Facilitators and barriers to substance-free pregnancies in high-income countries: A meta-synthesis of qualitative research

Background: Previous studies have associated substance use (alcohol, illicit drugs and smoking) to negative pregnancy outcomes, including higher risk of stillbirth. Aim: This study aims to identify facilitators and barriers reported by women to remain substance free during pregnancy. Methods: A systematic search was conducted in six databases from inception to March 2019 and updated in November 2020. Qualitative studies involving pregnant or post-partum women, from high-income countries, examining women's experiences of substance use during pregnancy were eligible. Meta-ethnography was used to facilitate this meta-synthesis. Findings: Twenty-two studies were included for analysis. Internal barriers included the perceived emotional and social benefits of using substances such as stress coping, and the associated feelings of shame and guilt. Finding insensitive professionals, the lack of information and discussion about risks, and lack of social support were identified as external barriers. Furthermore, the social stigma and fear of prosecution associated with substance use led some women to conceal their use. Facilitators included awareness of the health risks of substance use, having intrinsic incentives and finding support in family, friends and professionals. Discussion: Perceived benefits, knowledge, experiences in health care settings, and social factors all play important roles in women's behaviours. These factors can co-occur and must be considered together to be able to understand the complexity of prenatal substance use. Conclusion: Increased clinical and community awareness of the modifiable risk factors associated with substance use during pregnancy presented in this study, is necessary to inform future prevention efforts.