Of the 802 pregnant Israeli women participants, 67.2% reported drinking any dose of alcohol in the 2 mo before learning they were pregnant. This high percentage aligns with worldwide findings regarding alcohol consumption that suggest women aged 18 to 29 year are more likely to drink alcohol, engage in heavy episodic drinking (four or more drinks during a drinking day), and meet criteria for an alcohol-use disorder . Furthermore, in the United States, nearly 50% of young women drink alcohol and, in one study, 20% reported heavy episodic drinking in the previous 30 d . These rates are worrying because the women might continue such drinking behavior while they are already pregnant but still unaware of it.
When most women become aware of their pregnancy, their consumption behavior certainly changes. We found that 86.6% of our sample reduced their alcohol consumption after conception and throughout pregnancy, which is consistent with previous studies [30, 31]. This finding may indicate that most pregnant women are aware of the harmful effects that alcohol has on the fetus.
However, the high percentage (almost 70%) who consumed alcohol during the 2 mo immediately before pregnancy must arouse great concern among policymakers. More public health awareness is needed to prevent alcohol exposure during conception and early pregnancy. Furthermore, the identification of this risk factor creates the option to implement specific actions and projects aimed at ensuring proper care and at filling knowledge gaps related to this issue. Moreover, 12% reported drinking alcohol during their current pregnancy. Sadly, this rate is close to the 14.1% that Senecky et al. reported 10 year ago in Israel  and to the 10% Popova et al. reported, referring to the global prevalence of alcohol use during pregnancy .
The estimated rate of drinking during pregnancy is even more alarming if we base the estimate on reports of “another pregnant woman drinking.” As presented in the Results section, the percentage of women who claimed they personally knew women who drank alcohol during pregnancy (28.1%) was much higher than the percentage of women who acknowledged their own drinking (12.0%). This raises a question regarding the validity and reliability of self-reporting alcohol consumption before and during pregnancy. A possible explanation for this disparity might be an underreporting of alcohol consumption, as presented in Weiss et al.’s study . Those authors found that among 2,477 Israeli women who gave birth in one medical center between the years 1999 and 2000, only 1.13% reported drinking any amount of alcohol, and then only in small amounts and at low frequencies during pregnancy. The researchers explained this low prevalence as underreporting due to the mothers’ fear of stigmatization, denial, and/or reluctance to share this information. Whatever the reason, the important insight that emerges from these results is that the rates of maternal drinking during pregnancy might be much higher than reported.
Moreover, professional health providers should be aware that women find it difficult to report drinking alcohol during or shortly before pregnancy, be sensitive to their difficulty, and allocate alternative methods or indirect techniques to reveal alcohol use among pregnant women. This issue is becoming even more urgent due to the current reality worldwide, but more specifically in Israel, in which diagnosis of FASD remains challenging for the clinician and is often overlooked . In cases for which the history of maternal alcohol consumption is unreliable or unavailable, health professionals might misdiagnose these children, incurring all clinical and social implications of that mistake . As mentioned before, it is extremely important to identify mothers with a history of alcohol consumption because this will facilitate early diagnosis and possibly prevent future cases of FASD in the same family [33, 34].
Regarding the background and demographical data, our data indicate that alcohol consumption before pregnancy was greatest among Jewish women between the ages 26 and 34 year, secular women with advanced education, and those in their first pregnancy. According to data published by the Israeli Central Bureau of Statistics in 2019 , the average age for marriage in Israel among all women is 25 year and among Jewish women is 25.8 year. The average age of Israeli women at the time they first give birth is 27.8 year; those who give birth at a younger age are usually nonsecular. These data can explain the profile we have just described of newly married young women who continue with drinking habits characterized for young people, without knowing they are pregnant. However, alcohol consumption during pregnancy significantly correlated only with the number of children and with the religious level, such that women with four or more children and nonsecular women consumed significantly less alcohol. These results were predictable because, among traditional and Orthodox Jewish communities (who statistically have more children in the family), it is less common for women to drink alcohol . Moreover, as can be seen in the results, the strongest drop in the rates of drinking after realizing that they are pregnant (from 33–4%) was found among those women who before pregnancy drank only during a Kiddush (blessing of the wine on Shabbat evening and other holy days). A final comment about demographic background regards the consumption of alcohol among Muslim women. Although the Islam religion forbids drinking alcohol, our survey showed a small percentage (0.4%) of consumption. Given the online nature of our survey, it is likely that those Muslims who reported consuming alcohol lived in a city and were relatively more educated and modern than Muslim women who live in more traditional and religious villages. In the villages, the percentage of drinking is likely much lower or even negligible.
Regarding recommendations related to alcohol consumption during pregnancy, 39.5% of the pregnant women who participated in our survey reported they had not received any recommendations. A similar percentage (41.4%) reported a lack of information regarding smoking. On one hand, these results provide some modest source of optimism when compared to the findings of 10 year ago, in which 74.9% lacked information on this topic . On the other hand, a deeper look at the results reveals that of the 60% of women who had received some education, only 0.6% received it from a public-sector physician. The majority (87%) of our sample had medical follow-up during pregnancy and, based on their reports, received public-sector health services. Thus, our findings call for a much stronger education effort from public-health services, specifically those treating pregnant women, to enhance these women’s level of knowledge and awareness of the risks of drinking. The dissemination of this knowledge might be especially important among women who smoke. A potentially important link between the risks for smoking and drinking during pregnancy arises from our results because we found that women who smoked during the pregnancy knew less about the risks of alcohol consumption. These results align with Senecky et al.’s findings that more smokers than nonsmokers reported drinking alcohol before and during pregnancy .
Several explanations could be given to the discrepancy between the estimated rate of alcohol consumption during pregnancy and the rate of FASD-diagnosed cases in Israel:
(a) The estimate of drinking rates could be inaccurate and outdated, given that there had been only one survey and it is a decade old. Moreover, the only previous survey was conducted on women after their full-term delivery (i.e., not during pregnancy), which limited the sample to pregnancies that ended successfully on term, and the reports were retrospective . However, the findings of the present study replicated those of the previous survey and suggest that the rates of alcohol consumption during pregnancy remain high and have not changed much over the past 10 year.
(b) The general population, and specifically pregnant women, lacks knowledge about the dangers of alcohol consumption during pregnancy. The findings of the present study strengthen this assumption and indicate that about 40% of the pregnant women did not receive proper official information regarding the dangers of alcohol consumption and that the overall level of awareness and knowledge on this topic is low. This finding is especially worrying given the relatively high education levels among our sample participants. Completing our survey online might have created a sampling bias in this respect.
(c) Health care professionals lack knowledge, awareness, and training regarding the prevalence of maternal drinking and the diverse manifestations of FASD . That is, if children are not being correctly screened and diagnosed, then the actual indices of FASD in Israel are much higher than the current rates of diagnosed children and similar to rates found in other Western countries. The few studies (discussed earlier) that have been conducted so far within an education and behavior correctional facility in central Israel and among adopted children certainly supported the possibility of a lack of knowledge and awareness about FASD among professionals in Israel and rates of FASD similar to other countries. The fact that so few health professionals who treat pregnant woman warn them about alcohol consumption provides an indirect testimony of these professionals’ lack of awareness; still, further research is needed in this respect.
Overall, our findings suggest that all three explanations might co-exist and together explain the substantial gap between the data on drinking and the number of documented FASD cases in Israel.
Despite the importance and strength of the present study’s findings, several limitations should be acknowledged. First, because participation was voluntary and online, we needed to keep the questionnaire as short as possible. Therefore, we were very restricted in the number of items we could include, which prevented the possibility to separate between knowledge and awareness or to differentiate among domains of knowledge. Second, as with any survey of this type, our sample was restricted to pregnant women with access to the Internet and willingness to participate; thus, the results cannot automatically be generalized to other populations of Israeli pregnant women who do not have such access or willingness. Last, as with any survey, we had to rely on the participants’ sincerity and willingness to provide truthful responses and limit possible recall bias. The question about knowing other pregnant women who drink was a successful attempt to bypass this limitation.