Between invisibility and stigma: consumption of psychoactive substances among pregnant and postpartum women at three Argentine general hospitals. Undergraduate degree in Psychology. Social worker, Hospital Dr. The problematic consumption of legal and illegal substances in pregnant and postpartum women is a growing socio-sanitary concern that has infrequently been studied from a gender perspective. This article presents the results of a multi-center, cross sectional study employing a mixed qualitative-quantitative approach that was conducted between May and June The aim of this research was to describe the patterns of psychoactive substance use as well as access to healthcare services among pregnant and postpartum women. Semi-structured interviews were conducted with a purposive sample of 62 women attending Bariloche, Concordia, and La Matanza General Hospitals. Results showed evidence of the taboo associated with psychoactive substance use among pregnant and postpartum women, the discrimination that these women experience in healthcare services, and their lack of material support, which makes it difficult for them to take care of themselves. Problematic substance consumption in pregnant and postpartum women is a growing socio-sanitary concern for a number of reasons, among them the increase in consumption in this population, the social stigma that falls upon drug-using mothers and the lack of orientation that health teams report regarding how to handle such situations. This phenomenon has installed itself as a problem around the world. Recent data from international organizations highlight that drug consumption patterns are changing: not only is the gender gap associated with drug use closing in many countries, but also drug consumption appears to be commencing at increasingly early ages. In Latin America this same tendency can be observed. Argentina and Uruguay present the highest level of cocaine consumption in the region 1. Additionally, the difference between women and men is notoriously less in Argentina and Uruguay, with three male consumers for every female consumer, as opposed to countries like Venezuela, where the ratio is eight males for every female, or Columbia and Peru, where it is six males for every female. Women also show a greater nonmedical use of psychopharmacological drugs - such as prescription-controlled sedatives and stimulants, synthetic drugs and opioids - than men. According to data from the latest national study on substance consumption in the general population, 3 for women between to the consumption of any illicit drug increased from 3. Nevertheless, information regarding drug use in pregnant and postpartum women is scarce and centers primarily on the consumption of legal substances, such as alcohol and tobacco, and not illegal substances. The omission of pregnant women in the construction of statistics and data is another important aspect of this problem. To this interaction between invisibility and vulnerability, the literature adds the issue of stigmatization, as drug use is one of the areas of social life most subject to prejudice. Faced with the fear of being judged, stigmatized and rejected, women hide their consumption and internalize the negative vision that society has of them, often showing low self-esteem. Socialized within a patriarchy, women who use substances diverge from the expectations surrounding their role as women, protective and submissive mothers who live for others. If women also use illegal drugs, the rejection is greater due to the illegality of the substances 16 and they become the object of moral and social penalization for their transgression. Another important aspect to highlight here is the problematic conceptualization of maternity as a natural, instinctive and generalizable experience, as this is not biological fact but rather a social construction. Omitting a gender perspective additionally implies that the patterns of drug use are explained from an andocentric perspective. These practices include the range of representations and actions that a population uses autonomously to diagnose, explain and attend to processes that affect health without the direct and intentional intervention of professional healers. Therefore, when the material possibility of women to access and sustain treatment is analyzed, various dimensions must be considered. Traditionally, women have been assigned responsibility for domestic tasks and care of dependent others and at the same time have less social support. This makes starting and continuing treatment difficult, given that doing so means delaying responsibilities assigned to their gender role. In using the aforementioned dimensions to examine the issue, two extremes become apparent, that seem opposed but the results of which are the same for the population under study. From this perspective, the general aim of the study upon which this article is based was to describe the patterns of consumption of pyschoactive substances, the access to care, and the social determinants of health in pregnant and postpartum women. The work of this article is structured around the following questions: What particularities are there in the use of alcohol, tobacco, cannabis and cocaine among pregnant and postpartum women? What are the social representations regarding substance use and the care strategies of women who consume psychoactive substances during pregnancy, childbirth and postpartum? This study is exploratory-descriptive, multi-center, qualitative-quantitative and cross-sectional. The hospitals included in the study were Hospital Zonal Dr. The choice of institutions was subject to criteria of accessibility and feasibility. However, to ensure a richer set of data, the sample was homogenous in terms of the type of health care provider general provincial hospitals and yet heterogeneous in including different regions of the country. The research team was made up of the study coordinator and seven psychology and social work professionals with experience in the subject at a clinical and research level. The fieldwork took place between July and January , as established by the timetable approved by the funder. Semi-structured interviews were carried out, during which the same instrument was applied in all three institutions. The instrument contained both open- and closed-ended questions taken from modules of previously validated instruments. Although consolidating modules from a number of other instruments resulted in a rather lengthy instrument for our study, using tools validated by international organizations such as the Pan American Health Organization PAHO or by national government agencies offered the advantage of providing us with interpretational parameters based on studies showing the distribution of these same indicators at different scales. Current and prior pregnancies: questions regarding the planned or unplanned nature of the pregnancy, the existence of obstetric check-ups, and the establishments where care for the pregnancy was received. Postpartum and infant feeding: questions regarding infant feeding practices, including both exclusive breastfeeding and mixed feeding, as well as other food sources. Both this category and the prior one used as reference the questions from the national Perinatal Information System. Gender violence: the questions were based in the National Study on Violence Against Women of the National Ministry of Justice and Human Rights, 35 which looks into gender violence experienced throughout the lifespan and in the last year, as well as the perpetrator of the violence. Social support : questions regarding the number of close friends or other people with whom the interviewee is able to talk about her problems, using an adapted version of the questionnaire from the Medical Outcomes Study Social Support Survey MOS-SSS. Representations regarding substance use : a series of statements created by the research team reflecting beliefs regarding the dangerousness of different drugs and their possible health consequences, to which interviewees expressed their degree of agreement. Accessibility : a list of possible barriers and difficulties in accessing health services was created, with fixed ordinal responses defined based on the results of a study regarding accessibility of public health services for drug users in Buenos Aires and Rosario. Employment situation : the questions of this section were based on the third National Survey on Risk Factors for Non-Communicable Diseases. The main variables were selected based on a process of operationalization of the study dimensions and a critical analysis of the advantages and disadvantages of using certain empirical definitions, stemming from a review of the indicators utilized in validated instruments for which there was also epidemiological data for Argentina available for comparison. The criteria used in choosing these questions were their relevance for the stated research aims, the recommendations offered by the five intervening ethics committees and the overall duration of the interview. The way in which the semi-structured interviews were carried out showed particularities in each location according to the form of access. In Bariloche, meetings in which the project was presented were carried out for different key actors who then provided contact with the women. In Concordia, given that the Hospital Dr. Felipe Heras did not have a maternity and obstetrics ward, women seen at the Hospital General de Agudos Masvernat were also included. The interviews were scheduled at days and times that generated a space of confidentiality. Notes were taken of everything the women expressed, although the only interviews recorded were those carried out in La Matanza, as per the decision of the interviewers and with the express oral and written consent of the women. The study was approved by the authorities of each hospital and the research project was evaluated and approved by all the hospital and provincial Ethics Committees. Data was triangulated with qualitative analysis, using the corpus of textual material that was segmented and coded in order to perform content analysis based on the recognition of regularities and identified patterns. The process then combined the criteria deriving in the central categories of the study, included in the specific aims, and the criteria for constructing emerging codes of meaning that unfolded from the qualitative empirical material. Sixty-two women from La Matanza, Concordia and Bariloche were interviewed, of which 24 were pregnant and 38 were postpartum, 48 were aged years and 14 aged years. In relation to educational level, 6 women had started or completed primary school, while 42 had started or completed secondary school and 4 had started or completed tertiary or university education Table 1. Source: Own elaboration. Regarding their living situation, 57 of the women interviewed lived with others family members or friends , of which 32 lived in nuclear families and 25 in extended or blended families. Only 3 lived alone and another 2 were homeless. Regarding their employment situation, 12 women were economically inactive they did not have nor were they seeking employment , 24 were unemployed they did not have formal nor informal work but were seeking employment , 24 had worked the week prior to the interview, and 2 women did not explain their employment situation Table 1. Of the 24 women who had worked the week prior to the interview, only 3 were formally employed, while the rest had informal jobs: 10 worked odd jobs primarily in jobs associated with care provision , 8 were self-employed in their own businesses without other employees and 3 were sex workers Table 1. Of the women interviewed, 33 were within the day period stipulated for legal maternity leave: 4 were in the last four weeks of pregnancy and 29 were in the postpartum period with children up to two months of age. However, of these 33 women, only 6 were actually able to access maternity leave: 3 legally as workers with formal employment and 3 others as part of an agreement in their informal employment. The networks of belonging and social support the women have could be a protection factor, understood as the set of contextual resources that favor well-being and protect people from the adversities of the environment. Nevertheless, the interviewees received less material support in activities that require active assistance: 12 women a little or none of the time had someone to help them with daily chores if they were sick and 10 did not have someone who could take them to the doctor if they needed it. Therefore, although there appears to be a high level of social support, when the support is disaggregated into particular dimensions imbalances can be seen, and the answers seem to highlight that support in domestic and care activities is less than emotional, affective or recreational support. With respect to the index of social support among the women interviewed, 43 had a high overall level of social support, 9 had a medium level of support and 10 had a low level. Own elaboration based on the validation of the MOS social support survey by Revilla et al. In the group of 24 pregnant women it can be seen that, throughout their lives, 22 had at one time consumed alcohol and 21 tobacco; additionally, 10 had used cannabis and 9 cocaine. In this same group, in the three months prior to the interview, 19 continued to smoke and 16 to drink alcohol. Regarding the use of illegal substances, 7 had used cannabis and 8 cocaine. Therefore, the primary substances consumed in this group were alcohol and tobacco. Among the 33 women breastfeeding postpartum, it was observed that all had had alcohol at least once in their lives and 30 had smoked tobacco; in addition, 24 had used cannabis and 16 cocaine. On the other hand, in the last three months, among these same women, 17 had consumed tobacco, another 17 alcohol, 7 cannabis and 6 cocaine. Among these same women, 31 had used a substance during pregnancy, 24 had smoked tobacco daily throughout the pregnancy, and 24 had consumed alcohol. Regarding the use of illegal substances, 15 had smoked marijuana and 11 had used cocaine Table 3. Lastly, among the 5 postpartum women who were not breastfeeding Table 3 , all reported having drunk alcohol at least once, while 3 had used cocaine and 2 cannabis. In the past three months all had consumed tobacco and 2 alcohol. All 5 had smoked tobacco during the pregnancy while 2 had drunk alcohol and 2 had taken cocaine. Based on this data, in the groups of pregnant and postpartum women both breastfeeding and not , for lifetime use as well as use in the last three months and during pregnancy, the largest consumption was of tobacco and alcohol, which coincides with the National Study on the Consumption of Psychoactive Substances. One known factor associated with consumption patterns is living on a day to day basis with other people who use drugs. Of the 44 women who provided information regarding the substance use of the other people with whom they lived, the substances were distributed in the following way categories are not mutually exclusive : 36 alcohol, 29 tobacco, 9 cannabis, 5 cocaine base paste and 4 cocaine. Additionally, of the 13 women who had a partner at the time of the interview but did not live with them, 8 reported that their partner was a substance user Table 4. With relation to the meanings that the women attribute to substance use - and in particular to their first experiences - the large majority of the women reported having used them in the company of friends, in recreational situations. Some of the contexts of initiation mentioned were nighttime outings, concerts and parties. Some women also reported that drugs helped them disconnect from problematic situations. Among the concerns the women experienced due to substance use during pregnancy, many mentioned the consequences their consumption could have on the physical health of their unborn children and, to a lesser degree, the fear that the consumption could cause their children to be born prematurely. It should be highlighted that the interviewees discussed the pleasure of consumption, mentioning the feeling of calm and relaxation the substances offered and the attention they receive from those around them when consuming. Only one of the interviewees reported that nothing about consumption provided them with pleasure. I like to smoke tobacco because it takes the stress away, marijuana relaxes me. Cigarettes calm me down. Alcohol makes things fun. The women interviewed mostly subscribed to representations that imply negative value judgments of women who, as mothers, use psychoactive substances. The fact that the interviewees subscribe to such representations results in a negative valuing of themselves expressed through guilt and self-reproach and in the fears of being reported to the authorities, of not receiving health care and of being discriminated against punishment. In relation to this last aspect, 32 interviewees reported having felt discriminated against at some point in their lives. The places most reported as sites of discrimination were: health establishments, in general society on the street, in their neighborhood or at hang out spots , educational institutions, at the workplace and within the family Table 5. In the places mentioned, the women indicated that they had been treated differently and negatively due to their personal characteristics. Because of my skin \\\\\[scabies infection\\\\\] Other characteristics for which the women mentioned having been discriminated against included age, features of their phenotype such as skin color, and immigration status. Gender discrimination was also highlighted by the women. This refers to all constructions that assign certain roles and sociocultural attributes based on biological sex and transform sexual difference into social inequality. They always treat me badly for being young and having a lot of kids. Because I take drugs, they called me a whore, a drug addict. Some women reported haven been victims of derogatory treatment on the part of health care staff for the double condition of being pregnant or postpartum and being a drug user. They treated me badly for taking drugs and being the mother of a premature baby. In this way, it can be inferred that often the situation of discrimination is obscured by the concealing of drug use. In relation to way the women were treated by the health agents upon receiving care for the pregnancy, birth and postpartum periods, some women reported haven been victims not only of discrimination but also of obstetric violence. Their accounts include a certain naturalization of the situation, especially lack of access to and comprehension of relevant information, insufficient accompaniment, little consideration of the unique life experience they were going through, and unnecessary prolongation of pain, among others. Other women spoke of a certain degree of insensitivity on the part of the health agents regarding their pain. They gave accounts of a variety of different situations of distress and disorientation in which they did not understand what was happening in procedures such as a miscarriage or stillbirth, or in situations in which they considered that they had been unable to make decisions about the type of birth, in violation of their rights. In accordance with this, when asking the women what they did to quit using whether or not the attempt was successful , accessing more professional resources from the formal health system was infrequent. Out of the 61 women, only 5 mentioned having started psychiatric or psychological treatment. Table 8 shows the other care strategies the pregnant and postpartum women mentioned, related mainly with self-care. I know that smoking during pregnancy is bad. The cigarette packs even say it. With this information it can be inferred that, sometimes the largest motivating factors for quitting are becoming responsible for the care of children or at the request of loved ones. In the study that informs this article, it was possible to see, in a small sample of 62 women from three cities, the transformation in the consumption patterns mentioned in the introduction. The data on substance use showed that in all use categories - at least once in their lifetime, in the last three months and during pregnancy - the most frequently consumed substances were tobacco and alcohol. It was also shown that quitting or cutting back on substance use during pregnancy is a way for women to care for their unborn children or family members, situating themselves more as caregivers than subjects with a right to care. Another notable aspect was the existence of a strong connection between the substance use of the women and that of those they lived with, showing that when these women had a sexual-affective relationship with a man, their use adjusted to that of their partners. This finding is similar to another study of cocaine users 41 which demonstrated how substance use becomes a form of communication or identification in the partner relationship. With respect to the level of social support, it was seen that some of the interviewees, despite reporting that they had support all or most of the time, did not go to those people to share their most private fears and problems, and the support diminished in relation to the distribution of household chores and care work. In accordance with the above, the low response regarding material support can be understood in light of the data from the third Survey of Risk Factors 43 on unpaid work and time use. The survey showed that certain conditions extended the amount of time that women dedicated to unpaid care work, including: being of productive age years , being spouses, having children under 6 years of age in the home and living in homes with a low income level, characteristics that abound among the women in our study. In parallel, performing unpaid work is possible for them only when they reduce the time spent on their own care, rest and enjoyment, which has a negative impact on their quality of life and constitutes another indicator of gender inequity. In relation to the representations that women attribute to their substance use, some women reported concern regarding the consequences of substance use during pregnancy, others signified substance use as a way to avoid their everyday problems, and a number of them mentioned fun and pleasure. The omission of the dimension of pleasure associated with drug use in both academic studies and the construction of statistics should be questioned. This could be interpreted as an operation of power, a disciplinary device to consolidate gender mandates that, at the same time, equate drugs with trouble. From this perspective discourses of guilt and fear are installed, associating the use of drugs only with dependency. Stigmatizing social representations are also reproduced regarding drug users, identified with social images connoting negative value judgments of women who, as mothers, use psychoactive substances and break with social mandates surrounding being a women and mother. Therefore, the women in our study state having been discriminated against in different types of places for different reasons, not just due to their socioeconomic situation, their age or their race, but also for specifically gender-related reasons - such as being pregnant or postpartum drug users - that have on occasion made them feel rejected and humiliated. On the other hand, discrimination in health services can stem from the symbolic position that health agents occupy in the microcosm of the medical field, 46 that is, the power asymmetries established within the health system between professionals and health system users. In particular, in this area, frequently invisibilized situations of obstetric violence were mentioned, that is, dehumanized treatment and abuse of medicalization exercised by health personnel upon the body and reproductive processes of the women. A gap in the literature regarding the overlap of these types of violence and drug use from a gender perspective can be seen. The difficulties these women had in accessing health services centered on the fact that they do not fit the androcentric model upon which the health system was designed. By not incorporating in the approach to the problem the specificities of this population, these women become dangerous and strange others and the subjective asymmetry in the professional-user relationship favors the reification and objectification of this population. The other side of this situation has to do with other health care strategies put into play by the women, often ignored in the literature on this subject, related to self-care, 47 through modifications in both individual and collective regulation of consumption practices. In some cases, as we have shown in other studies, 48 , 49 changes in the regulation of these practices are due to the emergence of certain life events. Different results converge in one shared experience: how the expectations related to gender roles in some way situate and structure the particularities of the diverse situations that the interviewed women face. In this way, the rejection towards women who take drugs during pregnancy, childbirth and postpartum can be considered an analyzer through which the idealization of and demands surrounding motherhood that fall upon women are expressed. The multiple types of violence - gender as well as racial and obstetric - that these women drug users are exposed to intersect with one another and multiply. As a result, the health inequities related to gender disproportionately affect poor, young women from ethnic minorities. In this sense, being a woman, mother and substance user implies multiple positions of social subordination based upon which cultural and symbolic barriers are exacerbated. In this way, the expectations associated with gender roles and the lack of treatments that take into account their social position conditions these women to hide their consumption and to enact strategies of self-care. At the same time, stigmatization could generate little recognition of a series of individual and collective consumption regulation strategies put in place and of the concealment of consumption that, in turn, makes it difficult to visibilize discrimination processes. With their practices, health care providers can deepen or revert the inequalities experienced by women when accessing care. In this regard, it is urgent for the programs dealing with problematic consumption to include the perspective of harm and risk reduction. It is necessary for health teams to recognize that there are numerous modes of consumption resulting from the situational interweaving of the subjects, contexts and substances at play. Finally, it should be highlighted that this study seeks to contribute to the production of evidence that permits health care providers to approach this issue from a complexity perspective, understanding that offering quality accompaniment for women-mothers-drug users requires understanding the specific problems they face. Only through this recognition will health teams be able to accompany women in the construction of alternatives that allow them to make decisions about their consumption without having to sacrifice their health or their children in the process. Our thanks to Gabriela Olivera for suggesting and offering materials related to the subject matter. Oficina de las Naciones Unidas contra la Droga y el Delito. Tabaquismo durante el embarazo en Argentina y Uruguay. El uso indebido de drogas y la consulta de emergencia, quinto estudio nacional: Informe final de resultados Argentina \\\\\[Internet\\\\\]. Anuario de Investigaciones. Rengel D. Allport G. The nature of prejudice. Massachusetts: Wesley Publishing; El estigma social: la diferencia que nos hace inferiores. Madrid: Pearson Prentice Hall; Parga J. El doble estigma de la mujer consumidora de drogas: estudio cualitativo sobre un grupo de autoapoyo de mujeres con problemas de abuso de sustancias. Alternativas: Cuadernos de Trabajo Social. Tortosa PI. Maffia D. El ocultamiento de las mujeres en el consumo de sustancias psicoactivas. En: Horizontes en intervenciones sociales \\\\\[Internet\\\\\]. Buenos Aires: Teseo; \\\\\[citado 10 mar \\\\\]. Chodorow N. El ejercicio de la maternidad. Barcelona: Gedisa; Castilla V, Lorenzo G. De sujetos saberes y estructuras. Buenos Aires: Lugar Editorial; Comes Y. Galicia: Xunta de Galicia; Lagarde M. Los cautiverios de las mujeres: madresposas, monjas, putas, presas y locas. Medical Care. Medicina de Familia And. Psicodebate, ; Buenos Aires: Ministerio de Salud; Buenos Aires: Intercambios AC; Nueva Sociedad. Mujer, pobreza y adicciones. Goltzman P. Las tareas y compromisos del investigador social. Buenos Aires: Eudeba; Ley \\\\\[Internet\\\\\]. Rossi D, Rangugni V. Cambios en el uso inyectable de drogas en Buenos Aires Received: August 30, ; corrected: July 25, ; Accepted: August 06, ; pub: September 21, Servicios Personalizados Revista. Citado por SciELO. Similares en SciELO. Articles Between invisibility and stigma: consumption of psychoactive substances among pregnant and postpartum women at three Argentine general hospitals. ABSTRACT The problematic consumption of legal and illegal substances in pregnant and postpartum women is a growing socio-sanitary concern that has infrequently been studied from a gender perspective. Processes of stigmatization, invisibility and vulnerability To this interaction between invisibility and vulnerability, the literature adds the issue of stigmatization, as drug use is one of the areas of social life most subject to prejudice. Characteristics of the sample: Who were the women interviewed? Casilla de correo No. Someone to turn to for suggestions about how to deal with a personal problem. It is often more looked down upon that a mother use drugs than that a father do so. Pregnant women often hide their substance use out of fear of being judged and discriminated against. Pregnant women often hide their substance use out of fear of being reported to the authorities. People often think that you are a bad mother if you use drugs when you are pregnant. Pregnant women often hide their substance use out of fear of losing their children. Pregnant women often hide their substance use due to feelings of shame and guilt. People often believe that pregnant women who consume base paste are harming their health more than those who consume cocaine. Pregnant women often hide their substance use out of fear of not receiving care in the health system. People often think that smoking tobacco during pregnancy is less harmful that smoking marijuana. 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