Predictive value of alcohol use questionnaires for adverse pregnancy outcomes: Evidence from a Finnish birth cohort

Prenatal alcohol exposure is associated with preterm birth (PTB) and impaired fetal growth, but identification of risky alcohol use during pregnancy remains challenging. Brief self-report screening tools are widely used, highlighting the need to evaluate Alcohol Use Disorders Identification Test (AUDIT)-based measures in pregnancy. We assessed the ability of the full AUDIT, its abbreviated versions (AUDIT-C and AUDIT-4), and selected items to identify women at increased risk of PTB and small for gestational age (SGA) in the Kuopio Birth Cohort (KuBiCo) and to detect hazardous alcohol use.

In this population-based cohort study, 7141 singleton pregnancies in KuBiCo between 2012 and 2023 were analyzed. Pregnancies with delivery at ≥22 + 0 gestational weeks and completion of an electronic AUDIT questionnaire during the first trimester were included. Birth outcomes (SGA and PTB) were obtained from the birth register. Associations between pre-pregnancy alcohol use and adverse birth outcomes were analyzed using logistic regression to estimate adjusted odds ratios (aORs) with 95% confidence intervals (CIs). Predictive performance of the full and abbreviated AUDIT measures and selected items for hazardous alcohol use (AUDIT ≥6) was evaluated using receiver operating characteristic analysis with area under the curve and optimal cut-offs based on Youden's index.

Alcohol use in the year before pregnancy was primarily captured by AUDIT items assessing drinking frequency and typical quantity. Using established thresholds, alcohol use defined by the AUDIT (≥6) and AUDIT-4 (≥5) was associated with an increased risk of PTB (aOR 1.43; 95% CI 1.05-1.95 and aOR 1.42; 95% CI 1.04-1.95, respectively). Heavy episodic drinking, identified by AUDIT item 3 (score ≥2), was associated with an increased risk of SGA, whereas concern expressed by others about drinking (AUDIT item 10 ≥2) was associated with PTB. For hazardous alcohol use, AUDIT-4 and AUDIT-C demonstrated excellent discrimination, with an optimal cut-off of ≥4.

Abbreviated versions of the AUDIT, particularly AUDIT-4, appear comparable to the full AUDIT for identifying risky alcohol use and PTB risk. Women reporting recurrent heavy episodic drinking may benefit from targeted counseling before and during pregnancy.