Abstract
Background
Substance use in this country, among pregnant women, is a recent phenomenon as our women embrace western culture. More worrisome is the current finding showing no ‘safe’ level of alcohol exposure for possible adverse effect or harm to the developing child to occur. Aims and Objectives: To determine what substances are used and the prevalence of substance use among pregnant women attending the antenatal clinic of the Jos University Teaching Hospital, Jos, Northcentral Nigeria. Design: Cross-sectional study.Setting: Jos University Teaching Hospital.
Results
A total of 557 women were administered the pre-tested questionnaire. The mean age was 29.1 years, with a range of 15 to 48 years. The prevalence rate of substance used among the pregnant women was 43.8%. In all, 244 of the 557 women were taking one substance or the other. About 61.9% of the women abuse Kolanuts. There was no significant difference in the age group between those who sue it and those who do not (p-value 0.7411).
Other substances were chlorpheniramine 10.6%, alcohol 8.6%, diazepam 4.5% and promethazine 2.5%, cigarettes/tobacco 2.9%, phenobarbitone 2.9%, cocaine 2.5%, codeine 2.0%, and marijuana 1.6%. A significant number 22.8% admit to using other substances in pregnancy. The commonest reason given for substance use is to control nausea and vomiting of early pregnancy.
Conclusion
Nigerian pregnant women use and abuse a wide variety of substances and drugs during pregnancy just as their counterparts in the developed world. The high prevalence observed in this study was largely due to the consumption of locally available substances.
Introduction
About 2.6 million women who deliver each year use alcohol at some point during their pregnancy and about 1 million children each year are exposed to alcohol, tobacco and illegal drugs (MATID) during gestation.1 These figures may even be an underestimate because prevalence rates are often dependent on self-reporting by pregnant women, which is associated with the global challenge of under-reporting.2,3,4 Maternal self-report of drug use is problematic because of the fear of the consequences of admitting to the use of drugs such as involvement of Child Protective Services (CPS), the threat of child removal from mother, and more importantly in our environment it is socially unacceptable. Furthermore, self-report is unreliable because of the inaccuracy of recall, especially when questions such as "when", "how often" and "how much" are asked.5 Substance use during pregnancy is a major public health issue and a social policy concern.6,7,8,9 This is because women account for majority of drug addicts in the developed countries.10 Importantly, current reports showed no ‘safe’ level of alcohol exposure for the possible adverse effect or harm to the developing child caused by the chemical effect of the drug to occur.11 Maternal prenatal substance abuse is defined as chronic use of alcohol and/or other drugs.
The teratogenic effects of alcohol are well established. One of the most widely chronicled problems attributed to alcohol use is fetal alcohol syndrome (FAS).12 FAS is arguably the most common known non-genetic cause of mental retardation. FAS was first described in the published medical literature in 1968 and refers to a constellation of physical abnormalities. Maternal alcohol ingestion is associated not only with physical malformations but also disruption of brain development, significant impairments in behavior, attention control and language development, and an increased risk of offending behavior in later life. Different labels have been used to describe this heterogeneous group including fetal alcohol effects (FAE) and alcohol-related neuro-developmental disabilities (ARND).13 Ethanol freely crosses the placenta, thus directly affecting developing embryonic and fetal tissue leading to miscarriage, microcephaly and mid-face abnormalities.14,15,16 Some of the mechanism by which alcohol exert its teratogenic effects is by induction of apoptosis, cell adhesion defects, accumulation of free radicals, effect on growth factors and antagonism of retinoic acid biosynthesis. As with most other teratogens, the mechanism of damage may vary according to the stage of embryological development.
Similar effects may occur in a range of circumstances where infants are exposed to a variety of neuroactive substances and drugs of abuse. Mothers who abuse opiates do not usually take care of their own health antenatally,17 and the infants are often raised in less than ideal family circumstances
There is a marked variation between countries (and even between regions of countries) in quantities, patterns and types of alcohol consumed and illicit drugs used. Therefore, generalization from one country to another is probably unwise, and researchers, clinicians and policy makers should rely on local estimates rather than extrapolating. More so, there have been few studies investigating the prevalence of illicit drug use in pregnant women. Importantly, substance use in this country is a recent phenomenon as our women embrace the western culture.
Therefore, accurate identification of women who are at risk of drug-exposed-pregnancy and intervening with them is important not only to understand the nature and magnitude of the problem, but also an essential strategy for preventing drug–exposed pregnancies. Importantly, early detection of infants with significant exposure history is critical so that they can be monitored for possible developmental problems.
Although the use of maternal serum biochemical makers such as gamma- glutamyl transferase, mean corpuscular volume, haemoglobin-associated acetaldehyde, carbohydrate-deficient as a means of identifying heavy drinking in pregnancy is the ideal, are still under evaluation.
Hence, maternal reports using structured questionnaire or information collected about the mother from medical record review remain acceptable methods. This study was based on self-administered structured questionnaire.
Although there are a number of promising approaches using biomarkers of exposure, self-report still remains the main method of exposure ascertainment and is likely to remain so. This method relies on several assumptions that have been shown to be problematic. In addition, there are several factors such as shame, fear, of disclosure, or the concern about admitting to engaging in socially/culturally undesirable behavior that will affect willingness to report drug or alcohol use accurately. These factors are likely to play an even more important role in pregnancy, where both drinking alcohol and drug use have been associated with harm to the unborn child.
There have been few studies investigating the prevalence of illicit drug use and types of substances used by pregnant women in Nigeria in general and in Central Nigeria in particular. The aim of the study is to determine the prevalence and types of substances used by pregnant women attending the antenatal clinic of the Jos University Teaching Hospital in North-Central Nigeria.
Reports
Materials and Methods
Study Area
Jos is the capital of Plateau State in northern Nigeria. It lies between latitude 09° 52'N and longitude 008° 54'E at an elevation of 1,285M above sea level.12 The Jos University Teaching Hospital (JUTH) is a federal tertiary care facility located within Jos metropolis.
Study Sample
All pregnant women attending the ANC were eligible for recruitment into the study. These included women of all age group, parity, social status, etc. Approval for the study was obtained from the JUTH Ethical Committee. Informed consent was obtained from all participants.
Study Protocol
This study was done between January and June 2011, a period of 6 months. Participants were recruited from the antenatal clinic of JUTH. The questionnaire was written in English language and interpretation in the dominant local language (Hausa) was conducted by a member of the research team where necessary. The purpose of the study, as well as risks and benefits, were explained to all participants.
Statistical Methods
Data were analyzed with Epi Info 3.5.3 (CDC, Atlanta, Georgia) and Microsoft Office Excel 2003 (Microsoft Corporation, Redmond, Washington). Results are expressed as mean and standard deviation except where specified. Linear regression was used to assess correlations between continuous variables.
Results
A total of 557 women were administered questionnaire. The mean age was 29. 2± 5.3 years; Variance of 28.03; Median of 29 years and a mode of 28 years with a range of between 15 and 48 years. The prevalence of substance use among the women was as high as 43.8%. That is 244 of the 557 women were taking one form of substance or the other. About 27.1% used kolanuts, chlorpheniramine 4.7%, alcohol 3.8%, diazepam 2.9%, promethazine 2.0%, cigarettes / tobacco 1.3%, phenobarbitone 1.3%, cocaine 1.1%, codeine 0.9% and marijuana 0.7%. Other substances were piriton and chlorpheniramine 10.6% each, alcohol 8.6%, diazepam 4.5%, promethazine 2.5%, cigarettes/tobacco 2.9%, phenobarbitone 2.9%, Cocaine 2.5%, codeine 2.0%, and marijuana 1.6%.
Surprisingly, up to 22.7% of the substance users were aware of problems associated with their use in pregnancy. Yet, a significant number 22.8% assert to use of other substances in pregnancy. These drugs or medications were not stated and the reason for using them was unclear.
About half (49.2%) of the women used these substances to relieve nausea and vomiting in early pregnancy. The second commonest reason was the belief that these substances especially alcohol would help in the development of the baby (28.5%). The other reason was to improve appetite (7.8%). Surprisingly, about 11.7% of the women had no reason for the substance used as seen in Figure 1.
Kolanuts were the most abused substance. There was no significant difference in the age group with those that do not use, p-value is 0.7411. The age distribution of the women is shown in Figure 2. Women of active reproductive age group (25-30 years) were the main users of alcohol.
Figure 1:
Reasons for Use of Substance during Pregnancy
Figure 2:
Age distribution of women Using Kola during Pregnancy
Conclusions
Pregnant women in north central Nigeria just like other women in other parts of the world also use substances during pregnancy. However, the prevalence is still low. The high prevalence observed in this study was largely due to the consumption of locally available substances. The locally available Kolanut which contain caffeine was used by majority of the women to curtail nausea and vomiting calls for in-depth analysis to determine its full contents and its effect on the pregnant woman, her unborn child and subsequent development of the infant. Cigarette smoking is still very low among the pregnant women.
The risk of fetal alcohol syndrome in the baby should be emphasized to pregnant mothers to counter the notion that alcohol improves fetal development. There is need for policy formulation to educate expectant mothers on the dangers of substance use especially in early pregnancy.
Discussion
Substance use during pregnancy is a major public health issue and a social policy concern. This is because research has shown that women account for majority of drug addicts in the developed society. While mothers who abuse substances do not usually take care of their own health antenatally, the impact of substance use extends far beyond maternal health to that of a large number of the unborn population. Reports from across Europe have shown that although many women stop taking alcohol once pregnant, a significant number continue to drink.18 A prevalence of 2.5% of women drinking in pregnancy reported in the developed world.19 This is lower than the 3.8 percent in this study. This may be due to the widespread consumption of the local brew called burukutu in the study environment. Also the drinking of refined alcohol (Guinness) and gin is practiced as a form of haematinic and blood cleanser respectively especially for the pregnant woman.
Illicit drug use has been conceptualized as a spectrum with occasional experimental use of ‘soft’ drugs at one end, which is virtually universal in many developed countries, through to dependent drug use at the other end. In the middle of this spectrum is the recreational use of drugs. Although it is surprising to observe that about 1.1% and 0.7% of our study population consent to the use cocaine and marijuana respectively, this is even lower than the 4.6% to 5.5% reported among women using illicit drugs while pregnant.20,21,22 Only 1. 3% of the respondents used cigarette/tobacco in pregnancy.
Kolanuts are used by the general population as a stimulant, widely available and cheap that it can easily be obtained from street hawkers. Also, it has no religious or social stigmatization.
About a quarter (22.8%) of the respondents admitted to use of other substances during pregnancy. There is need to explore further to identify these other substances women may be using during pregnancy.
The women had many reasons for the use of the substances. These included things like the relief of nausea and vomiting in 49.2% of the women; to help with the development of their baby in 28.5%; to improve their appetite and heap them eat better in 7.8%; their husbands wanted them to take in 0.6% and other reasons in 2.2%. About 11.7% of the women, however, had no reason for taking the substances. All women taking kolanuts did so to control the nausea and vomiting associated with early pregnancy. The taking of alcohol, especially Guinness Lager beer as erroneously believed, was to help in the development of their babies.
It is believed that pregnant women are not likely to volunteer information about their drug and alcohol consumption given the likely stigmatization of their behavior. In fact, they tend to hide such behaviours because of fears of being deemed unfit to bring up their baby, and possibly other older siblings, if there are child protection issues. About 1.1% use diazepam and cocaine, and 22.7% are aware of problems associated with the use of cocaine in pregnancy, while 2.7% use non-prescribed promethazine.
The findings from this study raise the novel and exciting possibility that pregnant women abuse a lot of substances and drugs during pregnancy in the developing world as their counter-parts in the developed world. About a quarter of the respondents admitted to use of other substances during pregnancy. There is need to explore further to identify these other substances women may be abusing in pregnancy. Therefore, a well-designed study is needed to establish the extent of abuse and the temporal relationship with congenital malformation seen in the region.
Footnotes
Competing Interests: The authors have declared that no competing interests exist.
Grant support: None
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