Predictors of alcohol and other drug use among pregnant women in a peri-urban South African setting

Alcohol and other drugs (AOD) use among pregnant women has been identified as associated with adverse health outcomes for mother and child both during and after pregnancy [1‐3]. AODs has also been identified as a means for ‘coping with everyday life’ for pregnant women in adverse environments where poverty and other societal harms exist [2, 4]. Exposure to alcohol during pregnancy has been identified as one of the main avertable causes of birth defects and developmental impairment in offspring [5]. Frequent AOD use has also been identified as associated with low weight gain during pregnancy [6], diminished fetal growth [7], and premature deliveries [5]. Studies have found that South Africa has one of the highest prevalence rates for Fetal Alcohol Spectrum Disorders (FASD) in the world [8, 9]. A study in South Africa, using urine analysis, found the prevalence of drug and alcohol use among pregnant women attending antenatal clinics in Cape Town to be 8.8 and 19.6 % respectively [9]. The 2010/2011 snap-shot survey report on substance abuse in the nine provinces in South Africa, indicated that the use of drugs was twice the global average and that South Africa was amongst the top ten nations in high alcohol consumption [10].

AOD use have been found to be associated with age [11], poverty [12, 13], unemployment [14, 15], interpersonal conflict [16, 17], multiple depressive episodes [18], anxiety [19], suicidality [20] among pregnant women. Low income pregnant women have higher vulnerability to AOD use in both developed and developing country settings [11, 12, 21]. Studies in high income countries have shown that there is a strong correlation between low socioeconomic status, minority race, and AOD use among pregnant women [22], indicating that older black women with average incomes consume more alcohol than their white counterparts in the USA. However, younger white women consume more than their female black counterparts of the same age. There is evidence of a strong association between poverty and drug use among pregnant women in the USA [23] disaggregated by race.

In South Africa, studies have examined alcohol use among pregnant women [24, 25] but less data is available on drug use [9]. Few studies have looked at the association between hazardous behaviour, demographic, and socioeconomic factors among pregnant women [26]. Studies have predominantly focused on the impact on FASD and health outcomes of children [1, 3, 27, 28] with few studies having looked at the relationship between AOD use and life events among pregnant women [29]. Most studies have however disaggregated data into racial categories [14, 22, 27]. A study in South Africa analysed the predictors of alcohol and drug use among pregnant women using screening tools; the Alcohol Use Disorders Identification Test (AUDIT) and the Drug Use Disorders Identification Test (DUDIT) [30]. However, the study did not use a diagnostic tool to determine alcohol and drug use and also did not perform multiple regression analysis.

The aim of this study is to determine the association between demographic, economic and psychosocial life events with alcohol and drug use among pregnant women in Hanover Park, Cape Town using The Expanded Mini-International Neuropsychiatric Interview (MINI Plus) Version 5.0.0. as the diagnostic interview for mental health disorders.

This study has confirmed the vulnerability of pregnant women in low-income, peri-urban settings to alcohol abuse and other drugs use. AOD use is closely associated with the factors that are prevalent in their living environment. The risk profile of these women indicates that there is prevailing poverty, food insecurity, intimate partner violence, and often a history of previous mental health problems. These risk factors are associated with the presence of comorbidities of AOD use with depression, anxiety and suicidality. McLanahan [56] and Gorski [4] argue that AOD use among vulnerable families results in the “production of poverty” which in turn pushes these families deeper into AOD use and poverty. This speaks to the findings of this study and suggests that pregnant women’s use of AODs places them at risk of mental health problems, poverty, and relationship difficulties, while their adverse environment places them at risk for AOD use.

Women in the mid to late twenties age group have been shown to have a higher chance of AOD use than younger or older age groups, regardless of their pregnancy status [57]. This age group has been identified as associated with higher risk-taking behaviour in South Africa [57]. Alcohol and drug use has also been shown to be associated with unprotected sex which in turn leads to pregnancy [58], and, at recognition of pregnancy, alcohol and drug use in poor women may provide a means to avoid confronting the difficulties associated with becoming pregnant [59]. Further studies in high income countries identified that women in their early to late twenties have a higher likelihood of AOD use prior to pregnancy recognition [60‐62] and to alcohol abuse after confirmation of conception [59, 61]. Education, which is associated with enhanced rational knowledge and risk adverse behaviour [63, 64], was found to be negatively associated with AOD use. This indicates that the more educated a woman is, the less likely she would use AODs during pregnancy [59, 64, 65]. This study concurs with this literature.

Although over half of the women in our study were employed, more than 40 % of the sample’s earnings were below the stipulated cross-sectoral minimum wage determination as defined by the South African Department of Labour [66]. Further, having employment did not preclude these women from poverty, as over 40 % of these employed women belonged to a low socioeconomic index. The findings that women who were currently employed had more chances of using AODs contradicts findings from other studies in low-, middle-, and high-income countries [26, 67, 68]. A possible explanation for this is that those women who were employed had low incomes and low socioeconomic status. Hence, being employed did not prevent them from experiencing poverty but may have enabled sufficient financial access to procure alcohol and substances. Their pregnancy, and lack of maternity benefits, may have been added stressful life factors, predisposing them to use AODs. Food security has been identified in literature as a measure of access to enough food to meet daily dietary and energy requirements, which in turn is a measure of poverty [69, 70]. Also, results from the analysis indicate that these women had low food security as 30 % of those that were employed were food insecure and over half of those that were not employed had food insecurity. Although women that were food insecure were more likely to use AODs in this study, food insufficiency, which is a severe form of food insecurity, was found to be a stronger predictor of AOD use. This attests to the aforementioned results that illustrates that poverty and poverty-related problems predispose women to AODs, and that AOD use may contribute to their poverty.

A majority of the women in the study had a partner and were living together with their partners. Over half of the reported cases of IPV were among women cohabiting with their partners. A systematic review by Shamu et al. [71] noted that the prevalence of IPV during pregnancy ranged from 5 to 57 % in 19 studies conducted in five African countries. Although women that were cohabiting with their partners were less likely to use AODs than those living alone, those that experienced IPV were more likely to use AODs. While women that had casual partners had greater chances of using AODs, almost three quarters of those that had a casual partner lived alone. Martin et al. [72] in the USA found that the links between women’s experiences of intimate partner violence and their use of substances became stronger after pregnancy recognition, with women who experienced partner violence being more likely to use both alcohol and illicit drugs. Another explanation may be that AODs among partners may act to trigger IPV which may, in turn, create a greater likelihood of AOD use, thereby creating a vicious cycle of IPV and AODs. Makayoto et al. [73], Leonard [74], Kagle [75] and Smith [76] contend that women who use AODs are at more risk for domestic violence since their AOD use may be viewed by their partners as being inappropriate and hence may lead the partner to physically ‘‘discipline’’ the woman for her ‘‘unfeminine’’ conduct. In the Hanover Park context, there are high rates of AOD use among men, in particular the use of methamphetamine which reduces inhibitions and stimulates aggression [77, 78].

The interrelationships between perceived partner support, difficult life events, and AODs among pregnant women has been documented in literature among low income groups in predominantly high income countries [11, 79, 80]. In these settings, pregnant women who perceived lack of support from their partners and experienced adverse life events were more likely to have past mental health disorders and use AODs. Muckle et al. further demonstrated in low-income women, that the coexistence of adverse past events and past mental health problems possibly create an enabling environment for AOD use during and after pregnancy [11]. Harrison and Sidebottom found that, perceived lack of social support, and difficult live events were predictors of continued alcohol use after pregnancy recognition among women in the USA [7]. These findings resonate with the results of this study and further illustrates that the use of AODs are linked to the relationship between perceived lack of support and difficult circumstances.

Coexistence of AOD use with other forms of mental health problems like depression, anxiety, and suicidality have been identified in literature. A cohort study of women in Australia [81] found that the association of high alcohol consumption with symptoms of depression and anxiety may vary in course of a woman’s life but these associations can be confounded by low income and smoking especially during and after pregnancy. Also, a review of studies that assessed anxiety during pregnancy and postpartum among women in 27 high- and low-income countries indicate that AOD use may be used to suppress distress around pregnancy [80]. Systematic reviews of 47 studies that investigated the association between AOD use and suicidality [82‐84] found that AOD use was associated with suicide for all categories of abuse and use disorders among men and women. These shows that suicide during pregnancy is disproportionately high in low income settings in both developed and developing contexts [21].

Findings from this study should be viewed in light of several design limitations. The sample size was small, limiting the ability to generalize these findings across the entire study population. The study did not assess biomedical markers for AODs by collecting urine or blood samples, thereby leaving room for underreporting of alcohol and drug use, and may have created a response bias. All data collected was self-reported since the study did not verify information like asset ownership. Several key questions were not asked in the survey. For instance, participants were not asked to report their alcohol and drug use prior to pregnancy or on the condition of assets owned. Also, HIV status was not assessed at data collection but was collected retrospectively, hence it could not be included as a predictor of AOD use. Our sampling strategy did not include non-users of antenatal services who might be particularly vulnerable to AOD use. Despite these limitations, this study has the strength of being one of the few studies that have examined the predictors of alcohol abuse and drug use among low income pregnant women in Africa. Furthermore, this study also examines inter-related, multiple risk factors that place pregnant women at greater risk of AOD use.

In conclusion, our study shows that demographic, economic, and psychosocial factors play a major role in predisposing pregnant women in adverse environments, like Hanover Park, to alcohol abuse and other drug use. Further, the association between diagnosed depression and anxiety, suicidality, and AOD use among these women may largely reflect how complex environmental factors support the coexistence of multiple mental health problems. These problems are of critical concern since these women are pregnant and the outcomes for their own health and that of their infants are placed at high risk. The results have implications for planning appropriate interventions and raise questions for further research. Integrating evidence-based mental health, alcohol and drug use interventions into routine primary care settings may substantially impact outcomes for low income pregnant women. In addition, a concerted intersectoral approach is required to address the social and economic determinants of AODs and common mental disorders.