Pregnancy is a health condition that involves physical and psychosocial changes in a woman’s life. These changes are influenced by the family’s social and psychological conditions (Maldonado, 2017), among which alcohol and drug use is associated with high-risk pregnancies, which are more likely to present complications and atypical events (Ministry of Health, 2012a). Surveys on drug use indicate that it predominantly occurs during childbearing age, and women tend to use licit drugs (Bastos et al., 2017; United Nations Office on Drugs and Crime [UNODC], 2016; Romo-Aviles, 2018). Guimarães et al. (2018) corroborate these data, reporting that alcohol was the drug most frequently consumed by pregnant women; alcohol consumption presented a prevalence of 22.32%, followed by tobacco, with 4.22%, and 1.45% for illicit drugs.

Substance use ranges from recreational use to dependence, causing problems for the mother and fetus, including malformation, neurodevelopmental disorders, and malnutrition (Antunes et al., 2018; Ministério da Saúde, 2012a). Moreover, these problems are related and intensify in the presence of other risk factors such as poverty, lack of prenatal care, sexually transmitted infections, and violence, among others (Acosta et al., 2016; Silva et al., 2021; Tuchman, 2010) – suggesting that harm may sometimes result from the individuals’ lifestyle rather than the drug itself (Ministério da Saúde, 2012a).

In addition to biological issues, a pregnancy in such a context causes expectations and insecurity. Hence, this is an opportune time for professionals to encourage women to decrease the use or even abstain from drugs (Fonti et al., 2016; Hooks, 2015; Ministério da Saúde, 2012a; Tamashiro et al., 2020). The guidelines recommend equally screening all women using brief interventions. Early identification can decrease risks and should be attempted at the first prenatal care visit (Courchesne & Meyers, 2020). Thus, professionals must provide an environment where women feel comfortable. Pregnancy is a health condition that involves physical and psychosocial changes in a woman’s life. These changes are influenced by the family’s social and psychological conditions (Maldonado, 2017), among which alcohol and drug use is associated with high-risk pregnancies, which are more likely to present complications and atypical events (Ministério da Saúde, 2012a). Surveys on drug use indicate that it predominantly occurs during childbearing age, and women tend to use licit drugs (Bastos et al., 2017; United Nations Office on Drugs and Crime [UNODC], 2016; Romo-Aviles, 2018). Guimarães et al. (2018) corroborate these data, reporting that alcohol was the drug most frequently consumed by pregnant women; alcohol consumption presented a prevalence of 22.32%, followed by tobacco, with 4.22%, and 1.45% for illicit drugs.

Substance use ranges from recreational use to dependence, causing problems for the mother and fetus, including malformation, neurodevelopmental disorders, and malnutrition (Antunes et al., 2018; Ministério da Saúde, 2012a). Moreover, these problems are related and intensify in the presence of other risk factors such as poverty, lack of prenatal care, sexually transmitted infections, and violence, among others (Acosta et al., 2016; Silva et al., 2021; Tuchman, 2010) – suggesting that harm may sometimes result from the individuals’ lifestyle rather than the drug itself (Ministério da Saúde, 2012a).

In addition to biological issues, a pregnancy in such a context causes expectations and insecurity. Hence, this is an opportune time for professionals to encourage women to decrease the use or even abstain from drugs (Fonti et al., 2016; Hooks, 2015; Ministério da Saúde, 2012a; Tamashiro et al., 2020). The guidelines recommend equally screening all women using brief interventions. Early identification can decrease risks and should be attempted at the first prenatal care visit (Courchesne & Meyers, 2020). Thus, professionals must provide an environment where women feel comfortable discussing this matter. In this sense, an approach to encourage the disclosure of substance use during prenatal care includes asking open, non-judgmental questions during interviews (Courchesne & Meyers, 2020). According to Marcolino et al. (2018), it is crucial for pregnant women that healthcare professionals show an effort to understand their needs and be patient and kind.

Despite the potential of interventions, the literature reports that pregnant women either hide their consumption of alcohol and drugs or substance abuse from professionals or stop attending the services (Stone, 2015). In addition, these women tend to attend fewer prenatal consultations, less than three, while six or more consultations are recommended for low-risk pregnancies (Ministério da Saúde, 2012b; Motta & Linhares, 2016). The reasons for these women to withdraw from prenatal care include moralizing and discriminatory practices based on standardized behaviors, focused on total abstinence, disregarding these individuals’ needs, and the complexity surrounding this matter (Malvezzi & Nascimento, 2018).

In the study conducted by Marcolino et al. (2018), pregnant drug users revealed that there was no direct communication from healthcare professionals about the effects of substances on a baby’s health, which prevented them from obtaining knowledge, considering that the focus was on assessing the pregnancies’ development. The authors also note that the women felt judged and mocked rather than supported, suggesting the workers were indifferent, which favored tension and psychological discomfort. Additionally, these women fear being punished when disclosing drug use, such as having their children taken for adoption (Stone, 2015).

Therefore, among the factors promoting or hindering care delivery are the healthcare workers’ attitudes. The workers’ attitudes concern an evaluative process of an object, in which they either manifest positive attitudes and approach the object with favorable responses or manifest negative attitudes; that is, unfavorable responses, in which unpleasant feelings are experienced, including withdrawal and rejection. Alternatively, they display ambivalent responses when there are inconsistencies in their’ attitude, combining pros and cons attitudes (Cavazza, 2008; Neiva & Mauro, 2011). These assessments are learned throughout an individual’s life but are subject to change and are constituted by three components: cognitive, in which beliefs are included, which are configured as the information we accept about an event; affective, in which physiological responses and feelings arise from the contact with a specific object and, finally, the behavioral component, which is configured as a set of actions directed to the object (Cavazza, 2008; Rodrigues et al., 2014). Hence, changes in one of these components can reshape attitudes.

Based on the previous discussion, a systematic review was conducted with the general objective of identifying the attitudes and beliefs of healthcare professionals toward the use of alcohol and other drugs and pregnant users. More specifically, we verified: a) whether there are positive attitudes toward the practice implemented with pregnant women consuming alcohol and drugs; b) whether there are negative attitudes towards the practice implemented with pregnant women consuming alcohol and drugs; c) whether workers find it challenging working with these women; and d) if there are failures in screening and implementing interventions addressing drug use among pregnant women.

Method

This systematic literature review complied with the PRISMA protocol – Preferred Report Items for Systematic Reviews and Meta-Analyses. The search was performed in February 2020 and updated in June 2022. Two researchers independently conducted all the steps, and a third researcher made the final decision in case of disagreements.

The bibliographic survey was conducted in five databases: Scielo, Lilacs, Medline/Pubmed, Scopus, and PsycINFO. The terms used were divided into three main elements: a) pregnancy (“Pregnant Women”; Pregnancy); b) substance use (“Substance Abuse”; “Substance-Related Disorders”; “Illicit drugs”); and c) the attitudes and beliefs of healthcare professionals (“Attitude of Health Personnel”; “Health Personnel”; “Social Stigma”; “Beliefs and Attitude of Health Personnel”; “Health Knowledge, Attitudes, Practice”; “Health Professionals” and “Health Care Workers”). All terms were selected from Health Science Descriptors (DeCS) and Medical Subject Headings (MeSH). The synonyms composing each element were combined using the Boolean operator OR, and the Boolean operator AND was used between the terms.

The search results were exported to the Endnote Web platform, where duplicate papers were cataloged and discarded. First, the papers’ titles and abstracts were read to identify whether they met the inclusion criteria described below. Next, the full texts of the remaining studies were read and resulted in observations that had not been previously identified. For instance, the samples and the studies’ foci were better understood, so other studies were excluded. Finally, only those studies that met all the inclusion criteria remained. The studies were described in terms of country of origin, year of publication, language, samples’ characteristics, type of substance addressed, and main results.

Inclusion criteria were: a) scientific papers written in Portuguese, English, or Spanish; b) published between 2000 and June 2022; c) free of charge; d) investigating attitudes/beliefs/practices of healthcare professionals toward drug use among pregnant women. The papers included samples composed of healthcare professionals with different backgrounds. No specific criterion was established for the studies’ design; different designs were included. Exclusion criteria were: a) papers, the full texts of which were not available free of charge; b) texts published in the form of books, book chapters, monographs, dissertations, or theses; c) non-empirical papers, such as literature reviews and theoretical treatises; d) papers addressing only students or pregnant women, or focusing only on the fetus, rather than on the professionals’ beliefs, attitudes, and practices. Figure 1 describes the exclusion process according to each criterion.

Results

A total of 707 papers were identified; 429 appeared more than once and were discarded. Next, the titles and abstracts of the 278 remaining papers were read, which resulted in the selection of the full texts of 37 papers. Ten of these papers were excluded; hence, 27 met the inclusion criteria and composed the final selection of papers analyzed in this review. Figure 1 describes the selection process.

All the papers are written in English, and their respective countries of origin are listed in Table 1. Most reports were conducted in the United States (55.5%), followed by Australia (14.8%) and England (7%). The remaining countries present only one publication each. Considering the year of publication, papers dating from 2002 to 2022 were found; 66.6% of the documents were published from 2011 onwards (Table 1).

Regarding the periodicals, 20 different journals were found, with 29.6% of the papers indexed in journals in the field of Gynecology and Obstetrics, followed by 26% in journals addressing Maternal-Fetal Health, 18.5% in journals whose theme is Alcohol and Drugs, 11.1% Collective Health, 7.4% Pediatrics, and the same percentage of papers in the Education and Health field. Furthermore, five journals presented more than one publication: Midwifery, with four publications; Patient Education and Counseling, Women and Birth, Maternal and Child Health; and Journal of Addiction Medicine, with two publications each. As for the methodological characteristics concerning data collection and analysis and the sample’s characteristics, only one of the papers was retrospective; the others adopted a cross-sectional design. Finally, most papers were quantitative (62.9%), whereas 29.6% presented a qualitative approach, and 7.4% collected and analyzed quantitative and qualitative data.

Regarding the samples, Table 1 shows that data were collected among professionals focused on maternal-fetal health (25.9%), including gynecologists, obstetricians, midwives, pediatricians, and neonatal nurses. Multidisciplinary teams were addressed by 29.7% of the studies. These samples included more than one profession, not necessarily restricted to the maternal and child health field, such as general practitioners, care coordinators, and mental health professionals. All the papers in this category addressed nurses and doctors from different specialties. However, only two studies included social workers. None of the studies specified the presence of psychologists. Two papers mentioned that ‘mental health professionals’ (Chisolm et al., 2010) and therapists (Benoit et al., 2014) composed their samples, though they did not specify their backgrounds. Finally, of the papers addressing only one profession, 22.2% addressed midwives, 11.1% obstetric gynecologists, and 11.1% addressed only doctors, not necessarily specialists in maternal-fetal health.

Even though the papers addressing only pregnant women were excluded, one study remained. It divided the sample between professionals and pregnant women and was categorized as “Multiprofessional” because it focuses on the professionals’ attitudes.

Regarding the substances the papers addressed, the highest percentage of papers considered substances a single category without specifying them individually (40.8%), followed by papers dealing with legal drugs; the same portion of papers focused on alcohol and tobacco (18.5%). Another 11.1% addressed only marijuana, and the same percentage of articles addressed “illicit drugs” without specifying the substances. Finally, only five papers (18.5%) addressed decreasing harm as a possibility of intervention or practice. The results concerning professional attitudes were conflicting. Both negative and moralizing attitudes and positive and ambivalent attitudes were found. Negative attitudes were identified by 33.3% of the papers. They were manifested as drug use being primarily a legal problem rather than a health problem (Holland et al., 2016a; 2016b) and professionals recommending legal measures (Abel & Kruger, 2002; Brown et al., 2012). The workers also believed that pregnant women could not provide maternal care (Benoit et al., 2014). They often underestimated their desires and accomplishments in changing habits, such as abstaining from tobacco (Chisolm et al., 2010). In addition to a lack of interventions to address the problem (Van der Wulp et al., 2013, Miller-Thomas et al., 2014), one of the papers reports that toxicological tests were discriminatorily implemented among pregnant women (Kerker et al., 2004).

Positive attitudes were identified by 44.5% of the papers. They included the workers seeing the problem as having a biopsychosocial origin (Geraghty et al., 2019); being more empathic (Miles et al., 2014, Petersen et al., 2015); and having the belief that intervening in the consumption of alcohol and other drugs is one of their professional responsibilities (Herzig et al., 2006; Ko et al., 2020; Röske et al., 2009), such as promoting interventions focused on the problem from a healthcare perspective (Mendez et al., 2003; Ordean et al., 2020). Positive attitudes also included being willing and trusting the results of interventions implemented among patients (Oser et al., 2011; Fonti et al., 2016, Wangberg, 2015) and supporting patients to cope with barriers preventing them from accessing healthcare, such as stigma (Louis et al., 2022).

Ambivalent attitudes (22.2%) included the workers recognizing their professional responsibility and seeing it as crucial to screen and guide pregnant women regarding substance use. However, when the workers were asked about their practice, inconsistencies were found between what they believed to be adequate and what they effectively did. As a result, fewer screenings, interventions, and referrals than ideal were implemented. Hence, beliefs and attitudes are sometimes favorable, though they are not always translated into actual practice (Condliffe, 2005; Gérardin et al., 2011; Göransson et al., 2004; Oni et al., 2020; Taylor et al., 2007).

Additionally, some studies addressing the professionals’ beliefs and attitudes towards interventions directed at pregnant women consuming alcohol and other drugs report some barriers preventing interventions. For example, Doi, Cheyne, and Jepson (2014) verified that even though the workers acknowledged the importance of screening and implementing brief interventions, most believed these actions have a low priority compared to other daily demands. Wangberg (2015), Geraghty et al. (2019), and Ordean et al. (2020) note obstacles such as limited time and a lack of organizational support.

Other obstacles include staff and organizational issues such as lack of employee interest, staff shortages, work overload, language barriers (Wangberg, 2015), and the potential judicialization of cases (Taylor et al., 2007). Van der Wulp et al. (2013) note that the most significant disadvantage of providing advice during prenatal care, from the midwives’ perspective, is that pregnant women who consume alcohol during pregnancy may experience guilt or anxiety. Petersen et al. (2015) note that the workers mentioned potential barriers preventing effective interventions, including poor personal communication, and reprimanding women for their behavior, even though the workers’ self-reports described the opposite of such behaviors.

Additionally, 30% of the papers showed that the workers were unprepared to provide care, had insufficient knowledge regarding alcohol consumption and drug use among pregnant women, or lacked referral information (Condliffe et al., 2005). The workers also reported that they lacked the tools or proper training to deal with the condition (Brown et al., 2012; Gérardin et al., 2011; Holland et al., 2016a; 2016b; Miller-Thomas et al., 2014; 2016a; 2016b; Oni et al., 2020; Van Der Wulp et al., 2013).

Some of the results concern comparisons between attitudes between professions and professional characteristics. Such comparisons were mainly found in studies addressing the professionals’ beliefs and attitudes toward smoking cessation (Miller-Thomas et al., 2014; Röske et al., 2009). Röske et al. (2009) report that midwives and obstetricians implemented more interventions and were more confident in interventions than pediatricians. Fonti et al. (2016) also compared professionals’ attitudes toward fetal and maternal care, though no significant differences were found. Brown et al. (2012) also performed comparisons and noted that pediatricians were more likely than obstetricians to resource to the legal system if a dependent pregnant woman refused treatment.

Discussion

This literature review shows the need for papers to address this topic in Brazil and Latin American countries. A theoretical gap is apparent because no articles discussing professional beliefs and attitudes toward the consumption of alcohol and drug use among pregnant women were found in these countries.

It is also noteworthy that, even though the studies addressed professionals from different backgrounds (e.g., care coordinators, social workers), some workers were less frequently investigated; that is, studies including workers with biomedical training (i.e., nurses and doctors) were more prevalent. The field of psychology, for instance, was not addressed in any of the papers. This finding shows a need for studies including workers from the psychology field, given their relevance to the team and the care provided to pregnant women.

The number of studies published increased from 2011 onwards. This increase may be related to an expansion in the use of alcohol and drugs by women in recent years (UNODC, 2016). Another potential reason is that there has been a more significant concern in recent years with this condition, which has been increasingly considered a health problem. Thus, rather than focusing only on women’s behavior, the professionals’ beliefs and attitudes are relevant aspects to be analyzed and developed.

The results are heterogeneous, which may be related to different factors, such as using different strategies to measure and analyze the constructs, sampling methods, and services addressed. For instance, some studies addressing drug users, in general, indicate that closer interactions between professionals and users can decrease negative beliefs (Ketteres et al., 2014). Petersen et al. (2015) and Miles et al. (2014) corroborate this information since the midwives reported that time of experience contributed as a modulator of more positive attitudes.

In this sense, positive attitudes towards pregnant women and interventions directed at them are essential in professional practice and maternal and fetal health. Women who establish a good relationship with healthcare professionals, feel supported by the team and receive nonjudgmental treatment tend to report substance use more spontaneously and achieve better pregnancy outcomes (Hooks, 2015). A brief, routine intervention transmitting harm reduction messages demands little time from workers. It can make a big difference for patients (Tamashiro et al., 2020) who can use the information to decrease substance use (Herzig et al., 2006). Therefore, some attitudes are essential, such as grounding the dialogue on genuine respect and trust (Miles et al., 2014), establishing specific ways to address the issue and how to ask questions to address substance use, asking about increased substance consumption, and attempting to ask questions in a less threatening manner, or even asking more general questions like “how is the pregnancy going?” (Herzig et al., 2006). These actions are essential for health care to be an opportunity to provide health education and implement preventive measures and interventions intended to promote more positive obstetric and pediatric outcomes (Miles et al., 2010).

As for interventions, some studies report that professionals believe that intervening in the use of alcohol and drugs is their professional responsibility (Condliffe et al., 2005; Taylor et al., 2007). On the other hand, some results indicate the presence of moralizing attitudes, a belief that workers cannot act, and a lack of knowledge and interventions. These findings suggest that workers are sometimes indifferent in their practice, so beliefs and attitudes do not always materialize into interventions. The reasons include a need for better professional training and continuing education for workers to adequately address the problem (Brown et al., 2012; Gérardin et al., 2011; Holland et al., 2016a; 2016b; Van Der Wulp et al., 2013; Miller-Thomas et al., 2014). Additionally, because attitudes are changeable and can be learned, the explanatory three-dimensional theoretical model indicates that a change in any of the components (e.g., acquiring new information or having a specific experience) may cause a change in attitudes (Cavazza, 2008; Rodrigues et al., 2014). A second reason would be that most studies adopt self-report instruments (e.g., questionnaires, interviews, focus groups), which may lead to biased results considering that such instruments may not reveal what happens in practice. Brown et al. (2012) and Van der Wulp et al. (2013) have already reported such limitations.

Another factor contributing to heterogeneous results is the state of legalization/criminalization of drugs in the study setting, considering that current legislation may interfere with the professionals’ attitudes (Holland et al., 2016a) and the focus given to the substance in question. Regarding this variable, note that all the papers that focused on marijuana reported a lack of knowledge and interventions based on general statements without providing specific information about the risks of pregnancy, i.e., mainly, the workers offered moral information (Gérardin et al., 2011; Holland et al., 2016a; 2016b).

Abel and Kruger (2002) report that moralizing attitudes denote an individualizing character; that is, the professionals consider they have a moral duty to ensure that these women’s babies are born healthy. Benoit et al. (2014) note that professionals even experienced difficulty separating personal beliefs from professional attitudes when facing such an issue. Hence, the professionals face a dilemma between the women’s bodily autonomy and fetal care, which is apparent in divergent attitudes between professionals with a maternal focus and those with a focus on the fetus, as Brown et al. (2012) noted. Thus, besides the already very complex phenomenon of drug use, new problems emerge when it comes to a pregnant woman because women’s bodies appear as a place where ideological wars are fought, resulting in competing rights claims (Wright and Walker, 2007).

According to Romo-Avilés (2018), when women use substances, they break with socially and culturally assigned roles, such as motherhood. For this reason, a social sanction is generated every time women use illegal drugs and break the restrictions imposed by patriarchy. As a result, these women are rejected for breaking with what was socially expected from them. Hence, women who abuse substances face the consequences because access to effective treatment that considers their specific needs and life circumstances is often restricted. Therefore, despite positive practices, especially screenings, and interventions, some authors note that adequate intervention models and procedures are rare, especially for women’s substance abuse (Courchesne & Meyers, 2020).

Final Considerations

This literature review provides an opportunity to organize knowledge regarding the attitudes of healthcare professionals toward pregnant women consuming alcohol and drugs. The results reinforce this topic’s complexity, eliciting different responses from professionals. Negative attitudes that are commonly directed toward users and widely discussed in the literature are also reported by studies presented here. However, the relevance of positive attitudes is highlighted because they can boost the integral and humanized care provided to these women.

Different professionals, such as nurses, midwives, obstetricians, and pediatricians, are involved in the care provided to pregnant women, who may present different attitudes. In this sense, studies addressing workers with a psychosocial focus are relevant because they are represented in a small portion of the studies analyzed in this review.

The studies also report the need and potential for training professionals. For example, acquiring more excellent knowledge and familiarity with the topic, receiving guidance on screening patients, and improving communication skills can promote a change of beliefs. Additionally, overcoming organizational barriers, such as alleviating these professionals’ work overload, is a practical advancement that can manifest more favorable attitudes.

Finally, studies indicate a need for larger-scale studies with more precise measures. This study’s limitations include the fact that only papers available free of charge and published in a specific timeframe were included. For this reason, the findings do not exhaust the topic as reported in the literature. Changing the descriptors may also allow access to different attitudes and beliefs directed at these women.

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Author notes

Correspondence concerning this article should be addressed to Júlia Magna da Silva Teixeira, Rua Padre Café, 631, apto 103, Juiz de Fota, MG, Brazil, CEP: 36016450. Email: julia.magnas@gmail.com