04 December 2014 In Pregnant Women

BACKGROUND: Research on alcohol consumption during pregnancy and miscarriage spans over three decades, yet the relationship is still not well-understood.

OBJECTIVES: To assess the relationship between volume and type of alcohol consumed during pregnancy in relation to miscarriage.

METHODS: We utilized data from a population-based cohort study of pregnant women (n = 1061) of which 172 (16%) women had a miscarriage. Upon study entry, participants were asked about their alcohol consumption during pregnancy. Based on the average number of drinks per week, women were categorized into one of three categories: four or more drinks per week (n = 32, 3%), less than four drinks per week (n = 403, 38%), and no alcohol intake (n = 626, 59%). In addition, women were categorized by the type of alcohol beverage they consumed: beer only (n = 47, 4%), spirits only (n = 56, 5%), wine only (n = 160, 15%), or a combination of two or more types of alcohol (n = 172, 16%).

RESULTS: A significant increased risk of miscarriage (adjusted hazard ratio (aHR): 2.65; 95% confidence interval (CI): 1.38, 5.10) was found for women who drank four or more drinks a week. Our findings also suggest the relationship between alcohol intake during pregnancy and miscarriage is strongest for miscarriage occurring prior to 10 weeks of gestation. In addition, women who drank only spirits had more than a two-fold increased risk of miscarriage compared to women who abstained (aHR: 2.24; 95% CI: 1.32, 3.81). Conclusions/Importance: Future research assessing the factors that may contribute to an increased risk of miscarriage should consider the type of alcohol consumed.

OBJECTIVE: The effects of binge-drinking during pregnancy on the fetus and child have been an increasing concern for clinicians and policy-makers. This study reviews the available evidence from human observational studies.

DESIGN: Systematic review of observational studies. Population: Pregnant women or women who are trying to become pregnant.

METHODS: A computerised search strategy was run in Medline, Embase, Cinahl and PsychInfo for the years 1970-2005. Titles and abstracts were read by two researchers for eligibility. Eligible papers were then obtained and read in full by two researchers to decide on inclusion. The papers were assessed for quality using the Newcastle-Ottawa Quality Assessment Scales and data were extracted.

MAIN OUTCOME MEASURES: Adverse outcomes considered in this study included miscarriage; stillbirth; intrauterine growth restriction; prematurity; birth-weight; small for gestational age at birth; and birth defects, including fetal alcohol syndrome and neurodevelopmental effects.

RESULTS: The search resulted in 3630 titles and abstracts, which were narrowed down to 14 relevant papers. There were no consistently significant effects of alcohol on any of the outcomes considered. There was a possible effect on neurodevelopment. Many of the reported studies had methodological weaknesses despite being assessed as having reasonable quality.

CONCLUSIONS: This systematic review found no convincing evidence of adverse effects of prenatal binge-drinking, except possibly on neurodevelopmental outcomes.

OBJECTIVE: To examine whether the frequency and timing of binge drinking episodes (intake of five or more drinks on one occasion) during the first 16 weeks of pregnancy increase the risk of fetal death.

METHODS: The study is based upon data from 89,201 women who were enrolled in the Danish National Birth Cohort from 1996 to 2002 and participated in an interview that took place in midpregnancy (n=86,752) or after a fetal loss (n=2,449). In total, 3,714 pregnancies resulted in fetal death. Data were analyzed by means of Cox regression models.

RESULTS: Neither the frequency nor the timing of binge episodes was related to the risk of early (at or before 12 completed weeks) or late (13-21 completed weeks) spontaneous abortion. However, three or more binge episodes showed an adjusted hazard ratio of 1.56 (95% confidence interval 1.01-2.40) for stillbirth (22 or more completed weeks) relative to nonbinge drinkers. Women with an average intake of three or more drinks per week and two or more binge drinking episodes had a hazard ratio of 2.20 (95% confidence interval 1.73-2.80) compared with women with no average intake and no binge drinking.

CONCLUSION: Binge drinking three or more times during pregnancy is associated with an increased risk of stillbirth, but neither frequency nor timing of binge drinking was associated with an increased risk of spontaneous abortion in clinically recognized pregnancies.

Wagenaar et al.'s meta-analysis assessing the impact of price on drinking in this issue of Addiction is a true tour de force that will serve as an invaluable resource for researchers, public health practitioners, alcohol control advocates and policy makers for many years to come. Using state-of-the-art methods applied to a comprehensive set of English-language studies from economics and other social sciences, public health and other fields, they demonstrate clearly that higher alcoholic beverage taxes and prices reduce alcohol use. They find that this applies across beverages, with spirits and wine consumption more responsive to price than beer drinking, and that it applies to not only overall consumption, but also to measures of heavy drinking.These findings provide a strong rationale for using increases in alcoholic beverage taxes to promote public health by reducing drinking. Further support comes from the extensive literature that examines the relationships between alcoholic beverage taxes and prices and a variety of consequences of alcohol use and abuse. The Centers for Disease Control and Prevention estimate that excessive alcohol use resulted in 79 000 deaths annually in the United States from 2001 to 2005. In a recent study, Wagenaar and his colleagues found that the 1983 and 2002 alcoholic beverage tax increases in Alaska reduced alcohol-related disease mortality significantly, including deaths from liver cirrhosis, acute alcohol poisoning, alcohol-related cancers, cardiovascular diseases and others. In a series of studies, Markowitz et al. have shown that higher alcoholic beverage taxes and prices reduce violence, including spouse abuse, child abuse, suicide and other violent crime. Others have documented the reductions in fatal traffic crashes among youth, young adults and adults caused by alcohol that result from higher taxes and prices. Still others have shown that higher alcohol taxes and prices reduce other health consequences of alcohol use and abuse, including non-fatal work-place accidents , teenage pregnancy and the incidence of sexually transmitted diseases. At the same time, higher alcoholic beverage taxes and prices can improve educational outcomes among youths and young adults. In addition to the public health toll resulting from the morbidity, mortality and violence it causes, alcohol use and abuse impose substantial economic costs. The most recent estimates for the United States indicate that the economic costs of alcohol abuse were nearly $200 billion in 1998. Economists have shown that existing alcoholic beverage taxes fall well short of the costs that alcohol abusers impose on society. Despite the large and growing literature that higher alcoholic beverage taxes would reduce drinking and its consequences significantly, many governments are unwilling to raise these taxes. The stability of these taxes results in inflation eroding their value over time and, as a result, to declining real alcoholic beverage prices. In the United States, for example, rare federal tax increases and infrequent state tax increases have contributed to a sharp reduction in inflation-adjusted beer, wine and spirits prices over the past few decades. Given Wagenaar et al.'s findings on the relationships between prices and drinking, these falling prices have led to more drinking than would have been the case had taxes and prices kept pace with inflation and, as a result, greater consequences from alcohol abuse. This stands in clear contrast to cigarette taxes in the United States, which have risen sharply over the past two decades, raising inflation-adjusted cigarette prices and reducing significantly youth smoking initiation and leading many adult smokers to quit.The price elasticity estimates from Wagenaar et al.'s meta-analysis demonstrate that higher alcoholic beverage taxes can both reduce drinking and its consequences and raise new revenues for governments. The inelastic estimates they obtain for beer, wine, spirits and overall alcohol consumption imply that the quantity of alcohol consumed falls relatively less than price rises. For example, their estimated price elasticity of -0.44 for total alcohol means that a 10% increase in alcoholic beverage prices would reduce overall alcohol consumption by 4.4%. Given that alcohol beverage taxes account for only a fraction of the price of alcohol, relatively large increases in taxes will raise prices by a smaller percentage. If, for example, alcohol taxes account for one-quarter of alcoholic beverage prices, a doubling of the tax will raise the price by 25% (assuming that the tax is passed on fully to consumers). This price increase would reduce consumption by 11% while at the same time resulting in a nearly 80% rise in alcoholic beverage tax revenues.Perhaps the current economic downturn and resulting revenue needs of governments, coupled with the strong evidence-base on the benefits of higher taxes and prices reviewed thoroughly by Wagenaar et al. and others, will stimulate national and subnational governments to raise their alcoholic beverage taxes.

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