The increasing illicit drug use among South African women, particularly those of reproductive age, is raising concerns about the heightened risk of pregnancy complications and the long-term development of their infants and children.
High levels of poverty among women; lower levels of educational and unemployment status; extended family responsibilities in single woman-headed households; exposure to intergenerational trauma and gender-based violence; and mental illness including anxiety and depression; are among the reasons for women turning to substance abuse.
A 2024 study found that use of illicit drugs among South African adults almost doubled from 2002 to 2017, to 10% of the population, double the global average. Although mainly driven by cannabis use, use of opioids, cocaine and stimulants increased 10-fold, with drug use among women increasing from 0.2% to 5% over the period.
Speaking ahead of International Women’s Day on Saturday, 8 March 2025, Dr Lisa Dannatt, member of the South African Society of Psychiatrists (SASOP), said that substance use in pregnancy increased the risks of “negative pregnancy and child health outcomes”, while also impeding access to pregnancy healthcare due to stigma and judgement.
“Women are at greatest risk of developing a substance use disorder in their reproductive years with the highest prevalence rates seen in adolescence and early adulthood.
“Although substance use is still more prevalent among men, research has shown that once women start using substances, they increase their rate of use more rapidly and progress more quickly to substance-use disorders with a higher rate of negative physical, mental, and social sequelae than men,” she said.
Substance use risks pregnancy
Dannatt said a further concern was that 41% of all pregnancies globally are unplanned, which means that many women use substances before they become aware of their pregnancy, while substance use itself increases the risk of unintended pregnancy.
Additionally, women may develop new onset mental illness in pregnancy or cease using prescribed psychopharmacological treatments when learning that they are pregnant. This can lead to the pregnant women using substances including alcohol, tobacco and cannabis to manage their symptoms.
As an indicator of the prevalence of substance use among pregnant women, she said studies in the Western Cape found that 36% smoked, 20% used alcohol and 8% tested positive for drugs.
“All drugs, including nicotine and alcohol, carry risks to both the developing foetus and the health of the expectant mother. Risks for the pregnant woman include pre-eclampsia, miscarriage, premature delivery and excessive bleeding during and after birth.
“Substances of abuse readily cross the placenta, risking poor growth and development of foetal vital organs, especially the brain. The infant is at risk of birth defects, low birth weight, and cardiac and respiratory problems at birth. All of these lead to significant negative health outcomes, both at birth and long term,” Dannatt said.
First 1,000 days of life
She said a child’s lifelong prospects for physical health and brain development are laid down in the first 1,000 days of life, from conception to about two years’ old.
“Substance use in these first 1,000 days not only impacts on the developing foetus but goes further into impacting on mother-child bonding, breastfeeding, and the child’s ongoing growth and development, and their prospects in education and life,” she said.
Poor maternal bonding can lead to the child developing social and emotional difficulties, while children raised in substance-using households are more likely to have schooling and behavioural difficulties, mental health challenges, and may go on to develop problems with substance dependence and abuse.
Dannatt highlighted that the health of women using drugs and alcohol during pregnancy is further endangered by barriers to accessing pregnancy care.
“Women using substances are often reluctant to seek maternal healthcare or struggle to keep appointments. Their substance use may be linked to co-occurring physical and mental illness, and they fear being stigmatised or having the baby removed from their care.
“They may have transport and childcare difficulties, poor coping skills and lack of social or family support. The lack of access to care and untreated medical and mental health co-morbidity can all negatively affect pregnancy outcomes and child health,” she said.
Misinformation fuels substance use
She said that misinformation on substance use in pregnancy was rife, with many women not concerned about the impacts of legal or socially acceptable substances such as alcohol, tobacco or cannabis.
“The reasons for women’s use of substances and their vulnerability to substance disorders differs from men’s. Particularly in relation to maternal healthcare, an integrated and women-specific approach is needed which would address physical and mental health.
“Healthcare practitioners need to address misinformation and educate against substance use in pregnancy, and prevent and manage maternal substance use.”
In addition to initiatives aimed at preventing substance use, Dannatt emphasised the need for measures to reduce stigma and improve access to healthcare and substance treatment services for pregnant women.
She also highlighted the importance of supporting women in better pregnancy planning and providing social support. Pregnant women using substances are advised to urgently contact their healthcare provider for assessment and further care.
