Alcohol and Alcoholism, 2016, 51(3) 339–346 doi: 10.1093/alcalc/agv112 Advance Access Publication Date: 25 September 2015 Review

Review

Trajectories of Alcohol Use and Binge Drinking Among Pregnant Inuit Women Marilyn Fortin1,2,*, Gina Muckle1,2, Elhadji Anassour-Laouan-Sidi2, Sandra W. Jacobson3, Joseph L. Jacobson3, and Richard E. Bélanger2,4 1

Department of Psychology, Laval University, Québec, QC, Canada, 2Population 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, MI, USA, and 4Department of Pediatrics, Centre Mère-enfant Soleil, CHUQ, Laval University, Québec, QC, Canada *Corresponding author: Population Health and Optimal Health Practices Research Unit, CHU de Québec Research Centre, 2875, boulevard Laurier, Édifice Delta II, Bureau 600, 6e étage, Québec, QC, Canada G1V 2M2. Tel.: +418-525-4444; E-mail: [email protected]; [email protected] Received 22 April 2015; Revised 27 August 2015; Accepted 2 September 2015

Abstract Background: 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. nonbinging and binging) were explored by Markov modeling across time periods. Two hundred and forty-eight Inuit women from Arctic Quebec were interviewed at mid-pregnancy, 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.

INTRODUCTION In most countries and cultures, alcohol is strongly embedded in modern life (Heath, 1986; Gusfield, 1996; 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 (World Health Organization (WHO), 2014). In North America, the vast majority of adults are

considered active drinkers (Health Canada, 2011; Substance Abuse and Mental Health Services Administration (SAMHSA), 2012). Excessive alcohol consumption is attributable to 5% of the worldwide global burden of disease (World Health Organization (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

© The Author 2015. Medical Council on Alcohol and Oxford University Press. All rights reserved

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340 and substance dependence (National Institute of Alcohol Abuse and Alcoholism (NIAAA), 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 with 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 (Substance Abuse and Mental Health Services Administration (SAMHSA), 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 (Carney and Chermak, 1991; Burd and Moffatt, 1994; 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 (Horrigan et al., 2000; Haynes et al., 2003; Archibald, 2004; Fortin et al., 2015), 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 (Curran et al., 1998; Barnes et al., 2000; Fuzhong et al., 2001; Maggs and Schulenberg, 2004–2005; Bobo and Greek, 2011). In certain Occidental cultures, pregnancy is associated with decreased alcohol consumption (Denny et al., 2009; Walker et al., 2011; Cameron et al., 2013). 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). 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 (a) 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 (b) assessed transitions between time periods. Since variations in drinking patterns have been reported in many populations in relation to personal and familial factors, (c) 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.

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METHODS 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 2000-km shoreline of Hudson Bay, the Hudson Strait and Ungava Bay. They live in 14 villages, ranging from 160 to 2055 inhabitants per village. From November 1995 to November 2000, a midwife or nurse in each of the three 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).

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

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Alcohol and Alcoholism, 2016, Vol. 51, No. 3 Predictors Based on the literature (Fillmore et al., 1991; Wilsnack et al., 2000, 2009; Nunavik Inuit Health Survey, 2004; Muckle et al., 2011; Fraser et al., 2012), 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 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 three 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).

Statistical analyses 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 Wugalter, 1992; Collins et al., 1994; Collins and Lanza, 2010), 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 (Guo et al., 2000; Jackson et al., 2001; White et al., 2009; Bray et al., 2014). 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). 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: (a) from drinking status to abstainer from T1 to T2, and (b) 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.

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 one-third of them used marijuana in early pregnancy.

Proportions and trajectories of alcohol use and binge drinking Table 2 presents the proportions of alcohol use and binge drinking over study periods T1–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,

Table 1. Sample characteristics

Age (years)—mean (SD) Marital status (In a couple)—% [95% CI] SES—% [95% CI] Unskilled laborers, menial service workers Machine operators, semiskilled workers Skilled craftsmen, clerical, sales workers Technical, major or medium-size business or professional Total pregnancies—mean (SD) Marijuana use at conception (Yes)— % [95% CI]

N

Characteristics

248 248 247

24.9 (5.8) 68.1% [62.3–73.9] 55.5% [49.3–61.7] 23.9% [18.6–29.2] 16.6% [12.0–21.2] 4.0 [1.6–6.5]

248 248

3.9 (2.3) 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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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 Fig. 1b. Transition rates of changing status from binge drinking to non-binge drinking (which included abstainers

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 Before conception (T1) At conception (T2) During pregnancy (T3) Postnatal year (T4)

Binge drinking Before conception (T1) At conception (T2) During pregnancy (T3) Postnatal year (T4)

Drinking

Non-drinking

0.73 0.36 0.60 0.62

0.27 0.64 0.40 0.38

Binging

Non-binging

0.54 0.10 0.19 0.33

0.46 0.90 0.81 0.67

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 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. 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 nonbingers 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.

Variables related to changes in drinking status 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

Fig. 1. (a) Proportions and transition rates of alcohol drinking over time. (b) Proportions and transition rates of binge drinking over time.

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Alcohol and Alcoholism, 2016, Vol. 51, No. 3 Table 3. Multivariate logistic regression of personal and SES variables on alcohol and binge drinking trajectories at conception Covariates

OR

Decreasing alcohol use (N = 93) Age—14–24 years 1.33 Marital status—In a couple 0.99 SES—Low 1.13 Marijuana—Yes 0.64 Decreasing binge drinking (N = 107) Age—14–24 years 0.80 Marital status—In a couple 1.74 SES—Low 1.59 Marijuana—Yes 0.41 Constant binge drinking (N = 26) Age—14–24 years 2.12 Marital status—In a couple 1.91 SES—Low 1.13 Marijuana—Yes 0.81

CI

P-value

0.78–2.25 0.56–1.74 0.67–1.90 0.37–1.09

0.29 0.96 0.65 0.10

0.47–1.35 0.99–3.07 0.94–2.70 0.24–0.72

0.40 0.05* 0.08 0.002*

0.90–5.00 0.81–4.47 0.50–2.59 0.35–1.89

0.09 0.14 0.80 0.63

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

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).

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. 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 (Cutter and O’Farrell, 1984; Cox and Klinger, 1988; Cooper et al., 1992; Arokiasamy, 1995; Beck et al., 1995; Heath, 2000; Gire, 2002; Kuntsche et al., 2006), psychosocial (Harrison and Sidebottom, 2009), or specific factors and situations (Harford, 1979; Gusfield, 1987). 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 (Perham-Hester and Gessner, 1997; Kim et al., 2012). 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 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 subgroup 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 (Neve et al., 1997; Hajema and Knibbe, 1998; Gmel et al., 2000; Cho and Crittenden, 2006; Kuntsche et al., 2006). Similar results have been obtained for women in couples who are not married (Gladstone et al., 1997; Perham-Hester and Gessner, 1997; Ebrahim et al., 1998). 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 (Kearns-Bodkin and Leonard, 2005; Leonard and Eiden, 2007; Holt-Lunstad et al., 2008), 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; Kairouz et al., 2002; Kairouz and Greenfield, 2007; Frohlich et al., 2008).

Limitations One limitation of our study is the loss to follow-up after delivery (30%). The statistical likelihood technique allowed latent transitional

344 class analysis to counter this 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 tend 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 (NIAAA), 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 (Midanik, 1989; Grønbæk and Heitmann, 1996; Rehm, 1998; Greenfield and Kerr, 2008). 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.

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 sensitive periods for interventions. Research focusing on motives, contexts and beliefs surrounding alcohol drinking during pregnancy may also contribute to the development of culturallysensitive prevention and intervention programs.

ACKNOWLEDGEMENTS We are grateful to the Nunavik population and their organizations 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.

DISCLOSURE AND ETHICS APPROVAL The authors declare no competing financial interests. Ethics approval is not required for this study because it uses secondary data from Nunavik Child Development Study sample. The content of this study is solely the authors’ responsibility.

FUNDING 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), Public Health Direction of the Nunavik Regional Board of Health and Social Services, 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 M.F.

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CONFLICT OF INTEREST STATEMENT None declared.

REFERENCES Archibald L. (2004) Teenage Pregnancy in Inuit Communities: Issues and Perspectives. Pauktuutit Inuit Women’s Association. Arokiasamy C. (1995) Alcohol and culture in Malaysia. In Heath DB (eds). International Handbook of Alcohol and Culture. Westport, CT: Greenwood Press, 176–7. Badry B, Felske A. (2013) Exploring the prevention of fetal alcohol spectrum disorder in the Northwest Territories of Canada: brightening our home fires. Int J Alcohol Drug Res 2:7–15. Balachova T, Bonner B, Chaffin M, et al. (2012) Women’s alcohol consumption and risk for alcohol-exposed pregnancies in Russia. Addiction 107:109–17. Barnes GM, Reifman AS, Farrell MP, et al. (2000) The effects of parenting on the development of adolescent alcohol misuse: a six-wave latent growth model. J Marriage Fam 62:175–86. Beck KH, Thombs DL, Mahoney CA, et al. (1995) Social context and sensation seeking: gender differences in college student drinking motivations. Int J Addict 30:1101–15. Berg N, Kiviruusu O, Karvonen S, et al. (2013) A 26-year follow-up study of heavy drinking trajectories from adolescence to mid-adulthood and adult disadvantage. Alcohol Alcohol 48:452–7. Bobo JK, Greek AA. (2011) Increasing and decreasing alcohol use trajectories among older women in the U.S. across a 10-year interval. Int J Environ Res Public Health 8:3263–76. Branco E, Kaskutas L. (2001) If it burns going down: how focus groups can shape fetal alcohol syndrome (FAS) prevention. Subst Use Misuse 36:333–45. Bray BC, Grace PL, Liu W, et al. (2014) Transitions in gambling participation during late adolescence and young adulthood. J Adolesc Health 55:188–94. Brodbeck J, Bachmann MS, Croudace TJ, et al. (2013) Comparing growth trajectories of risk behaviors from late adolescence through young adulthood: an accelerated design. Develop Psychol 49:1732–8. Burd L, Moffatt ME. (1994) Epidemiology of fetal alcohol syndrome in American Indians, Alaskan natives, and Canadian aboriginal peoples: a review of the literature. Public Health Rep 109:688–93. Cameron CM, Davey TM, Kendall E, et al. (2013) Changes in alcohol consumption in pregnant Australian women between 2007 and 2011. Med J Aust 199:355–7. Carney LJ, Chermak GD. (1991) Performance of American Indian children with fetal alcohol syndrome on the test of language development. J Commun Disord 24:123–34. Cho YI, Crittenden KS. (2006) The impact of adult roles on drinking among women in the United States. Subst Use Misuse 41:17–34. Chudley AE, Conry J, Cook JL, et al. (2005) Fetal alcohol spectrum disorder: Canadian guidelines for diagnosis. Can Med Assoc J 172(5 Suppl):S1–S21. Collins LM, Lanza ST. (2010) Latent Class and Latent Transition Analysis. With Applications in the Social, Behavioral, and Health Sciences. Wiley Series in Probability and Statistics. New Jersey: John Wiley & Sons, Inc. Collins LM, Wugalter SE. (1992) Latent class models for stage-sequential dynamic latent variables. Multivar Behav Res 27:131–57. Collins LM, Graham JW, Long JD, et al. (1994) Crossvalidation of latent class models of early substance use onset. Multivar Behav Res 29:165–83. Cooper ML, Russell M, Skinner JB, et al. (1992) Development and validation of a three-dimensional measure of drinking motives. Psychol Assess 4:123–32. Cox WM, Klinger E. (1988) A motivational model of alcohol use. J Abnorm Psychol 97:168–80. Curran PJ, Muthén BO, Harford TC. (1998) The influence of changes in marital status on developmental trajectories of alcohol use in young adults. J Stud Alcohol 59:647–58. Cutter HS, O’Farrell TJ. (1984) Relationship between reasons for drinking and customary drinking behavior. J Stud Alcohol 45:321–5. Day NL, Jasperse D, Richardson G., et al. (1989) Prenatal exposure to alcohol: effect on infant growth and morphologic characteristics. Pediatrics 84:536–41.

Alcohol and Alcoholism, 2016, Vol. 51, No. 3 Demers A, Kairouz S, Adlaf EM, et al. (2002) Multilevel analysis of situational drinking among Canadian undergraduates. Social Sci Med 55:415–24. Denny CH, Tsai J, Floyd RL, et al. (2009) Alcohol use among pregnant and non-pregnant women of childbearing age—United States, 1991–2005. Morb Mortal Wkly Rep 58:529–32. Ebrahim SH, Luman ET, Floyd RL, et al. (1998) Alcohol consumption by pregnant women in the United States during 1988–1995. Obstet Gynecol 92:187–92. Fillmore KM, Hartka E, Johnstone BM, et al. (1991) A meta-analysis of life course variation in drinking. Brit J Addict 86:1221–68. Fortin S, Jacobson SW, Gagnon J, et al. (2015) Socioeconomic and psychosocial adversity in Inuit mothers from Nunanik during the first postpartum year. J Aborig Health 9:63–76. Fraser SL, Muckle G, Belkacem BA, et al. (2012) Effect of binge drinking on infant growth and development in an Inuit sample. Alcohol 46:277–83. Frohlich KL, Corin E, Potvin L. (2008) La relation entre contexte et maladie: une proposition théorique. In Frohlich KL, De Koninck M, Demers A, Bernard P (eds). Les Inégalités Sociales de Santé au Québec. Les Presses de l’Université de Montréal. Fuzhong L, Barrera M, Hops H, et al. (2001) The longitudinal influence of peers on the development of alcohol use in late adolescence: a growth mixture analysis. J Behav Med 25:293–315. Gire JT. (2002) A cross-national study of motives for drinking alcohol. Subst Use Misuse 37:215–223. Gladstone J, Levy M, Nulman I, et al. (1997) Characteristics of pregnant women who engage in binge alcohol consumption. Can Med Assoc J 15:789–94. Gmel G, Bloomfield K, Ahlstrom S, et al. (2000) Women’s roles and women’s drinking: a comparative study in four European countries. Subst Abuse 21:249–64. Godel JC, Pabst HF, Hodges PE, et al. (1992) Smoking and caffeine and alcohol intake during pregnancy in a Northern population: effect on fetal growth. Can Med Assoc J 147:181–8. Godel JC, Lee B, McCallun D. (2000) Exposure to alcohol in utero: influence on cognitive function and learning in a Northern elementary school population. Pediatr Child Health 5:93–100. Greenfield TK, Kerr WC. (2008) Alcohol measurement methodology in epidemiology: recent advances and opportunities. Addiction 103:1082–99. Grønbæk M, Heitmann BL. (1996) Validity of self-reported intakes of beer, wine and spirits in population studies. Eur J Clin Nutr 50:487–90. Guo J, Collins LM, Hill KG, et al. (2000) Developmental pathways to alcohol abuse and dependence in young adulthood. J Stud Alcohol 61: 799–808. Gusfield JR. (1987) Passage to play, rituals of drinking time in American society. In Douglas M (ed). Constructive Drinking. Perspectives on Drink From Anthropology. Paris: Cambridge University Press. Editions de la Maison des Sciences de l’Homme, 57–74. Gusfield JR. (1996) Contested Meanings: the Construction of Alcohol Problems. Madison, WI: University of Wisconsin Press. Hajema KJ, Knibbe RA. (1998) Changes in social roles as predictors of changes in drinking behaviour. Addiction 93:1717–27. Harford TC. (1979) Beverage specific drinking contexts. Int J Addict 14:197–205. Harrison PA, Sidebottom AC. (2009) Alcohol and drug use before and during pregnancy: an examination of use patterns and predictors of cessation. Matern Child Health J 13:386–94. Haynes G, Dunnagan T, Christopher S. (2003) Determinants of alcohol use in pregnant women at risk for alcohol consumption. Neurotoxicol Teratol 25:659–66. Heath D. (1986) Cultural definitions of drinking: note toward a semantic approach. Drink Drug Pract Surv 21:17–22. Heath D. (2000) Drinking Occasions. Comparative Perspectives on Alcohol and Culture. Library of Congress Cataloging-in-Publication Data. Health Canada. (2008) A National Survey of Canadians’ Use of Alcohol and Other Drugs. Focus on Gender. Ottawa, ON: Health Canada Publications. Health Canada. (2011) Enquête de surveillance canadienne de la consommation d’alcool et de drogues. Faits saillants. http://www.hc-sc.gc.ca/hc-ps/

345 drugs-drogues/stat/_2011/summary-sommaire-fra.php (9 October 2012, date last accessed). Hollingshead AB. (2011) Four factor index of social status. Yale J Sociol 8:21–51. Holt-Lunstad J, Birmingham W, Jones BQ. (2008) Is there something unique about marriage? The relative impact of marital status, relationship quality, and network social support on ambulatory blood pressure and mental health. Ann Behav Med 35:239–44. Horrigan TJ, Schroeder AV, Schaffer RM. (2000) The triad of substance abuse, violence, and depression are interrelated in pregnancy. J Subst Abuse Treat 18:55–8. Hoyme HE, May PA, Kalberg WO, et al. (2005) A practical clinical approach to diagnosis of fetal alcohol spectrum disorders: clarification of the 1996 Institute of Medicine criteria. Pediatrics 115:39–47. Jackson KM, Sher KJ, Wood PK. (2000) Trajectories of concurrent substance use disorders: a developmental, typological approach to comorbidity. Alcohol Clin Exp Res 24:902–13. Jackson KM, Sher KJ, Gotham HJ, et al. (2001) Transitioning into and out of large-effect drinking in young adulthood. J Abnorm Psychol 110:378–91. Jacobson SW, Chiodo LM, Jacobson JL, et al. (2002) Validity of maternal report of alcohol, cocaine, and smoking during pregnancy in relation to infant neurobehavioral outcome. Pediatrics 109:815–25. Jacobson SW, Carr LG, Croxford J, et al. (2006) Protective effects of the alcohol dehydrogenase-ADH1B allele in African American children exposed to alcohol during pregnancy. Pediatrics 148:30–7. Jacobson JL, Jacobson SW, Muckle G, et al. (2008) Beneficial effects of a polyunsaturated fatty acid on infant development: evidence from the Inuit of Arctic Quebec. Pediatrics 152:356–64. Kairouz S, Greenfield TA. (2007) Comparative multi-level analysis of contextual drinking in American and Canadian adults. Addiction 102:71–80. Kairouz S, Gliksman L, Demers A, et al. (2002) For all these reasons, I do drink: a multilevel analysis of contextual reasons for drinking among Canadian undergraduates. J Stud Alcohol 63:600–8. Kaskutas L. (2000) Understanding drinking during pregnancy among urban American Indians and African Americans: health messages, risk beliefs, and how we measure consumption. Alcohol Clin Exp Res 24:1241–50. Kearns-Bodkin JN, Leonard KE. (2005) Alcohol involvement and marital quality in the early years of marriage: a longitudinal growth curve analysis. Alcohol Clin Exp Res 29:2123–34. Kim IO, Jeong GC, Yang EK. (2012) Effects of knowledge and recognition of alcohol use during pregnancy on actual alcohol use during pregnancy. Korean J Women Health Nurs 18:279–89. Korhonen M. (2004) Alcohol Problems and Approaches: Theories, Evidences and Northern Practices. Ottawa, ON: National Aboriginal Health Organization (NAHO). Kuntsche S, Gmel G, Knibbe RA, et al. (2006) Gender and cultural differences in the association between family roles, social stratification, and alcohol use: a European cross-cultural analysis. Alcohol Alcohol 41(Suppl 1):i37–46. Lanza ST, Tan X, Bray BC. (2013) Latent class analysis with distal outcomes: a flexible model-based approach. Struct Eq Model 20:1–26. Leonard KE, Eiden RD. (2007) Marital and family processes in the context of alcohol use and alcohol disorders. Annu Rev Clin Psychol 3:285–310. Maggs JL, Schulenberg JE. (2004–2005) Trajectories of alcohol use during the transition to adulthood. Alcohol Res Health 28:195–201. Malet L, de Chazeron I, Llorca PM, et al. (2006) Alcohol consumption during pregnancy: an urge to decrease prevention and screening. Eur J Epidemiol 21:787–8. May PA, Marais AS, Gossage JP, et al. (2013) Case management reduces drinking during pregnancy among high-risk women. Int J Alcohol Drug Res 2:61–70. Midanik LT. (1989) Perspectives on the validity of self-reported alcohol use. Br J Addict 84:1419–23. Montag A, Clapp JD, Calac D, et al. (2012) A review of evidence-based approaches for reduction of alcohol consumption in native women who are pregnant or of reproductive age. Am J Drug Alcohol Abuse 38:436–43. Muckle G, Ayotte P, Dewailly É, et al. (2001) Determinants of polychlorinated biphenyls and methylmercury exposure in Inuit women of child-bearing age. Environ Health Perspect 109:957–63.

346 Muckle G, Boucher O, Laflamme D, et al. (2007) Qanuippitaa? How are we? Alcohol, Drug use and Gambling among the Inuit of Nunavik: Epidemiological Profile. Quebec: Institut national de santé publique du Québec and Nunavik Regional Board of Health and Social Services. Muckle G, Laflamme D, Gagnon J, et al. (2011) Alcohol, smoking, and drug use among Inuit women of childbearing age during pregnancy and the risk to children. Alcohol Clin Exp Res 35:1081–91. Muthén L, Muthén B. (1998–2002) Mplus User’s Guide. Los Angeles: Muthén & Muthén. Nathoo T, Poole N, Bryans M, et al. (2013) Voices from the community: developing effective community programs to support pregnant and early parenting women who use alcohol and other substances. First Peoples Child Fam Rev 8:93–106. National Institute of Alcohol Abuse and Alcoholism (NIAAA). (2008) A women health issue. U.S. Department of Health and Human Services. Neve RJ, Lemmens PH, Drop MJ. (1997) Gender differences in alcohol use and alcohol problems: mediation by social roles and gender-role attitudes. Subst Use Misuse 32:1439–59. Nunavik Inuit Health Survey. (2004) Qanuippitaa? How are we? Alcohol, drug use and gambling among the Inuit of Nunavik: epidemiological profile. INSPQ. Nunavik Regional Board of Health and Social Services. Oxford ML, Gilchrist LD, Morrison DM, et al. (2003) Alcohol use among adolescent mothers: heterogeneity in growth curves, predictors, and outcomes of alcohol use over times. Prevent Sci 4:15–25. Perham-Hester KA, Gessner BD. (1997) Correlates of drinking during the third trimester of pregnancy in Alaska. Matern Child Health J 13:165–72. Rehm J. (1998) Measuring quantity, frequency and volume of drinking. Alcohol Clin Exp Res 22(Suppl 2):4S–14S.

Alcohol and Alcoholism, 2016, Vol. 51, No. 3 Rehm J, Mathers C, Popova S, et al. (2009) Global burden of disease and injury and economic cost attributable to alcohol use and alcohol-use disorders. Lancet 373:2223–33. Spears GV, Stein JA, Koniak-Griffin D. (2010) Latent growth trajectories of substance use among pregnant and parenting adolescents. Psychol Addict Behav 24:322–32. Substance Abuse and Mental Health Services Administration (SAMHSA). (2012) National Survey on Drug Use and Health (NSDUH). http://www. samhsa.gov/data/NSDUH/2012SummNatFindDetTables/DetTabs/NSDUHDetTabsSect2peTabs43to84-2012.htm#Tab2.71B (15 September 2013, date last accessed). Walker MJ, Al-Sahab B, Islam F, et al. (2011) The epidemiology of alcohol utilization during pregnancy: an analysis of the Canadian Maternity Experiences Survey (MES). BMC Pregnancy Childbirth 11:52. Werk CM, Cui X, Tough S. (2013) Fetal alcohol spectrum disorder among aboriginal children under six years of age and living off reserve. First Peoples Child Fam Rev 8:7–16. White HR, Bray BC, Fleming CB, et al. (2009) Transitions into and out of light and intermittent smoking during emerging adulthood. Nicotine Tob Res 11:211–9. Wilsnack RW, Vogeltanz ND, Wilsnack SC, et al. (2000) Gender differences in alcohol consumption and adverse drinking consequences: cross-cultural patterns. Addiction 95:251–65. Wilsnack R, Wilsnack SC, Kristjanson AF, et al. (2009) Gender and alcohol consumption: patterns from the multinational GENACIS Project. Addiction 104:1487–500. World Health Organization (WHO). (2014) Global Status Report on Alcohol and Health—2014 Edition. WHO Library Cataloguing-in-publication Data.