|Year : 2018 | Volume
| Issue : 1 | Page : 8-12
Psychoactive substance use and psychiatric morbidity among pregnant women attending an ante-natal clinic in Benin City, Nigeria
Oluyemisi O Adebowale, Bawo O James
Department of Clinical Services, Federal Neuro-Psychiatric Hospital, Benin-City, Edo State, Nigeria
|Date of Web Publication||17-Apr-2018|
Dr. Oluyemisi O Adebowale
Department of Clinical Services, Federal Neuro-Psychiatric Hospital, Benin-City, Edo State
Source of Support: None, Conflict of Interest: None
Objective: This study sought to determine the prevalence, patterns and feasibility of screening for psychoactive substance use among pregnant women in an antenatal clinic in Nigeria. It also aimed to determine the relationship between psychoactive substance use risk severity and psychiatric morbidity. Methods: A cross-sectional study was undertaken among 395 pregnant women previously booked for ante-natal care. A sociodemographic questionnaire, the Alcohol Smoking and Substance Involvement Test (ASSIST) and the 20-item self-reporting questionnaire-20 were interviewer administered. The t-test and ANOVA were used to analyse the relationship between substance use risk severity of probable psychiatric symptoms and lifetime use of psychoactive substance/risk severity, respectively. Results: Participants reported lifetime (50.4%) and preceding 3 months (17%) use of alcohol. Nicotine and sedatives use was rare (n = 2; 0.5%). About a tenth (11.6%) screened positive for psychiatric morbidity. Those reporting alcohol use were significantly more likely to report a greater severity of probable psychiatric symptoms (1.79 vs. 0.92; t = 3.43, P < 0.002). Significant differences were observed according to severity of risk (moderate risk [2.08] vs. low risk [1.72] vs. never used [0.92], F = 6.043, P = 0.03). Conclusion: ASSIST is feasible screening tool among pregnant women. At least, half of the participants report alcohol use in pregnancy and use was significantly associated with psychiatric morbidity.
Keywords: Alcohol smoking and substance involvement test, alcohol use, ante-natal clinic, Nigeria, pregnant women, psychiatric morbidity, psychoactive substance use
|How to cite this article:|
Adebowale OO, James BO. Psychoactive substance use and psychiatric morbidity among pregnant women attending an ante-natal clinic in Benin City, Nigeria. Niger Postgrad Med J 2018;25:8-12
|How to cite this URL:|
Adebowale OO, James BO. Psychoactive substance use and psychiatric morbidity among pregnant women attending an ante-natal clinic in Benin City, Nigeria. Niger Postgrad Med J [serial online] 2018 [cited 2018 May 27];25:8-12. Available from: http://www.npmj.org/text.asp?2018/25/1/8/230194
| Introduction|| |
According to the 2009 Global Health Risks report, psychoactive substance use is among the top 20 risk factors for death and disability worldwide. Globally, there is an increasing trend for people to use multiple substances, either together or at different times, further increasing risk. Psychoactive substance use is now common among Nigerian women, not excluding those pregnant, and its use during pregnancy has been a major public health issue. Despite this alarming fact, it has been reported that health-care providers do not routinely screen for psychoactive substance use among pregnant women. While routine checks are available for some medical conditions (for instance, diabetes and anaemia) at the ante-natal clinic, health-care providers are reluctant to screen for psychoactive active substances citing lack of effective screening tools and knowledge deficits. This inaction has persisted despite evidence specific to alcohol use that shows that pregnant women will at least reduce use if a brief intervention is offered.
Screening for psychoactive substance cannot be over-emphasised given its harmful effects to maternal and foetal physical and mental health. Hazardous and harmful substance use are risk factors for a wide variety of social, financial, legal and relationship problems for individuals and their families. These women are more at risk for complications; ectopic pregnancy, premature rupture of membranes, placenta complications and spontaneous abortions., Foetuses are at risk of interuterine growth restriction, prematurity, foetal alcohol syndrome and mental retardation., Psychiatric co-morbidities are associated with psychoactive substance use. A large percentage may have a co-morbid depressive illness or anxiety disorder. The impaired judgement resulting from a psychiatric morbidity may result in inconsistent ante-natal clinic attendance further worsening maternal and foetal prognosis.
This study aimed to add to sparse data on psychoactive substance use and its association with psychiatric morbidity among pregnant women in Nigeria. This knowledge may, in turn, sensitise awareness of the concept of screening with the Alcohol Smoking and Substance Involvement Test (ASSIST) and provide evidence on the utility of brief interventions in ante-natal care settings. Timely identification and management of psychiatric morbidity will reduce negative health outcomes.
| Subjects and Methods|| |
This cross-sectional descriptive study was conducted between August 2015 and February 2016 at the Ante-Natal Clinic of the Central Hospital, Benin-City which is the largest secondary health-care facility in the city. It provides services to the primary catchment areas with an approximate population of 1 million persons.
Study sample and procedure
The sample size was calculated using the formula for proportions  with a 95% confidence interval and an error margin of 0.05. Three hundred and ninety-five pregnant women aged between 16 and 49 years attending the follow-up clinic were recruited after they gave written informed consent. Those who declined participation or could not communicate in the English language were excluded. A systematic random sampling technique was employed in the selection of study participants. Interviews were conducted in a private consultation room with questionnaires administered in face-to-face interviews.
A semi-structured sociodemographic questionnaire was designed to elicit information on the following variables: age, marital status, educational level, parity and employment status.
Alcohol, smoking and substance involvement test
The ASSIST was developed under the auspices of the World Health Organization (WHO) by an international group of addiction researchers and clinicians in response to the overwhelming public health burden associated with psychoactive substance use worldwide., It is an 8-item questionnaire designed to be administered by a health worker to a client. It is culturally neutral and usable across a variety of cultures to screen for the use of the following substances: tobacco products, alcohol, cannabis, cocaine, amphetamine-type stimulants, sedatives and sleeping pills (benzodiazepines), hallucinogens, inhalants, opioids and 'other drugs'. The ASSIST obtains information from clients about lifetime use of substances and use of substances over the past 3 months. It determines a risk score for each substance which is used to start a discussion (brief intervention) with clients about their substance use. The score obtained for each substance falls into a 'low', 'moderate' or 'high' risk category which determines the most appropriate intervention for that level of use ('no treatment', 'brief intervention' or 'referral to specialist assessment and treatment').
Internal consistency was over 0.80 for the majority of domains. It has also been validated for use in Nigeria, and its diagnostic accuracy was >95%. Eleven domains of the ASSIST had internal correlation coefficients of >0.7. It has been used severally in studying associations between mental illness and substance use.
The self-reporting questionnaire-20 (SRQ-20) was developed as part of a collaborative study coordinated by the WHO  on strategies for extending mental health care. It consists of twenty yes/no questions with a reference period to the previous 30 days. It has acceptable levels of reliability and validity in many settings and is recommended by the WHO as a screening tool for psychiatric morbidity. It has previously been used to screen for maternal illness in the developing countries (including Ethiopia) of similar sociocultural setting, and a cut-off score of 7/8 was used to separate probable non-cases from cases of common mental disorders.
The scale consists of twenty dichotomous items covering depression, anxiety and somatisation symptoms. Scores range from 0 to 20 and implicitly increase with the degree of psychological distress. The SRQ was validated in a primary care setting in rural south-western Nigeria  and found to effectively discriminate between patients with and without psychiatric morbidity. This was best done at a cut-off point of 5, which has the optimal sensitivity of 98.8% and specificity of 90.9%. A cut-off point of 5 was therefore used for this study.
Ethical clearance was obtained from the Ethics Committee of the Edo State Ministry of Health before commencement of the study. Approval was gotten from the Chief Executive of the Hospital Management Board of Edo State, Nigeria with Ref No: AT/A.740/6 on the 30 January, 2015. Individuals at 'moderate risk' on the ASSIST for a psychoactive substance use received a brief intervention, while those at 'high risk' were referred to the Drug Treatment Unit of the nearby Federal NeuroPsychiatric Hospital, Benin-City. Those with SRQ-20 scores indicative of mental ill health received counselling and a referral to a mental health practitioner as appropriate.
The data collected were analysed using the Statistical Package for the Social Sciences version 20. The t-test was used to analyse the relationship between severity of probable psychiatric symptoms and psychoactive substance use while the ANOVA explored that between severity of probable psychiatric symptoms and risk severity. For all analysis, level of statistical significance was set at P ≤ 0.05 a priori.
| Results|| |
A total of 412 pregnant women attending the Ante-Natal Clinic were approached for consent to participate in this study. Twelve women declined due to non-interest. Four women gave consent but stopped during the interview because they had urgent matters to attend to. One was not recruited as she could not communicate in the English language. There was no significant difference between responders and non-responders as regards sociodemographic characteristics. In total, 395 pregnant women who gave consent were recruited into the study with a response rate of 95.87%. Questionnaire administration took about 15–20 min for each participant.
Participants were aged between 16 and 44 years with a mean age (standard deviation [SD]) of 30.05 (5.3) years. About a quarter (n = 84; 21.3%) were unemployed, and among those employed, a majority were service and sales workers (178/311; 57.2%). Two hundred and seventy-two (68.8%) participants were married while 115 (29.1%), (n = 142; 36%) were nulliparous [Table 1].
Prevalence of psychoactive substance use among participants
Alcohol was the most commonly used psychoactive substance with a lifetime prevalence of 50.4%. Among participants with a lifetime history of use, 67 (17%), had used alcohol in the preceding 3 months. Two participants (0.5%) reported a lifetime history of tobacco and sedatives use, respectively. None of the participants reported either a lifetime or 3 months history of cannabis, cocaine, amphetamine-type stimulants, inhalants, hallucinogens, opioids or any other psychoactive substance use [Table 2].
Level of risk among participants using psychoactive substances
One hundred and eighty-six (93.5%) of those who reported using alcohol were classified as low risk on the ASSIST. Twelve (6.03%) were at moderate risk requiring a brief intervention while one (0.47%) participant was at high risk and needed further assessment and treatment. Participants who reported a history of tobacco and sedatives use were both at low risk [Table 3].
|Table 3: Level of risk among participants using psychoactive substances (Alcohol Smoking and Substance Involvement Screening Test)|
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Relationship between alcohol use and severity of psychiatric symptoms
Participants who reported lifetime use of alcohol had significantly higher mean (SD) scores; 3.03 (0.22) on the SRQ-20 compared to those who had never used alcohol in their lifetime; 1.83 (1.83); t = 3.43, P < 0.002. Furthermore, participants with moderate risk of health problems due to alcohol use on the ASSIST had significantly higher mean scores on the SRQ-20 as compared to those who were 'low risk' or had never used alcohol (P < 0.003) [Table 4].
|Table 4: Comparison of levels of risk (alcohol) with severity of probable psychiatric symptoms|
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| Discussion|| |
Prevalence and pattern of psychoactive substance use among participants
Over half (50.4%) of the participants reported the use of alcohol in their lifetime. The use of alcohol by women is accepted in some Nigerian cultures. With the continued westernisation of the African woman, women are more liberal and consume alcohol in social settings. Over 90% of those who had ever used alcohol in this study were classified 'low risk' by the ASSIST. In this study, 17% of participants reported using alcohol in the preceding 3 months. This coincides with their current pregnant state as the average booking gestational age in the Central Hospital, Benin, was 24 weeks. Lower prevalence rates of alcohol use; 3.5% and 8.6% have been reported in Nigeria. This may be due to the separation of the prevalence of alcohol in traditional herbs and other alcoholic drinks. Higher prevalence (43.7%) of alcohol use among antenatal patients in South-east Nigeria have also been reported. Methodological differences may account for this.
Pregnant women in our environment often use alcohol-based herbal mixtures due to the myth that it prevents abortions and premature labour, improves sleep and enable them have a strong and healthy baby. This study provides evidence on the use of alcohol in pregnant women in Benin-city, Nigeria and the need for the incorporation of health talks on its harmful effect to the woman and the unborn child. It also establishes the need for routine screening and provision of brief interventions in ante-natal care settings. Findings of minimal reported use of other psychoactive substance (apart from alcohol) in this study is a positive behaviour which should be encouraged. This should be reinforced by health talks emphasising physical and mental health benefits to the mother and child of abstaining from all psychoactive substance.
Alcohol use and psychiatric morbidity
This study adds to the sparse evidence available for low- and middle-income countries that alcohol is implicated with psychiatric morbidity even among pregnant women. Participants who reported a lifetime use of alcohol had higher mean SRQ-20 scores compared to those who had never used alcohol in their lifetime. Those with a moderate risk of health problems due to alcohol use on the ASSIST also had significantly higher mean scores on the SRQ-20 as compared to those who were 'low risk' or had never used alcohol. Burn et al. in Australia had reported that respondents with an alcohol use disorder were 10 times more likely to have a drug use disorder, four times more likely to have an affective disorder and three times more likely to have an anxiety disorder. Another study reported that the magnitude of psychiatric morbidity is related to the severity of substance use. Pregnant women with depression have been shown to be more at risk to have small for gestational age infant, deliver a low birth weight infant or have a preterm delivery. Similar outcomes are associated with psychoactive substance use in pregnancy., Pregnancy outcomes are hence worsened for women who abuse psychoactive substances and have co-existing psychiatric morbidity.
With the potential impact of mental disturbances on maternal and infant outcomes, further investigations into the psychiatric evaluation and treatment of pregnant women in the obstetric sector are required in Nigeria. There is a need to expand the evidence base on co-morbidity between psychoactive substance use and psychiatric morbidity among pregnant women, particularly in low- and middle-income countries. Future research should address the physiological and social mechanisms associated with mental ill-health that might contribute to an increased risk of poor outcomes. Policies for screening for psychoactive substance in the antenatal clinic should be implemented as this will likely improve maternal and foetal well-being.
This study had the following strengths; the use of the ASSIST which is fast to administer and cross-culturally validated for screening multiple psychoactive substances, and a large sample size which ensured adequate study power. The results should be interpreted with the following limitations; the use of a secondary health-care facility and the urban-based nature of the study may restrict the generalisation of our findings to the wider community especially rural areas, where the level of health care and socioeconomic status are likely to be different. Second, this study did not find the prevalence of current use of psychoactive substances in pregnancy and gestational age of pregnancy as this will be more appropriate to categorically state use in pregnancy.
| Conclusion|| |
Psychoactive substance use screening is feasible in ante-natal clinics in Nigeria. The ASSIST is an applicable screening tool among pregnant women. At least, half of the participants reported alcohol use in pregnancy and use was significantly associated with psychiatric morbidity. Further research is recommended to ascertain the impact of ASSIST linked brief interventions of feto-maternal health in Nigeria.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
World Health Organization. Global Health Risks. WHO Press, Geneva Switzerland: World Health Organization; 2009.
Mutihir J, Musa J, Daru P, Nyango D, Audu M. Substance abuse among antenatal patients at Jos University Teaching Hospital, North central Nigeria. J West Afr Coll Surg 2012;2:50-62.
Hotham E. Investigation of the Alcohol, Smoking and Substance Involvement Screening Test (the ASSIST) in Pregnancy (Doctoral dissertation); 2010.
Kelly R, Zatzick D, Anders T. The detection and treatment of psychiatric disorders and substance use among pregnant women cared for in obstetrics. Am J Psychiatry 2001;158:213-9.
Quinlivan JA, Evans SF. The impact of continuing illegal drug use on teenage pregnancy outcomes – A prospective cohort study. BJOG 2002;109:1148-53.
Fergusson DM, Horwood LJ, Northstone K, ALSPAC Study Team. Avon Longitudinal Study of Pregnancy and Childhood. Maternal use of cannabis and pregnancy outcome. BJOG 2002;109:21-7.
Ness RB, Grisso JA, Hirschinger N, Markovic N, Shaw LM, Day NL, et al.
Cocaine and tobacco use and the risk of spontaneous abortion. N Engl J Med 1999;340:333-9.
Goodwin RD, Keyes K, Simuro N. Mental disorders and nicotine dependence among pregnant women in the United States. Obstet Gynecol 2007;109:875-83.
Farrell M, Howes S, Bebbington P, Brugha T, Jenkins R, Lewis G, et al.
Nicotine, alcohol and drug dependence and psychiatric comorbidity. Results of a national household survey. Br J Psychiatry 2001;179:432-7.
Population of Edo State. National Population Commision of Nigeria. Available from: http://www.population.gov.ng
. [Last accessed on 2014 Jan 01].
Kish L. Survey Sampling. New York: John Wiley and Sons Incoporated; 1965.
Humeniuk R, Ali R. Validation of the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) and Pilot Brief Intervention: A Technical Report of Phase II Findings of the World Health Organization ASSIST Project; 2006. p. 1-125.
Onifade PO, Bello AO, Abiodun O, Sotunsa JO, Ladipo OA, Adesanya O. Psychometric Properties of Alcohol Smoking and Substance Involvement Screening Test (Assist V3.0) Among University Students. J Addict Behav Ther Rehabil 2014;3:3.
Beusenberg M, Orley J. A User's Guide to The Self Reporting Questionnaire (SRQ). Geneva: World Health Organization; 1994.
Abiodun OA. Sensitivity and validity of the self-reporting questionnaire (SRQ) in a primary health care centre in a rural community in Nigeria. Psychopathol Afr 1988;22:79-88.
Brisibe S, Ordinioha B, Dienye P. Sensitivity and validity of the self-reporting questionnaire (SRQ) in a primary health care centre in a rural community in Nigeria. J Interpers Violence 2012;27:513-22.
Abasiubong F, Bassey EA, Udobang JA, Akinbami OS, Udoh SB, Idung AU, et al.
Self-medication: Potential risks and hazards among pregnant women in Uyo, Nigeria. Pan Afr Med J 2012;13:15.
Okonkwo J, Uwakwe R. Use of substance and non-prescription drugs by pregnant Nigerian women. Int J Med Heal Dev 2003;8:23-6.
Burns L, Teesson M. Alcohol use disorders comorbid with anxiety, depression and drug use disorders. Findings from the Australian National Survey of Mental Health and Well Being. Drug Alcohol Depend 2002;68:299-307.
Steer RA, Scholl TO, Hediger ML, Fischer RL. Self-reported depression and negative pregnancy outcomes. J Clin Epidemiol 1992;45:1093-9.
[Table 1], [Table 2], [Table 3], [Table 4]