Neurotoxicologyand Teratology, Vol. 13, pp. 535-540. ©PergamonPress plc, 1991. Printedin the U.S.A.
0892-0362/91 $3.00 + .00
Maternal Recall of Alcohol, Cocaine, and Marijuana Use During Pregnancy S A N D R A W . J A C O B S O N , 1 J O S E P H L. J A C O B S O N , R O B E R T J. S O K O L , S U S A N S. M A R T I E R , J O E L W. A G E R A N D M E L I S S A G. K A P L A N
Fetal Alcohol Research Center, Wayne State University, Detroit, M I 48202 R e c e i v e d 27 F e b r u a r y 1991 JACOBSON, S. W., J. L. JACOBSON, R. J. SOKOL, S. S. MARTIER, J. W. AGER AND M. G. KAPLAN. Maternal recall of alcohol, cocaine, and marijuana use during pregnancy. NEUROTOXICOL TERATOL 13(5) 535-540, 1991.--Alcohol, cocaine, and marijuana use during pregnancy was .reported antenatally and at 13 months postpartum by 361 black inner city mothers. The two reports were moderately related for all three substances, but levels reported retrospectively were substantially higher. MAST scores did not differ for the two interviews. Most of the correlations of the antenatal and retrospective reports with maternal and infant characteristics were similar in magnitude; those that differed were somewhat stronger for the antenatal measures. Although the retrospective reports may provide a better indication of mean levels of fetal exposure, they may be less precise in rank ordering among individuals for purposes of correlational analysis. Women with higher MAST scores were particularly prone to report higher levels of both alcohol and cocaine when interviewed retrospectively, and more severely depressed mothers were more likely to report higher levels retrospectively for all three substances. These data suggest that women reporting more than 1.3 drinks/week antenatally (AA/day>0.1) may actually be drinking at levels at risk for alcohol-related birth defects. Alcohol Cocaine Marijuana Substance abuse during pregnancy
MAST
Underreporting
BOTH matemal reports and biological measures have been used to assess exposure in human teratological studies. For some environmental contaminants, such as polychlorinated biphenyls, which have a long half-life in human tissue, a blood or adipose specimen provides a reliable record of prenatal exposure (15). By contrast, many drugs, such as alcohol and caffeine, are excreted within hours of ingestion, and investigators must, therefore, often depend on maternal report. Although self-report data are often derogated as being inherently unreliable, the accuracy of self-report varies considerably depending on the substance, time of interview, skill of the interviewer, and other factors. In one study, maternal recall at 4 years postpartum for smoking during pregnancy was found to he markedly more reliable ( r = .81) than for alcohol consumption (r = .53), presumably because smoking is more habitual and therefore easier to recall (16), Although the 4-year recall coefficient for alcohol was much lower than the 1-week coefficient of .90 reported by Streissguth, Martin, and Buffington (31), it was comparable to the 4- and 5-month recall coefficients of .61 and .53 reported by other investigators (19,25). In comparing alcohol consumption reports provided during pregnancy and again 5 years postpartum, Emhart and her associates noted a strong tendency for mothers to report higher levels of pregnancy drinking retrospectively (9,23). Moreover, the 5-year recall was found to be as valid as the mother's contemporaneous report when assessed in relation to eraniofacial anomalies associated with drinking during pregnancy, and more valid than the contemporaneous report in relation to other physical
Maternal report
anomalies, leading the authors to conclude that the women had been underreporting their drinking levels when interviewed during pregnancy. This underreporting is attributed to factors, such as social stigma and guilt associated with pregnancy drinking, which are alleviated after delivery of an apparently healthy infant (19). Other studies have also reported underreporting during pregnancy [e.g., (18,26)], although Hingson et al. (12) found that fewer women reported drinking two or more drinks per day when interviewed in the hospital after delivery than in the prenatal clinic. One implication of these findings is that the levels reported during pregnancy may underestimate fetal exposure, but the findings to date have not suggested a threshold above which risk-drinking should he suspected. The purpose of this study was (a) to determine whether the pattern of underreporting seen in Ernhart et al.'s lower middle class biracial Cleveland sample holds for a black disadvantaged inner city sample, Co) to see if a similar pattern holds for illicit drugs, such as cocaine and marijuana, and (c) to examine which maternal characteristics may help identify those gravidas most likely to underreport levels of substance abuse. First, the testretest reliability of the maternal report was assessed for each substance. The maternal report data were then grouped into categories to determine what percentages of the reports were inconsistent. The relative validity of the antenatal and retrospective reports was then examined in correlational analyses with other variables which have been found to be related to substance abuse, such as maternal age and parity (29), depression (10, 27, 33), and birth size [e.g., (5, 7, 12, 30, 34)]. Finally, maternal
~Requests for reprints should be addressed to Sandra W. Jacobson, Department of Psychology, Wayne State University, Detroit, MI 48202.
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536
JACOBSON ET AL.
ment staff who was unaware of her antenatal report.
TABLE 1 INTER.CORRELATIONOF ALCOHOL,COCAINE,AND MARIJUANAUSE DURINGPREGNANCYREPORTED ANTENATALLYAND R E T R O S P ~ Y
AA/Day Cocaine* Marijuana*
Procedure
AA/Day
Cocaine*
Marijuana*
1.00 .26:~ .04
.28~ 1.00 .19~:
.14t .25:~ 1.00
Values below diagonal indicate intereorrelation of alcohol and drug use reported antenatally; values above the diagonal, intercorrelation of levels reported retrospectively. *Days/month. ?p
0892-0362/91 $3.00 + .00
Maternal Recall of Alcohol, Cocaine, and Marijuana Use During Pregnancy S A N D R A W . J A C O B S O N , 1 J O S E P H L. J A C O B S O N , R O B E R T J. S O K O L , S U S A N S. M A R T I E R , J O E L W. A G E R A N D M E L I S S A G. K A P L A N
Fetal Alcohol Research Center, Wayne State University, Detroit, M I 48202 R e c e i v e d 27 F e b r u a r y 1991 JACOBSON, S. W., J. L. JACOBSON, R. J. SOKOL, S. S. MARTIER, J. W. AGER AND M. G. KAPLAN. Maternal recall of alcohol, cocaine, and marijuana use during pregnancy. NEUROTOXICOL TERATOL 13(5) 535-540, 1991.--Alcohol, cocaine, and marijuana use during pregnancy was .reported antenatally and at 13 months postpartum by 361 black inner city mothers. The two reports were moderately related for all three substances, but levels reported retrospectively were substantially higher. MAST scores did not differ for the two interviews. Most of the correlations of the antenatal and retrospective reports with maternal and infant characteristics were similar in magnitude; those that differed were somewhat stronger for the antenatal measures. Although the retrospective reports may provide a better indication of mean levels of fetal exposure, they may be less precise in rank ordering among individuals for purposes of correlational analysis. Women with higher MAST scores were particularly prone to report higher levels of both alcohol and cocaine when interviewed retrospectively, and more severely depressed mothers were more likely to report higher levels retrospectively for all three substances. These data suggest that women reporting more than 1.3 drinks/week antenatally (AA/day>0.1) may actually be drinking at levels at risk for alcohol-related birth defects. Alcohol Cocaine Marijuana Substance abuse during pregnancy
MAST
Underreporting
BOTH matemal reports and biological measures have been used to assess exposure in human teratological studies. For some environmental contaminants, such as polychlorinated biphenyls, which have a long half-life in human tissue, a blood or adipose specimen provides a reliable record of prenatal exposure (15). By contrast, many drugs, such as alcohol and caffeine, are excreted within hours of ingestion, and investigators must, therefore, often depend on maternal report. Although self-report data are often derogated as being inherently unreliable, the accuracy of self-report varies considerably depending on the substance, time of interview, skill of the interviewer, and other factors. In one study, maternal recall at 4 years postpartum for smoking during pregnancy was found to he markedly more reliable ( r = .81) than for alcohol consumption (r = .53), presumably because smoking is more habitual and therefore easier to recall (16), Although the 4-year recall coefficient for alcohol was much lower than the 1-week coefficient of .90 reported by Streissguth, Martin, and Buffington (31), it was comparable to the 4- and 5-month recall coefficients of .61 and .53 reported by other investigators (19,25). In comparing alcohol consumption reports provided during pregnancy and again 5 years postpartum, Emhart and her associates noted a strong tendency for mothers to report higher levels of pregnancy drinking retrospectively (9,23). Moreover, the 5-year recall was found to be as valid as the mother's contemporaneous report when assessed in relation to eraniofacial anomalies associated with drinking during pregnancy, and more valid than the contemporaneous report in relation to other physical
Maternal report
anomalies, leading the authors to conclude that the women had been underreporting their drinking levels when interviewed during pregnancy. This underreporting is attributed to factors, such as social stigma and guilt associated with pregnancy drinking, which are alleviated after delivery of an apparently healthy infant (19). Other studies have also reported underreporting during pregnancy [e.g., (18,26)], although Hingson et al. (12) found that fewer women reported drinking two or more drinks per day when interviewed in the hospital after delivery than in the prenatal clinic. One implication of these findings is that the levels reported during pregnancy may underestimate fetal exposure, but the findings to date have not suggested a threshold above which risk-drinking should he suspected. The purpose of this study was (a) to determine whether the pattern of underreporting seen in Ernhart et al.'s lower middle class biracial Cleveland sample holds for a black disadvantaged inner city sample, Co) to see if a similar pattern holds for illicit drugs, such as cocaine and marijuana, and (c) to examine which maternal characteristics may help identify those gravidas most likely to underreport levels of substance abuse. First, the testretest reliability of the maternal report was assessed for each substance. The maternal report data were then grouped into categories to determine what percentages of the reports were inconsistent. The relative validity of the antenatal and retrospective reports was then examined in correlational analyses with other variables which have been found to be related to substance abuse, such as maternal age and parity (29), depression (10, 27, 33), and birth size [e.g., (5, 7, 12, 30, 34)]. Finally, maternal
~Requests for reprints should be addressed to Sandra W. Jacobson, Department of Psychology, Wayne State University, Detroit, MI 48202.
535
536
JACOBSON ET AL.
ment staff who was unaware of her antenatal report.
TABLE 1 INTER.CORRELATIONOF ALCOHOL,COCAINE,AND MARIJUANAUSE DURINGPREGNANCYREPORTED ANTENATALLYAND R E T R O S P ~ Y
AA/Day Cocaine* Marijuana*
Procedure
AA/Day
Cocaine*
Marijuana*
1.00 .26:~ .04
.28~ 1.00 .19~:
.14t .25:~ 1.00
Values below diagonal indicate intereorrelation of alcohol and drug use reported antenatally; values above the diagonal, intercorrelation of levels reported retrospectively. *Days/month. ?p
