Abstract
Introduction
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.
Material and Methods
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.
Results
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.
Conclusions
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.
Keywords: alcohol drinking, AUDIT, cohort studies, infant, pregnancy, premature birth, questionnaires, small for gestational age
In this large Finnish birth cohort, alcohol use defined by AUDIT‐based instruments before pregnancy was associated with higher odds of preterm birth and small for gestational age.
Abbreviations
- AUDIT
Alcohol Use Disorders Identification Test
- CI
confidence interval
- KuBiCo
Kuopio Birth Cohort
- PTB
preterm birth
- SGA
small for gestational age
Key message.
Identifying risky alcohol use before pregnancy remains challenging. The abbreviated Alcohol Use Disorders Identification Test (AUDIT)‐4 performs similarly to the full AUDIT in predicting preterm birth. Screening for binge drinking may help identify women at risk of impaired fetal growth.
1. INTRODUCTION
It is well established that alcohol consumption during pregnancy exposes the fetus to a toxic substance for which it has no tolerance. This exposure can lead to a range of adverse outcomes, collectively referred to as Fetal Alcohol Spectrum Disorders (FASD). 1 FASD is a collection of diverse disorders, including physical, behavioral, and cognitive problems. 2 In addition to the neurodevelopmental outcomes encompassed by FASD, prenatal alcohol exposure has also been associated with adverse perinatal outcomes such as preterm birth (PTB) and impaired fetal growth. 3 , 4 Since it is not possible to determine a safe level of alcohol consumption during pregnancy, the only feasible recommendation for all pregnant women, and also those planning pregnancy, is complete abstinence from alcohol. 5 , 6
The importance of screening for alcohol use before and during pregnancy has grown, as even relatively low levels of prenatal exposure have been associated with adverse birth outcomes, including low birthweight and small for gestational age (SGA). 7 Various alcohol use screening tools, including questionnaires and biomarkers, have been developed and are widely used across diverse health care settings and populations. 8 , 9 Among the available tools, questionnaires such as TWEAK, T‐ACE, and Alcohol Use Disorders Identification Test (AUDIT)‐C have demonstrated high sensitivity in identifying prenatal risk drinking. 10 The World Health Organization recommends the AUDIT questionnaire, which evaluates drinking frequency, quantity, and patterns through 10 structured items. 11 The AUDIT questionnaire has also been validated for pregnant populations. 12 Unfortunately, screening tools developed for the general population often fail to identify risky alcohol use among pregnant women. 13 Accurately assessing maternal alcohol consumption is challenging, as self‐reported data may be influenced by social desirability and recall bias, as well as feelings of guilt and concerns about negative consequences related to alcohol use during pregnancy. 14
The aim of this study was to evaluate the ability of the AUDIT, AUDIT‐C (AUDIT items 1–3), and AUDIT‐4 (AUDIT items 1–3 and 10) questionnaires, as well as individual AUDIT items, in identifying increased risk of adverse pregnancy outcomes, specifically PTB and SGA, in a large Kuopio birth cohort (KuBiCo). A secondary aim was to evaluate the diagnostic accuracy of abbreviated AUDIT versions (AUDIT‐C and AUDIT‐4) and selected single items (items 3 and 10) in identifying hazardous drinking, using AUDIT ≥6 as the reference standard.
2. MATERIAL AND METHODS
This observational, prospective cohort study is based on register‐linked data from the KuBiCo population collected between 2012 and 2023. KuBiCo (www.kubico.fi) is a collaborative research project involving the University of Eastern Finland (UEF), Kuopio University Hospital (KUH), and the Finnish Institute for Health and Welfare (THL). The project aims to improve understanding of how genetic, epigenetic, environmental, lifestyle, nutritional, and medical factors during pregnancy influence maternal and child health. All pregnant women in the Northern Savo region expected to deliver at KUH are invited to participate. Over 90% of participants are recruited during early pregnancy (gestational weeks 6–9) at routine prenatal visits. 15 This study population comprised 7644 pregnant women who completed the AUDIT questionnaire during the first trimester between 2012 and 2023, and had a singleton pregnancy resulting in delivery at ≥22 + 0 gestational weeks.
In Finland, antenatal health care is provided free of charge, and standard care begins with an appointment with a midwife or nurse between approximately 7 and 12 weeks of gestation (first trimester). In the Kuopio region, antenatal care typically includes two visits to a general practitioner, at least five visits to a midwife or nurse, and ultrasound examinations between the 12th and 14th weeks, as well as a detailed structural scan around the 20th week of pregnancy. At the first maternity appointment (typically ≤9 weeks of gestation), participants completed an online 10‐item AUDIT questionnaire as part of routine early pregnancy assessment. The questionnaire, completed either immediately before or after the visit, assessed alcohol consumption prior to pregnancy, including quantity (number of standard drinks containing 12 g of ethanol), frequency, and alcohol‐related problems. The AUDIT questionnaire documented alcohol consumption during the year preceding pregnancy. Each item is scored on a scale from 0 to 4, yielding a total AUDIT score ranging from 0 to 40.
In Finnish clinical practice, a total AUDIT score of ≥6 has been recommended as an optimal screening cut‐off for hazardous or harmful alcohol use among women. 16 For each respondent, scores for the short version, AUDIT‐C, comprising the first three items (range 0–12), were also calculated. 17 AUDIT‐C scores of 3–4 were interpreted as indicating problematic alcohol use, and scores of ≥5 as high‐risk drinking. 18 In addition, AUDIT‐4 scores, based on items 1–3 and item 10 of the full AUDIT, were calculated, with a score of ≥5 indicating risky drinking among women. 19 AUDIT item 3 was included as an independent variable, as it reflects binge drinking, defined as the consumption of ≥6 alcoholic drinks on one occasion, a pattern that has been strongly associated with adverse fetal outcomes in previous studies. 2 AUDIT item 10 was also examined separately, as it showed sufficient variability to allow meaningful statistical comparisons. In contrast, item 5 was excluded from single‐item analyses because its highly skewed distribution (97.6% responded “never”) limited its interpretability as an independent predictor.
Descriptive maternal and newborn characteristics were obtained from the KUH birth registry. Maternal demographic and prenatal data included age, pre‐pregnancy height and weight, parity, and relationship status. Additional information was collected on pre‐existing and pregnancy‐related conditions, including hypertensive disorders, diabetes, and infertility treatments prior to the current pregnancy. Smoking exposure was defined as active smoking before or during pregnancy, as well as exposure to second‐hand smoke. Hypertensive disorders included preeclampsia, gestational hypertension, and pregestational hypertension, while diabetes included both pregestational and gestational diabetes. All medical diagnoses were defined using ICD‐10 codes, with hypertensive disorders identified by codes O10, O11, O13, O14, O15, and O16, and diabetes by codes starting with O24. Information on newborns' sex, birthweight, and gestational age at delivery was also obtained from the birth registry. According to the WHO, PTB was defined as delivery before 37 completed weeks of gestation. 20 SGA was defined as a birthweight corrected for gestational age below 2 standard deviations (SD) from the mean, based on the sex‐specific Finnish fetal growth curves. 21
Statistical analyses were performed using IBM SPSS Statistics for Mac OS, Version 29.0 (IBM Corp., Armonk, NY, USA). A p‐value <0.05 was considered statistically significant. Descriptive statistics included absolute and relative frequencies, as well as means with standard deviations (SDs) to summarize maternal and neonatal characteristics and the distribution of responses to all 10 AUDIT items. Participants were classified into high‐ and low‐risk drinking groups according to each screening tool and its predefined cut‐off.
Associations between hazardous alcohol use and birth outcomes were evaluated using logistic regression analyses. For each screening tool, the low‐risk group served as the reference category. Results are presented as odds ratios (ORs) and adjusted odds ratios (aORs) with 95% confidence intervals (CIs). The models were adjusted for maternal age, pre‐pregnancy body mass index (BMI), parity, relationship status, pregestational or gestational diabetes, infertility treatment, smoking, and hypertensive disorders. These covariates were selected based on previous evidence of their relevance to neonatal and birth outcomes. 22 , 23
The shortened versions of the AUDIT and individual items 3 and 10 were compared with the reference standard (AUDIT score ≥6) using receiver operating characteristic (ROC) curve analysis. The area under the ROC curve (AUC) with 95% CIs and Youden's index (sensitivity + specificity – 1) were used to determine optimal cut‐off points balancing sensitivity and specificity.
In supplementary analyses, AUDIT items were dichotomized as 0 vs ≥1 point, and for items 9 and 10, according to the AUDIT scoring system, as 0 vs ≥2 points. In addition, three‐level score categories (0, 1, and 2–4 points) were applied for AUDIT items 1–3 because of sufficient variability in response distributions. Differences in outcome frequencies were assessed using Pearson's chi‐square test or Fisher's exact test, as appropriate. We further evaluated the ability of AUDIT item 10 to identify increased risk of adverse pregnancy outcomes among women classified as low risk by other thresholds. Missing data were minimal. For infertility treatment, 123 observations (1.7%) were missing and were assigned to the most frequent category. All other variables had complete data.
3. RESULTS
Of the 7644 women who completed the AUDIT questionnaire in early pregnancy, 7141 were included in the final analyses. A total of 503 participants were excluded because of multiple pregnancies, miscarriage, or delivery outside the study hospital. A flowchart detailing participant exclusions and final sample selection is presented in Figure 1.
FIGURE 1.
Flowchart of the study population at Kuopio University Hospital.
The distribution of AUDIT item responses among 7644 pregnant women is shown in Table 1. Total AUDIT scores ranged from 0 to 32 (mean 2.9; median 3.0; interquartile range 3.0). Regarding item 1, 16% reported abstinence, 49% consumed alcohol monthly or less, and 30.8% reported drinking two to four times per month. For item 2, 65.4% of respondents reported consuming one to two drinks on a typical occasion, and 20.8% reported three to four drinks. Item 3 indicated that 40.4% had never consumed six or more drinks on one occasion, while 53% did so less than monthly. Responses on questions related to alcohol dependence were uncommon: impaired control (item 4) was reported by 1.4%, failure to meet obligations (item 5) by 2.4%, and morning drinking (item 6) by 0.6%. Regarding harmful use, 10% reported guilt after drinking (item 7), 7.5% memory loss (item 8), 2.2% alcohol‐related injuries (item 9), and 4.2% concern expressed by others (item 10).
TABLE 1.
AUDIT questionnaire response patterns among 7644 pregnant women: alcohol use in the year preceding pregnancy.
| Alcohol use questions | AUDIT response scale | N (%) |
|---|---|---|
| 1. How often do you have a drink containing alcohol? | Never | 1220 (16.0) |
| Monthly or less | 3743 (49.0) | |
| 2–4 times/month | 2355 (30.8) | |
| 2–3 times/week | 316 (4.1) | |
| ≥4 times/week | 10 (0.1) | |
| 2. How many drinks containing alcohol do you have on a typical day when you are drinking? | 1–2 glasses | 4999 (65.4) |
| 3–4 glasses | 1592 (20.8) | |
| 5–6 glasses | 754 (9.9) | |
| 7–9 glasses | 233 (3.0) | |
| ≥10 glasses | 66 (0.9) | |
| 3. How often do you have six or more drinks on one occasion? | Never | 3085 (40.4) |
| Less than monthly | 4050 (53.0) | |
| Monthly | 453 (5.9) | |
| Weekly | 56 (0.7) | |
| Daily | 0 (0) | |
| 4. How often during the last year have you found that you were not able to stop drinking once you had started? | Never | 7539 (98.6) |
| Less than monthly or more frequent | 105 (1.4) | |
| 5. How often during the last year have you failed to do what was normally expected from you because of drinking? | Never | 7458 (97.6) |
| Less than monthly or more frequent | 186 (2.4) | |
| 6. How often during the last year have you needed a first drink in the morning to get yourself going after a heavy drinking session? | Never | 7599 (99.4) |
| Less than monthly or more frequent | 45 (0.6) | |
| 7. How often during the last year have you had a feeling of guilt or remorse after drinking? | Never | 6877 (90.0) |
| Less than monthly or more frequent | 767 (10.0) | |
| 8. How often during the last year have you been unable to remember what happened the night before because you had been drinking? | Never | 7072 (92.5) |
| Less than monthly or more frequent | 572 (7.5) | |
| 9. Have you or someone else been injured as a result of your drinking? | Never | 7479 (97.8) |
| During or before the last year | 165 (2.2) | |
| 10. Has a relative or friend or a doctor or another health worker been concerned about your drinking or suggested you cut down? | Never | 7324 (95.8) |
| During or before the last year | 320 (4.2) |
Figure 2 shows substantial variation in the proportion of women with high‐risk drinking across screening tools and cut‐offs, ranging from 4.2% to 48.5%. Using the full AUDIT (≥6), 11.6% were classified as high risk. Lower cut‐offs in abbreviated versions (AUDIT‐C and AUDIT‐4) yielded higher prevalence estimates, whereas single items (3 and 10) identified smaller high‐risk groups.
FIGURE 2.
Proportion of women with high‐ or low‐risk drinking (N = 7644) prior to pregnancy according to different screening tools.
Table 2 presents the demographic characteristics of the 7141 participating mother–newborn dyads. The mean age of the mothers at birth was 30.8 years. The average pre‐pregnancy weight was 69.3 kg, and the mean height was 165.3 cm, resulting in a mean BMI of 25.3 kg/m2. On average, mothers had 0.8 previous children and a mean gravidity of 2.3. Half (49.7%) were married. Approximately one quarter of the women (23.2%) reported smoking exposure before or during pregnancy. Pregnancy‐related hypertensive disorders were diagnosed in 6.2% of the women, and 20.4% had gestational or pregestational diabetes. Among the newborns, the mean gestational age at birth was 39.4 weeks, and the average birthweight was 3489 grams. PTB (<37 weeks) occurred in 5.3% and SGA in 2.5% of newborns.
TABLE 2.
Baseline characteristics of the study population.
| Variable | Mean (SD) or N (%) | Range |
|---|---|---|
| Mothers | ||
| Age (years) | 30.8 (5.1) | 16–48 |
| Weight before pregnancy (kg) | 69.3 (15.4) | 38–190 |
| Height (cm) | 165.3 (6.0) | 144–191 |
| BMI (kg/m2) | 25.3 (5.3) | 15.0–72 |
| Nulliparous | 3439 (48.2) | — |
| Parity | 0.8 (1.1) | 0–14 |
| Gravidity | 2.3 (1.6) | 1–20 |
| Married | 3552 (49.7) | — |
| Smoking exposure | 1658 (23.2) | — |
| Hypertensive disorders | 443 (6.2) | — |
| Diabetes | 1460 (20.4) | — |
| Infertility treatments | 503 (7.0) | — |
| Newborns | ||
| Gestational age (weeks) | 39.4 (1.9) | 22.1–42.3 |
| Birth weight (g) | 3489 (543) | 395–5320 |
| Preterm birth (<37 weeks) | 378 (5.3) | — |
| Small for gestational age | 177 (2.5) | — |
| Female infants | 3527 (49.3) | — |
| Total | 7141 (100) | |
Note: Values are mean (SD) or n (%).
Regarding PTB, 7.2% of women with AUDIT ≥6 and 7.9% of those with AUDIT item 10 (score ≥2) delivered preterm. Both groups had significantly increased odds of PTB, with aORs of 1.43 (95% CI 1.05–1.95) for AUDIT ≥6 and 1.65 (95% CI 1.05–2.58) for item 10 (score ≥2). Although only 4.1% of women reported concern about their drinking on AUDIT item 10, this subgroup showed the highest risk of PTB. Elevated odds were also observed among women with AUDIT‐4 (score ≥5) (aOR 1.42; 95% CI 1.04–1.95). In logistic regression analyses, AUDIT item 3 (score ≥2) was associated with more than a twofold increase in the odds of SGA (crude OR 2.08; 95% CI 1.32–3.28), and this association remained statistically significant after adjustment (aOR 1.67; 95% CI 1.02–2.71) (Table 3).
TABLE 3.
Associations between AUDIT, AUDIT‐C, and AUDIT‐4 scores before pregnancy and small for gestational age (SGA) and preterm birth (PTB) among 7141 pregnant women.
| Screening tool and cut‐off | N (%) | SGA, n (%) | Crude OR (95% CI) | aOR (95% CI) | PTB, n (%) | Crude OR (95% CI) | aOR (95% CI) |
|---|---|---|---|---|---|---|---|
| AUDIT ≥6 | 811 (11.4) | 29 (3.6) | 1.55 (1.03–2.32) | 1.24 (0.80–1.91) | 58 (7.2) | 1.45 (1.08–1.93) | 1.43 (1.05–1.95) |
| AUDIT‐C ≥3 | 3458 (48.4) | 82 (2.4) | 0.92 (0.68–1.24) | 0.73 (0.53–1.00) | 186 (5.4) | 1.03 (0.84–1.27) | 0.97 (0.78–1.22) |
| AUDIT‐C ≥4 | 1733 (24.3) | 50 (2.9) | 1.24 (0.89–1.72) | 1.02 (0.72–1.46) | 102 (5.9) | 1.16 (0.92–1.47) | 1.14 (0.89–1.47) |
| AUDIT‐C ≥5 | 692 (9.7) | 23 (3.3) | 1.41 (0.90–2.19) | 1.15 (0.71–1.84) | 44 (6.4) | 1.24 (0.90–1.72) | 1.28 (0.90–1.81) |
| AUDIT‐4 ≥4 | 1838 (25.7) | 50 (2.8) | 1.14 (0.82–1.59) | 0.93 (0.65–1.33) | 107 (5.8) | 1.15 (0.91–1.45) | 1.12 (0.88–1.44) |
| AUDIT‐4 ≥5 | 833 (11.7) | 27 (3.3) | 1.38 (0.91–2.09) | 1.13 (0.73–1.76) | 57 (6.8) | 1.37 (1.02–1.83) | 1.42 (1.04–1.95) |
| AUDIT item 3 ≥2 | 467 (6.5) | 22 (4.8) | 2.08 (1.32–3.28) | 1.67 (1.02–2.71) | 26 (5.6) | 1.06 (0.70–1.60) | 1.02 (0.66–1.56) |
| AUDIT item 10 ≥2 | 292 (4.1) | 9 (3.1) | 1.27 (0.64–2.50) | 1.08 (0.54–2.17) | 23 (7.9) | 1.56 (1.01–2.43) | 1.65 (1.05–2.58) |
Note: Adjusted for maternal age, pre‐pregnancy BMI, parity, relationship status, infertility treatment, smoking exposure, hypertensive disorders, and diabetes.
Abbreviations: aOR, adjusted odds ratio; CI, confidence interval; OR, odds ratio; PTB, preterm birth; SGA, small for gestational age.
Table 4 presents the diagnostic accuracy of the shortened AUDIT screening tools using AUDIT ≥6 as the reference standard. AUDIT‐4 showed the best overall performance, with the highest Youden's index and an AUC in the excellent range (AUC 0.96). AUDIT‐C also demonstrated excellent discriminative ability with a similar optimal cut‐off. Among the individual AUDIT items, item 3 showed moderate discrimination with high specificity but limited sensitivity, whereas item 10 showed poor overall discriminative performance.
TABLE 4.
Diagnostic accuracy of shortened AUDIT screening tools using AUDIT ≥6 as the reference standard; cut‐offs derived from ROC analysis.
| Screening test | Cut‐off | Sensitivity (95% CI) | Specificity (95% CI) | Youden's Index | AUC (95% CI) | Interpretation a |
|---|---|---|---|---|---|---|
| AUDIT‐4 | ≥4 | 93.9 (92.1–95.4) | 83.1 (82.2–84.0) | 0.77 | 0.959 (0.953–0.965) | Excellent |
| AUDIT‐C | ≥4 | 87.5 (85.5–89.9) | 84.1 (83.2–84.9) | 0.72 | 0.933 (0.925–0.941) | Excellent |
| AUDIT item 3 | ≥2.0 | 47.1 (43.7–50.4) | 98.6 (98.3–98.9) | 0.46 | 0.847 (0.834–0.860) | Good (high specificity, moderate discrimination) |
| AUDIT item 10 | ≥2.0 | 26.4 (23.5–29.5) | 98.7 (98.4–99.0) | 0.25 | 0.626 (0.604–0.648) | Poor (limited discrimination despite high specificity) |
Note: n = 7644 women included in the ROC analyses. High‐risk drinking was defined as an AUDIT total score ≥6.
Interpretation based on commonly used AUC thresholds: excellent (≥0.90), good (0.80–0.89), fair (0.70–0.79), poor (<0.70).
Associations between individual AUDIT items and birth outcomes are presented in Tables S1 and S2. In dichotomized analyses (0 vs ≥1 point), items 5 and 10 were associated with PTB. When three‐level score categories (0, 1, and ≥2 points) were applied to AUDIT items 1–3, only item 3 was associated with SGA. No significant associations with PTB or SGA were observed for items 1 and 2. In women classified as low risk according to the overall AUDIT, AUDIT‐C, or item 3, a high score on item 10 (≥2 points) did not predict an increased risk of PTB or SGA. Outcome frequencies were similar between women scoring 0 and ≥2 points on item 10, and no statistically significant differences were observed.
4. DISCUSSION
In this large Finnish birth cohort, we examined the associations between self‐reported alcohol use prior to pregnancy, assessed using AUDIT‐based screening tools, and adverse pregnancy outcomes. Alcohol use, defined by established AUDIT thresholds (AUDIT ≥6, AUDIT‐4 ≥5, and AUDIT item 10 ≥2), was associated with an increased risk of PTB compared to women below these thresholds. Binge drinking, assessed by AUDIT item 3 (≥2), was associated with an increased risk of SGA infants compared to women reporting infrequent binge drinking. These findings indicate that both overall risky drinking patterns and episodic heavy drinking before pregnancy are associated with adverse perinatal outcomes.
Current guidelines recommend screening women for unhealthy alcohol use before pregnancy and in early pregnancy using validated instruments, and providing brief interventions to those who report alcohol use. 6 , 24 However, systematic comparisons between different AUDIT‐based instruments in predicting specific perinatal outcomes remain limited. In our cohort, AUDIT ≥6 and AUDIT‐4 ≥5 were associated with approximately 40% higher odds of PTB. Given the low prevalence of PTB (5.3%) and SGA (2.5%), these odds ratios closely approximate relative risks. The magnitude of the observed associations is comparable to established modifiable risk factors, such as maternal smoking during pregnancy in relation to PTB (aOR 1.39) and pre‐pregnancy obesity among women aged 30–34 years (aOR 1.32). 25 , 26 Monthly or more frequent binge drinking (AUDIT item 3 ≥2) was associated with 67% higher odds of SGA, an effect size approaching that reported for maternal smoking in relation to SGA (aOR 2.27). 25 These findings suggest that risky alcohol use identified through AUDIT‐based screening represents a clinically relevant risk marker.
Our results indicate that both AUDIT‐4 and AUDIT‐C, when using a cut‐off of ≥4 points, can identify risky alcohol use with performance comparable to the full 10‐item AUDIT. To our knowledge, this is the first study to demonstrate the suitability of the AUDIT‐4 at this cut‐off value. However, AUDIT‐C was less strongly associated with PTB than the full AUDIT or AUDIT‐4. The association between the full AUDIT and PTB may be attributed to its inclusion of items assessing alcohol‐related harm and dependence, whereas AUDIT‐C is limited to consumption patterns. Similarly, the addition of item 10 in AUDIT‐4, which captures concern expressed by others about one's drinking, appears to provide prognostic value beyond consumption measures alone. In contrast, individual AUDIT items were not sufficient as stand‐alone screening tools.
In our cohort, alcohol use was mainly reflected in AUDIT items assessing drinking frequency and quantity, whereas symptoms indicative of alcohol dependence or alcohol‐related harm were less frequently reported. This pattern suggests that many women engaging in risky alcohol use before pregnancy may not meet formal ICD‐10 criteria for alcohol dependence, but may nonetheless face clinically meaningful risks. In this study, AUDIT items were used to characterize patterns and levels of alcohol use, rather than to diagnose alcohol use disorders. Among the individual items, item 10, which reflects concern expressed by others, was independently associated with PTB. This finding may indicate a broader psychosocial burden beyond alcohol consumption alone, as concern from others may reflect underlying difficulties not captured by consumption measures. Previous research supports this interpretation, demonstrating that alcohol‐related problems frequently co‐occur with anxiety and mood disorders. 27 While individual AUDIT items should not be used in isolation, they may provide clinically relevant contextual information.
The observed association between alcohol use and PTB is consistent with previous population‐based studies indicating that both the dose and timing of alcohol exposure before conception and during pregnancy influence gestational length. 4 , 28 , 29 Emerging evidence suggests that periconceptional alcohol exposure, including episodic binge drinking at mild‐to‐moderate levels, may be particularly relevant. 28 The first trimester appears especially sensitive to alcohol's effects. 30 We also observed an association between monthly or more frequent binge drinking and SGA. This finding aligns with prior studies linking periconceptional and prenatal alcohol exposure to reduced fetal growth. 31 Specifically, those with moderate or heavy drinking (≥4 drinks per week) who also engaged in binge drinking have been shown to be about twice as likely to deliver an SGA infant, which supports our findings regarding the risks of episodic heavy drinking patterns. 32 Potential biological mechanisms may include alcohol‐related alterations in placental growth, vasculature, and molecular regulation. 33 However, causal pathways cannot be inferred from observational data.
Despite the acknowledged limitations of self‐report, current evidence indicates that no single blood biomarker can be recommended as a replacement for self‐report. 34 Although AUDIT primarily reflects pre‐pregnancy alcohol use, previous literature has demonstrated its effectiveness in screening unhealthy alcohol use during pregnancy. 35 Our findings support the utility of full AUDIT‐based screening, as it identified women with higher odds of PTB and, through the binge drinking item, women with higher odds of SGA. Taken together, our findings and existing evidence support the continued clinical relevance of AUDIT‐based screening in antenatal care.
Our study has several limitations. First, alcohol consumption is inherently difficult to measure reliably. Reporting of prenatal alcohol use is known to be affected by both the phrasing and timing of the questions. 13 Additionally, women may underreport alcohol consumption during pregnancy. 14 We used an electronic version of the AUDIT questionnaire to reduce social desirability bias. However, misclassification related to the timing or quantity of exposure is possible. Second, the AUDIT assesses alcohol use during the year preceding pregnancy and does not allow precise differentiation between periconceptional, early pregnancy, and pre‐pregnancy exposure. Therefore, the exact timing of alcohol exposure in relation to critical windows of fetal development cannot be determined. Although we adjusted for several established risk factors, residual confounding due to unmeasured or imprecisely measured variables remains possible. The number of outcome events in some high‐risk subgroups was limited, which may have reduced statistical power and contributed to imprecision in certain estimates. Furthermore, the KuBiCo cohort includes only a subset of all births in the region, which may introduce selection bias and limit the generalizability of the findings to the wider population. Distribution of the AUDIT scores in KuBiCo was mostly similar to the distribution in the whole population at the time of collection. 36
5. CONCLUSION
Our findings suggest that shortened versions of the AUDIT, particularly the AUDIT‐4, may be as useful as the full AUDIT in identifying clinically relevant risky alcohol use. Such validated brief screening tools can be implemented in routine care for women of reproductive age during pregnancy as well as in the preconception period, to facilitate early identification of those at risk and to enable targeted interventions to reduce alcohol‐exposed pregnancies and optimize reproductive outcomes. Discontinuation of alcohol use before conception is crucial for supporting optimal maternal and fetal health and reducing adverse perinatal outcomes. Healthcare interventions should therefore address alcohol use among all women of reproductive age, rather than focusing solely on those who are already pregnant, in order to minimize the risk of unintentional alcohol exposure in early pregnancy.
AUTHOR CONTRIBUTIONS
Päivi Nuttunen: Conceptualization, data curation; formal analysis, methodology, writing—original draft, writing—review and editing. Timo Purmonen: Conceptualization, visualization, writing—review and editing. Ulpu Ålander: Writing—review and editing. Olli Kärkkäinen: Data curation, formal analysis, methodology, writing—review and editing, supervision. Leea Keski‐Nisula: Conceptualization, formal analysis, methodology, data curation, supervision, writing—review and editing.
FUNDING INFORMATION
P.N. received grants from the Finnish Foundation for Alcohol Studies and the Paulo Foundation to support this work.
CONFLICT OF INTEREST STATEMENT
Timo Purmonen is employed by Oriola Finland Oy. The other authors declare no conflicts of interest.
ETHICS STATEMENT
Participants were included from the Kuopio Birth Register, and the study was approved by the Ethics Committee of the Kuopio University Hospital (5302500, 84/2014, and 1474/2019, October 19, 2019) and the Hospital District of Central Finland, Jyväskylä (18 U/2011, October 6, 2016). Due to the retrospective, register‐based nature of the study, the requirement for individual informed consent was waived by the review authority.
Supporting information
Table S1. Associations between individual AUDIT items and preterm birth (PTB) and small for gestational age (SGA) (n = 7141).
Table S2. Associations between AUDIT items 1–3 and preterm birth (PTB) and small for gestational age (SGA) using three‐level score categories (n = 7141).
Table S3. Predictive value of AUDIT item 10 for adverse outcomes among pregnant women (n = 7141) classified in low‐risk groups according to AUDIT, AUDIT‐C, and AUDIT item 3 thresholds.
ACKNOWLEDGMENTS
Open access publishing facilitated by Ita‐Suomen yliopisto, as part of the Wiley ‐ FinELib agreement.
DATA AVAILABILITY STATEMENT
The data that support the findings of this study are available from Kuopio Birth Cohort Study (KuBiCo). Restrictions apply to the availability of these data, which were used under license for this study. Data are available from the author(s) with the permission of Kuopio Birth Cohort Study (KuBiCo).
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Table S1. Associations between individual AUDIT items and preterm birth (PTB) and small for gestational age (SGA) (n = 7141).
Table S2. Associations between AUDIT items 1–3 and preterm birth (PTB) and small for gestational age (SGA) using three‐level score categories (n = 7141).
Table S3. Predictive value of AUDIT item 10 for adverse outcomes among pregnant women (n = 7141) classified in low‐risk groups according to AUDIT, AUDIT‐C, and AUDIT item 3 thresholds.
Data Availability Statement
The data that support the findings of this study are available from Kuopio Birth Cohort Study (KuBiCo). Restrictions apply to the availability of these data, which were used under license for this study. Data are available from the author(s) with the permission of Kuopio Birth Cohort Study (KuBiCo).