Abstract
Objectives:
Prenatal alcohol exposure poses a substantial risk to fetal development. Efforts were made in 2011-2020 to increase public awareness of and prevent alcohol consumption during pregnancy. We conducted a cross-sectional survey in Israel of pregnant women’s alcohol consumption from January 2021 through June 2023 and compared our results with the results of a survey conducted during 2009-2010 to assess changes over time.
Methods:
We conducted cross-sectional surveys at 3 public hospitals in central and northern Israel. Surveyors visited hospitals twice weekly and used a questionnaire consistent with one used in 2009-2010 that focused on alcohol consumption 3 months before pregnancy and during pregnancy. We conducted a stratified analysis of the prevalence of alcohol consumption during pregnancy by demographic characteristics. We also used a multivariable logistic regression model to examine variables associated with receiving guidance on alcohol consumption during pregnancy.
Results:
Of 1915 women in the 2021-2023 survey (mean [SD] age, 30.8 [5.6] y), 1204 (62.9%) reported never consuming alcohol before pregnancy and 1708 (89.2%) reported no alcohol consumption during pregnancy. During pregnancy, 157 (8.2%) women reported consuming alcohol weekly or less, 12 (0.6%) more frequently, and 52 (2.7%) binge drinking. We found a significant decrease in alcohol consumption during pregnancy in 2021-2023 as compared with 2009-2010 (odds ratio, 0.68; 95% CI, 0.52-0.88; P = .03). Predictors of alcohol consumption during pregnancy included alcohol consumption before pregnancy, parity, and smoking. Significantly more women in the 2021-2023 sample (n = 569; 29.7%) than in the 2009-2010 sample received guidance on alcohol consumption during pregnancy (P < .001).
Conclusions:
Educational efforts should continue to increase awareness of the risks of prenatal alcohol exposure in the general population and among health professionals.
Keywords: alcohol consumption, pregnancy, prenatal alcohol exposure, fetal alcohol spectrum disorder, FASD
Alcohol is the most common teratogen in the Western world; its consumption during pregnancy can cause defects in the brain and other organs.1-3 Collectively, the effects of alcohol on fetuses result in fetal alcohol spectrum disorders (FASDs), characterized by typical dysmorphic changes and neurologic findings, as well as various developmental, behavioral, and learning disabilities.4-6 Other morbidities include miscarriage, prematurity, and stillbirth.7-9
The global scale of alcohol consumption during pregnancy is uncertain. However, findings from the US Centers for Disease Control and Prevention based on data from the 2018-2020 Behavioral Risk Factor Surveillance System showed a notable increase in alcohol consumption among pregnant adults aged 18 to 49 years in the United States. 10 Specifically, 13.5% reported consuming alcohol at least once in the past 30 days and 5.2% reported binge drinking, defined as having ≥4 drinks on 1 occasion, during that time frame. These rates represent a 2 percentage point–increase in current and binge drinking as compared with the 2015-2017 period. 10 Globally, the prevalence of alcohol consumption during pregnancy is about 25.2% in the World Health Organization European Region, 11 ranging from 4.1% in Norway 12 to 60.4% in Ireland. 11 In 11 European countries, 15.8% of pregnant and puerperal women reported alcohol consumption. 12
Akin to data from countries such as the United Kingdom and Australia, 1 data on the scale of alcohol exposure in Israel are limited. Estimates indicate that prenatal alcohol exposure affects approximately 1900 children of 190 000 live births annually, leading to various health outcomes, such as growth retardation, cognitive impairments, behavioral and emotional difficulties, and speech and language delay. In 2020, about one-third of adopted children in Israel (18 of 59; 30.5%) were confirmed to have been exposed to alcohol during pregnancy. Of these, 8 exhibited health issues, such as neurodevelopmental disorders or birth defects associated with alcohol exposure, and 2 were diagnosed with fetal alcohol syndrome. 13 In a 2020 survey, nearly two-thirds of participants reported consuming alcohol in the 2 months before pregnancy diagnosis; 12% continued to drink during that pregnancy, aligning with the global estimate of 10%. 14 Despite the lack of precision, these data highlight prenatal alcohol exposure as a major global health concern.
There is no safe time window or threshold amount for exposure to alcohol during pregnancy.15,16 Binge drinking (ie, consuming ≥4 drinks on 1 occasion) and heavy drinking (ie, consuming >6 drinks per week) have the worst influence on development of the fetus’s brain. 15 Nevertheless, consuming alcohol at even low levels (<4 drinks per week) can increase the chance of children having behavior difficulties, 17 and prenatal exposure to alcohol can disrupt fetal development as early as the pregnancy is diagnosed. 18
The belief that certain alcohol types may be less harmful than other alcohol types during pregnancy is a misconception. 19 Thus, it is crucial to emphasize that all forms of alcohol pose equal risks, with no differentiation among beer, wine, and liquor. 20 Despite the ongoing debate on the safety of low to moderate alcohol consumption during pregnancy, 21 these emerging findings underscore the need for caution. Prevention of FASDs can be achieved by avoiding alcohol exposure while planning for a pregnancy or during pregnancy. Raising the awareness among women of reproductive age about prenatal alcohol risks could help decrease the incidence of FASDs.
A risk factor that emerged with the COVID-19 pandemic was increased alcohol consumption as a mechanism for coping with pandemic-related stress and uncertainty. Several publications highlighted a substantial surge in alcohol consumption in the general population and emphasized a noteworthy rise among pregnant women.22-25 This trend underscores the need for heightened awareness and support to address the potential health risks associated with increased alcohol consumption during public health emergencies such as pandemics.
In 2009-2010, a study conducted in maternity wards postdelivery surveyed 3815 women from diverse religious and ethnic backgrounds in Israel. 26 The study found that 14.1% of respondents reported consuming alcohol during their pregnancy and highlighted the limited information that physicians provide. It concluded that alcohol was common among pregnant Israeli women (with significant sector-based variations). The prevalence of alcohol consumption was notably higher among Jewish women (>17.0%) than among Christian women (11.1%) but nonexistent among Muslim women (0%). 2
In 2021, Hen-Herbst et al 27 examined alcohol consumption patterns among pregnant Israeli women, focusing on their behavior during pregnancy and predelivery. Of 802 women in the sample, 539 (67.2%) self-reported consuming alcohol in the 2 months before learning they were pregnant, and 96 (12.0%) consumed alcohol during pregnancy. This trend was particularly notable among young secular Jewish women with high education levels. The study also exposed a concerning lack of knowledge among Israeli women about the risks of prenatal alcohol exposure.
Given the backdrop of prior research endeavors, the current study aimed to investigate demographic and behavioral factors that are associated with alcohol consumption during pregnancy by comparing data across 2 periods and examining participants’ reception of educational information. Our methodology mirrored that of our previous study (2009-2010), 26 with a focus on longitudinal analysis to discern changes over time.
Methods
Study Design and Population
From January 2021 through June 2023, we conducted a comprehensive cross-sectional survey geared toward women in the maternity wards of 3 tertiary hospitals in diverse regions of Israel (central, north central, and north). Surveyors visited all 3 hospitals twice weekly throughout the 2.5-year study period to recruit mothers uniformly. These hospitals, identical to settings in the 2009-2010 study, cater to a large heterogeneous population representing various cultural and religious backgrounds, including Arab, Jewish, and Christian people. These data offer insight into the hospitals’ patient volume: Of the 182 000 women in Israel who went into labor in 2019, about 7700 (4.2%) were documented by the central region hospital, 4700 (2.6%) by the northern hospital, and 6618 (3.6%) by the north central hospital. The Ethics Review Committee at Belinson Medical Center approved this study (approval RMC-1016-20). All participants provided written informed consent prior to enrollment in the study.
Surveyors recruited participants through direct distribution of surveys to postpartum women in the maternity wards of the 3 hospitals. Specifically, the surveyors personally visited the maternity wards, invited patients to complete a questionnaire, and handed the questionnaires to and retrieved them directly from the patients. We informed patients that they could terminate their participation at any time without consequences to them or the quality of their health care and that all information obtained would be kept confidential. The inclusion criteria were postpartum status within 3 days and the ability to speak Hebrew or Arabic or communicate effectively with a translator’s assistance.
Using the same process as in our previous study, 26 we rigorously compared this study’s sample with the Israeli population census and confirmed that it represented the female population of reproductive age. The comparisons showed similar proportions in the 2009-2010 and 2021-2023 samples as in the national figures. To illustrate, in the 2021-2023 study, Jewish women represented 76.5% of the sample (vs 81.8% nationally), Muslim women 16.3% (vs 16.5% nationally), and Christian women 0.9% (vs 2.1% nationally) (eTable in the Supplement).
Data Collection
Participants signed official informed consent forms before completing the questionnaire. The questionnaire was consistent with the one used in our previous research, 26 facilitating direct comparisons with that study’s results. Its comprehensive set of multiple-choice questions explored the participants’ experiences and knowledge about alcohol consumption during pregnancy. It covered multiple topics, including the participants’ attitudes toward pregnant women who consume alcohol and the education that they received from health care professionals and immediate social circles about alcohol consumption during pregnancy. Participants were asked about the frequency and quantity of their alcohol consumption in the 2 months before they discovered they were pregnant and during pregnancy (in the 3 months before delivery in the 2009-2010 survey but throughout pregnancy in the 2021-2023 survey). Questions included inquiries such as “If you drank alcohol in the 2 months preceding the discovery of the pregnancy, how many servings did you typically consume per week?” A standard serving size was defined on the questionnaire as 1 glass of wine, 1 bottle of beer, or 1 glass of a strong alcoholic beverage. Participants were asked if they engaged in binge drinking, defined as consuming ≥4 servings of alcohol in a single evening, which allowed us to assess the frequency and quantity of alcohol consumption and any pattern of heavy episodic drinking.
In addition to questions about alcohol consumption, the 2021-2023 survey added questions about various sociodemographic factors, including education, marital status, and prenatal care initiation. Participants were asked about the week of pregnancy in which they discovered they were pregnant, enabling us to determine the timing of prenatal care initiation. Furthermore, the questionnaire inquired about the frequency and quantity of other substance use (eg, cigarette smoking). Participants were also asked about guidance they received from trained professional nurses or physicians or from friends and family on other health behaviors during pregnancy, such as vitamin use, diet, smoking, and physical activity, which allowed us to compare this guidance with the guidance they received on alcohol consumption.
Statistical Analysis
We performed all analyses using SPSS version 25 (IBM Corp) and R version 4.3.1 (R Foundation). We calculated the proportions of women who reported consuming any alcohol and who binge drank 3 months before delivery for the following maternal characteristics: age (17-24, 25-29, 30-34, 35-39, ≥40 y), nationality (Jewish, Arab-Christian, Arab-Muslim, other), religiosity (ultraorthodox, orthodox, observant, secular, other), education (0-11, 12, 13-15, ≥16), birthplace (Israel, other [non-Israel]), smoking (no, yes), parity (1, 2 or 3, 4-6, ≥7 children), and alcohol consumption before pregnancy (did not drink, consumed <1 drink per week, consumed 1-3 drinks per week, consumed ≥4 drinks per week).
At the bivariate level, we assessed differences in the proportion of people who consumed alcohol for each predictor. Accurate alcohol use measurement is challenging—limited by recall and social desirability biases 27 —and respondents may refuse to answer, resulting in an underestimation of alcohol consumption; as such, we also assessed the proportion of women who self-reported not consuming alcohol.
We conducted a stratified analysis of the prevalence of alcohol consumption during pregnancy by demographic characteristics, such as religiosity and parity, per age group to highlight trends essential for developing targeted public health interventions. We also used a multivariable logistic regression model to examine variables associated with receiving guidance on alcohol consumption during pregnancy.
We calculated descriptive statistics using the Pearson χ2 test, considering standardized mean differences >0.2 meaningful and P < .05 significant. We used mean and SD for continuous variables. To assess differences between the 2009-2010 survey 26 and the 2021-2023 survey in self-reported alcohol consumption during pregnancy, we conducted multivariable logistic regression using a pooled database (2009-2010 and 2021-2023). We used this modeling strategy to examine variables associated with alcohol consumption during pregnancy, including its relationship to the year of the survey, while adjusting for all other confounders. We calculated odds ratios (ORs) using 95% CIs; manually performed back-step analyses, excluding the least significant variable; and reran the model until the remaining variables had P < .05. We used adjusted ORs and 95% CIs in the final model. We used the Hosmer-Lemeshow goodness-of-fit test 28 to evaluate the final models.
Results
Of 2134 participants who began the survey process, 219 answered <90% of the questionnaire and were removed from the analysis. Of the 1915 women who fully completed the questionnaires, 911 (47.6%) had been recruited from the central hospital, 500 (26.1%) from the north central hospital, and 504 (26.3%) from the northernmost hospital (Table 1).
Table 1.
Characteristics of women delivering at 3 public hospitals in Israel who were surveyed about alcohol consumption before and during pregnancy during 2021-2023 and 2009-2010, Israel
| Characteristic | 2021-2023 (n = 1915) | 2009-2010 (n = 3815) | P value | Standard mean difference (95% CI) |
|---|---|---|---|---|
| Age, mean (SD), y | 30.8 (5.6) | 30.3 (5.3) | .01 | 0.09 (0.04 to 0.15) |
| Birthplace | .76 | 0.01 (−0.05 to 0.06) | ||
| Israel | 1612 (84.2) | 3224 (84.5) | ||
| Other | 303 (15.8) | 591 (15.5) | ||
| Nationality/religion | .96 | 0.02 (−0.04 to 0.07) | ||
| Jewish | 1570 (82.6) | 3115 (82.1) | ||
| Arab-Muslim | 304 (16.0) | 623 (16.4) | ||
| Arab-Christian | 16 (0.8) | 36 (0.9) | ||
| Other | 10 (0.5) | 19 (0.5) | ||
| No answer | 15 | 22 | ||
| Religiosity level | <.001 | 0.36 (0.30 to 0.41) | ||
| Ultraorthodox | 386 (20.6) | 410 (10.8) | ||
| Orthodox | 533 (28.5) | 1026 (27.1) | ||
| Observant | 430 (23.0) | 863 (22.8) | ||
| Secular | 494 (26.4) | 1466 (38.8) | ||
| Other | 30 (1.6) | 15 (0.4) | ||
| No answer | 42 | 35 | ||
| Parity | <.001 | 0.13 (0.07 to 0.18) | ||
| 1 | 503 (26.3) | 922 (24.2) | ||
| 2 or 3 | 889 (46.4) | 1951 (51.1) | ||
| 4-6 | 365 (19.1) | 670 (17.6) | ||
| ≥7 | 82 (4.3) | 99 (2.6) | ||
| No answer | 76 (4.0) | 173 (4.5) | ||
| Birth week, mean (SD) | 38.7 (1.8) | 39.0 (1.8) | <.001 | −0.16 (−0.21 to −0.10) |
| Birth weight, mean (SD), g | 3236.9 (498.7) | 3213.6 (505.7) | .10 | 0.05 (−0.01 to 0.10) |
| Hospital location of participants recruited | <.001 | 0.68 (0.62 to 0.74) | ||
| Central | 911 (47.6) | 765 (20.1) | ||
| North central | 500 (26.1) | 2050 (53.7) | ||
| Northern | 504 (26.3) | 1000 (26.2) | ||
| Smoking, prepregnancy | <.001 | 0.14 (0.08-0.19) | ||
| Yes | 217 (11.3) | 476 (12.5) | ||
| <1 cigarette/d | 45 (2.3) | 37 (1.0) | ||
| No | 1641 (85.7) | 3293 (86.3) | ||
| Refuse/unknown | 12 (0.6) | 8 (0.2) | ||
| No answer | 0 | 1 | ||
| Alcohol consumption, prepregnancy | .001 | 0.18 (0.13-0.24) | ||
| No | 1205 (63.7) | 2667 (70.0) | ||
| <1/wk | 507 (26.8) | 889 (23.3) | ||
| 1-3/wk | 125 (6.6) | 225 (5.9) | ||
| ≥4/wk | 6 (0.3) | 14 (0.4) | ||
| Refuse/unknown | 50 (2.6) | 17 (0.4) | ||
| No answer | 22 | 3 |
Data are presented as no. (%) unless noted otherwise.
The mean (SD) age of the 1915 participants in the 2021-2023 survey was 30.8 (5.6) years. Most were Jewish, born in Israel, and multiparous (Table 1). The mean (SD) week of gestation at birth was 38.7 (1.9) weeks, and the mean (SD) offspring birthweight was 3236.9 (498.7) grams. We found no significant difference in these characteristics between the 2021-2023 and 2009-2010 survey samples. However, the proportion of ultraorthodox Jewish participants was significantly higher in the 2021-2023 survey than in the 2009-2010 survey (20.6% vs 10.8%; P < .001).
A total of 1708 (89.2%) participants reported never consuming alcohol during pregnancy (vs 3269 [85.7%] in the 2009-2010 survey; P < .001); 157 (8.2%), drinking weekly or less (vs 496 [13.0%]); and 12 (0.6%), more frequent drinking (vs 46 [1.2%]) (Figure 1). In 2021-2023, the highest proportion of women consuming any amount of alcohol during pregnancy was recorded among those who self-described as smokers, unmarried, and secular (Figure 2).
Figure 1.
Proportion of alcohol consumption in the 3 months before and during pregnancy, by year of survey, Israel, 2021-2023 (n = 1915) and 2009-2010 (n = 3815). Data from the 2009-2010 survey are related to alcohol consumption 3 months predelivery, whereas data from the 2021-2023 survey are related to alcohol consumption throughout the pregnancy.
Figure 2.
Characteristics of women who reported consuming any amount of alcohol during pregnancy, Israel, 2021-2023. Data were gathered from a survey administered in 3 public hospitals; 1915 women completed the survey. All values are percentages.
Fifty-two women who reported consuming alcohol in the 2021-2023 survey indicated binge drinking at least once during pregnancy. These women constituted 2.7% of the respondents, comparable to the 2.8% in the 2009-2010 survey. In contrast to this declining alcohol consumption rate during pregnancy, we recorded an increase in alcohol consumption before pregnancy. The proportion of respondents who reported never drinking before pregnancy declined from 69.9% in 2009-2010 to 62.9% in 2021-2023 (P < .001). The largest increase (from 23.3% to 26.5%) was among respondents who indicated drinking weekly or less frequently.
The multivariable logistic regression analysis based on pooled data (2009-2010 and 2021-2023) showed that the 2021-2023 participants were significantly less likely than the 2009-2010 participants to consume alcohol during pregnancy (adjusted OR = 0.68; 95% CI, 0.52-0.88; P = .026) (Table 2). Consuming alcohol during the 3 months before pregnancy was a strong indicator of alcohol consumption during pregnancy. When compared with participants who reported never drinking alcohol, prepregnancy consumption of <1, 1 to 3, and ≥4 servings per week was associated with ORs of, respectively, 50.20 (95% CI, 35.39-72.11), 88.59 (95% CI, 58.52-134.12), and 186.47 (95% CI, 64.70-537.40) for alcohol consumption during pregnancy. Other important model predictors were parity >2 (having a child or children before the index pregnancy), smoking, and alcohol consumption before pregnancy.
Table 2.
Logistic regression model for combined data on alcohol consumption during pregnancy in national surveys of women delivering at public hospitals in Israel, 2009-2010 (n = 3805) and 2021-2023 (n = 1864)
| Characteristic | No. of participants | Odds ratio (95% CI) a |
|---|---|---|
| Age, per year | 5669 | 1.00 (0.97-1.02) |
| Year of survey | ||
| 2009-2010 | 3805 | 1 [Reference] |
| 2021-2023 | 1864 | 0.68 (0.52-0.88) |
| Parity | ||
| 1 | 1415 | 1 [Reference] |
| 2 or 3 | 2809 | 2.05 (1.60-2.65) |
| 4-6 | 1028 | 2.39 (1.63-3.51) |
| ≥7 | 180 | 3.17 (1.52-6.59) |
| Smoking before pregnancy | ||
| No | 4898 | 1 [Reference] |
| Yes | 771 | 1.47 (1.12-1.92) |
| Alcohol consumption before pregnancy, servings/wk | ||
| 0 | 3846 | 1 [Reference] |
| <1 | 1389 | 50.20 (35.39-71.22) |
| 1-3 | 348 | 88.59 (58.52-134.12) |
| ≥4 | 20 | 186.47 (64.70-537.40) |
| No. of times binge drinking before pregnancy | ||
| 0 | 5344 | 1 [Reference] |
| 1 | 177 | 1.70 (1.16-2.51) |
| 1 or 2 | 94 | 1.67 (1.01-2.75) |
| >2 | 17 | 0.88 (0.22-3.50) |
Mutually adjusted for all variables in the table and for hospital, religiosity level, and nationality/religion.
Seventy-seven (4.0%) women reported smoking cigarettes daily in the 3 months before delivery, which was significantly lower than the 5.8% in the 2009-2010 survey (P = .005). Smoking rates before pregnancy dropped from 12.5% in 2009-2010 to 11.3% in 2021-2023, but the decrease was not significant (P = .18).
Of the 626 pregnant women (32.7%) in the current study who reported receiving guidance about alcohol consumption during pregnancy, 331 (17.3%) stated that it came from physicians and 295 (15.4%) from nurses. The percentage of women (32.7%; n = 626) receiving information about the risks of alcohol consumption from health care providers was a significant increase from the 21.5% in the 2009-2010 survey (P < .001). The main increase was in the proportion receiving guidance from physicians (from 8.0% to 17.3%; eFigure in the Supplement). However, that proportion was lower than among those who received other health behavior advice, such as advice about vitamin use (81%), diet (58%), or physical activity (40%) (Table 3).
Table 3.
Receipt of health information from care providers or friends about pregnancy-related topics among women delivering at 3 public hospitals in Israel who responded to a survey about alcohol consumption before and during pregnancy, 2021-2023 (n = 1915)
| Topic: response | No. (%) |
|---|---|
| Diet | |
| Yes | 1119 (58.4) |
| No | 644 (33.6) |
| Not applicable | 152 (7.9) |
| Vitamins | |
| Yes | 1547 (80.8) |
| No | 206 (10.8) |
| Not applicable | 162 (8.5) |
| Alcohol | |
| Yes | 569 (29.7) |
| No | 1231 (64.3) |
| Not applicable | 115 (6.0) |
| Physical activity | |
| Yes | 763 (39.8) |
| No | 992 (51.8) |
| Not applicable | 160 (8.4) |
| Smoking | |
| Yes | 559 (29.2) |
| No | 1221 (63.8) |
| Not applicable | 135 (7.0) |
When we included data on receiving guidance about alcohol consumption during pregnancy in the multivariable model, guidance from physicians was associated with an OR of 0.61 (95% CI, 0.44-0.84) as compared with women who indicated receiving no guidance. Guidance from other professionals or friends was not significantly associated with alcohol consumption during pregnancy (OR = 0.88; 95% CI, 0.66-1.16).
Discussion
Our findings provide insight into alcohol consumption trends during pregnancy among Israeli women from 2009-2010 to 2021-2023. A primary finding was the significant decrease in alcohol consumption among pregnant women during pregnancy from 2009-2010 to 2021-2023. This decrease is noteworthy, particularly amid the COVID-19 pandemic (2020-2023), which saw a general increase in alcohol consumption even among pregnant women. 22 However, our study’s assessment, conducted at only 2 time points approximately 13 years apart, may restrict a comprehensive understanding of alcohol consumption during pregnancy. Alcohol consumption during pregnancy may have fluctuated, potentially decreasing and then increasing again during the pandemic.24,25
Alcohol consumption is not a common cultural practice among the ultraorthodox population, and the percentage of ultraorthodox women in the 2021-2023 study cohort nearly doubled from the 2009-2010 cohort. The higher percentage of this population in the 2021-2023 sample might explain the observed decrease in alcohol consumption and clarify the variance between this survey and the online survey by Hen-Herbst et al, 27 in which secular women reported higher alcohol consumption rates than nonsecular participants.
In the 2009-2010 study, a substantial percentage of pregnant women (72.7%) reported receiving no educational exposure; by 2021-2023, this proportion had decreased to 62.3%. The decline from 72.7% to 62.3% during a >10-year period does not reflect a substantial improvement in educating pregnant women about the harms of alcohol consumption. This finding is concerning, particularly considering the substantial efforts that Israel has invested in raising awareness about alcohol exposure among women of reproductive age. These efforts include lectures, conferences, educational programs for primary care physicians, and establishing a specialized FASD clinic. 13 Nevertheless, according to our results, advice from health care providers to avoid consuming alcohol during pregnancy was significantly less common than advice on vitamin use, diet, and physical activity (eFigure in the Supplement). Most guidance on alcohol consumption during pregnancy came from physicians, followed by nurses.
This study highlights an increase in alcohol consumption before pregnancy. Consuming alcohol 3 months before pregnancy was identified as the strongest indicator of alcohol consumption during pregnancy. This finding aligns with a previous study suggesting that prepregnancy alcohol consumption is a predictor of alcohol consumption during pregnancy. 29 The proportion of women who reported consuming alcohol before pregnancy has increased, implying a shift in alcohol consumption behavior. This finding underscores the importance of reaching women of reproductive age with educational campaigns that stress the importance of refraining from alcohol even before conception. Finally, our study identified several factors that are associated with alcohol consumption during pregnancy, including prior consumption, parity, and smoking. These findings emphasize the importance of educating women about the risks of alcohol consumption, especially if they have a history of consumption or experience as pregnant mothers.
Limitations
This study had several limitations. First, we collected data at only 3 tertiary hospitals in diverse regions of Israel; as such, our results may not be representative of all regions in Israel. However, these hospitals were chosen for their broad demographic coverage of the national population, including Jewish, Arab, and Christian people. In a process detailed in our previous publication, 26 our rigorous comparisons with the Israeli population census confirmed that our 2009-2010 and 2021-2023 samples represented the female population of reproductive age. This alignment reinforces the representativeness of our findings and supports the claim that the data can reflect national trends despite the apparent limitation of sampling from only 3 hospitals. Second, we used self-reported data, which are limited by a potential social desirability bias and other differential biases (recall, underreporting, and nonresponse). 30 Therefore, we may have underestimated the frequency and quantity measures of alcohol consumption during pregnancy. 31 Third, we did not assay biological markers for alcohol consumption (eg, phosphatidyl ethanol measured from whole blood 32 ), which could have improved the validity of the data. Fourth, the 2009-2010 survey questionnaire referred to the 3-month period before delivery, 26 whereas our questionnaire asked about the entire pregnancy period. This potential misclassification bias only attenuates the improvement in alcohol consumption in the 2021-2023 questionnaire because it refers to a longer observation period. Finally, we interviewed women after they gave birth; thus, pregnancies terminated early due to miscarriage were not represented in our cohort.
Conclusion
Sustained efforts are crucial to maintain and improve Israel’s progress in reducing alcohol consumption during pregnancy. Despite the positive trends, the current alcohol consumption rates are concerning. Continuous awareness campaigns focused on women of reproductive age are essential to prevent FASD and associated health issues. Health care providers must actively provide guidance and support to ensure the well-being of mothers and their unborn children.
Supplemental Material
Supplemental material, sj-docx-1-phr-10.1177_00333549241289035 for Steps Toward Decreasing Maternal Alcohol Consumption in Israel: Nationwide Trends During a Decade by Yehuda Senecky, Noam Zrubavel Yaaron, Gabriel Chodick, Andrea Berger, Liat Hen-Herbst, Ilana Barta Fund, Manal Massalha, Ran Matot and Esther Ganelin-Cohen in Public Health Reports®
Supplemental material, sj-docx-2-phr-10.1177_00333549241289035 for Steps Toward Decreasing Maternal Alcohol Consumption in Israel: Nationwide Trends During a Decade by Yehuda Senecky, Noam Zrubavel Yaaron, Gabriel Chodick, Andrea Berger, Liat Hen-Herbst, Ilana Barta Fund, Manal Massalha, Ran Matot and Esther Ganelin-Cohen in Public Health Reports®
Acknowledgments
The authors thank all participants for completing the questionnaires and the National Authority for Community Safety for its financial support.
Footnotes
Authors’ Note: Yehuda Senecky and Noam Zrubavel Yaaron contributed equally to this article as co–first authors.
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding: The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the National Authority for Community Safety (grant 5700-0035-2020-003417), specifically covering expenses related to statistical experts and compensating those involved in the questionnaire provision.
ORCID iD: Liat Hen-Herbst, PhD 
https://orcid.org/0000-0002-1039-0837
Supplemental Material: Supplemental material for this article is available online. The authors have provided these supplemental materials to give readers additional information about their work. These materials have not been edited or formatted by Public Health Reports’s scientific editors and, thus, may not conform to the guidelines of the AMA Manual of Style, 11th Edition.
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Supplementary Materials
Supplemental material, sj-docx-1-phr-10.1177_00333549241289035 for Steps Toward Decreasing Maternal Alcohol Consumption in Israel: Nationwide Trends During a Decade by Yehuda Senecky, Noam Zrubavel Yaaron, Gabriel Chodick, Andrea Berger, Liat Hen-Herbst, Ilana Barta Fund, Manal Massalha, Ran Matot and Esther Ganelin-Cohen in Public Health Reports®
Supplemental material, sj-docx-2-phr-10.1177_00333549241289035 for Steps Toward Decreasing Maternal Alcohol Consumption in Israel: Nationwide Trends During a Decade by Yehuda Senecky, Noam Zrubavel Yaaron, Gabriel Chodick, Andrea Berger, Liat Hen-Herbst, Ilana Barta Fund, Manal Massalha, Ran Matot and Esther Ganelin-Cohen in Public Health Reports®