that all the above factors reciprocally function to decrease theadjusted odds ratio for alcohol consumption during the first trimesterof pregnancy.
This study indicated that lifestyle habits, such as smoking and sleep,were significantly associated with alcohol consumption. Previous epi-demiological studies pointed out an association between smoking andalcohol consumption among pregnant women as well as the generalpopulation (Serdula et al., 1991; Nakamura et al., 1996; Floyd et al.,1999; Matsubara et al., 2000). Furthermore, an epidemiological studyon the general Japanese population reported that alcohol consumptionand difficulty maintaining sleep were closely associated (Kaneita et al,2007). All these findings suggest that associations between alcoholconsumption and smoking/sleep are not only evident amongpregnant women but also among the general population. Becausesmoking and sleep disturbance cause various health hazards tofetuses (Olsen et al., 1991; Fox et al., 1994; Suzuki et al., 2003;Hammoud et al., 2005), similar to alcohol consumption, promotionof comprehensive health guidance regarding all of these lifestylebehavior among pregnant women is recommended. Recently, manyreports have indicated the effects of motivational interviewing andbrief intervention on self-restraint among pregnant women withregard to alcohol consumption (Manwell et al., 2000; Chang et al.,2005, 2006; Floyd et al, 2006). Health guidance on behavioralchanges like these, as well as awareness, is being actively promoted.The extent to which such health guidance is actually beingpromoted in Japan is not known, but it is hoped that it will becomemore widespread in the future.
Study limitations
This study had a few limitations. The response rate from theparticipating obstetric facilities was low, approximately 37%. Onereason for this may be a decrease in recent years in the number ofobstetric clinical facilities in Japan. In effect, approximately 18% of theclinical facilities (210) that clearly stated reasons for non-participa-tion in the present survey cited a discontinuation of maternity
Table 6Logistic regression analysis using the subjects who consumed alcohol during pregnancy among Japanese pregnant women
Crude OR 95%CI P-valuea Adjusted OR 95%CI P-value b
Age (year) b0.001 0.412Under 20 0.39 0.16–0.96 0.39 0.12–0.1320–24 0.93 0.74–1.17 0.94 0.71–1.2525–29 0.87 0.73–1.03 0.99 0.81–1.2030–34 1.00 1.0035–39 1.32 1.09–1.59 1.12 0.90–1.4040 or above 0.92 0.55–1.54 0.78 0.45–1.36
Pregnancy trimester 0.013 0.024First trimester (∼13 weeks) 1.00 1.00Second trimester (14 weeks–27 weeks) 1.58 1.12–2.23 1.56 1.05–2.32Third trimester (28 weeks∼) 1.66 1.19–2.33 1.71 1.15–2.53
Number of pregnancies b0.001 b0.001First 1.00 1.00Second 1.81 1.55–2.13 2.45 2.03–2.96Third 2.66 2.20–3.22 3.07 2.42–3.89Fourth or more 2.74 2.07–3.63 2.99 2.13–4.18
Schooling (years) b0.001 0.03312≧ 1.34 1.17–1.54 1.20 1.02–1.4312b 1.00 1.00
Current employment status 0.057 0.026Not employed 1.00 1.00Employed 1.16 0.99–1.34 1.23 1.03–1.47
Smoking during pregnancy b0.001 b0.001No 1.00 1.00Yes 2.50 2.07–3.02 1.53 1.21–1.93
Drinking before pregnancy 0.001 0.001No 1.00 1.00Yes 19.30 14.79–25.28 2.49 1.49–4.17
About effects of drinking on fetuses 0.760 b0.001Unknown 1.03 0.87–1.21 1.43 1.18–1.73Known 1.00 1.00
Advised to quit drinking 0.009 0.001No 1.00 1.00Yes 1.22 1.10–1.41 1.32 1.13–1.55
Sleep duration (hours) 0.003 0.7597N 1.00 1.007≦ 0.80 0.69–0.93 0.97 0.81–1.67
Difficulty in initiating sleep 0.137 0.962No 1.00 1.00Yes 1.15 0.96–1.38 1.01 0.80–1.27
Difficulty maintaining sleep b0.001 0.042No 1.00 1.00Yes 1.34 1.20–1.58 1.19 1.01–1.41
Early morning awakening 0.004 0.862No 1.00 1.00Yes 1.37 1.10–1.69 0.98 0.74–1.29
Daytime sleepiness 0.014 0.002No 1.00 1.00Yes 1.38 1.07–1.78 1.56 1.17–2.08
Data were collected in February in 2006.For each item, the subjects who did not answer the related questions were excluded from analyses.
a P-values were calculated by univariate model.b P-values were calculated by multivariate model.
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services in recent years. Other reasons for the low response rate werenot known. However, as mentioned previously, the participants of thesurvey were representative of the population of Japanese pregnantwomen.
Second, self-reported data were used for evaluation of alcoholconsumption behavior; biological and chemical measurements werenot utilized. Third, alcohol consumption behavior during pregnancywas evaluated at the time of the survey. Fluctuations in alcoholconsumption behavior, such as relapse of alcohol consumption afterabstention, were not surveyed. To understand such fluctuations inalcohol consumption behavior during pregnancy, a survey on womenafter they give birth, using questionnaires that include items onabstention from and relapse of alcohol consumption is required; or,multiple surveys need to be conducted on the same pregnant women.Furthermore, detailed questions on alcohol consumption, such asfrequency of consumption, reasons for abstention, and awarenessabout specific influences of alcohol consumption on fetuses, were not
included in the questionnaire. This issue must be resolved in ourfuture studies.
Fourth, as this was a cross-sectional survey, the causal relationshipbetween alcohol consumption behavior and each factor could not bedetermined. Therefore, it was not clear whether all the items thatwere recognized as being related to alcohol consumption were riskfactors for alcohol consumption. Although the risk factors could not beidentified in our study, the factors associated with alcohol consump-tion were indicated, which we believe will contribute to drawing upguidelines for improving future maternal and child health activities.
Conclusion
Greater number of weeks of pregnancy, more pregnancies, feweryears of schooling, being employed, alcohol consumption before theconfirmation of pregnancy, smoking during pregnancy, ignoranceabout the effects of alcohol consumption on fetuses, receiving advice
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regarding alcohol abstention, difficulty maintaining sleep, and day-time sleepiness were associated with promoting alcohol consumptionduring pregnancy. These results indicate the need for preventionefforts to reduce prenatal alcohol consumption. It is recommendedthat more effective strategies to motivate alcohol abstention amongpregnant women in Japan are developed and evaluated in the future.
Conflict of interest statementWe declare that there are no conflicts of interest.
Acknowledgments
We would like to express our appreciation to the Japan Asso-ciation of Obstetricians and Gynecologists for their cooperation.
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