Use of Coffee, Alcohol, Cigarettes Raises Risk of Poor Birth Outcomes

Use of Coffee, Alcohol, Cigarettes Raises Risk of Poor Birth OutcomesAuthor(s): S. EdwardsSource: Family Planning Perspectives, Vol. 24, No. 4 (Jul. - Aug., 1992), pp. 188-189Published by: Guttmacher InstituteStable URL: http://www.jstor.org/stable/2136025 .

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Digests

criterion was scored differently: Six categories of considerations (material impact/ self; material impact/others; material impact/child; psychological impact/self; psychological impact/others; psychological impact/child) were defined. Content analysis was then performed on pilot interviews and on a subset of experimental interviews, and 32 distinct considerations were iden- tified and then classified as belonging to one of the six basic categories. Finally, one of three raters scored each interview. Final agreement among raters was assessed by having all three score 20 interviews in a blind comparison.

Multivariate analysis of variance was used to compare the scores on the four criteria of competence for three different age- groups-young minors (15 and younger), older minors (aged 16-17) and legal adults (18-21)-by whether the participant considered abortion. Competence varied significantly across age-groups, but not between those who considered abortion and those who did not. The competence of each group of minors was then contrast- ed with that of legal adults who considered abortion. (Legal adults who did not consider abortion were not included in the comparison because the implications of their decision presumably differed sub- stantially from those for minors.) The decision-making competence of all minors who considered abortion and of older minors who did not consider abortion was comparable to that of adults. Only minors aged 15 and younger who did not consider abortion were less competent than adults: They were judged less able to make a voluntary and independent decision and to consider the probable consequences of their alternatives; they also received a lower rating for the quality of their reasoning process and the reasons they gave.

Regression analyses were then conducted with the 47 study participants who said at the time of their pregnancy test that they would consider abortion. First, 11 psychosocial variables-age, social support, cognitive problem-solving skills, conflict in making a decision, educational goals, negative emotion, positive emotion, abortion knowledge, adoption knowledge, pregnancy and parenthood knowledge, and pregnancy and parenthood experi- ence-were entered in a reverse stepwise multiple regression to identify those variables that predict decision-making competence. Variables that did not contribute significantly to the equation were dropped. The variables were not highly intercorre- lated, nor was age highly correlated with the psychosocial predictors, indicating that

the individual variables captured unique information about patients.

The investigators then used the psychosocial regression model in a hierar- chical regression in which age was entered first, thereby assessing the predictive power of the psychosocial model after controlling for age. Regression models using psychosocial variables predicted all four criteria of competence. In addition, psychosocial models outperformed age in predicting all criteria of competence ex- cept the ability to consider the probable consequences, and accounted for a significant amount of variance in all four criteria, even after the effects of age were controlled for.

Social support was the most consistent psychosocial predictor of competence, as it appeared in all four equations. The researchers suggest that social support may enhance competence by providing teenagers with a means to obtain information, receive emotional support and practice decision-making. Other variables that predicted at least one of the criteria of competence were the adolescent's conflict in making a decision; her knowledge of abortion; her educational goals; and her cognitive problem-solving skills. Age predicted two criteria-the respondent's ability to consider the consequences of the decision and the quality of her reasoning- but did not predict the respondent's ability to make a voluntary and independent decision or the types of considerations she expressed in reaching her decision.

The investigators urge care in drawing conclusions about adolescent development or social policy based on the study's findings, pointing out that they used a re- gional sample that was modest in size compared with the total population of adolescent minors. Further, their study design could not accommodate random assign- ment to treatment groups or baseline as- sessment of cognitive development, making it difficult to disentangle individual from developmental differences. They also note that the study was conducted in one setting, in one community, during one his- torical time; subtle changes in sample, setting, community or time period could in- fluence results.

Even with these limitations, however, the researchers argue that the study can inform the public policy debate on parental involvement in a minor's abortion decision. They note, for example, that although age 18 may be a convenient legal dividing line, based on the tradition of ma- jority, the study results indicate that it may have questionable scientific validity as the

point at which individuals become competent decision-makers. They also point out that their results undercut the argu- ment that laws requiring parental consent or notification on abortion are necessary to protect minors from making an ill-considered or uninformed decision.

The researchers conclude that for the one group of teenagers who were not competent to make the abortion decision- those who did not consider abortion in de- ciding how to resolve an unplanned pregnancy-parental consent and notification statutes are irrelevant, since these minors do not need to be protected from incompetent consent to a procedure that they are not considering. The goal of pro- tecting other minors from unwise repro- ductive decisions can be achieved by pre- suming them to be competent and by developing procedures for obtaining consent that promote their genuine informed consent. A legal presumption of competence moves minors' decision-making from an adversarial legal setting to a health care setting. Such an approach does not leave minors unprotected, the researchers assert, because health care pro- fessionals will continue to have a legal and ethical obligation to assure that minor patients give informed consent.-P. Donovan

Reference 1. B. Ambuel and J. Rappaport, "Developmental Trends in Adolescents' Psychological and Legal Competence to Consent to Abortion," Law and Human Behavior, 16:129, 1992.

Use of Coffee, Alcohol, Cigarettes Raises Risk Of Poor Birth Outcomes Smoking cigarettes increases a woman's risk of spontaneous abortion and premature birth; drinking alcoholic beverages increases the risk of spontaneous abortion and possibly of congenital musculoskeletal defects; and drinking coffee slightly increases the risk of spontaneous abortion, premature birth and possibly congenital defects. These are among the findings of three studies conducted in Montreal, Que- bec, on the effects on birth outcome of cigarette, alcohol and coffee consumption during pregnancy.'

Spontaneous Abortion To determine the effects of cigarette, alcohol and coffee consumption on spontaneous abortion, the researchers inter- viewed approximately 56,000 women who had had a delivery or a spontaneous abortion in 11 Montreal hospitals during

188 Family Planning Perspectives



the two-year period 1982-1984. The interview consisted of questions about a woman's occupational, personal and social characteristics during her recently completed and previous pregnancies. For each pregnancy a woman reported, she was asked the number of cigarettes, cups of coffee and alcoholic drinks she had consumed per day during the first trimester. Women who had had induced abortions were excluded from the study. Using logistic regression, the researchers analyzed data from a final sample of 47,146 previous pregnancies, controlling for confounding variables such as age, education, ethnic group and employment. Previous live births and spontaneous abortions were included as risk factors.

The researchers found that 22% of the women had had previous pregnancies that ended in spontaneous abortion. Com- pared with women who abstained during pregnancy, women who smoked cigarettes had a 20% increase in spontaneous abortion (odds ratio of 1.20) for each 10 cigarettes smoked per day; women who drank alcoholic beverages had a 26% increase in spontaneous abortion (odds ratio of 1.26) for each drink per day; and women who drank coffee had a 2% increase in spontaneous abortion (odds ratio of 1.02) for each cup per day. When the researchers com- bined these three risk factors with other variables, they found statistically significant interactions between smoking cigarettes and age, smoking cigarettes and drinking alcohol, and drinking coffee and number of pregnancies.

The investigators concluded that if the observed associations were causal, cigarette smoking would account for 11% of all spontaneous abortions, increasing to 40% among women who smoked more than 20 cigarettes per day. Similarly, alcohol consumption would account for 5% of spontaneous abortions, with this pro- portion rising to 45% among women who consumed three or more drinks per day. Coffee consumption would account for 2% of all spontaneous abortions, increasing to 16% in women who drank 10 cups of coffee per day.

Prematurity In another study, the authors of the previous study examined the effects of cigarettes, alcohol and coffee on the risk of prematurity. Using three measures of prematurity-low birth weight (<2500 grams), preterm birth (<37 weeks) and low birth weight for gestational age (the low- est 5%)-the researchers analyzed outcome information for 40,445 women who had re-

cently given birth. Women who had other risk factors that affect gestation and birth weight, such as multiple pregnancy, induced labor, hypertension, diabetes, and prenatal bleeding and illness, were excluded from the study The researchers then conducted a logistic regression analysis that controlled for possible confounding factors, such as age, pregnancy order, previous spontaneous abortion, previous low- birth-weight infant, prepregnancy weight, ethnic group, education and employment.

Overall, 7.0% of the infants were born preterm, 5.7% had low birth weight and 5.2% had low birth weight for gestational age. The risk of all three problems was higher among women who smoked cigarettes during pregnancy, and increased with the number of cigarettes smoked. For every 10 cigarettes smoked, the risk of low birth weight for gestational age increased by 50% (odds ratio of 1.51). Compared with nonsmokers, women who smoked 20 or more cigarettes per day had odds ra- tios of 3.19 for low birth weight for gestational age, 2.85 for low birth weight and 1.33 for preterm birth. According to the investigators, smoking may have accounted for 39% of the cases of low birth weight for gestational age, 35% of low-birth- weight cases and 11% of preterm births.

Further investigation revealed that women who smoked before the first trimester but not during it had no increased risk of premature delivery. Among women who stopped smoking before the second trimester, the risk of prematurity was reduced to a level almost equal to that of nonsmokers.

The effects of alcohol consumption on prematurity were not as clear. In the sample studied, the researchers found that compared with total abstainers, women who occasionally drank alcoholic beverages (1-6 drinks per week) had a small but statistically significant reduction in risk for all three measures of prematurity. Women who consumed larger quantities of alcohol (21 or more drinks per week) had an increased risk of prematurity, especially low birth weight. The researchers discov- ered that the increased risk of prematurity was related to the type of alcoholic bev- erage consumed: Those who consumed beer or spirits had a higher risk of prematurity than those who drank only wine.

The investigators also found small increases in the risk of low birth weight and low birth weight for gestational age among women who drank coffee: Those who drank 10 or more cups of coffee per day had an odds ratio of approximately 1.4 on both measures when compared with women who did not drink coffee.

Congenital Defects In a third study, the researchers analyzed data for 89,317 previous and recently completed pregnancies to determine the effects of smoking cigarettes and drinking alcoholic beverages on the incidence of congenital defects. From this sample, they examined 80,319 pregnancies to determine the effects of drinking coffee. The researchers obtained data from pediatric records for recently completed pregnancies, inter- viewing the women for information about their previous pregnancies. They classified the defects into 90 groups. Using logistic regression, they performed separate analyses for recently completed and previous pregnancies, controlling for maternal age, educational level and ethnic group.

The investigators found no consistent evidence of an increased risk of congenital defects among women who smoked during the first trimester of pregnancy. Al- though they found some evidence of an increased risk of musculoskeletal defects in infants born to women who had consumed alcoholic beverages during pregnancy, they caution that their study was limited because only 3% of the women in the sample had consumed one or more drinks per day, and only 0.3% had consumed three or more drinks per day. The researchers found a slight association between maternal coffee consumption and infant heart defects, but noted that other studies had found no such association. S. Edwards

Reference 1. B. G. Armstrong, A. D. McDonald and M. Sloan, "Cig- arette, Alcohol, and Coffee Consumption and Sponta- neous Abortion," American Journal of Public Health, 82:85, 1992; A. D. McDonald, B. G. Armstrong and M. Sloan, "Cigarette, Alcohol, and Coffee Consumption and Pre- maturity," American Journal of Public Health, 82:87, 1992; and , "Cigarette, Alcohol, and Coffee Consumption and Congenital Defects," American Journal of Public Health, 82:91, 1992.

Among Native American Teenagers, Sex Without Contraceptives Is Common Among Native American teenagers who participated in a recent health survey, 65% of males and 57% of females had had sexual intercourse by the time they were in the 12th grade.' Although Native American adolescents feared contracting AIDS or be- coming pregnant, only 40% of sexually active males and 50% of sexually active females said they always used contraceptives. More than one-third of males and more than one-half of females in grades 7-9 reported having had sexual intercourse

Volume 24, Number 4, July/August 1992 189



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Use of Coffee, Alcohol, Cigarettes Raises Risk of Poor Birth Outcomes