Risky drinking patterns are being continued into pregnancy: A prospective cohort study

Risky patterns of alcohol use prior to pregnancy increase the risk of alcohol-exposed pregnancies and subsequent adverse outcomes. It is important to understand how consumption changes once women become pregnant. The aim of this study was to describe the characteristics of women that partake in risky drinking patterns before pregnancy and to examine how these patterns change once they become pregnant.

A sample of 1577 women from the 1973–78 cohort of the Australian Longitudinal Study on Women’s Health were included if they first reported being pregnant in 2000, 2003, 2006, 2009 and reported risky drinking patterns prior to that pregnancy.

  • When reporting risky drinking patterns prior to pregnancy only 6% of women reported weekly drinking only, whereas 46% reported binge drinking only and 48% reported both.
  • Women in both binge categories were more likely to have experienced financial stress, not been partnered, smoked, used drugs, been nulliparous, experienced a violent relationship, and were less educated.
  • Most women (46%) continued these risky drinking patterns into pregnancy, with 40% reducing these behaviours, and 14% completely ceasing alcohol consumption.
  • Once pregnant, women who binged only prior to pregnancy were more likely to continue (55%) rather than reduce drinking (29%).
  • Of the combined drinking group 61% continued to binge and 47% continued weekly drinking.
  • Compared with the combined drinking group, binge only drinkers prior to pregnancy were less likely to reduce rather than continue their drinking once pregnant.

Over a third of women continued risky drinking into pregnancy, especially binge drinking, suggesting a need to address alcohol consumption prior to pregnancy.

Citation: Anderson AE, Hure AJ, Forder PM, Powers J, Kay-Lambkin FJ, Loxton DJ (2014). Risky drinking patterns are being continued into pregnancy: A prospective cohort study. PLOS One, 9 e86171

Referral for management of emotional health issues during the perinatal period: Does mental health assessment make a difference?

Routine assessment of current or past mental health issues during pregnancy and the postnatal period has been endorsed in clinical practice guidelines in Australia and a number of other countries. However, there is little evidence as to whether such assessments increase rates of referral for further treatment or management.

The aim of this study was to evaluate the impact of current and past mental health on referral for additional support or treatment during pregnancy and the first postpartum year. A subsample of 1,804 women from the 1973-78 cohort of the Australian Longitudinal Study on Women’s Health (ALSWH) provided data.

  • The strongest predictor of being given a referral for additional treatment or support during pregnancy was being asked by a health professional about past mental health.
  • Women who were asked about current mental health were also more than twice as likely to receive a referral.
  • The odds of receiving a referral were around 14 times higher for women who were asked about both their current and past mental health than for women who did not receive any form of assessment.
  • Being asked about one’s past or current mental health during the postnatal period also increased the likelihood of referral during the postnatal period.
  • The odds of receiving a referral were around 16 times higher for women who were asked about both their current and past mental health compared with women who received no assessment.
  • Experiencing significant emotional distress also predicted referral during both the prenatal and postnatal periods, suggesting that assessment did not inappropriately inflate referral rates.

The findings indicate that enquiry into risk factors such as past history (in addition to current mental health) enhances initiation of referrals, and highlights the importance of a comprehensive approach to mental health assessment.

Citation: Reilly N, Harris S, Loxton D, Chojenta C, Milgrom J, Austin M-P (2013). Referral for management of emotional health issues during the perinatal period: Does mental health assessment make a difference? Birth, 40(4), 297-306.

How do previous mental health, social support, and stressful life events contribute to postnatal depression in a representative sample of Australian women?

Postnatal depression (PND) is a debilitating condition that affects between 10-20% of Australian mothers. Several factors have been found to be predictive of PND, including a higher rate of obstetric interventions, having a caesarean birth, as well as suffering from depression and anxiety during or immediately prior to pregnancy.

However, while a number of studies have examined the predictors of PND, most have focused on events immediately prior to pregnancy and birth. The aim of this study was to examine both short- and long-term risk factors for PND using data collected before, during, and after pregnancy. The study used data from women born 1973-78, who had completed the first four surveys from the Australian Longitudinal Study on Women’s Health from 1996-2006.

  • The strongest predictor of PND was a history of depression; compared with women who had not reported depression, women who reported depression 3 or 6 years prior to pregnancy were more than twice as likely to experience PND.
  • Stressful life events reported both six years prior to, and at the time of the fourth survey were related to future PND, while women who had less affectionate support/positive social interaction were also at higher risk.
  • Contrary to other studies, demographic factors, including ability to manage on income, area of residence and education level were not associated with PND.

The findings suggest that PND has both short- and long-term risk factors. It is important that healthcare providers are aware of the range of factors that may increase the risk of PND in order to allow for a more targeted detection of women who may develop the condition.

Citation: Chojenta C, Loxton D, Lucke J (2012). How do previous mental health, social support, and stressful life events contribute to postnatal depression in a representative sample of Australian women? Journal of Midwifery and Women’s Health, 57(2), 145-150.

History of pregnancy loss increases the risk of mental health problems in subsequent pregnancies but not in the postpartum

Women who experience a pregnancy loss, including medical termination, miscarriage, ectopic pregnancy and stillbirth, commonly experience mental health problems such as depression and anxiety following the loss. However, little is known about mental health outcomes during subsequent pregnancies and following healthy births.

The aim of this study was to examine the impact of pregnancy loss on mental health in subsequent pregnancies and during the postnatal period. Data were obtained from a sub-sample of 584 women from the Australian Longitudinal Study on Women’s Health who had previously experienced a loss.

  • Nearly half of the women (45.5%) indicated that they experienced at least one emotional issue during their most recent pregnancy with anxiety being the most commonly reported issue (26.4%), followed by stress or distress (25%), and sadness or low mood (20.2%).
  • Just over half of the women (51.9%) reported at least one emotional issue during the postnatal period, with sadness and low mood being the most commonly reported issue (30.1%), followed by stress or distress (25.3%) and anxiety (22.3%).
  • Women who had a previous pregnancy loss were more than twice as likely to report excessive worry during a subsequent pregnancy, and were also more likely to report sadness or low mood.
  • However, there was no relationship between prior pregnancy loss and any emotional issue during the postnatal period.

Women who have experienced a pregnancy loss are particularly vulnerable to mental health problems during subsequent pregnancies. It is important to monitor the mental health of these women during this time, and if necessary offer anxiety or stress interventions. Such interventions will potentially benefit the woman, as well as reduce adverse outcomes for offspring.

Citation: Chojenta C, Harris S, Reilly N, Forder P, Austin M-P, Loxton D (2014). History of pregnancy loss increases the risk of mental health problems in subsequent pregnancies but not in the postpartum. PLOS One, 9(4): e95038. doi: 10.1371/journal.pone.0095038

Predictors of antenatal alcohol use among Australian women: A prospective cohort study

A large proportion of Australian women consume alcohol during pregnancy. It is important to identify predictors of such use; however no previous study has examined a comprehensive set of predictors using a population-based sample.

Data was obtained from women from the 1973-78 cohort of the Australian Longitudinal Study on Women’s Health, who indicated they were pregnant at survey two, three, four or five (from 2000-2009). Thirty-six variables were investigated as potential predictors of alcohol use during pregnancy, including sociodemographic factors, reproductive health, mental and physical health, health behaviours, alcohol guidelines and healthcare factors.

  • Most (82%) women continued to drink alcohol during pregnancy.
  • Women were more likely to drink alcohol during pregnancy if they had consumed alcohol on a weekly basis before pregnancy, binge drank before pregnancy, or if they were pregnant while alcohol guidelines recommended low alcohol versus abstinence.
  • Drinking during pregnancy was less likely if women had a Health Care Card or if they had ever had fertility problems.

Most Australian women who drank alcohol continued to do so during pregnancy. To ensure that women can make informed decisions about alcohol use during pregnancy, healthcare professionals should be providing all women with information about the potential harms of alcohol use and the reasons why abstinence is the safest option.

Citation: Anderson AE, Hure AJ, Powers JR, Kay-Lambkin FJ, Loxton DJ (2013). Predictors of antenatal alcohol use among Australian women: A prospective cohort study. BJOG, 120:1366-1374.

Disparities in reported psychosocial assessment across public and private maternity settings: A national survey of women in Australia

Psychosocial assessment in the perinatal period refers to the clinical evaluation of a broad number of risk factors that may contribute to the mental health outcomes of a woman and her infant. It is recommended that all women are assessed as part of routine pregnancy and postnatal care.

However, it is not clear how comprehensive such screening is, with most research focusing solely on the assessment of depression. Furthermore, most studies that have investigated screening have not been sufficiently inclusive of the 30% of women whose maternity care is provided in the private sector.

The aim of this study was to examine rates of assessment across a range of psychosocial domains, as well as the provision of mental health promotion information. A sub-study of 1,804 women from the Australian Longitudinal Study on Women’s Health (ALSWH) provided data.

  • Rates of assessment for the prenatal and postnatal periods respectively were: current mental health 66.8%, 75.6%, mental health history 52.9%, 41.2%, level of support 69.9%, 70.1%, drug and alcohol use 67.6%, 35.3%, and domestic violence or abuse 35.7%, 31.8%.
  • Mental health promotion information was received by 78.3% of women during pregnancy, and 81.6% of women during the postnatal period.
  • During pregnancy, women who gave birth in the public sector were far more likely to report being assessed across all domains of psychosocial assessment than women in the private sector.
  • The disparity between public and private settings did not extend to the postnatal period however, with similar figures observed for most measures.
  • Differences were observed between state/territory of residence for each of the measures. For example, assessment of mental health history during pregnancy ranged from 43.3% in Victoria to 63.8% in New South Wales, while domestic violence/abuse assessment ranged from 20.2% in Western Australia to 52.8% in New South Wales.
  • During the postnatal period, 89.1% of women from Western Australia had their current mental health assessed, compared to 58.7% of Queensland women.

The results indicate that there has been significant penetration in some areas of assessment, both during pregnancy and in the postnatal period. However, the low rates of screening for mental health history and domestic violence/abuse are concerning. It is important to minimise the current shortfall in assessment rates in private maternity settings, particularly during pregnancy.

Citation: Reilly N, Harris S, Loxton D, Chojenta C, Forder P, Milgrom J, Austin M-P (2013). Disparities in reported psychosocial assessment across public and private maternity settings: A national survey of women in Australia. BMC Public Health, 13:362.

Determinants of pregnant women’s compliance with alcohol guidelines: A prospective cohort study

In 2009, Australian alcohol guidelines for pregnancy changed from low to no alcohol intake. Previous research found a high proportion of pregnant Australian women drank during pregnancy; however, there has been limited investigation of whether pregnant women comply with 2009 alcohol guidelines.

The purpose of this study was to provide an assessment of pregnant women’s compliance with 2009 Australian alcohol guidelines and identify predictors of such compliance. Data from 837 women from the 1973–1978 cohort of the Australian Longitudinal Study on Women’s Health was analysed, involving women aged 30–36 years who were pregnant at the 2009 survey.

  • 72% of pregnant women did not comply with the 2009 alcohol guidelines and 82% of these women drank less than seven drinks per week, with no more than one or two drinks per drinking day.
  • Women who previously complied with the 2001 alcohol guidelines were more than 3 times as likely to comply with the 2009 guidelines as those who did not.
  • Women whose household incomes were $36,400 or more were less likely to comply with the guidelines, as were women who consumed alcohol at least weekly prior to pregnancy
  • Those who abstained from alcohol prior to pregnancy were more likely to comply.

Most pregnant women did not comply with alcohol guidelines promoting abstinence. Prior alcohol behaviour was the strongest predictor of compliance during pregnancy, suggesting alcohol use should be addressed in women of child-bearing age.

Citation: Anderson AE, Hure AJ, Powers JR, Kay-Lambkin FJ, Loxton DJ (2012). Determinants of pregnant women’s compliance with alcohol guidelines: A prospective cohort study. BMC Public Health, 12:777. doi:10.1186/1471-2458-12-777

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Recruiting online: Lessons from a longitudinal survey of contraception and pregnancy intentions of young Australian women

Recruiting participants for health surveys has become increasingly difficult, particularly where young people are concerned. Traditional recruitment practices involve methods such as postal, telephone and face-to-face invitations, which may not be compatible with the high usage and reliance on more modern forms of technology amongst younger people.

In recent years researchers have made use of social media as a means of recruiting young participants into health surveys, but it is not yet clear whether this is a cost-effective approach, or whether it can provide samples that demographically reflect the general population, particularly for longitudinal research.

In the current study, the researchers assessed the effectiveness of online recruitment methods in recruiting women aged 18-23 for the Contraceptive Use, Pregnancy Intention, and Decisions (CUPID) Study. A variety of methods were used, including Facebook advertisements and posts, Twitter, and online forums, as well as face-to-face events, distribution of promotional material, and media releases.

Over the one-year recruitment period, a total of 3,795 women were recruited to take part in the online survey, almost double the original target of 2,000. Women were recruited at an average cost of $11 per participant, substantially lower than that for the pilot version of the study, which, using mailed invitations, attracted only 54 participants at a cost of around $100 each. The sample was found to be broadly representative of 18-23 year old women in Australia in terms of demographics, with the exception of a higher proportion of women who had completed year 12 education.

While the use of multiple approaches makes it difficult to determine the success of individual strategies, Facebook appears to be a particularly effective means of recruitment, with a large daily increase in respondents observed following changes to the placement of advertisements from the sidebar to the central newsfeed.

facebook-793049_1280The findings from the current study suggest that it is possible to recruit a demographically representative sample of young women using online methods, and that this can be done at a reasonable cost.

This paper generated significant interest, with an invited commentary commissioned by the American Journal of Epidemiology. In this commentary Dr Jenifer Allsworth from the University of Missouri – Kansa City praised the study design, suggesting that the study was well conducted and made an important contribution to the literature.

Contact person: Melissa.Harris@newcastle.edu.au

Citation: Harris ML, Loxton D, Wigginton B, Lucke J. Recruiting online: Lessons from a longitudinal survey of contraception and pregnancy intentions of young Australian women. American Journal of Epidemiology, 2015. doi: 10.1093/aje/kwv006

Acquisition and utilization of information about alcohol use during pregnancy among Australian pregnant women and service providers

pregnant-216160_1280Because of an unknown safe level of alcohol consumption during pregnancy and inconsistent alcohol guidelines for pregnant women, it is unclear what information is being circulated with regard to alcohol use and pregnancy. This study aimed to explore how pregnant women and service providers acquire and utilize information about alcohol use during pregnancy.

The study involved 10-minute semi-structured interviews with 74 mothers of young children and focus groups with 14 service providers in urban and rural areas of New South Wales in 2008 and 2009.

  • Women and service providers expressed uncertainty about what the alcohol recommendations were for pregnant women.
  • Health care providers were inclined to discuss alcohol use with women they perceived to be high risk but not otherwise.
  • Women felt pressure to both drink and not drink during their pregnancies.
  • Those who drank discounted abstinence messages and reported a process of internal bargaining on issues such as the stage of their pregnancy and the type of beverages they consumed.
  • Those who abstained did so mainly because they were afraid of being held responsible for any problems with their pregnancies or infants that might have occurred from drinking.

Confusion surrounding the recommendations regarding alcohol use during pregnancy, inconsistency in addressing alcohol use with pregnant women, information overload, and a perceived culture of drinking appear to contribute to the high proportion of Australian women drinking during pregnancy.beer-199650_1280

Citation: Loxton D, Chojenta C, Anderson AE, Powers JR, Shakeshaft A, Burns L (2013). Acquisition and utilization of information about alcohol use during pregnancy among Australian pregnant women and service providers. Journal of Midwifery and Women’s Health, 58(5):523-530.

Contact person: Deborah Loxton Deborah.Loxton@newcastle.edu.au

Dietary intervention increases the size of the baby at birth

What you need to know:

There is evidence that dietary intervention during pregnancy can increase the size of the baby at birth. Interventions providing food and fortified food products or targeting pregnant women who are underweight, nutritionally at-risk or from a low income country are the most promising strategies to increase the size of the baby at birth. However, size is just a surrogate marker for other health and economic outcomes. Further large high-quality randomised controlled trials investigating combination dietary intervention and micronutrient provision from food are needed. Future trials spanning preconception, the duration of pregnancy and even between pregnancies are needed to advance our understanding of optimal maternal nutrition for maternal-child health.

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What this research is about:

Nutrition before conception and during pregnancy is important to ensure a healthy pregnancy outcome. Research has demonstrated the importance of diet as a prevention strategy for some adverse neonatal outcomes, particularly the role of folic acid for the prevention of neural tube defects. However, there is a clear need to identify the best dietary interventions for pregnant women aimed at preventing adverse neonatal and infant outcomes. The aim of this study was to synthesise the best of the available evidence by conducting a systematic review and meta-analysis to determine whether dietary interventions before or during pregnancy have any effect on neonatal or infant outcomes.

What did the researchers do:

A systematic review was conducted without date restrictions. Randomised controlled trials evaluating whole diet or dietary components and pregnancy outcomes were included. Two authors independently identified articles for inclusion and assessed methodological quality. Meta-analysis was conducted separately for each outcome using random effects models. Results were reported by type of dietary intervention: (i) counselling, (ii) food and fortified food products, or (iii) combination (counselling + food); and collectively for all dietary interventions. Results were further grouped by trimester when the intervention commenced, nutrient of interest, country income and body mass index.

What did the research find:

Of the 2326 abstracts screened, a total of 29 randomised controlled trials (31 publications) were included in this review, which included 10,026 participants. Results indicate that food or fortified food products increase birth weight (by approximately 125g) and reduce the incidence of low birth weight (by approximately 27% decrease in odds). Combining all dietary interventions, both increase birth weight and reduce the incidence of low birth weight (62g and 24% decreased odds respectively), and increase length (0.07cm). In sub-group analyses the largest gains in birth size are made in underweight and nutritionally at-risk populations, in both high and low income countries, and dietary interventions that focus on macronutrients.

How can you use this research:

This review advances our understanding of the role of nutrition for a healthy birth outcome. Providing nutrition education as well as food or fortified food products to pregnant women, particularly those who are underweight, at nutritional risk, or come from a low income country, is likely to increase the size of the baby at birth with important health and financial ramifications.

Contact person: Ellie Gresham ellie.gresham@uon.edu.au

Citation: Gresham, E., Byles, J.E., Bisquera, A., & Hure, A.J. The effects of dietary interventions on neonatal and infant outcomes: a systematic review and meta-analysis. American Journal of Clinical Nutrition. 2014.