RUNNING HEAD: Drinking trajectories and pregnant Inuit women

“Trajectories of Alcohol Use and Binge Drinking among Pregnant Inuit Women”

Marilyn Fortin, Ph.D.1,2,, Gina Muckle, Ph.D.1,2, Elhadji Anassour-Laouan-Sidi, M.Sc.2, Sandra W. Jacobson, Ph.D.3, Joseph L. Jacobson, Ph.D.3, Richard E. Bélanger, M.D.2,4

1Department of Psychology, Laval University, Québec (QC) Canada2Population Health and Optimal Health Practices Research Unit, CHU de Québec

Research Centre, Québec (QC), Canada.3Department of Psychiatry and Behavioral Neurosciences, Wayne State University

School of Medicine, Detroit, Michigan, USA4Department of Pediatrics, Centre mère-enfant Soleil, CHUQ, Laval University, Québec

(QC) Canada

Word count abstract: 250Word count text: 4,018Number of tables: 3Figures: 1

Declaration of interest

This study was supported by the National Institute of Environmental Health and

Sciences⁄National Institutes of Health (R01-ES07902); Indian and Northern Affairs

Canada (Northern Contaminants Program); Health Canada; Hydro-Québec

(Environmental Child Health Initiative); the Public Health Direction of the Nunavik

Regional Board of Health and Social Services; the Joseph Young, Sr. Fund from the State

of Michigan, USA; and by postdoctoral research awards from the Canadian Institutes of

Health Research (CIHR) (RN188397-299895) and the Nasivvik Centre for Inuit Health

and Changing Environments (to Marilyn Fortin). The authors declare no competing

financial interests.

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AbstractBackground: This study investigated trajectories of alcohol use and binge drinking

among Inuit women starting from a year before pregnancy until a year after delivery,

examined transition rates between time periods, and established whether specific factors

could be identified as predictors of changes in alcohol behaviors.

Methods: Drinking trajectories and movement among alcohol users and binge drinkers

(i.e., non-binging and binging) were explored by Markov modeling across time periods.

Two hundred and forty-eight Inuit women from Arctic Quebec were interviewed at

midpregnancy, and at 1 and 11 months postpartum to obtain descriptive data on alcohol

use during the year before pregnancy, the conception period, the pregnancy and the year

after delivery.

Results: The proportions of drinkers and bingers were 73% and 54% during the year

prior to pregnancy and 62% and 33% after delivery. Both alcohol use and binge drinking

trajectories demonstrated a significant drop in prevalence between the year before

conception to the conception period. We also noted high probabilities of becoming an

abstainer or not binging at this time. However, up to 60% of women continued to drink

alcohol during pregnancy. Women in couples and not consuming marijuana were more

likely to decrease their binge drinking at conception.

Conclusions: This study emphasizes the importance of including the period around

conception in the definition of drinking patterns during pregnancy. The importance of

considering alcohol consumption in a multidimensional way (personal, familial and

social determinants) is also addressed while trying to minimize problems both for the

fetus and the mother.

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Keywords: Trajectory, Alcohol, Binge drinking, Women, Pregnancy, Inuit, Markov

models, Marijuana

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Title: Trajectories of Alcohol Use and Binge Drinking among Pregnant Inuit Women

1. Introduction

In most countries and cultures, alcohol is strongly embedded in modern life

(Gusfield, 1996; Heath, 1986; World Health Organization (WHO), 2014). The WHO

estimated that in 2010 one-third of adults worldwide drank alcohol at least once in their

lives, and three-quarters of them drank alcohol in the previous year (WHO, 2014). In

North America, the vast majority of adults are considered active drinkers (Health Canada,

2011; Substance Abuse and Mental Health Services Association, 2012). Excessive

alcohol consumption is attributable to 5% of the worldwide global burden of disease

(WHO, 2014), healthcare costs of 12.8% in high-income countries (Rehm et al., 2009),

and a number of associated short and long-term health problems, such as violence, heart

disease, stroke, cancer, mental health and substance dependence (National Institute of

Alcohol Abuse and Alcoholism, 2008).

The Inuit – an Aboriginal population living in North America and Greenland –

have their own cultural and social history related to alcohol. Accordingly, their alcohol

consumption frequency is relatively low, and abstinence is high compared to their fellow

Canadian citizens (Muckle et al., 2007, cited in Muckle et al. 2011). However, the

amount of alcohol Inuit men and women consume per drinking day is much greater, and

episodes of binge drinking are three times more frequent (Korhonen, 2004; Muckle et al.,

2007).

Maternal alcohol drinking during pregnancy is of particular concern. As many

women continue to drink heavily or have binge-drinking episodes during pregnancy

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(Substance Abuse and Mental Health Services Administration, 2012), alcohol exposure in

utero may result in a constellation of growth, developmental and behavioral problems

falling under the umbrella of fetal alcohol spectrum disorders, including fetal alcohol

syndrome (FAS) and alcohol-related neurodevelopmental disorders (Hoyme et al., 2005).

Higher FAS rates have been reported among American and Canadian aboriginal groups

in comparison to the general population (Burd and Moffat, 1994; Carney and Chermak,

1991; Chudley et al., 2005; Werk et al., 2013). Alcohol use during pregnancy is also

associated with socioeconomic insecurity, poor social support, smoking and drug use and

abuse by mothers (Archibald, 2004; Fortin et al., 2015; Haynes et al., 2003; Horrigan et

al., 2000), which can also negatively impact child health.

Considerable intra-individual variability of alcohol drinking exists over time and

according to specific lifetime periods or stage of development, personal and familial

status, family and peer influences as well as lifestyle (Barnes et al., 2000; Bobo and

Greek, 2011; Curran et al., 1998; Fuzhong et al., 2001; Maggs and Schulenberg, 2004-

2005). In certain Occidental cultures, pregnancy is associated with decreased alcohol

consumption (Cameron et al., 2013; Denny et al., 2009; Walker et al., 2011). Women

from Russia (Balachova et al., 2012) and France (Malet et al., 2006) have been found to

report no significant difference in alcohol consumption before and during pregnancy.

Exceedingly heavy binge drinking before and during pregnancy has also been noted

among the Cape Colored (mixed ancestry) community in South Africa (Jacobson et al.,

2006; May et al., 2013), resulting in some of the highest prevalence of FAS in the world.

This trend has also been observed among older and single women of low socioeconomic

status who consume recreational drugs (Cameron et al., 2013).

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While some studies have established how much Inuit women drink during and

around the time of pregnancy (Godel et al., 1992, 2000; Muckle et al. 2011), none has

conducted time trends analyses of longitudinal data to follow the evolution of drinking

patterns in the context of pregnancy. To our knowledge, only few have examined the

question of time-specific variation in alcohol use across pregnancy and how such

variability could impact future drinking patterns among female western populations (Day

et al., 1989; Jacobson et al., 2002).

This study (1) investigated trajectories of alcohol consumption and binge drinking

among Inuit women beginning the year prior to pregnancy until the end of the first

postpartum year, and (2) assessed transitions between time periods. Since variations in

drinking patterns have been reported in many populations in relation to personal and

familial factors, (3) we examined whether these influences could be identified as

predictors of changes in alcohol behavior. Our study has the potential to contribute to the

development of prevention and intervention programs adapted for Inuit women.

2. Methods

2.1 Study procedures and sample

Pregnant Inuit women were invited to participate in a prospective mother-child

cohort in Northern Quebec, Nunavik, Canada (Muckle et al., 2001, 2011; Jacobson et al.,

2008). The Nunavik region is located north of the 55th parallel in the province of Quebec

(Canada). About 11,000 Inuit are scattered along a 2,000-km shoreline of Hudson Bay,

the Hudson Strait and Ungava Bay. They live in 14 villages, ranging from 160 to 2,055

inhabitants per village. From November 1995 to November 2000, a midwife or nurse in

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each of the 3 largest Inuit villages on the Hudson Bay coast provided us with the names

of pregnant women shortly after their first prenatal visit. A project research assistant

contacted potential participants by telephone and invited them to meet at the village’s

nursing station to learn more about the study’s objectives and procedures. Women

without telephones were reached by announcement on the village’s radio station.

Maternal interviews were conducted at the nursing station in mid-pregnancy and at 1 and

11 months postpartum by a research assistant with a master or doctoral degree in

psychology. Interviews were conducted in English, French or Inuktitut with the help of a

female Inuit interpreter. Detailed, informed consent was obtained from all participants

and the research procedures were approved by the Ethics Review Boards of Université

Laval (Canada) and Wayne State University (USA).

Four hundred and seventeen pregnancies were identified during the study period.

Fifty-nine potential participants were excluded for the following reasons: inclusion in the

cohort during a previous pregnancy, miscarriage during the first trimester of pregnancy,

or could not be contacted. Of the 417 pregnant women identified, 110 (26.4%) refused to

participate. Women who agreed to participate were interviewed during pregnancy (N =

248, 59.5% of all pregnancies during that period), then at 1 (N = 248) and 11 months

postnatally (N = 174). The main reasons for loss of participants after delivery were: infant

adopted (28%) or mother moved to a community not participating in the study (22%),

miscarriage and infant mortality (22%), and mother could not be found for subsequent

follow-up (18%). The refusal rate after enrollment was 6.7% at 11-month follow-up (for

more information, see Muckle et al., 2011).

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2.2 Measures

Alcohol use. During the prenatal interview, alcohol consumption was assessed for

3 time periods: the year prior to pregnancy (T1), the periconceptual period (which

corresponded to the 3-week period after the first day of the last menses) (T2), and the

period from conception to the prenatal interview (part of T3). The interview, conducted 1

month after delivery, documented alcohol consumption in the period from the initial

maternal interview to the end of pregnancy (part of T3). As a result, data from the

prenatal interview were considered together with those obtained from the 1-month

postnatal interview as alcohol use during the pregnancy period (T3). The interview at 11

months postpartum documented alcohol use from delivery until interview (T4).

Frequency and quantity of alcohol intake were assessed through semistructured

interviews designed to document number of drinking days, number of standard drinks

(beer, wine, or liquor) per drinking day, binge drinking episodes, and number of standard

drinks per binge drinking episode. Binge drinking was defined as the consumption of at

least 5 standard drinks of alcohol (beer, wine or liquor) during a single occasion. To

characterize alcohol consumption longitudinally, we focused on dichotomous indicators

of alcohol use (yes/no) and binge drinking (yes/no) from T1 to T4.

Predictors. Based on the literature (Fillmore et al., 1991; Fraser et al., 2012;

Muckle et al., 2011; Nunavik Inuit Health Survey, Qanuippitaa?, 2004; Wilsnack et al.,

2000, 2009), the following potential predictors of alcohol drinking trajectories,

documented during the prenatal interview, were considered in the analyses: maternal age,

marital status, socioeconomic status, total number of pregnancies (gravidity), smoking

and illicit drug use during pregnancy and during life. Maternal age was analyzed as

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median values of 24 years versus those above. Marital status (married, living with

someone, single, divorced or widower) was documented as couple versus single.

Socioeconomic status (SES) was assessed using the Hollingshead Index (Hollingshead,

2011), which is based on the level of educational attainment of mother and father as well

as each parent’s occupational status. The Hollingshead Index ranges from 0 to 66: 0-19 =

unskilled laborers, menial service workers; 20-29 = machine operators, semiskilled

workers; 30-39 = skilled craftsmen, clerical, sales workers; 40 and above = technical,

major or medium-size business or professional). Scores were recorded according to the

median value of 15: 0-15 = low SES (55%) versus over 15 = other (45%). Number of

previous pregnancies, including current pregnancy, was dichotomized according to the

median value of 3 pregnancies: 0-3 pregnancies = 48% versus >3 pregnancies. The

following illicit drugs were documented by yes⁄no questions for the lifetime and perinatal

periods: marijuana, cocaine (including crack and cocaine), solvent sniffing (mainly glue,

gas, and nail polish remover), heroin, mushrooms, PCP (phencyclidine), angel dust,

sedatives, and amphetamines. Marijuana, as the most prevalent drug consumed in the

context of pregnancy, was retained for further analysis, but other drugs were discarded

because of their low use (below 5.6%; see Muckle et al., 2011). To best evaluate possible

associations between marijuana and alcohol drinking trajectories, we selected the closest

indicator of active marijuana use available: at conception. We excluded measurements of

tobacco as 9 out of 10 women reported smoking cigarettes during pregnancy (Muckle et

al., 2011).

2.3 Statistical analyses

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Drinking patterns across the pregnancy period were explored by Markov

modeling. We applied a Markov model in which stages were based on a single measure

of alcohol use (yes/no) (first model) and a binge drinking measure only (yes/no) (second

model) with the assumption of no measurement error. This method provides a way of

describing and predicting trajectories and movement between stages (times) of use and

non-use. Markov models (Collins and Lanza, 2010; Collins and Wugalter, 1992; Collins

et al., 1994), sometimes referred to as “latent transition” models, are commonly tested in

alcohol research when drinking patterns are conceptualized as a multidimensional,

discrete variable in a developmental process (Bray et al., 2014; Guo et al., 2000; Jackson

et al., 2001; White et al., 2009).

The analytical strategy seeks to introduce drinking variables from T1 to T4 (first

model: yes/no question about alcohol use; second model: yes/no question about binge

drinking) to calculate prevalence over time. Prevalence rates correspond to the

proportions of individuals in each class at each time. To assess the stability of drinking

trajectories over time and to ascertain if there were changes in drinking behaviors over

time, we referred to transition rates. Transition rates represent the proportions of

individuals in different stages at time t + 1 conditional on drinking stage at time t, and

interpreted as probabilities of staying in the trajectory at this time. Models were

estimated by PROC LTA procedures for latent transition analysis with SAS version 9.3

(Lanza et al., 2013) and replicated with Mplus (Muthén and Muthén, 1998-2002).

Missing data on latent class indicators (alcohol and binge variables; 28.9% at T4) were

handled with the maximum likelihood technique and the expectation-maximization

algorithm, assuming that data were missing at random (Collins and Lanza, 2010).

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With Markov modeling, it is also possible to estimate associations of predictors

on baseline membership (T1) and between times via multivariate logistic regression.

However, analysis of predictors of drinking behaviors between times required

measurements of the predictors at each time point, which were not available in our study.

Moreover, in the context of alcohol research, it is particularly relevant to estimate the

effects of predictors on drinking behavior at a significant time. For these reasons, we

ascertained the probability of belonging to a specific alcohol drinking trajectory at T2 (at

conception) via traditional multivariate logistic regression assessing which predictors

may explain the significant change of drinking behavior from the conception period.

We identified which predictors were associated with changes: 1) from drinking

status to abstainer from T1 to T2, and 2) from binge drinker to abstainer from T1 to T2.

The third regression analysis was designed to identify predictors related to stability of

binge drinking status from T1 to T2. Because very few women continued to drink from

T1 to T2 (0.8%), we were unable to look at predictors of stable status. Multivariate

logistic regression was performed with SPSS 13.

3. Results

Table 1 summarizes sample characteristics. The majority (80%) were between 18

and 33 years, with only 24 (10%) below 18 and 5 (2%) above 38. More than half of the

women were part of a couple and were unskilled laborers or menial service workers

(mean for sample = 17.5). The average number of pregnancies was 3.9, with 38 women

who were primiparous (15%), and about a third of them used marijuana in early

pregnancy.

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____________________________________________________________________________________________________________

INSERT TABLE 1

3.1 Proportions and trajectories of alcohol use and binge drinking

Table 2 presents the proportions of alcohol use and binge drinking over study

periods T1 to T4. The proportion of drinkers declined from its peak during the year prior

to pregnancy to the conception period and then rose back in the pregnancy period and

during the year after pregnancy. Similarly, the proportion of binge drinking women

dropped between the year before pregnancy to the conception period, rose during the

pregnancy period and increased substantially by the year after pregnancy.

Figure 1a illustrates the proportions of alcohol use over time but, more

importantly, provides the transition rates of changing status from period to period. The

lowest probability of stay in drinking status was between the year before pregnancy and

the conception period (48%), indicating instability of drinking status at this time. During

the pregnancy period, the majority of drinkers had the probability of staying in the

drinking trajectory. In contrast, one-quarter of drinkers had the chance to move from

drinking to non-drinking behavior a year after delivery. The probability of transitioning

from non-drinking to drinking behavior over time was more stable. At all time periods,

less than 50% of non-drinkers had the probability of moving from non-drinking to

drinking status, and this probability was higher a year after delivery (43%). Transition

probabilities of binge drinking over time are presented in Figure 1b. Transition rates of

changing status from binge drinking to non-binge drinking (which included abstainers

and alcohol users who did not binge drink) were substantially higher over time than

transition rates of not binging to binge drinking status. The probability of staying in the

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binging trajectory was lowest between the year before pregnancy and the conception

period (19%) and was higher between the pregnancy period and a year after delivery

(62%). At all time periods, the probability of moving from non-binging to binging status

was less than 30% for non-bingers. For both alcohol and binge drinking trajectories, the

probability of transitioning from user to abstainer or non-binging status was higher from

the year before pregnancy to the conception period. Status change from non-binging to

binge drinking was greater from the pregnancy period to the postpartum year, while the

probability of moving from abstainer to alcohol user status was greater after conception

and was similar to that reported for the pregnancy period to the postpartum year.

____________________________________________________________________________________________________________

INSERT TABLE 2____________________________________________________________________________________________________________

INSERT FIGURE 1a and 1b 3

Prevalence and transition rates describe drinking trajectories and change over

time. However, they do not provide information about the proportions of participants who

remained non-drinkers or non-bingers over the course of the study. Among participants

who provided data on alcohol use for all four time periods (N = 174), 18.7% were alcohol

drinkers during all four periods, and 12.7% were abstainers. Only 1.6% reported binge

drinking throughout the course of the study. In comparison, 31.1% of women never

binged in all four time periods.

3.2 Variables related to changes in drinking status

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Table 3 presents the results of multivariate logistic regression analysis. Because

the total number of pregnancies was highly correlated with maternal age (rs = 0.772;

p<0.001), two regression models were tested with only one variable at each time period.

Among the potential predictors considered, being in a couple was related to

greater probability of moving from binge drinking status the year before conception to

abstainer status at conception. In contrast, women who reported marijuana use during

conception were less likely to move from binge drinking status the year before

conception to abstainer status at conception. Change from alcohol user to abstainer and

stability of binge drinking status were not related to socioeconomic status or marijuana

use. The results were similar when total number of pregnancies were included in the

regression models (data not shown).

____________________________________________________________________________________________________________

INSERT TABLE 3

4. Discussion

Our analysis of Inuit alcohol consumption is the first to present distinctive

trajectories covering the year before conception to the year after pregnancy. Our results

indicated that the proportions of alcohol use and binge drinking varied considerably

across specific periods related to pregnancy, and that probability of transitioning from

drinking to non-drinking behavior and vice versa changed considerably across these

periods. Yet, most notably, 60% of women did not change status and were alcohol

consumers during all four time periods, indicating that alcohol use in this specific

population is not well understood.

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Drinking trajectories have previously been reported across several years for the

general population (Jackson et al., 2000), specifically during the potentially more

tumultuous periods of adolescence and young adulthood (Berg et al., 2013; Brodbeck et

al., 2013), even among adolescent mothers (Oxford et al., 2003). To our knowledge, only

one other study examined trajectories in the perinatal period (Spears et al., 2010) and

focused on adolescent girls from the USA who were followed during pregnancy at 3 and

6 months and then at 12 months postpartum. The prevalence rate of drinking was lower

than in the Inuit and, as they did not include a measure of binge drinking in their work,

they failed to observe excessive alcohol use and abuse during pregnancy. Among the

Inuit, transition probabilities revealed great instability of drinking status during almost a

3-year period starting the year before pregnancy to the end of the first postpartum year.

Sources of drinking status variations at different time periods are well known to be

multifactorial and may be individual, social, familial and cultural (Arokiasamy, 1995;

Beck et al., 1995; Cooper et al., 1992; Cox and Klinger, 1988; Cutter and O’Farrell,

1984; Gire, 2002; Heath, 2000; Kuntsche et al., 2006), psychosocial (Harrison and

Sidebottom, 2009), or specific factors and situations (Gusfield, 1987; Harford, 1979).

Our findings support the view that both alcohol use and binge drinking status are

more likely to change to abstainer or non-binge drinker in the conception period. Such

changes in alcohol behavior may reflect general pregnancy-related lifestyles and life

habit changes, especially among women who planned the pregnancy (Kim et al., 2012;

Perham-Hester and Gessner, 1997). Alcohol awareness and prevention programs started

to get delivered to the Inuit population of Northern Quebec in the 1990s, (Korhonen,

2004). Changes in drinking behavior in early pregnancy may be the result of these

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interventions, or prenatal care, which increase population knowledge about the harmful

effects of alcohol use during pregnancy (Badry and Felske, 2013; Nathoo et al., 2013).

Our findings also indicate that Inuit women are more likely to change from

abstainer to alcohol user after the conception period. This outcome is a particular public

health concern as the long-lasting effects of fetal exposure to alcohol are well-

documented. According to Kaskutas (2000) and Branco and Kaskutas (2001), in the

general population, “many women have a limited understanding of the health

consequences of drinking alcohol during pregnancy and a misperception regarding the

amount of alcohol they are consuming” (Montag et al., 2012, p. 441). It is not clear if

trajectories of drinking and binging reported here could be replicated nowadays since the

Inuit are better informed of the effects of maternal alcohol use during pregnancy on child

health and development. However, drinking remains a problem in Nunavik, and alcohol

use and abuse is still present among pregnant women. In contrast, according to our

results, a sub-group of women consistently remained abstainers or non-bingers

throughout pregnancy. Future studies dedicated to FAS prevention should focus on these

abstinent Inuit women, and a qualitative research approach may provide insights to

develop culturally-sensitive prevention and intervention programs based on their

experiences.

Regarding predictors of alcohol use and binge drinking, we reported that being in

a couple is related to a greater probability of moving from binge drinking status the year

before conception to abstainer status at conception. This finding corroborates numerous

studies showing that being married reduces heavy drinking among both men and women

(Cho and Crittenden, 2006; Gmel et al., 2000; Hajema and Knibbe, 1998; Kuntsche et al.,

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2006; Neve et al., 1997). Similar results have been obtained for women in couples who

are not married (Ebrahim et al., 1998; Gladstone et al., 1997; Perham-Hester and

Gessner, 1997). Quality of and satisfaction with the relationship as well as marital

support are additional influential factors of adoption of drinking type, especially a low

drinking pattern (Holt-Lunstad et al., 2008; Kearns-Bodkin and Leonard, 2005; Leonard

and Eiden, 2007), although being in a couple is associated with greater probability of

moving from binge drinking status the year before conception to abstainer status at

conception.

Our study revealed that marijuana use decreases the likelihood of moving from

binge drinking status the year before conception to abstinence at conception. Gladstone et

al. (1997) and Harrison and Sidebottom (2009) demonstrated that curtailed alcohol use

during pregnancy is more frequent among irregular drinkers, non-smokers and drug non-

users. Concomitant use or abuse of other substances needs to be seen as a factor that may

help identify women at greater risk of being unable to decrease alcohol consumption in

pregnancy or among those wishing to have a child. Several studies have already pointed

out the efficiency of a multidimensional framework in alcohol research and public health

(Demers et al., 2002; Frohlich et al., 2008; Kairouz et al., 2002; Kairouz and Greenfield,

2007).

4.1 Limitations

One limitation of our study is the loss to follow-up after delivery (30%). The

statistical likelihood technique allowed latent transitional class analysis to counter this

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drawback. In addition, information about pregnancy planning was not documented.

Planning a pregnancy is likely to influence alcohol consumption around conception, and

our study could not take this into account in the interpretation of transitional rates from

the year before pregnancy to the conception period. Moreover, our study does not include

spouse drinking status and information about family violence and marital problems.

Women tends to drink more in the context of family problems or when men drink at

home (Health Canada, 2008; National Institute of Alcohol Abuse and Alcoholism, 2008).

Future research has to analyze the impact of these factors on the trend in alcohol use

among pregnant Inuit women. Our study may also present a recall bias (or response bias)

relative to self-reported alcohol use (Greenfield and Kerr, 2008; Grønbæk and Heitmann,

1996; Midanik, 1989; Rehm, 1998). However, our pregnancy alcohol ascertainment

approach has been validated in relation to child cognitive outcomes (Jacobson et al.,

2002). Finally, because data were collected from 1995 to 2000, it would be informative to

document whether proportions and the longitudinal transitioning portrait of drinkers have

changed for the Inuit in subsequent years in which programs tried to increase public

awareness and implement prevention programs.

5. Conclusion

Our results emphasize the importance of future studies on alcohol use around the

pregnancy period to document trajectories of consumption and to identify determinants of

specific drinking trajectory among the Inuit and other indigenous groups. Spotting

transitional periods where alcohol use and binge drinking status are most likely to change

adds to the typical description of prevalent alcohol use in a time period, and help to flag

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sensitive periods for interventions. Research focusing on motives, contexts and beliefs

surrounding alcohol drinking during pregnancy may also contribute to the development

of culturally-sensitive prevention and intervention programs.

Acknowledgments

We are grateful to the Nunavik population and their organisations for participating

in this research. We thank R. Sun, G. Lebel, E. Lachance, C. Bouffard, K. Poitras, C.

Vézina, J. Gagnon, L. Chiodo, B. Tuttle and N. Dodge for their committed study

involvement, and N. Forget-Dubois for her support in data analysis. This manuscript was

edited by Ovid M. Da Silva.

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Table 1: Sample characteristics N Characteristics

Age (years) – mean (SD) 248 24.9 (5.8)

Marital status (In a couple) – % [95% CI] 248 68.1% [62.3-73.9]

SES – % [95% CI] 247

Unskilled laborers, menial service workers 55.5% [49.3-61.7]

Machine operators, semiskilled workers 23.9% [18.6-29.2]

Skilled craftsmen, clerical, sales workers 16.6% [12.0-21.2]

Technical, major or medium-size business or professional

4.0 [1.6-6.5]

Total pregnancies – mean (SD) 248 3.9 (2.3)

Marijuana use at conception (Yes) – % [95% CI] 248 35.1 [29.1-41.1]

CI: confidence interval; SD: standard deviation; SES: socioeconomic status based on the Hollingshead Index (Hollingshead, 2011).

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Table 2: Proportions of alcohol and binge drinking from the year before conception to the end of the postnatal year (N = 248)

Proportions

Alcohol use Drinking Non-drinking

Before conception (T1) .73 .27

At conception (T2) .36 .64

During pregnancy (T3) .60 .40

Postnatal year (T4) .62 .38

Binge drinking Binging Non-binging

Before conception (T1) .54 .46

At conception (T2) .10 .90

During pregnancy (T3) .19 .81

Postnatal year (T4) .33 .67

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Table 3: Multivariate logistic regression of personal and SES variables on alcohol and binge drinking trajectories at conception

Covariates OR CI p-value

Decreasing alcohol use (N=93)

Age – 14-24 years. 1.33 0.78-2.25 0.29

Marital status – In a couple 0.99 0.56-1.74 0.96

SES – Low 1.13 0.67-1.90 0.65

Marijuana – Yes 0.64 0.37-1.09 0.10

Decreasing binge drinking (N=107)

Age – 14-24 years 0.80 0.47-1.35 0.40

Marital status – In a couple 1.74 0.99-3.07 0.05*

SES – Low 1.59 0.94-2.70 0.08

Marijuana – Yes 0.41 0.24-0.72 0.002*

Constant binge drinking (N=26)

Age – 14-24 years 2.12 0.90-5.00 0.09

Marital status – In a couple 1.91 0.81-4.47 0.14

SES – Low 1.13 0.50-2.59 0.80

Marijuana – Yes 0.81 0.35-1.89 0.63

OR: odds ratio; CI: confidence interval; SES: socioeconomic status

30

Figure 1a: Proportions and transition rates of alcohol drinking over time

Figure 1b: Proportions and transition rates of binge drinking over time

31

A year before conception At conception

During pregnancy

A year after delivery

Non-drinking

Drinking

27% 64% 40% 38%

73% 36% 60% 62%

97% 60% 57%

48% 98% 75%

40% 43%3%

52% 2% 25%

A year before conception At conception

During pregnancy

A year after delivery

Non-binging

Binging

46% 90% 81% 67%

54% 10% 19% 33%

100%% 84% 74%

19% 46% 62%

16% 26%0%

80% 54% 38%

27%27%27%27%27%27%27%27%27%27%27%27%27%27%27%27%27%27%27%27%27%27%27%27%27%27%27%27%27%27%

62%62%62%62%62%62%62%62%62%62%62%62%62%62%62%62%62%62%62%62%62%62%62%62%62%62%62%62%62%62%73%73%73%73%73%73%73%73%73%73%73%73%73%73%73%73%73%73%73%73%73%73%73%73%73%73%73%73%73%73%

38%38%38%38%38%38%38%38%38%38%38%38%38%38%38%38%38%38%38%38%38%38%38%38%38%38%38%38%38%38%

60%60%60%60%60%60%60%60%60%60%60%60%60%60%60%60%60%60%60%60%60%60%60%60%60%60%60%60%60%60%36%36%36%36%36%36%36%36%36%36%36%36%36%36%36%36%36%36%36%36%36%36%36%36%36%36%36%36%36%36%

40%40%40%40%40%40%40%40%40%40%40%40%40%40%40%40%40%40%40%40%40%40%40%40%40%40%40%40%40%40%64%64%64%64%64%64%64%64%64%64%64%64%64%64%64%64%64%64%64%64%64%64%64%64%64%64%64%64%64%64%

46%46%46%46%46%46%46%46%46%46%46%46%46%46%46%46%46%46%46%46%46%46%46%46%46%46%46%46%46%46%

33%33%33%33%33%33%33%33%33%33%33%33%33%33%33%33%33%33%33%33%33%33%33%33%33%33%33%33%33%33%54%54%54%54%54%54%54%54%54%54%54%54%54%54%54%54%54%54%54%54%54%54%54%54%54%54%54%54%54%54%

67%67%67%67%67%67%67%67%67%67%67%67%67%67%67%67%67%67%67%67%67%67%67%67%67%67%67%67%67%67%

19%19%19%19%19%19%19%19%19%19%19%19%19%19%19%19%19%19%19%19%19%19%19%19%19%19%19%19%19%19%10%10%10%10%10%10%10%10%10%10%10%10%10%10%10%10%10%10%10%10%10%10%10%10%10%10%10%10%10%10%

81%81%81%81%81%81%81%81%81%81%81%81%81%81%81%81%81%81%81%81%81%81%81%81%81%81%81%81%81%81%90%90%90%90%90%90%90%90%90%90%90%90%90%90%90%90%90%90%90%90%90%90%90%90%90%90%90%90%90%90%