Maternal psychosocial factors associated with substance use in Mexican-origin and African American low-income pregnant women.
Preventable adverse birth outcomes associated with maternal substance use include premature delivery, retarded fetal growth, respiratory distress, inadequate maternal-infant bonding, and potential long-term effects on the social and developmental abilities of the child (Curry & Duby, 1994; Dattel, 1990; National Commission to Prevent Infant Mortality, 1992). A central risk marker for the association between substance use and adverse birth outcomes is poverty or low socioeconomic status. Yet, empirical work has used biologic and clinical markers to measure the effects of drug use on women and children, with limited attention to maternal prenatal, psychosocial, and environmental risk markers that may be linked to patterns of substance use among low-income pregnant racial/ethnic women (Robins, Mills, Krulewitch, & Herman, 1993).
Several studies suggest multiple factors in the environment of women that are associated with substance use. Maternal sociodemographic characteristics include being unmarried, unemployed, having less than 12 years of education, and low socioeconomic status (National Institute on Drug Abuse, 1994). The maternal prenatal risk factors include poor nutrition and low weight gain, lack of prenatal care, and absence of baby's father or partner in the home. Maternal psychosocial risk factors include history of depression, reporting less happiness about being pregnant, receiving less emotional support from others for the current pregnancy, and having partners who use drugs (Amaro, Fried, Cabral, & Zuckerman, 1990; Zuckerman, Amaro, Bauchner, & Cabral, 1989a; Center for Substance Use Prevention, 1993). Women report that the use of tobacco and psychotherapeutic drugs serve as a means to cope with stress and negative emotions (Biener, 1987). The evidence suggests that few sources of social support, coupled with multiple stressful life events, increase the risk among pregnant women of using substances and also increase their vulnerability of being a victim of violence. Although these factors disproportionately burden low-income women, limited systematic inquiry has been directed at examining patterns of prenatal substance use in pregnant, racial/ethnic women.
Studies on ethnic differences in substance use show that non-Hispanic white women are more likely than African American or Hispanic women to use cigarettes, and slightly more likely to use alcohol or marijuana during pregnancy (National Center for Health Statistics, 1996; Abma & Mott, 1991). Mexican immigrant women are least likely to use any substance during pregnancy compared to non-Hispanic women, but Mexican American women are more likely than Mexican immigrants to use substances during pregnancy. In fact, Mexican American women are at a 60% higher risk of delivering a low birth weight infant than Mexico-born women, suggesting an association between their higher rates of smoking and drinking, and adverse infant outcome (Guendelman & Abrams, 1994; Zambrana, Scrimshaw, Collins, & Dunkel-Schetter, in press). Preventive strategies to decrease substance use during pregnancy can be developed with additional knowledge of factors that are associated with substance use in at risk populations.
A study was undertaken to (a) describe ethnic-specific substance use before and during pregnancy in low-income pregnant women, (b) examine the associations between prenatal psychosocial factors (anxiety and mean life events) and patterns of substance use within ethnic groups, and (c) assess maternal sociodemographic, prenatal, and psychosocial factors of women who continue to use substances during pregnancy and those who do not.
Sampling and procedures. All respondents were primiparous (no prior pregnancies beyond 16 weeks gestation) and 17-35 years of age. These criteria for both parity and age permitted us to obtain a relatively homogenous sample to reduce variation in medical risk related to age or prior pregnancies. All respondents were at least 20 weeks gestation at time of interview (M = 30 weeks). This criterion was used to decrease experimental loss due to miscarriage or decision by women not to carry the fetus to term. In addition, only respondents who had completed 12 years of education or less, and were self-pay or had public health insurance were included in this study. Face-to-face interviews were conducted with African American (n=255) and Mexican-origin women in 22 community-based prenatal care clinics in Los Angeles county during the years 1987-1990.
To assess differences by place of birth, two distinct groups of Mexican-origin respondents were recruited for this study: Mexican-Americans (n=525) and recent Mexican immigrants (n=764), defined as born in Mexico and living in the United States for seven years or less. Ethnic descriptors were based on self-identification. A two-page screening form was used to identify eligible primiparous women from prenatal charts. Respondents, awaiting prenatal care appointments, were sequentially approached by a trained female interviewer of similar ethnic background, and asked questions to ascertain level of education and ethnic background. For eligible women who agreed to participate, the interviewer completed informed consent procedures, and provided the respondent with a copy of the consent form. Women were interviewed in English or Spanish. Slightly over one-third of the interviews were conducted in English (35%), and two-thirds (65%) were conducted in Spanish. The average interview lasted approximately 40 minutes. The study protocol yielded a high rate of cooperation from respondents with a refusal rate of 4.5%, with no significant ethnic group differences on rates of participation.
Instrument and study variables. The instruments selected had been administered previously to samples of low-income pregnant women. Most instruments had been translated into Spanish and validated in prior studies. Multiple-item interview assessments of stress and social support were adapted from an earlier pregnancy study focusing on these constructs (Lobel & Dunkel-Schetter, 1990; Collins, Dunkel-Schetter, Lobel, & Scrimshaw, 1993). For this study, all measures were pretested and piloted in both languages with a similar clinic-based sample. Confirmatory factor analytic techniques and standard assessments of reliability (Cronbach's alpha coefficients) were performed for all scales for each ethnic group and for the total sample. Analyses revealed high reliability coefficients and similar factor structures for scale measures in both English and Spanish (Zambrana, 1991).
A 76-item instrument was used to obtain data on maternal sociodemographic characteristics, prenatal and psychosocial factors, and substance use behaviors three months before and during pregnancy. Maternal data included age, type of health insurance coverage, work status, and living arrangements with the baby's father. Maternal prenatal factors included items on whether or not the pregnancy was planned, the week prenatal care was initiated (obtained from the prenatal care chart), whether respondents were able to initiate prenatal care as soon as they wanted, and medical risk indicators. Prenatal medical risk was measured by presence of pre-existing chronic conditions and pregnancy-induced problems using standard clinical definitions. Excluded from medical risk were use of alcohol, cigarettes, and drugs because these items were study variables. Data were abstracted from the prenatal medical chart, using a standardized codebook at interview site by trained interviewers. A respondent was defined as at medical risk if at least one risk condition was indicated on her prenatal care chart. Each woman was assigned a medical risk score that was the sum of all her medical risk conditions, using criteria from the Problem-Oriented Prenatal Risk Assessment System (POPRAS) (Hobel, Youkeles, & Forsythe, 1979).
Maternal psychosocial factors included measures of prenatal life events, distress associated with life events, state anxiety, and measures of social support from family and friends. A 16-item stressful life events inventory was used to assess whether particular life events such as "a recent move, loss of home, problems at work, or unusual money worries" had occurred since the respondent became pregnant (Golding, 1985). For these analyses, respondents reported whether these events had occurred ("yes" or "no" response option). A sum of life events yielded a mean life events score by ethnicity for each of the analyses. in addition to indicating the occurrence of each event during pregnancy, respondents rated the extent to which the events were upsetting on a five-point scale (1 = not at all to 5 = extremely). Anxiety was measured with the Spielberger State Anxiety Inventory (Spielberger, 1983). This instrument contains 20 items rated on a 4-point scale (1 = "not at all" to 4 = "very much"). Cronbach alpha coefficient for this scale was .82 in English and Spanish. For this study, shortened versions of two social support scales were used to measure perceived social support from family and friends (Procidano & Heller, 1983). The scales had 10 and 13 items respectively, and were scored on a 3-point scale. Separate reliability analyses on these scales by ethnic group yielded a Cronbach alpha that ranged from .83 to .85 for the Family Support Scale and .90 to .93 for the Friend Support Scale.
Substance use behaviors were measured using a modified version of an instrument developed by the Human Population Laboratory (Belloc & Breslow, 1972). Respondents were asked about their use of alcohol, cigarettes, and illicit drugs (cocaine, PCP, marijuana, and heroin) three months before they became pregnant and during pregnancy. All items were rated on a 6-point scale (1 = never to 6 = daily intake). For most analyses, respondents were assigned to one of eight mutually exclusive groups by ethnicity. These groups were included within three general categories: (a) women who reported never using alcohol, cigarettes, or drugs during pregnancy; (b) single substance users, which included the three groupings "alcohol use only," "smoke cigarettes only," or "use drugs only"; and (c) multiple substance users, which included the four groupings "smoke cigarettes and use alcohol," "use drugs and alcohol," "use drugs and smoke cigarettes," and "use a combination of cigarettes, alcohol, and drugs."
The data limitations involve the validity of self-report measures of use of substances. Although our overall rates of self-report of substance use appear comparable to national rates, the most valid measurement of use of substances is self-report data combined with confirmatory laboratory urine assay test at multiple points during the pregnancy (Zuckerman, Amaro, & Cabral, 1989b). Further, small sample size for Mexican-origin women among users of multiple substances did not permit separate analyses for some of the groups. Cells with one respondent or none (n=8) are not reported.
Analyses. Univariate and bivariate analyses (chi-square tests and ANOVAS) were conducted to assess ethnic group differences in maternal sociodemographic, prenatal, and psychosocial factors, and substance use behaviors. Descriptive statistics were used to examine frequency distributions for each ethnic group for each of the following groups: (a) never used cigarettes, alcohol, or drugs, (b) current and former smokers of cigarettes, and (c) users of illicit drug(s). Users of alcohol were assigned to one of two groups: light to moderate = 1 (drink once a week or less and less than 2 drinks at a sitting) and heavy = 2 (drink several times a week to daily and having 3 or more drinks at one sitting). Changes in substance use behaviors before versus during pregnancy were tested using McNemar's repeated-measures chi square test for change (Tabachnick & Fidell, 1983). A second set of analyses were performed to examine ethnic group differences in single and multiple use of alcohol, drugs, and cigarettes and to assess the associations between substance use behaviors and psychosocial factors (mean number of life events and mean anxiety score) within ethnic groups. The last set of analyses tested differences between users and non-users of substances during pregnancy on selected maternal demographic, psychosocial, and prenatal factors. Two-tailed tests of significance at values of p [less than or equal to] .05 or less are reported in text as statistically significant differences between groups.
Description of sample. African American women reported higher completed years of schooling with a mean educational level of 11.52 (SD = .74) years compared to Mexican American (M = 10.46; SD = 1.87) and Mexican immigrant women (M = 8.18; SD = 2.74). However, African American women were the least likely to be employed fulltime and live with baby's father, and most likely to receive public health insurance. Data reported elsewhere indicate that African Americans (64.7%) and Mexican Americans (64.4%) were more likely to initiate prenatal care in the first trimester than Mexican-immigrants (54.7%) (Zambrana, Scrimshaw, & Dunkel-Schetter, 1996). Table 1 displays descriptive statistics on selected maternal prenatal factors, psychosocial factors, and substance use behaviors by ethnicity. Data on maternal prenatal factors reveal that African American women were less likely to report obtaining care as soon as they wanted, were less likely to have planned the pregnancy, and were more likely to be identified at medical risk compared to Mexican-origin respondents. As shown in the second panel of Table 1, African American women reported more life events, more distress from these events, and higher anxiety than Mexican-origin respondents. Most frequently reported stressful life events for the total sample included experiences such as the death or injury of someone close, problems with alcohol and drugs, problems at work, an arrest, and problems with government agencies. Mexican-origin respondents were more likely to report money worries, a change in residence, and robberies or burglaries than did African American women. African American and Mexican American women were more likely than Mexican immigrants to report support from the family.
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As shown in the lower panel of Table 1, African American respondents were more likely than Mexican-origin respondents to use each of the reported substances. African American women were more likely to be heavy users of alcohol (5.5% compared to 1.7% for Mexican American and .7% for Mexican immigrants). Use of drugs was higher among African Americans (23.2%) than among Mexican American (7.6%) and Mexican immigrant respondents (1.2%). Over one-third of the African American respondents reported smoking cigarettes (34.6%), while 27.8% of Mexican-American and 18.8% of Mexican immigrant respondents reported current or former use of cigarettes.
Changes in substance use behavior by single and multiple use. Table 2 displays the frequency distribution for use of single and multiple substances before and during pregnancy. Across all ethnic groups, data on substance use before pregnancy reveal that approximately 12% used alcohol only, about one-tenth reported smoking only, or smoking and alcohol use. Use of drugs in any combination with another substance was most likely to be reported by African American women. African American women (10.6%) were twice as likely as Mexican American women (5.0%) to report use of all three substances, while less than 1% of the Mexican immigrant respondents reported use of all three substances.
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We examined changes, using McNemar's chi-square test, in substance use behaviors before versus during pregnancy. There were significant decreases in reported substance use for all respondents. However, about 20% of African American women continued to use substances during pregnancy compared to 4.2% of Mexican American and 3.7% of Mexican immigrant women. Close to 10% of the African American women reported use of cigarettes during pregnancy compared to only about 1% of Mexican-origin women. Approximately 2% of all respondents continued to use alcohol. Continued drug use during pregnancy was higher among African American women (6%) compared to 1% of Mexican American women and .3% of Mexican immigrant women.
Prenatal psychosocial factors by single and multiple substance use. Table 3 shows mean number of prenatal life events and mean anxiety scores by pattern of substance use for each ethnic group. We examined and compared intra-ethnic group differences in mean life events, mean anxiety score, and family and friend support for each substance use pattern group. For African American respondents, significant differences were found on mean life events between women who did not report the use of drugs and those who reported any use of drugs (F[2541=2.91, df=7, p[is less than].01). Noteworthy, there were no within-group differences for African American women on anxiety and family or friend support. For the Mexican American group, women who smoked or used alcohol experienced significantly more life events and anxiety than Mexican American respondents who never used any substance. Mexican American women who reported use of drugs had strikingly more life events and anxiety compared to other Mexican American respondents. Mexican immigrant respondents who reported the use of alcohol and cigarettes also reported significantly more life events and anxiety that those who reported no use of substances. There were no significant differences on family or friend support for either group of Mexican-origin women.
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Two observations are noteworthy across ethnic groups: among never-users of any substance, African American women reported more prenatal life events and more anxiety than the other two groups, and Mexican-origin respondents who smoked cigarettes or used drugs reported more anxiety and prenatal life events than comparable African American respondents.
Respondent profile of never use and substance users. In the last set of analyses, we examined differences (using t-tests and chi-square tests) between women who reported never using any substance and those who continue to use substances during their pregnancy. Table 4 presents selected maternal sociodemographic, psychosocial, and prenatal factors between these groups. The data reveal that women who continued to use substances experienced twice as many life events, were less likely to be living with the baby's father, had higher education levels, and were less likely to have planned their pregnancy. Not surprisingly, users of substances were almost twice as likely to be identified at medical risk and less likely to report being able to go for care when they wanted.
The study explored the associations between maternal prenatal and psychosocial factors and substance use behaviors during pregnancy by ethnicity. Our data reveal that a small but significant number of pregnant women in community-based clinics continue to use alcohol, drugs, and cigarettes during pregnancy. In this study, about 7% of all respondents reported use of drugs, which is comparable to national estimates (5.5%-11%) of drug use among women (Chasnoff, 1988; National Institute on Drug Abuse, 1994). Consistent with other evidence, African American women are more likely than Mexican-origin women to use single and multiple substances during pregnancy and to report more stressful life events and anxiety that are perhaps associated with the environments in which they live, institutional forms of discrimination, and limited access to resources (Amaro et al., 1990; Lillie-Blanton, Martinez, Taylor, & Robinson, 1993; Williams & Collins, 1995; Center for Substance Abuse Prevention, 1993). African American women, as noted in many past studies, remain vulnerable to a set of environmental, institutional, and economic factors that are associated with psychosocial morbidity, such as anxiety and depression, and few sources of social support (Zuckerman et al., 1989a). The combined effect of these factors may place African American women at risk for substance use (Amba & Mott, 1991; Institute of Medicine, 1988; National Center for Health Statistics, 1996, National Commission to Prevent Infant Mortality, 1992; National Institute on Drug Abuse, 1994). For African American women, prenatal care can serve an important mechanism for detection of use of substances, and promote favorable health practices by outreach, community education, and linking African American women to other psychosocial and substance use counseling programs.
Also consistent with prior evidence is that Mexican American women are more likely to use substances than Mexican immigrant women (Guendelman & Abrams, 1994; Scribner, 1996). National data on substance use behaviors among Mexican American women have shown that about 5% of women report use of alcohol and 6% report use of drugs (Center for Substance Abuse Prevention, 1993). Observed differences show that changes in culturally protective behaviors may be decreasing in Mexican American women as they integrate into U.S. society and as they experience less supportive community norms and a decreased quality of life (Scribner, 1996; Zambrana et al., in press). Focused preventive services, including community education, outreach, and intensive psychosocial counseling for Mexican-origin pregnant women (who have traditionally had low rates of substance use) are necessary to strengthen ethnic-specific protective health practices (Scribner, 1996; Guendelman & Abrams, 1994).
Overall, these data show a trend toward an increase in the number of prenatal life events and associated anxiety for all women who continue to use substances, particularly drugs and/or drugs in combination with other substances. These associations between substance use behaviors and reported stressful prenatal life events are of interest because the stressors confronting low-income women involve serious, chronic, and environmentally-linked events such as "being mugged or attacked" (7%) or "someone close injured" (20%). Thus, these respondents may be at particular risk for violence and depression (Amaro et al., 1990; Zuckerman et al., 1989). Prior evidence suggests that stressful, chronic life problems can contribute to substance use (Biener, 1987; Lillie-Blanton, et al., 1993). Alternatively, it may be that respondents who use drugs are more vulnerable to experiencing stressful life events.
Not unexpectedly, the profile of women who continue to use substances during pregnancy did not differ significantly by ethnicity. Regardless of ethnicity, these respondents reported higher levels of anxiety and more prenatal stressful life events. They were more likely to be at medical risk, and were less likely to be living with the baby's father or to have planned the pregnancy. Although these results must be interpreted with caution, our data confirm the presence of multiple prenatal risk factors that have been linked, in prior studies, to women who use substances (Amaro et al., 1990; Zuckerman et al., 1989a; Center for Substance Abuse Prevention, 1993).
These descriptive data provide unique information on substance use behaviors among a low-income, community-based clinic sample as well as comparative inter-group and intra-group differences. We speculate that psychosocial stress may increase the risk of substance use for low-income racial and ethnic women who live in resource-poor environments. Further, our study provides some additional evidence to suggest that when socioeconomic factors are accounted for, differences by race and ethnicity may no longer be significant (Lillie-Blanton et al., 1993; Williams & Collins, 1995). Nonetheless, these data do not suggest a causal set of relationships, but rather a multiple set of determinants and consequences of substance use behaviors in low-income women who have limited access to good quality health care and psychosocial resources.
Two important areas of future research exploration emerged from this study. We need to focus inquiry on those institutional, community, and family-related intervening or mediating factors within ethnic groups that promote positive health behaviors and decrease risk for substance use. Secondly, there is a need to explore, among African American women, the nature of socio-environmental factors that are contributing to such high levels of psychosocial stress.
Implications for Health Care
Systematic prenatal care surveillance systems to detect substance use in low-income pregnant women must be instituted to prevent the potential detrimental effects of behavioral risk factors on maternal and child health. Health care providers, particularly nurses, must be informed and trained to assume a health education role to inform and advise substance users who are at risk of negative birth outcome.
Equally important, nurses can serve as case managers to refer substance users to social services for psychosocial counseling, drug programs, and parenting programs as supplementary services to prenatal care. Multiple studies have concluded that children raised by drug-abusing women experience environmental and psychosocial disadvantages. This often is due to the mothers' inability to cope with the special demands of a drug-exposed infant who is unusually irritable, easily overloaded, and unresponsive. These children generally fail to display interactive behaviors expected at this age, and show a high proportion of insecure attachments (Center for Substance Abuse Prevention, 1993; Curry & Duby, 1994; Institute of Medicine, 1988).
Further, national data show that although 78% of women cease the use of substances during pregnancy, a significant number resume these practices after pregnancy (National Center for Health Statistics, 1996). Thus, postpartum parenting programs and developmental surveillance are central to promoting maternal and child well-being to prevent potential longterm social and developmental consequences for children (Curry & Duby, 1994).
The central roles that nurses can assume in these prenatal care settings as advocates and gate-keepers likewise may represent ethical dilemmas. Current policy aims to legally punish the substance user rather than engage in preventive approaches (Chavkin, 1991). Thus, health providers must advocate nationally for legislation that protects and promotes the health and welfare of future generations of children.
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|Title Annotation:||Continuing Education Series - Promoting Children's Health in Immigrant Populations; includes Posttest|
|Author:||Zambrana, Ruth E.; Scrimshaw, Susan C.M.|
|Date:||May 1, 1997|
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