Study design and period
Institution based cross sectional study was employed from May 7 to June 6, 2019.
The study area was Addis Ababa, the capital and largest city of Ethiopia. It is the seat of the Ethiopian federal government. It was founded by Emperor Menellik II in the late 19th century. In Addis Ababa, there are 12 public hospitals providing health services of medical management, surgical intervention, obstetric and gynecological management, antenatal care, pediatric, orthopedic, psychiatric and other essential service for a large number of people. From those with 12 hospitals according to high antenatal care service follow up five hospitals were selected. This includes St. Paul hospital, Zewditu memorial hospital, Yekatit 12 hospital, Minelik hospital and Ras desta hospital.
All pregnant women who had antenatal care visit in the public hospitals of Addis Ababa.
Pregnant women who were visiting antenatal care clinic at five selected public hospitals during study period.
Sample size determination
Sample size was determined by using Single population proportion formula. By taking from proportion of Alcohol use in pregnancy 34% a study which was done in Bahir Dar, Ethiopia, with 4% margin of error, 95% CI and 10% non-response rate.
Adding 10% non-response rate gives us a final sample size of 593
n= Minimum sample size required for the study
Z= Standard normal distribution (Z=1.96) with confidence interval of 95% and ⍺=0.05
P= Proportion of Alcohol use in pregnancy 34% a study which is done in Bahir Dar, Ethiopia
d= Absolute precision or tolerable margin of error (d) =4%=0.04
Concerning the sampling technique which was employed in the study was Systematic random sampling. Study population come from selected five public hospitals; this include, St. Paul’s Hospital Millennium Medical College, Zewditu memorial hospital, yekatit 12 hospital, Minilik hospital and Ras desta hospital. Study population was selected proportionally, from each hospital.
Systematic random sampling was used to select study subjects from each hospital. The interval size (k) was calculated using the following formula.
Therefore, the interval size for each hospital was 7. So that every seven persons was selected from the study population.
Where- Monthly population of selected hospitals
n- Sample size of each hospital
Measures for the dependent variable (Alcohol use during pregnancy)
Respondents who answered “Yes” to the question “Have you ever consumed alcohol during your current pregnancy?” had alcohol use in pregnancy.
Alcohol Use Disorders Identification Test (AUDIT) is a 10-item alcohol screening instrument was used to measure the frequency of consumption and alcohol use disorder. It was developed by the World Health Organization and has been found effective in identifying subjects with a drinking problem such as hazardous drinking harmful drinking, and alcohol dependence (sensitivity, 94.1%; specificity, 91.7%). AUDIT was originally designed as an instrument for use in primary care settings; several recent studies have validated it in other health care and community contexts including pregnant women. The first three questions (1-3) explore quantity and frequency of alcohol consumption, the second three questions (4-6) explore signs of alcohol dependency and the last four questions (7-10) explore alcohol-related problems (harmful alcohol use)(50). Response options for each item range from 0 to 4, resulting in a total possible score of 40.A total score of 1–7 indicates social drinking a score of 8–15 indicates “hazardous drinking” a score of 16-19 indicate “harmful drinking” and a score of 20 or above indicate probable alcohol dependence(50).
Measures for the predictor variables
Collected by semi-structured socio demographic questionnaires, obstetric factor also was collected by semi-structured questionnaires, and substance related factors was collected by substance related questions.
Oslo-3 item social support scale, it is 3 item questionnaires, commonly used to assess social support and it has been used in several studies, the sum score scale ranging from 3-14, which has 3 categories: poor support 3-8, moderate support 9-11 and strong support 12-14(47).
was measured using Kessler Psychological Distress Scale, 20-24 are likely to have a mild mental distress, score 25-29 are likely to have moderate mental distress and score 30 and over are likely to have a severe mental distress(48).
Intimate partner violence
Measured using HITS screening tool. During the HITS assessment, a provider asks a pregnant the following: How often does your partner physically Hurt you, Insult or talk down to you, threaten you with harm, and Scream or curse at you? Each category is graded on a scale of 1 (never) to 5 (frequently) and a sum of all the categories is generated. A total score of 10 is suggestive of IPV(49)
Data collection procedures
Data was collected using face to face interview with questionnaire. The data was collected by 5BSc. Female nurses, and supervised by two psychiatric nurses. Consequently, the entire data collection process had seven members. The nurses were employees of the hospitals. Accordingly, for each selected five hospitals there was one data collector and the supervisors were supervising them on each day. Training was provided to data collectors and supervisors for two days on methodology, ethical issue and how to administer questionnaires.
Data quality control
The entire questionnaire was translated into local languages Amharic then it was translated back to English by an independent person to check for consistency and understandability of the tool. The questionnaire was pretested one week prior to the actual data collection on 5% of sample size at Addis Ketema Felege Meles health center in antenatal clinic and the questionnaire was checked for its clarity, simplicity, and understandability and items of questions was modified accordingly. Data collectors were supervised daily and the filled questionnaire was checked daily by the supervisors.
Data processing and analysis
The collected data was checked visually for its completeness and the response was coded and entered into the computer using EPI data version 3.1, and then cleaned. The cleaned data was exported to SPSS Version 20 for analysis. Then the results were summarized and presented by tables, and charts. Furthermore, Percentage, frequency and mean were calculated. Firstly, bi-variate binary logistic regression was performed to screen determinant factors of the outcome variable. Secondly, those predictor variables which were significantly associated with outcome variable with a p-value<0.2 in the bi-variable logistic regression analysis were entered into the multivariate logistic regression model for controlling the possible effect of confounders. The strength of the associated factors was presented by odds ratio with 95% confidence interval. The variables which have a statistical significance association were identified on the basis of p-values ≤ 0.05. The model fitness for multivariate binary logistic regression was checked by using Hosmer and Lemeshow test.
Ethical clearance was obtained from ethical review committee office of Amanuel Mental Specialized Hospital, University of Gondar, College of medicine and health science, Addis Ababa regional health bureau and St. Paul’s hospital Millennium medical college. Written informed consent was secured from each participant during study period. Participants’ right to refuse the participation was kept. For some clinical outcome patients was linked to psychiatry support as necessary and for the participants who were found problematic alcohol users, psychological distress positive during the study, communication to nearby psychiatric clinic was done in order to have further assessment on their condition. Confidentiality of respondents was maintained.