Exposição maternal ao álcool e baixo peso ao nascer: revisão sistemática e metanálise

Pereira, Priscilla Perez da Silva; Mata, Fabiana Araújo Figueiredo Da; Figueiredo, Ana Claudia Morais Godoy; Silva, Roberta Borges; Pereira, Maurício Gomes

doi:10.1055/s-0039-1688905

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Revista Brasileira de Ginecologia e Obstetrícia

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Sumário

Review Article • Rev. Bras. Ginecol. Obstet. 41 (05) • Maio 2019 • https://doi.org/10.1055/s-0039-1688905 copiar

Exposição maternal ao álcool e baixo peso ao nascer: revisão sistemática e metanálise

Autoria SCIMAGO INSTITUTIONS RANKINGS

Resumo

Objetivo

Investigar a associação entre a exposição maternal ao álcool e o baixo peso ao nascer.

Método

A busca na literatura ocorreu em janeiro de 2017 nas seguintes bases de dados eletrônicas: Medline, Embase, LILACS, SciELO, Web of Science, Scopus, CINHAL, Proquest, e PsychInfo. A estratégia de busca utilizou os seguintes termos: alcohol drinking, binge drinking, alcohol-related disorders, alcoholism, alcohol addiction/use/ abuse/consumption, light/moderate/social/low drinking, low birthweight, case-control studies, retrospective studies, e cohort studies. Não houve restrição de idioma e ano de publicação. A busca na literatura identificou 2.383 artigos, e depois de analisados conforme os critério de elegibilidade, foram incluídos na revisão sistemática 39 estudos, e 38 estudos foram incluídos na metanálise.

Resultados

A amostra foi composta por 497.023 gestantes. O consumo materno de álcool foi associado ao baixo peso ao nascer entre os estudos de coorte retrospectiva (risco relativo [RR] = 1,37; IC [intervalo de confiança] 95%: 1,10-1,77; I2 = 98,4%; p < 0,01). Os estudos de coorte prospectiva (RR = 1,11; IC95%: 0,98-1,25; I2 = 81,5%; p < 0,01) e caso-controle (razão de chances [OR, na sigla em inglês] = 1,16; IC95%: 0,68-1,97; I2 = 61,2%; p = 0,05) não apresentaram associação entre o consumo e o desfecho. Não foi identificado viés de publicação, e a metarregressão mostrou que o tamanho da amostra influenciou a heterogeneidade entre os estudos de coorte prospectiva. Na análise por subgrupo, houve diferenças entre os grupos por tamanho de amostra, por tipo de ajuste e por ano de publicação.

Conclusão

Não encontramos associação entre o consumo e o baixo peso ao nascer em todas as análises por subgrupo. Além disso, encontramos alta heterogeneidade entre os estudos primários, e isto se deve possivelmente às diferenças metodológicas na condução destes estudos.

Palavras-chave:
gestante; baixo peso ao nascer; consumo de álcool; revisão sistemática; metanálise

First author, publication year	Country	Study period	Sample size	Association measure OR/RR (95%CI) reported on the article	Type of measure	Methodological quality of the study	Comments
Retrospective cohort
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2. Irner et al (2014)⁴³43 Irner TB, Teasdale TW, Nielsen T, Vedal S, Olofsson M. Substance use during pregnancy and postnatal outcomes. J Addict Dis 2012; 31(01):19-28. Doi: 10.1080/10550887.2011.642765 https://doi.org/10.1080/10550887.2011.64...	Denmark	1993–1995	164	2.20 (0.76–5.42)	Crude	5	Measure generated through contingency table. Pregnant women who are using substances. Includes multiple pregnancies.
3. Silva et al (2011)⁴⁶46 Silva Id, Quevedo LdeA, Silva RA, Oliveira SS, Pinheiro RT. Association between alcohol abuse during pregnancy and birth weight. Rev Saude Publica 2011;45(05):864-869. Doi: 10.1590/S0034-89102011005000062 https://doi.org/10.1590/S0034-8910201100...	Brazil	2007–2008	957	4.20 (1.25–14.12)	Adjusted	8	Consumption defined by CAGE scale (positive if > 2 points)
4. Gorn et al (2007)²³23 Gorn S, Romero Mendonza M, Tiburcio Sainz M, Medina-Mora Icaza ME, Rojas Guiot E. Risgos associados al consumo de alohol durante el embarazo en mujeres alcohólicas de la Ciudad de México. Salud Ment 2007;30:31-38	Mexico	Not reported	134	Any consumption during pregnancy: 1.90 (0.54–7.00)> 2 times/week: 0.42 (0.13–1.30)Dependence: 1.33.73 (1.1– 12.0)	Crude	5	Women who required help for problems related with alcohol consumption on treatment practices.
5. Okah et al (2005)⁵¹51 Okah FA, Cai J, Hoff GL. Term-gestation low birth weight and health-compromising behaviors during pregnancy. Obstet Gynecol 2005;105(03):543-550. Doi: 10.1097/01.AOG.0000148267. 23099.b7 https://doi.org/10.1097/01.AOG.000014826...	USA	1990–2002	78,397	0.96 (0.58–1.58)	Adjusted	7	All infants who were born at term gestation and on their mothers over a 13-year period.
6. Bada et al (2005)²⁵25 Bada HS, Das A, Bauer CR, et al. Low birth weight and preterm births: etiologic fraction attributable to prenatal drug exposure. J Perinatol 2005;25(10):631-637. Doi: 10.1038/sj.jp.7211378 https://doi.org/10.1038/sj.jp.7211378...	USA	1993–1995	8,637	1 d/w: 1.57 (1.12–2.22);1–3 d/m: 1.17 (0.83–1.65);< 1 d/m: 0.99 (0.79–1.24)	Crude	6	Included women that could have used cocaine, marijuana and opioids.
7. Dičkutė et al (2002)⁴⁵45 Dičkutė J, Padaiga Z, Grabauskas V, Gaižauskienė A, Basys V, Obelenis V. [Do maternal social factors, health behavior and work conditions during pregnancy increase the risk of low birth weight in Lithuania?] Medicina (Kaunas) 2002;38(03):321-332	Lithuania	1995–1998	151,700	10.3 (8.34–12.73)	Crude	7	National database.
8. Maruoka et al (1998)⁵²52 Maruoka K, Yagi M, Akazawa K, Kinukawa N, Ueda K, Nose Y. Risk factors for low birthweight in Japanese infants. Acta Paediatr 1998;87(03):304-309. Doi: 10.1111/j.1651-2227.1998.tb01442.x https://doi.org/10.1111/j.1651-2227.1998...	Japan	1987–1995	23,132	0.90 (0.74–1.09)	Crude	7	Measure generated through contingency table. Consumption was assumed as more than one drink per month during pregnancy.
9. Faden et al (1997)⁴⁷47 Faden VB, Graubard BI, DufourM. The relationship of drinking and birth outcome in a US national sample of expectant mothers. Paediatr Perinat Epidemiol 1997;11(02):167-180. Doi: 10.1046/ j.1365-3016.1997.d01-20.x https://doi.org/10.1046/...	USA	1988	15,737	1.02 (1.01–1.04)	Crude	8	Measure from the systematic review by Patra et al³3 Patra J, Bakker R, Irving H, Jaddoe VW, Malini S, Rehm J. Doseresponse relationship between alcohol consumption before and during pregnancy and the risks of low birthweight, pretermbirth and small for gestational age (SGA)-a systematic review and meta-analyses. BJOG 2011;118(12):1411-1421. Doi: 10.1111/j.1471-0528.2011.03050.x https://doi.org/10.1111/j.1471-0528.2011... (n= 10,083)
10. Windham et al (1995)²⁴24 Windham GC, Fenster L, Hopkins B, Swan SH. The association of moderatematernal and paternal alcohol consumptionwith birthweight and gestational age. Epidemiology 1995;6(06):591-597	USA	1986–1987	1,201	0.1-2 d/w: 0.99 (0.58–1.7);3–5 d/w: 2.5 (1.1–6.0);≥6 d/w: 2.8 (0.77–10.4);> 3 ≥ d/w: 2.6 (1.2-5.8)	Adjusted	7	Telephone interviews on 8^th and 9^th postpartum months. Consumption on 1^st month before pregnancy and 20 first weeks of pregnancy.
11. Lazzaroni et al (1993)¹⁸18 Lazzaroni F, Bonassi S, Magnani M, et al. Moderate maternal drinking and outcome of pregnancy. Eur J Epidemiol 1993;9 (06):599-606. Doi: 10.1007/BF00211433 https://doi.org/10.1007/BF00211433...	Italy	1989–1990	2,145	1–10 g/d: 0.75 (0.22–1.33); 11–20 g/d: 1.38 (0.62–3.75); > 20 g/d: 2.27 (0.86–6.02)	Adjusted	9	Low birhweight < 2,000 g.
12. Primatesta et al (1993)⁵³53 Primatesta P, Del Corno G, Bonazzi MC, Waters WE. Alcohol and pregnancy: an international comparison. J PublicHealthMed 1993; 15(01):69-76. Doi: 10.1093/oxfordjournals.pubmed.a042822 https://doi.org/10.1093/oxfordjournals.p...	Italy and UK	1986–1990	2,512	0.71 (0.50–1.00)	Crude	7	Measure generated through contingency table. In Italy, only a few selected women, mainly of lower social classes.
13. McDonald et al (1992)⁴⁸48 McDonald AD, Armstrong BG, Sloan M. Cigarette, alcohol, and coffee consumption and prematurity. Am J Public Health 1992;82 (01):87-90	Canada	1982–1984	40,445	0.86 (0.79–0.94)	Adjusted	9	Measure from the systematic review by Patra et al.³3 Patra J, Bakker R, Irving H, Jaddoe VW, Malini S, Rehm J. Doseresponse relationship between alcohol consumption before and during pregnancy and the risks of low birthweight, pretermbirth and small for gestational age (SGA)-a systematic review and meta-analyses. BJOG 2011;118(12):1411-1421. Doi: 10.1111/j.1471-0528.2011.03050.x https://doi.org/10.1111/j.1471-0528.2011... .
14. Virji (1991)³¹31 Virji SK. The relationship between alcohol consumption during pregnancy and infant birthweight. An epidemiologic study. Acta Obstet Gynecol Scand 1991;70(4-5):303-308. Doi: 10.3109/00016349109007877 https://doi.org/10.3109/0001634910900787...	USA	1980	5,400	1.13 (0.96–1.34);Light: 1.03 (0.84–1.26);Moderate: 1.23 (0.96–1.58);Heavy: 2.66 (1.32–5.38)	Crude	5	Measure generated through contingency table. Data related to white, married mothers giving birth to singletons.
15. Marbury et al (1983)³⁵35 Marbury MC, Linn S, Monson R, Schoenbaum S, Stubblefield PG, Ryan KJ. The association of alcohol consumptionwith outcome of pregnancy. Am J Public Health 1983;73(10):1165-1168	USA	1982	12,440	0.89 (0.76–1.04)	Crude	6	Measure from the systematic review by Patra et al.³3 Patra J, Bakker R, Irving H, Jaddoe VW, Malini S, Rehm J. Doseresponse relationship between alcohol consumption before and during pregnancy and the risks of low birthweight, pretermbirth and small for gestational age (SGA)-a systematic review and meta-analyses. BJOG 2011;118(12):1411-1421. Doi: 10.1111/j.1471-0528.2011.03050.x https://doi.org/10.1111/j.1471-0528.2011... Article only reported the consumption measure >14 g/w: 1.1 (0.4–3.4)
Prospective cohort
16. Witt et al (2016)³⁴34 Witt WP, Mandell KC,Wisk LE, et al. Infant birthweight in the US: the role of preconception stressful life events and substance use. Arch Women Ment Health 2016;19(03):529-542. Doi: 10.1007/s00737-015-0595-z https://doi.org/10.1007/s00737-015-0595-...	USA	2001	9,350	Alcohol use before pregnancy: 1.07 (0.88–1.29);Use on the last trimester:0.88 (0.54–1.42)	Adjusted	8	Only among very low birthweight (< 1,500 g).
17. Bird et al (2016)³⁰30 Bird AL, Grant CC, Bandara DK, et al. Maternal health in pregnancy and associations with adverse birth outcomes: Evidence from Growing Up in New Zealand. Aust N Z J Obstet Gynaecol 2017;57 (01):16-24. Doi: 10.1111/ajo.12557 https://doi.org/10.1111/ajo.12557...	New Zealand	2009–2010	6,822	Alcohol use before pregnancy: < 1 d/w: 0.82 (0.56–1.19);1 d/w: 0.88 (0.49–1.51);≥2 d/w: 0.78 (0.56–1.08);Alcohol use in 1st trimester <1 d/w :0.85 (0.52–1.31); 1 d/w: 0.95 (0.40–1.92); 2 d/w: 0.70 (0.43–1.08).Alcohol use in rest of pregnancy < 1 d/w: 0.70 (0.42–1.11); 1 d/w: 1.05 (0.36–2.38); ≥2 d/w: 0.54 (0.16–1.30)	Crude	7	Interview on the last month of pregnancy.
18. Sbrana et al (2016)⁴⁹49 Sbrana M, Grandi C, Brazan M, et al. Alcohol consumption during pregnancy and perinatal results: a cohort study. Sao Paulo Med J 2016;134(02):146-152. Doi: 10.1590/1516-3180.2015.02040211 https://doi.org/10.1590/1516-3180.2015.0...	Brazil	2010–2011	1,370	1.62 (1.03–2.54)	Adjusted	9	−
19. Lundsberg et al (2015)³³33 Lundsberg LS, Illuzzi JL, Belanger K, Triche EW, Bracken MB. Low-tomoderate prenatal alcohol consumption and the risk of selected birthoutcomes: a prospective cohort study.AnnEpidemiol2015;25 (01):46-54.e3. Doi: 10.1016/j.annepidem.2014.10.011 https://doi.org/10.1016/j.annepidem.2014...	USA	1996–2000	4,496	Alcohol use before pregnancy: (n= 4,116) < 0.10 g/d: 0.96 (0.61–1.5); 0.10–0.25 g/d: 0.57 (0.24–1.36); > 0.25 g/d: 0.52 (0.24–1.12);1^st trimester (n= 4,105): 0.78 (0.47–1.31)Use on baseline interview (n= 4,115):0.66 (0.46–0.96); 7^th month (n= 3,726): 0.67 (0.33–1.39);3^rd trimester (n= 3,672):0.56 (0.34–0.94)	Adjusted	9	Interview performed until 1^st month after birth.
20. Strutz et al (2014)⁵⁴54 Strutz KL, Richardson LJ, Hussey JM. Selected preconception health indicators and birth weight disparities in a national study. Womens Health Issues 2014;24(01):e89-e97. Doi: 10.1016/j.whi.2013.10.001 https://doi.org/10.1016/j.whi.2013.10.00...	USA	1994–2008	3,014	0.49 (0.14–1.69)	Adjusted	8	Self-reported birth weight.
21. Miyake et al (2014)¹⁹19 Miyake Y, Tanaka K, Okubo H, Sasaki S, Arakawa M. Alcohol consumption during pregnancy and birth outcomes: the Kyushu OkinawaMaternal and Child Health Study. BMC Pregnancy Childbirth 2014;14:79-90. Doi: 10.1186/1471-2393-14-79 https://doi.org/10.1186/1471-2393-14-79...	Japan	2007–2008	1,565	< 10 g/d: 0.98 (0.46–1.85);≥ 10 g/d: 1.31 (0.52–2.84)	Adjusted	8	−
22. Nykjaer et al (2014)²⁹29 Nykjaer C, Alwan NA, Greenwood DC, et al. Maternal alcohol intake prior to and during pregnancy and risk of adverse birth outcomes: evidence from a British cohort. J Epidemiol Community Health 2014;68(06):542-549. Doi: 10.1136/jech-2013-202934 https://doi.org/10.1136/jech-2013-202934...	UK	2003–2006	1,303	Before pregnancy≤ 2 d/w: 0.4 (0.1–2.7);> 2 d/w: 1.1 (0.2–6.1);1^st trimester≤ 2 d/w: 4.6 (1.4–14.7);> 2 d/w:: 3.5 (1.1–11.2) 2^nd trimester≤ 2 d/w: 0.8 (0.3–1.8);> 2 d/w: 0.9 (0.43–2.1);3^rd trimester≤ 2 d/w: 1.0 (0.3–3.2);> 2 d/w:1.0 (0.3–2.9)	Adjusted	9	Consumption was evaluated between 4 weeks before pregnancy until the 12th week of gestation; between weeks 13th to 28th; and between the 29th to 40th weeks of gestation.
23. Jaddoe et al (2007)²⁰20 Jaddoe VWV, Bakker R, Hofman A, et al. Moderate alcohol consumption during pregnancy and the risk of low birth weight and preterm birth. The generation R study. Ann Epidemiol 2007;17 (10):834-840. Doi: 10.1016/j.annepidem.2007.04.001 https://doi.org/10.1016/j.annepidem.2007...	Netherlands	2002–2006	7,141	< 1 d/w: 1.31 (0.87–2.44); 1- 6 d/w: 1.38 (0.66–2.90);> 1 d/d: 4.81 (1.10–21.08)	Adjusted	9	Information about maternal alcohol consumption was obtained by postal questionnaires in early, middle, and late pregnancy.
24. Li et al (2005)⁵⁵55 Li YM, Chang TK. Maternal demographic and psyhosocial factors associated with low birth weight in eastern Taiwan. Kaohsiung J Med Sci 2005;21(11):502-510. Doi: 10.1016/S1607-551X(09)70158-5 https://doi.org/10.1016/S1607-551X(09)70...	Taiwan	1998–1999	1,128	1.16 (0.39–3.42)	Adjusted	8	−
25. Ruijter et al (1999)⁴²42 Ruijter I, Miller JM Jr. Evaluation of low birthweight in African Americans. J Natl Med Assoc 1999;91(12):663-667	USA	1996–1997	225	5.15 (1.07–24.80)	Adjusted	5	Only African-Americans
26. Lundsberg et al (1997)²¹21 Lundsberg LS, Bracken MB, Saftlas AF. Low-to-moderate gestational alcohol use and intrauterine growth retardation, lowbirthweight, and preterm delivery. Ann Epidemiol 1997;7(07): 498-508. Doi: 10.1016/S1047-2797(97)00081-1 https://doi.org/10.1016/S1047-2797(97)00...	USA	1988–1991	2,714	1^st month≤ 0.10 g/d: 0.79 (0.48–1.28);0.10–0.25 g/d: 0.88 (0.48–1.59);0.25–1.00 g/d: 1.24 (0.66–2.33);≥ 1.00 g/d: 0.93 (0.23–3.72); 7^th month≤ 0.10 g/d: 3.20 (1.87–5.46); 0.10–0.25 g/d: 1.36 (0.48–3.88)	Adjusted	7	−
27. Passaro et al (1996)⁴¹41 Passaro KT, Little RE, Savitz DA, Noss J; The ALSPAC Study Team. Avon Longitudinal Study of Pregnancy and Childhood. The effect of maternal drinking before conception and in early pregnancy on infant birthweight. Epidemiology 1996;7(04):377-383. Doi: 10.1097/00001648-199607000-00007 https://doi.org/10.1097/00001648-1996070...	UK	1991–1992	10,539	0.74 (0.64–0.85)	Crude	6	Measure from the systematic review by Patra et al.³3 Patra J, Bakker R, Irving H, Jaddoe VW, Malini S, Rehm J. Doseresponse relationship between alcohol consumption before and during pregnancy and the risks of low birthweight, pretermbirth and small for gestational age (SGA)-a systematic review and meta-analyses. BJOG 2011;118(12):1411-1421. Doi: 10.1111/j.1471-0528.2011.03050.x https://doi.org/10.1111/j.1471-0528.2011... . Limiting analysis to exclude users of marijuana, crack, and cocaine, and excluding women with a history of alcoholism.
28. Olsen et al (1991)²⁶26 Olsen J, Pereira Ada C, Olsen SF. Does maternal tobacco smoking modify the effect of alcohol on fetal growth? Am J Public Health 1991;81(01):69-73	Denmark	1984–1987	11,698	1 g/w: 1.0 (0.7–1.3); 30 g/w: 1.0 (0.7–1.5); 60 g/w: 0.9 (0.5–1.5); 90 g/w: 0.9 (0.5–2.5); >120 g/w: 2.7 (1.5–4.8)	Adjusted	9	Information collected on 36^th gestational week.
29. Day et al (1989)⁴⁰40 Day NL, Jasperse D, Richardson G, et al. Prenatal exposure to alcohol: effect on infant growth and morphologic characteristics. Pediatrics 1989;84(03):536-541	USA	Not reported	650	1.46	Crude	5	Did not report 95%CI
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31. Little et al (1986)³⁹39 Little RE, Asker RL, Sampson PD, Renwick JH. Fetal growth and moderate drinking in early pregnancy. Am J Epidemiol 1986;123 (02):270-278. Doi: 10.1093/oxfordjournals.aje.a114235 https://doi.org/10.1093/oxfordjournals.a...	UK	1979–1980	144	8.70 (2.18–34.72)	Crude	5	Measure of systematic review by Patra et al.³ Sample of white women, aged 19–35 years, athletes, low middle class, non-smoker, non-alcoholic, good health and with the first prenatal visit until the 16th gestational week.
32. Lumley et al (1985)⁵⁰50 Lumley J, Correy JF, Newman NM, Curran JT. Cigarette smoking, alcohol consumption and fetal outcome in Tasmania 1981-82. Aust N Z J Obstet Gynaecol 1985;25(01):33-40	Australia	1981–1982	10,319	1.04 (0.88–1.23)	Crude	7	Measure from the systematic review by Patra et al.³3 Patra J, Bakker R, Irving H, Jaddoe VW, Malini S, Rehm J. Doseresponse relationship between alcohol consumption before and during pregnancy and the risks of low birthweight, pretermbirth and small for gestational age (SGA)-a systematic review and meta-analyses. BJOG 2011;118(12):1411-1421. Doi: 10.1111/j.1471-0528.2011.03050.x https://doi.org/10.1111/j.1471-0528.2011... All Tasmanian births.
33. Mills et al (1984)³⁷37 Mills JL, Graubard BI, Harley EE, Rhoads GG, Berendes HW. Maternal alcohol consumption and birth weight. How much drinking during pregnancy is safe? JAMA 1984;252(14):1875- -1879. Doi: 10.1001/jama.1984.03350140021018 https://doi.org/10.1001/jama.1984.033501...	USA	1974–1977	31,503	1.20 (1.09–1.32)	Crude	6
34. Grisso et al (1984)³⁸38 Grisso JA, Roman E, Inskip H, Beral V, Donovan J. Alcohol consumption and outcome of pregnancy. J Epidemiol Community Health 1984;38(03):232-235. Doi: 10.1136/jech.38.3.232 https://doi.org/10.1136/jech.38.3.232...	UK	1972–1973	1,256	0.95 (0.56–1.63)	Crude	5	Measure from the systematic review by Patra et al.³3 Patra J, Bakker R, Irving H, Jaddoe VW, Malini S, Rehm J. Doseresponse relationship between alcohol consumption before and during pregnancy and the risks of low birthweight, pretermbirth and small for gestational age (SGA)-a systematic review and meta-analyses. BJOG 2011;118(12):1411-1421. Doi: 10.1111/j.1471-0528.2011.03050.x https://doi.org/10.1111/j.1471-0528.2011... Survey mailed to participants. Group from a previous randomized trial regarding smoking.
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Case-control
36. Márquez et al (2011)⁴⁴44 Márquez RCM, Borroto KL, Ranero ABG. [Factors influencing low birthweight in the health area "Camilo Cienfuegos" Chambas, 2007-2008]Mediciego. 2011;17:1-7	Cuba	2007–2008	84	20.76 (1.08–400.49)	Crude	3
37. Jackson et al (2007)³²32 Jackson DJ, Batiste E, Rendall-Mkosi K. Effect of smoking and alcohol use during pregnancy on the occurrence of low birthweight in a farming region in South Africa. Paediatr Perinat Epidemiol 2007;21(05):432-440. Doi: 10.1111/j.1365-3016.2007.00847.x https://doi.org/10.1111/j.1365-3016.2007...	South Africa	2002–2003	400	Some use during pregnancy:1.38 (0.37–5.13);current drinking: 2.15 (1.37–3.39);CAGE score > 2: 1.28 (0.59–2.79)	Adjusted	7
38. Mariscal et al (2006)²²22 Mariscal M, Palma S, Llorca J, Pérez-Iglesias R, Pardo-Crespo R. Delgado-Rodríguez. Pattern of alcohol consumption during pregnancy and risk for low birthweight. Ann Epidemiol 2006; 6:432-438. Doi: 10.1016/j.annepidem.2005.07.058 https://doi.org/10.1016/j.annepidem.2005...	Spain	1998–2002	2,003	Alcohol consumption1–5.9 g/d: 0.64 (0.46–0.88);6–11.9 g/d: 0.92 (0.52–1.62);> 12 g/d: 1.56 (0.91–2.69);Type of beverage:Beer only: 0.59 (0.35–1.00);Wine only: 0.88 (0.64–1.22);Spirits only: 0.89 (0.34–2.35);Other patterns: 0.84 (0.46–1.53);On weekdays during pregnancy:1–11.9 g/d: 0.96 (0.44–2.06)> 12 g/d: 2.67 (1.39–5.12)	Adjusted	7
39. Borges et al (1993)²⁷27 Borges G, Lopez-Cervantes M, Medina-Mora ME, Tapia-Conyer R, Garrido F. Alcohol consumption, low birth weight, and preterm delivery in the National Addiction Survey (Mexico). Int J Addict 1993;28(04):355-368	Mexico	1988	1,372	Alcohol during pregnancy: 1.32 (0.85–2.06)Alcohol frequency last year: > once a month 1.17 (0.79–1.72); once a month 0.66 (0.32–1.37); 2–3 t/m: 0.79 (0.33–1.94); 1–2 t/w: 1.72 (0.81–3.67); ≥ 3 to 4 t/w: (0.17–3.34)Grams of alcohol0.01–1,800 g/y: 1.04 (0.73–1.50);1,800.01–3,600 g/y: 0.61 (0.18–2.08);≥ 3600.01 g/y: 1.28 (0.61–2.65)Drunkenness frequency last year: Never: 0.90 (0.63–1.31);1 to 7 t/y: 1 0.97 (1.09–3.56);once a month and more often: 2.45 (0.46–12.88);Alcohol drinking pattern: Infrequent: 1.17 (0.77–1.77); Less frequent, low maximum: 0.55 (0.27–1.14); Less frequent, high maximum: 1.30 (0.68–2.49); Frequent, low maximum: 1.13 (0.42–3.03); Frequent, high maximum: 1.20 (0.40–3.65); Frequent, heavy drinker: 4.21 (0.90–19.74); Alcohol dependency: 16.29 (1.65–160.9)	Adjusted	5	Household survey. Self-reports of alcohol consumption in the last 12 months.

Variable	Groups	Number of studies/participants	RR (95%)	I² (%)	Number of studies/participants	RR (95%)	I² (%)	Number of studies/participants	OR (95%)	I² (%)
		Retrospective cohort n= 15			Prospective cohort n= 19			Case-control n= 4
Sample size	< 1,000	3 /1,255	2.46 (1.28–4.74)	<1	2 /369	6.92 (2.45–19.55)	<1	2 /484	3.82 (0.29–50.01)	68.8
	≥ 1,000	12 / 370,032	1.31 (1.04–1.63)	98.7	17 / 120,858	1.08 (0.97–1.21)	81.0	2 / 3,375	1.01 (0.64–1.58)	62.8
Type of measure	Crude	9/ 219,856	1.45 (1.08–1.96)	99.0	8/ 33,780	1.13 (0.95–1.35)	91,1	1/ 84	20.75 (1.08–400.49)	−
Type of measure	Adjusted	6/ 151,437	1.24 (0.88–1.72)	90.1	11 / 84,447	1.08 (0.91–1.29)	44.2	3/ 3,775	1.02 (0.70–1.47)	43.6
Methodologic quality	High	10/ 330,793	1.36 (0.96–1.92)	98.4	13/ 62,433	1.08 (0.95–1.21)	61.5	2/ 2,403	0.84 (0.66–1.08)	<1
	Average	5/ 26,775	1.26 (0.90–1.77)	93.1	6/ 55,794	1.38 (0.93–2.03)	92.1	1/ 1,372	1.32 (0.85–2.05)	−
	Low	−	−	−	−	−	−	1/ 84	20.75 (1.08–400.49)	−
Year of publication	2010–2016	3 / 29,407	1.80 (1.05–3.10)	42.8	7 / 27,920	0.89 (0.65–1.21)	52.6	1 / 84	20.75 (1.08–400.49)	−
	2000–2009	4 / 238,868	2,38 (0,62–8,17)	99.0	2 / 8,269	1.32 (1.00–1.74)	<1	2 / 2,403	0.84 (0.66–1.08)	<1
	1990–1999	7/ 90,572	0.97 (0.87–1.09)	74.9	4/ 27,176	1.00 (0.75–1.33)	84.5	1/ 1,372	1.32 (0.85–2.05)	−
	1980–1989	1 / 12,440	0.89 (0.76–1.04)	−	6 / 56,862	1.32 (1.08–1.60)	90.7	−	−	−
Region	America	10 / 191,643	1.17 (0.97–1.43)	97.8	8 / 64,799	1.17 (0.92–1.48)	78.2	2 / 1,456	3.49 (0.26–46.13)	69.3
Region	Europa	4 / 156,521	2.11 (0.38–11.65)	98.3	7 / 33,594	1.05 (0.86–1.28	82.2	1 / 2,003	0.83 (0.65–1.06)	−
	Asia	1 / 23,132	0.90 (0.74–1.09)	−	2 / 2,693	1.11 (0.68–1.80)	89.6	−	−	−
	Oceania	−	−	−	2/ 17,141	1.03 (0.54–1.97)	<1	−	−	−
	Africa	−	−	−	−	−	−	1 / 400	1.38 (0.37–5.13)	−

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[1] Address for correspondence
Priscilla Perez da Silva Pereira, PhD, Departamento de Enfermagem, University Federal of Rondônia, Av. Presidente Dutra, 2967, 76801-016, Olaria, Porto Velho, Ro, Brazil (e-mail: priperez83@gmail.com).