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Facilitators and barriers to substance-free pregnancies in high-income countries: A meta-synthesis of qualitative research

  • Tamara Escañuela Sánchez
    Correspondence
    Corresponding author at: Office 5S30 Cork University Maternity Hospital, Wilton, Cork, Ireland.
    Affiliations
    Pregnancy Loss Research Group, Department of Obstetrics and Gynaecology, University College Cork. Cork University Maternity Hospital, Cork, Ireland

    INFANT Centre, University College Cork, Cork, Ireland
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  • Karen Matvienko-Sikar
    Affiliations
    School of Public Health, University College Cork, Cork, Ireland
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  • Laura Linehan
    Affiliations
    Pregnancy Loss Research Group, Department of Obstetrics and Gynaecology, University College Cork. Cork University Maternity Hospital, Cork, Ireland

    INFANT Centre, University College Cork, Cork, Ireland
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  • Keelin O’Donoghue
    Affiliations
    Pregnancy Loss Research Group, Department of Obstetrics and Gynaecology, University College Cork. Cork University Maternity Hospital, Cork, Ireland

    INFANT Centre, University College Cork, Cork, Ireland
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  • Molly Byrne
    Affiliations
    Health Behaviour Change Research Group, School of Psychology, NUI Galway, National University of Ireland, Ireland
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  • Sarah Meaney
    Affiliations
    Pregnancy Loss Research Group, Department of Obstetrics and Gynaecology, University College Cork. Cork University Maternity Hospital, Cork, Ireland

    National Perinatal Epidemiology Centre (NPEC), University College Cork. Dept. of Obstetrics and Gynaecology, 5th Floor, Cork University Maternity Hospital, Wilton, Cork
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Open AccessPublished:April 30, 2021DOI:https://doi.org/10.1016/j.wombi.2021.04.010

      Abstract

      Background

      Previous studies have associated substance use (alcohol, illicit drugs and smoking) to negative pregnancy outcomes, including higher risk of stillbirth.

      Aim

      This study aims to identify facilitators and barriers reported by women to remain substance free during pregnancy.

      Methods

      A systematic search was conducted in six databases from inception to March 2019 and updated in November 2020. Qualitative studies involving pregnant or post-partum women, from high-income countries, examining women’s experiences of substance use during pregnancy were eligible. Meta-ethnography was used to facilitate this meta-synthesis.

      Findings

      Twenty-two studies were included for analysis. Internal barriers included the perceived emotional and social benefits of using substances such as stress coping, and the associated feelings of shame and guilt. Finding insensitive professionals, the lack of information and discussion about risks, and lack of social support were identified as external barriers. Furthermore, the social stigma and fear of prosecution associated with substance use led some women to conceal their use. Facilitators included awareness of the health risks of substance use, having intrinsic incentives and finding support in family, friends and professionals.

      Discussion

      Perceived benefits, knowledge, experiences in health care settings, and social factors all play important roles in women’s behaviours. These factors can co-occur and must be considered together to be able to understand the complexity of prenatal substance use.

      Conclusion

      Increased clinical and community awareness of the modifiable risk factors associated with substance use during pregnancy presented in this study, is necessary to inform future prevention efforts.

      Keywords

      Statement of significance

      Problem

      Substance use during pregnancy is a major contributor to adverse pregnancy outcomes, including stillbirth.

      What is already known

      Although there is evidence of the risk of smoking, drinking and using illicit substances during pregnancy, there are some women who continue to engage in these behaviours during pregnancy.

      What this paper adds

      Stillbirth prevention strategies in high income countries should focus on modifiable risk factors. This paper providers further evidence to improve understanding of the complexities and factors affecting the use of substances during pregnancy.

      1. Introduction

      Prenatal smoking, consumption of alcohol and illicit drug use are significant public health concerns with important implications for women and infants [

      World Health Organization. WHO | Substance use in pregnancy. https://www.who.int/substance_abuse/activities/pregnancy_substance_use/en/ (Accessed 25 June 2020).

      ]. Smoking, consuming alcohol and using illicit drugs during pregnancy are well established risk factors for a wide range of adverse pregnancy outcomes [
      • Escañuela Sánchez T.
      • Meaney S.
      • O’Donoghue K.
      Modifiable risk factors for stillbirth: a literature review.
      ]. These include an increased risk of miscarriage [
      • Pineles B.L.
      • Hsu S.
      • Park E.
      • Samet J.M.
      Systematic review and meta-analyses of perinatal death and maternal exposure to tobacco smoke during pregnancy.
      ], ectopic pregnancy [
      • Gaskins A.J.
      • Missmer S.A.
      • Rich-Edwards J.W.
      • Williams P.L.
      • Souter I.
      • Chavarro J.E.
      Demographic, lifestyle, and reproductive risk factors for ectopic pregnancy.
      ], placental pathologies [
      • Castles A.
      • Adams E.K.
      • Melvin C.L.
      • Kelsch C.
      • Boulton M.L.
      Effects of smoking during pregnancy: five meta-analyses.
      ], low birth weight [
      • da S Pereira P.P.
      • Da Mata F.A.F.
      • Figueiredo A.C.G.
      • de Andrade K.R.C.
      • Pereira M.G.
      Maternal active smoking during pregnancy and low birth weight in the americas: a systematic review and meta-analysis.
      ], small for gestational age [
      • Wang X.
      • Lee N.L.
      • Burstyn I.
      Smoking and use of electronic cigarettes (vaping) in relation to preterm birth and small-for-gestational-age in a 2016 U.S. national sample.
      ], intrauterine growth restriction [
      • Mook-kanamori D.O.
      • Eilers P.H.
      Risk factors and outcomes associated with first-trimester fetal growth restriction.
      ], preterm delivery [
      • Wang X.
      • Lee N.L.
      • Burstyn I.
      Smoking and use of electronic cigarettes (vaping) in relation to preterm birth and small-for-gestational-age in a 2016 U.S. national sample.
      ], fetal alcohol syndrome [
      • Mattson S.N.
      • Bernes G.A.
      • Doyle L.R.
      Fetal alcohol spectrum disorders: a review of the neurobehavioral deficits associated with prenatal alcohol exposure.
      ], and neonatal death [
      • Pineles B.L.
      • Hsu S.
      • Park E.
      • Samet J.M.
      Systematic review and meta-analyses of perinatal death and maternal exposure to tobacco smoke during pregnancy.
      ]. Prenatal smoking, alcohol consumption and illicit drug use are also associated with an increased risk of stillbirth [
      • Pineles B.L.
      • Hsu S.
      • Park E.
      • Samet J.M.
      Systematic review and meta-analyses of perinatal death and maternal exposure to tobacco smoke during pregnancy.
      ,
      • Marufu T.C.
      • Ahankari A.
      • Coleman T.
      • Lewis S.
      Maternal smoking and the risk of still birth: systematic review and meta-analysis.
      ,
      • Bailey B.A.
      • Sokol R.J.
      Prenatal alcohol exposure and miscarriage, stillbirth, preterm delivery, and sudden infant death syndrome.
      ].
      The occurrence of stillbirth differs across countries. In 2008, 2.65 million stillbirths were estimated worldwide, with 98% of them occurring in low-income and middle-income countries [
      • Lawn J.E.
      • Blencowe H.
      • Pattinson R.
      • et al.
      Stillbirths: where? When? Why? How to make the data count?.
      ]. In 2015, the rates of stillbirth per 1000 births at 28 weeks gestation or more in high-income countries varied from 1.3 in Iceland to 8.8 in Ukraine [
      • Flenady V.
      • Wojcieszek A.M.
      • Middleton P.
      • et al.
      Stillbirths: recall to action in high-income countries.
      ]. However, it is difficult to compare rates of stillbirth amongst countries due to the variability in the definitions used and the under-reporting of stillbirths under 28 weeks gestation.
      In a systematic review and meta-analysis of 142 studies published in 2015, any active smoking and second-hand smoke exposure during pregnancy were associated with a higher risk of stillbirth (Standardised Rate Ratio (sRR) 1.46 and sRR 1.40 respectively) [
      • Pineles B.L.
      • Hsu S.
      • Park E.
      • Samet J.M.
      Systematic review and meta-analyses of perinatal death and maternal exposure to tobacco smoke during pregnancy.
      ]. Previous studies have also associated heavy consumption of alcohol with an increased risk of stillbirth [

      K. Dejong, A. Olyaei, J.O. Lo. Alcohol Use in Pregnancy. https://doi.org/10.1097/GRF.0000000000000414.

      ,
      • Aliyu M.H.
      • Wilson R.E.
      • Zoorob R.
      • et al.
      Alcohol consumption during pregnancy and the risk of early stillbirth among singletons.
      ]. Aliyu et al. concluded in their retrospective cohort study with more than 650,000 pregnancies, that the likelihood of stillbirth between 20 and 28 weeks gestations was higher in women who drank alcohol [
      • Aliyu M.H.
      • Wilson R.E.
      • Zoorob R.
      • et al.
      Alcohol consumption during pregnancy and the risk of early stillbirth among singletons.
      ]. According to this study, women consuming five or more drinks per week during pregnancy experienced a 70% increase in the risk of stillbirth. Women consuming 1–2 drinks per week had a hazard ratio of 1.5 (95% confidence interval 1.0–2.1), no increase in risk amongst women drinking 3–4 drinks per week, and a peak increase in women drinking 5 or more drinks per week. In terms of illicit drug consumption, Varner et al. concluded that a positive test for any illicit drug in the umbilical cord homogenate was associated with an increase in the risk of stillbirth at 20 weeks gestation (OR 1.94) [
      • Varner M.W.
      • Silver R.M.
      • Hogue C.J.R.
      • et al.
      Association between stillbirth and illicit drug use and smoking during pregnancy.
      ]. A recent meta-analysis reported that the global prevalence of smoking during pregnancy was estimated to be 1.7% [
      • Lange S.
      • Probst C.
      • Rehm J.
      • et al.
      National, regional, and global prevalence of smoking during pregnancy in the general population: a systematic review and meta-analysis.
      ]. This study concluded that the highest prevalence of smoking during pregnancy was in the European Region (8.1%) and the lowest in the African Region (0.8%) [
      • Lange S.
      • Probst C.
      • Rehm J.
      • et al.
      National, regional, and global prevalence of smoking during pregnancy in the general population: a systematic review and meta-analysis.
      ]. The five countries with the highest estimated prevalence of smoking during pregnancy, regardless of frequency or quantity, were Ireland (38.4%), Uruguay (29.7%), Bulgaria (29.4%), Spain (26.0%) and Denmark (25.2%) [
      • Lange S.
      • Probst C.
      • Rehm J.
      • et al.
      National, regional, and global prevalence of smoking during pregnancy in the general population: a systematic review and meta-analysis.
      ]. However, previous studies have reported variations in prevalence, such as a prevalence of 11 to 17% of smoking among pregnant women in Ireland [
      • Murphy D.
      • Dunney C.
      • Mullally A.
      • Adnan N.
      • Deane R.
      Population-based study of smoking behaviour throughout pregnancy and adverse perinatal outcomes.
      ,
      • Reynolds C.M.E.
      • Egan B.
      • McKeating A.
      • Daly N.
      • Sheehan S.R.
      • Turner M.J.
      Five year trends in maternal smoking behaviour reported at the first prenatal appointment.
      ]. Prevalence of prenatal alcohol consumption has been found to be higher than that of smoking. A systematic review and meta-analysis published by Popova et al. concluded that, globally, 9.8% of women consumed alcohol during their pregnancy [
      • Popova S.
      • Lange S.
      • Probst C.
      • Gmel G.
      • Rehm J.
      Estimation of national, regional, and global prevalence of alcohol use during pregnancy and fetal alcohol syndrome: a systematic review and meta-analysis.
      ]. The highest prevalence was observed in the European World Health Organization Region (25.2%), whereas the lowest was in the Eastern Mediterranean WHO Region (0.2%). The five countries with the highest estimated prevalence of alcohol use during pregnancy were Ireland (60.4%), Belarus (46.6%), Denmark (45.8%), United Kingdom (41.3%) and Russia (36.5%).
      Cocaine, amphetamines, opioids, marijuana, hallucinogens and toluene-based solvents are the illicit drugs that have been found to be most commonly used by pregnant women [
      • Kuczkowski K.M.
      The effects of drug abuse on pregnancy.
      ,
      • King J.C.
      Substance abuse in pregnancy.
      ], however, establishing the prevalence of illicit drug use in pregnant women may be more difficult than for alcohol and smoking. For example although social stigma can exist for all of these behaviours during pregnancy, legal repercussions associated with substance use might drive some women to avoid disclosure [
      • King J.C.
      Substance abuse in pregnancy.
      ,
      • Roberts S.
      • Pies C.
      Complex calculations: how drug use during pregnancy becomes a barrier to prenatal care.
      ]. However, in the 2010 National Survey on Drugs and Health conducted among pregnant women aged 15 and 44 in the USA, it was reported that 4% of pregnant women were current illicit drug users [

      Substance Abuse and Mental Health Service Administration. Results from the 2010 National Survey on Drug Use and Health: Summary of National Findings. Rockville, 2011 DOI:NSDUH Series H-41, HHS Publication No. (SMA) 11-4658.

      ].
      Understanding women’s attitudes, perceptions and experiences of substance use is essential to obtaining insight into the facilitators and barriers that modulate these behaviours during pregnancy. Qualitative research is a useful approach in this regard to explore and understand the nature and interaction of the different layers of the studied phenomenon while maintaining the particular complexities of human behaviour [
      • Black N.
      Why we need qualitative research.
      ]. To date a number of primary qualitative studies have been conducted to understand women’s prenatal smoking, alcohol and illicit substance consumption [
      • Bauld L.
      • Graham H.
      • Sinclair L.
      • et al.
      Barriers to and facilitators of smoking cessation in pregnancy and following childbirth: literature review and qualitative study.
      ,
      • Borland T.
      • Babayan A.
      • Irfan S.
      • Schwartz R.
      Exploring the adequacy of smoking cessation support for pregnant and postpartum women.
      ,
      • Britton G.R.
      • Collier R.
      • McKitrick S.
      • et al.
      CE: Original research: The experiences of pregnant smokers and their providers.
      ,
      • Crawford-Williams F.
      • Steen M.
      • Esterman A.
      • Fielder A.
      • Mikocka-Walus A.
      “My midwife said that having a glass of red wine was actually better for the baby”: a focus group study of women and their partner’s knowledge and experiences relating to alcohol consumption in pregnancy Fiona.
      ,
      • Gamble J.
      • Grant J.
      • Tsourtos G.
      Missed opportunities: a qualitative exploration of the experiences of smoking cessation interventions among socially disadvantaged pregnant women.
      ,
      • Herbec A.
      • Beard E.
      • Brown J.
      • Gardner B.
      • Tombor I.
      • West R.
      The needs and preferences of pregnant smokers regarding tailored internet-based smoking cessation interventions: a qualitative interview study.
      ,
      • Jessup M.A.
      • Humphreys J.C.
      • Brindis C.D.
      • Lee K.A.
      Extrinsic barriers to substance abuse treatment among pregnant drug dependent women.
      ,
      • Leppo A.
      ‘Subutex is safe’: perceptions of risk in using illicit drugs during pregnancy.
      ,
      • Leppo A.
      • Hecksher D.
      • Tryggvesson K.
      ‘Why take chances?’ Advice on alcohol intake to pregnant and non-pregnant women in four Nordic countries.
      ,
      • Sheridan K.
      Substance-using pregnant and parenting adolescent girls: considerations for preventive intervention using a resilience lens.
      ] and we found three meta-synthesis exploring experiences of women who commence pregnancy as smokers [
      • Flemming K.
      • McCaughan D.
      • Angus K.
      • Graham H.
      Qualitative systematic review: barriers and facilitators to smoking cessation experienced by women in pregnancy and following childbirth.
      ,
      • Flemming K.
      • Graham H.
      • McCaughan D.
      • Angus K.
      • Sinclair L.
      • Bauld L.
      Health professionals’ perceptions of the barriers and facilitators to providing smoking cessation advice to women in pregnancy and during the post-partum period: a systematic review of qualitative research.
      ,
      • Flemming K.
      • Graham H.
      • Heirs M.
      • Fox D.
      • Sowden A.
      Smoking in pregnancy: a systematic review of qualitative research of women who commence pregnancy as smokers.
      ]. However, no prior meta-synthesis has been conducted related to the other types of substances used during pregnancy.
      The aim of this meta-synthesis is to analyse and synthesise all of the evidence drawn from qualitative research to date in order to identify facilitators and barriers to a substance-free pregnancy in high income countries. This will facilitate developing in-depth insights and understandings of these prenatal health behaviours [
      • Atkins S.
      • Lewin S.
      • Smith H.
      • Engel M.
      • Fretheim A.
      • Volmink J.
      Conducting a meta-ethnography of qualitative literature: lessons learnt.
      ,
      • Mohammed M.A.
      • Moles R.J.
      • Chen T.F.
      Meta-synthesis of qualitative research: the challenges and opportunities.
      ]. By identifying barriers and facilitators common to different type of substances, we intend to inform the development of a behaviour change intervention applicable in high-income countries.
      The synthesis of qualitative research was informed by meta-ethnography. Meta-ethnography is a methodology originally developed by Noblit and Hare with an interpretative approach [
      • Noblit G.W.
      • Hare D.R.
      Meta-Ethnography: Synthesizing Qualitative Studies.
      ]. This methodology is utilised to “put together” all the available research through the translation of qualitative studies into one another [
      • Noblit G.W.
      • Hare D.R.
      Meta-Ethnography: Synthesizing Qualitative Studies.
      ]. In order to do this, the researcher translates the studies into one another’s terms, and into their own interpretation of the data and the world, which will result in a synthesis that is partially produced by the author [
      • Turner S.
      Sociological Explanation as Translation.
      ]. To facilitate the reporting of this meta-ethnography, we followed The eMERGe reporting guidance [
      • France E.F.
      • Cunningham M.
      • Ring N.
      • et al.
      Improving reporting of meta-ethnography: the eMERGe reporting guidance.
      ] (see Supplementary Table 1). We chose meta-ethnography because of its potential to produce new interpretations, models or theory [
      • France E.F.
      • Ring N.
      • Thomas R.
      • Noyes J.
      • Maxwell M.
      • Jepson R.
      A methodological systematic review of what’s wrong with meta-ethnography reporting.
      ].

      2. Methods

      2.1 Search strategy

      A comprehensive systematic search of the literature was performed for all qualitative research that explored women’s facilitators and barriers to abstain from substance use during pregnancy. The databases searched were CINHAL, PsychINFO, Pubmed, SOCindex and Web of Science and the searchers were conducted on the 28th and 29th of March 2019 with no restrictions on publication date. The search was updated on the 25th of November 2020 to identify new published articles relevant for our synthesis. Further, the reference list of each included study was hand-searched for additional studies.
      The protocol for this meta-synthesis was registered on Prospero (no. CRD42019120069). Originally this meta-synthesis had the objective to provide insights into different modifiable risk factors for stillbirth. However, due to the high volume and complexity of the qualitative research on antenatal behaviour practices, this meta-synthesis differs from the original protocol in that it focuses specifically on substance use during pregnancy rather than substance use, attendance at antenatal care and weight management as previously planned. Findings in relation to the other two modifiable risk factors will be published elsewhere.
      Search terms were selected based on a preliminary scan of the relevant literature. The search terms used were facilitators, barriers, promoter, benefit, attitude, opportunity, determinant, promotion, intention, education, initiative, prevention, pregnancy, smoking, smoking cessation, nicotine, alcohol, alcohol abuse, alcohol drinking, drug*, drug abuse, illicit drugs, oral drugs, intravenous drugs (see example of search in Supplementary file 1).

      2.2 Study selection

      Three members of the research team (SM, LL, TES) independently reviewed the titles and abstracts of the studies resulting from the database search. Additionally, two authors independently (SM, TES) conducted the full text screening of the eligible studies.
      Studies were included for further review if (1) they used a qualitative or mixed methods design, as long as they included primary qualitative data, (2) they were written in English, (3) the participants were women interviewed when pregnant or up to 12 months post-partum as long as the data referred to their experiences during their pregnancy, (4) they were conducted in high income countries, and (5) included extractable data about facilitators and barriers to remain abstinent from substance abuse during pregnancy.
      Studies were excluded if they did not include any qualitative data or if they were not original research. Studies that included different types of participants (e.g.: healthcare professionals and pregnant women, partners and pregnant women) were only included if the data extracted from the pregnant women was differentiated from the rest. In this meta-synthesis, we included studies that explored the views of women who were current substance users during their pregnancies and women who made the choice to remain abstinent during their pregnancy.

      2.3 Data extraction

      2.3.1 Study characteristics

      A data extraction sheet was used to extract the characteristics of the studies by one author (TES). The following data were extracted from each study: country of publication, year of publication, aims, design, data collection method, sampling or recruitment strategy, consent process, number of participants, age of participants, pregnancy status, timing of data collection and method of data analysis.

      2.3.2 Quality assessment

      The Critical Appraisal Skills Program (CASP) for qualitative studies was used independently by two authors (TES, SM) to assess the quality of the studies. Previous research in the area of quality appraisal has concluded that there is a correlation between the quality of reporting of a study and its value as a source for the final synthesis, and therefore it is appropriate to exclude inadequately reported studies [
      • Carroll C.
      • Booth A.
      • Lloyd-Jones M.
      Should we exclude inadequately reported studies from qualitative systematic reviews? An evaluation of sensitivity analyses in two case study reviews.
      ]. As a result, it was decided that only the studies with the highest quality (CASP ≥ 15) would be part of the synthesis.
      To assess our individual review findings, we used the GRADE-CERQual approach. This approach facilitates assessment of how much confidence can be places on individual review findings from a synthesis of qualitative research [
      • Lewin S.
      • Booth A.
      • Glenton C.
      • et al.
      Applying GRADE-CERQual to qualitative evidence synthesis findings: introduction to the series.
      ].

      2.3.3 Synthesis informed by meta-ethnogtraphy

      Noblit and Hare (1988) [
      • Noblit G.W.
      • Hare D.R.
      Meta-Ethnography: Synthesizing Qualitative Studies.
      ] proposed a series of phases that overlap and repeat along with the conduction of the synthesis (see Supplementary Table 2).
      Phase 1 and 2 – Selecting meta-ethnography and deciding what is relevant
      The first two phases of meta-ethnography involve identifying a research gap which has the potential to be filled by meta-ethnography, explaining the rational for using meta-ethnography and stating its purpose and focus, which we have done in the sections above. Phase 2 was completed by conducting a systematic search of the databases as outlined above, and importing the resulting studies into NVivo12 for analysis (see Fig. 1).
      Fig. 1
      Fig. 1PRISMA flow diagram showing the process of inclusion of studies. From: Moher D, Liberati A, Tetzlaff J, Altman DG, The PRISMA Group (2009). Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med 6(7): e1000097. doi:10.1371/journal.pmed1000097.
      Phase 3 – Reading the studies
      During Phase 3, the papers were read in depth several times and the characteristics and details of the papers were extracted and tabulated into the data extraction sheet (Supplementary Table 3). In this phase, each paper was read carefully and notes were used to identify the data that had to be extracted.
      Phase 4 – Determining how the studies are related
      Phase 4 involved the line-by-line coding of each selected study by one author (TES) using Nvivo12 in order to identify common metaphors and concepts, consulting with the rest of the team when in doubt. We refined the codes in our list and created new ones as the coding progressed in each new study. Every sentence of the studies had to be coded at least once. A second author (SM) coded a sample of the papers to facilitate reliability and validity in the coding process. Both first and second order constructs were extracted for analysis. We utilised second-order constructs to complement the primary data, which offered additional insights, context and explanations. Most of the studies had poor reflexive accounts, which hindered our assessment of the author’s background influence over their interpretations. The key concepts explored and compared in the analysis were related to factors that either facilitated or hindered access to antenatal care for pregnant women in high-income countries.
      Once the initial coding was completed, we examined the text added to each code for consistency of interpretation and additional coding was performed when necessary. We obtained a list of concepts that were grouped into themes and categories using thematic analysis.
      We used tables to display the concepts and themes across all studies, classifying them depending on the substance they were exploring, this helped us see which concepts and themes juxtaposed across the different studies and substances explored (see Supplementary Tables 4a and 4b). Classifying the studies based on the concepts and themes and grouping them by substance helped us understand how the studies were related and in which aspects they were different. Then concept maps were used to establish and discuss the influences of each concept over the other. After this phase, it was understood that most studies related reciprocally, except those that explore different aspects of the topic.
      Phase 5 – Translating studies into one another
      Phase 5 involved translating the studies into one another. In this phase, the themes and concepts were further refined to ensure that the themes reflected the meaning of each individual study. The initial codes and themes were examined and combined thematically when describing similar findings.
      The influence of each study over each concept obtained is documented using references and quotes. Quotes were obtained from primary study participants and by primary author’s explanations and interpretations. Since the context of the studies were very similar, the studies were organised in sub-groups depending on the substance they were exploring (either alcohol, smoking or illicit drug use, which included Cannabis). In our study, similar contexts are beneficial as they allow us to identify specific facilitators and barriers. This would then better inform the development of a context-specific intervention.
      In this article we are presenting first, second and third level interpretations, based on the women’s experiences.
      Phase 6 – Synthesizing translations
      The result of the translated concepts, their relationships and the primary data were used to create a textual line of argument, which is presented here. Three authors were involved in the synthesis (TES, KMS, SM) and the additional authors provided feedback and insights when necessary (KOD, MB, LL). The authors are from different disciplinary backgrounds including psychology, sociology, medicine, public health, epidemiology and behavioural science, which promoted discussion of potential different interpretations.
      Phase 7 – Expressing the synthesis
      The findings of this meta-ethnography are presented in this article, additionally, a summarised version of the findings can be found in our CerQual assessment and summary tables (see Supplementary Tables 6 and Table 4a and 4b).

      3. Results

      3.1 Search outcome

      Fig. 1 shows the process of inclusion of studies. The first database search was conducted in March 2019, and identified 25,508 studies. Of these, 18,159 remained after duplicate removal. After screening for titles and abstracts, 85 studies remained potentially eligible for full text review. Following full text screening of the remaining 85 studies, 18 studies met criteria for inclusion in the meta-synthesis. Twelve more studies were examined for potential inclusion after hand-searching the reference list of the included studies, and 2 additional studies were included. The search conducted in November 2020 identified 152 potential studies. Four studies remained potentially eligible after screening for title and abstract, of those, two studies were included in our synthesis. The final number of studies included for synthesis was 22.
      Several facilitators and barriers were identified during our analysis that have an influence on womens’ prenatal health behaviours. We classified these factors as internal factors or external factors, with internal factors being those that the woman might have some degree of control over and relate to her own beliefs, knowledge and intrinsic motivation to decide whether to use or not substances during their pregnancy. External factors are those which will have an influence on the woman’s behaviour but are elements over which women have very limited control and relate mostly to their social environment or the healthcare system.

      3.2 Study characteristics

      The characteristics of the studies included are shown in Supplementary Table 3. Of the 22 studies included for analysis, 14 focused on smoking, 1 on alcohol, 3 on illicit drugs and 4 on different multiple substances. Six were conducted in the UK, 3 in the USA, 3 in Australia, 1 in Canada, 1 in Sweden, 1 in Finland and 1 in New Zealand. The years of publication ranged from 1998 to 2020.
      Twenty-one of the studies were qualitative and one mixed-methods. The studies used different data collection methods; nineteen used semi-structured interviews, three used focus groups. The number of participants in the studies ranged from 6 to 53, with ages ranging from 15 to 49 years. Thirteen of the studies included pregnant women only, one included only postpartum women up to 12 months after birth and eight included both pregnant and postpartum women. Regarding the quality appraisals, most of studies performed poorly with regards to reflexibility and ethical considerations, and performed particularly well in the reporting of their aims, qualitative methodology, recruitment strategy and data collection methods justification (See Supplementary Table 5). Results from the GRADE-CERQual analysis are presented in Supplementary Table 6.

      4. Synthesis

      4.1 Internal factors

      Theme 1: Perceived incentives
      In this theme we identified internal factors reported by women that might increase or decrease their levels of motivation to use substances or remain abstinent. Women reported perceived psychological and social benefits from their substance use, and additionally, women expressed reasons why interrupting/ceasing their use would have negative consequences upon them. However, some other women were also able to identify benefits of abstaining from substance use.
      Category 1.1: Perceived benefits obtained from substance use
      Women reported several reasons for continuing to use substances during pregnancy. Lack of motivation to quit [
      • Bauld L.
      • Graham H.
      • Sinclair L.
      • et al.
      Barriers to and facilitators of smoking cessation in pregnancy and following childbirth: literature review and qualitative study.
      ,
      • Britton G.R.
      • Collier R.
      • McKitrick S.
      • et al.
      CE: Original research: The experiences of pregnant smokers and their providers.
      ,
      • Gamble J.
      • Grant J.
      • Tsourtos G.
      Missed opportunities: a qualitative exploration of the experiences of smoking cessation interventions among socially disadvantaged pregnant women.
      ,
      • Arborelius E.
      • Nyberg K.
      How should midwives discuss smoking behaviour in pregnancy with women of low educational attainment?.
      ,
      • McLeod D.
      • Benn C.
      • Pullon S.
      • et al.
      The midwife’s role in facilitating smoking behaviour change during pregnancy.
      ] and boredom [
      • Bauld L.
      • Graham H.
      • Sinclair L.
      • et al.
      Barriers to and facilitators of smoking cessation in pregnancy and following childbirth: literature review and qualitative study.
      ,
      • Britton G.R.
      • Collier R.
      • McKitrick S.
      • et al.
      CE: Original research: The experiences of pregnant smokers and their providers.
      ,
      • Gamble J.
      • Grant J.
      • Tsourtos G.
      Missed opportunities: a qualitative exploration of the experiences of smoking cessation interventions among socially disadvantaged pregnant women.
      ,
      • McLeod D.
      • Benn C.
      • Pullon S.
      • et al.
      The midwife’s role in facilitating smoking behaviour change during pregnancy.
      ] were two reasons commonly reported.“So you’re bored, what are you going to do? Sit down and smoke a cigarette.” [
      • Britton G.R.
      • Collier R.
      • McKitrick S.
      • et al.
      CE: Original research: The experiences of pregnant smokers and their providers.
      ]
      “The part that wants to quit is smaller than the part that doesn’t.” [
      • Britton G.R.
      • Collier R.
      • McKitrick S.
      • et al.
      CE: Original research: The experiences of pregnant smokers and their providers.
      ] [Smoking]
      Furthermore, women reported obtaining benefits from the use of the substances that act as barrier to remain substance free. The most commonly reported benefit of substance abuse was that “It makes me happy; it relaxes me” [
      • Britton G.R.
      • Collier R.
      • McKitrick S.
      • et al.
      CE: Original research: The experiences of pregnant smokers and their providers.
      ]; hence, many reported that due to this “total relaxation feeling” [
      • Raymond N.
      • Beer C.
      • Glazebrook C.
      • Sayal K.
      Pregnant women’s attitudes towards alcohol consumption.
      ] they used their habit as their main coping strategy for stressful situations [
      • Bauld L.
      • Graham H.
      • Sinclair L.
      • et al.
      Barriers to and facilitators of smoking cessation in pregnancy and following childbirth: literature review and qualitative study.
      [
      • Britton G.R.
      • Collier R.
      • McKitrick S.
      • et al.
      CE: Original research: The experiences of pregnant smokers and their providers.
      ,
      • Crawford-Williams F.
      • Steen M.
      • Esterman A.
      • Fielder A.
      • Mikocka-Walus A.
      “My midwife said that having a glass of red wine was actually better for the baby”: a focus group study of women and their partner’s knowledge and experiences relating to alcohol consumption in pregnancy Fiona.
      ,
      • Arborelius E.
      • Nyberg K.
      How should midwives discuss smoking behaviour in pregnancy with women of low educational attainment?.
      ,
      • McLeod D.
      • Benn C.
      • Pullon S.
      • et al.
      The midwife’s role in facilitating smoking behaviour change during pregnancy.
      ,
      • Raymond N.
      • Beer C.
      • Glazebrook C.
      • Sayal K.
      Pregnant women’s attitudes towards alcohol consumption.
      ,
      • Grant A.
      • Morgan M.
      • Gallagher D.
      • Mannay D.
      Smoking during pregnancy, stigma and secrets: visual methods exploration in the UK.
      ,
      • Nichter M.
      • Nichter M.
      • Muramoto M.
      • et al.
      Smoking among low-income pregnant women: an ethnographic analysis.
      ,
      • Fergie L.
      • Coleman T.
      • Ussher M.
      • Cooper S.
      • Campbell K.A.
      Pregnant smokers’ experiences and opinions of techniques aimed to address barriers and facilitators to smoking cessation: a qualitative study.
      ,
      • Barbosa-Leiker C.
      • Burduli E.
      • Smith C.L.
      • Brooks O.
      • Orr M.
      • Gartstein M.
      Daily cannabis use during pregnancy and postpartum in a state with legalized recreational cannabis.
      ]. For many women abstaining from the drug meant losing their only coping strategy for stress [
      • Bauld L.
      • Graham H.
      • Sinclair L.
      • et al.
      Barriers to and facilitators of smoking cessation in pregnancy and following childbirth: literature review and qualitative study.
      ,
      • Britton G.R.
      • Collier R.
      • McKitrick S.
      • et al.
      CE: Original research: The experiences of pregnant smokers and their providers.
      ,
      • Arborelius E.
      • Nyberg K.
      How should midwives discuss smoking behaviour in pregnancy with women of low educational attainment?.
      ,
      • McLeod D.
      • Benn C.
      • Pullon S.
      • et al.
      The midwife’s role in facilitating smoking behaviour change during pregnancy.
      ,
      • Raymond N.
      • Beer C.
      • Glazebrook C.
      • Sayal K.
      Pregnant women’s attitudes towards alcohol consumption.
      ,
      • Grant A.
      • Morgan M.
      • Gallagher D.
      • Mannay D.
      Smoking during pregnancy, stigma and secrets: visual methods exploration in the UK.
      ,
      • Nichter M.
      • Nichter M.
      • Muramoto M.
      • et al.
      Smoking among low-income pregnant women: an ethnographic analysis.
      ]. Taking the time to have a drink or smoke a cigarette gave them a sense of freedom and private time
      • Crawford-Williams F.
      • Steen M.
      • Esterman A.
      • Fielder A.
      • Mikocka-Walus A.
      “My midwife said that having a glass of red wine was actually better for the baby”: a focus group study of women and their partner’s knowledge and experiences relating to alcohol consumption in pregnancy Fiona.
      ,
      • Grant A.
      • Morgan M.
      • Gallagher D.
      • Mannay D.
      Smoking during pregnancy, stigma and secrets: visual methods exploration in the UK.
      ] whereby it was “the only time I get a 5-minute break” [
      • Bauld L.
      • Graham H.
      • Sinclair L.
      • et al.
      Barriers to and facilitators of smoking cessation in pregnancy and following childbirth: literature review and qualitative study.
      ]. In other cases, women also spoke about how using their substance of choice has a positive effect on their mood [
      • Arborelius E.
      • Nyberg K.
      How should midwives discuss smoking behaviour in pregnancy with women of low educational attainment?.
      ,
      • Raymond N.
      • Beer C.
      • Glazebrook C.
      • Sayal K.
      Pregnant women’s attitudes towards alcohol consumption.
      ], and the substances were perceived as source of enjoyment and socialisation [
      • Sheridan K.
      Substance-using pregnant and parenting adolescent girls: considerations for preventive intervention using a resilience lens.
      ,
      • Nichter M.
      • Nichter M.
      • Muramoto M.
      • et al.
      Smoking among low-income pregnant women: an ethnographic analysis.
      ,
      • Nichter M.
      • Nichter M.
      • Adrian S.
      • Goldade K.
      • Tesler L.
      • Muramoto M.
      Smoking and harm-reduction efforts among postpartum women.
      ]. In these cases, despite the fact that women might acknowledge the risks of the substance use, the benefits obtained outweighed the risks.“Smoking and drinking were an important part of her social life, and although she always imagined she would quit when she became pregnant, she found she was unable to do so” [
      • Nichter M.
      • Nichter M.
      • Muramoto M.
      • et al.
      Smoking among low-income pregnant women: an ethnographic analysis.
      ]
      “I felt like it was consistently helping me calm down and be able to function enough – well enough to parent my sixyear-old as a single parent and, um, deal with that” [
      • Barbosa-Leiker C.
      • Burduli E.
      • Smith C.L.
      • Brooks O.
      • Orr M.
      • Gartstein M.
      Daily cannabis use during pregnancy and postpartum in a state with legalized recreational cannabis.
      ] [Cannabis]
      In the case of Cannabis in particular, women spoke about its therapeutic effects [
      • Barbosa-Leiker C.
      • Burduli E.
      • Smith C.L.
      • Brooks O.
      • Orr M.
      • Gartstein M.
      Daily cannabis use during pregnancy and postpartum in a state with legalized recreational cannabis.
      ]. In one of the studies conducted in an American state where Cannabis use was legalised, women from different socioeconomic backgrounds used Cannabis to control their nausea, increase their appetite and manage stress as a “more natural alternative than prescribed medications” [
      • Barbosa-Leiker C.
      • Burduli E.
      • Smith C.L.
      • Brooks O.
      • Orr M.
      • Gartstein M.
      Daily cannabis use during pregnancy and postpartum in a state with legalized recreational cannabis.
      ].“It helps me feel hungry and it takes away my nausea completely. And it helps with the pain, too. And not so much that it takes away all of my pain, but it helps me mentally manage by pain better.” [
      • Barbosa-Leiker C.
      • Burduli E.
      • Smith C.L.
      • Brooks O.
      • Orr M.
      • Gartstein M.
      Daily cannabis use during pregnancy and postpartum in a state with legalized recreational cannabis.
      ]
      In addition, some perceived disadvantages of remaining abstinent were identified, including fear of harming the baby due to the consequences of the abstinence [
      • Bauld L.
      • Graham H.
      • Sinclair L.
      • et al.
      Barriers to and facilitators of smoking cessation in pregnancy and following childbirth: literature review and qualitative study.
      ,
      • Borland T.
      • Babayan A.
      • Irfan S.
      • Schwartz R.
      Exploring the adequacy of smoking cessation support for pregnant and postpartum women.
      ,
      • Britton G.R.
      • Collier R.
      • McKitrick S.
      • et al.
      CE: Original research: The experiences of pregnant smokers and their providers.
      ,
      • Crawford-Williams F.
      • Steen M.
      • Esterman A.
      • Fielder A.
      • Mikocka-Walus A.
      “My midwife said that having a glass of red wine was actually better for the baby”: a focus group study of women and their partner’s knowledge and experiences relating to alcohol consumption in pregnancy Fiona.
      ,
      • Nichter M.
      • Nichter M.
      • Adrian S.
      • Goldade K.
      • Tesler L.
      • Muramoto M.
      Smoking and harm-reduction efforts among postpartum women.
      ,
      • Van Scoyoc A.
      • Harrison J.A.
      • Fisher P.A.
      Beliefs and behaviors of pregnant women with addictions awaiting treatment initiation.
      ]; for instance, having increased levels of psychological stress [
      • Borland T.
      • Babayan A.
      • Irfan S.
      • Schwartz R.
      Exploring the adequacy of smoking cessation support for pregnant and postpartum women.
      ,
      • Britton G.R.
      • Collier R.
      • McKitrick S.
      • et al.
      CE: Original research: The experiences of pregnant smokers and their providers.
      ,
      • McLeod D.
      • Benn C.
      • Pullon S.
      • et al.
      The midwife’s role in facilitating smoking behaviour change during pregnancy.
      ,
      • Nichter M.
      • Nichter M.
      • Muramoto M.
      • et al.
      Smoking among low-income pregnant women: an ethnographic analysis.
      ,
      • Dunn C.L.
      • Pirie P.L.
      • Lando H.A.
      Attitudes and perceptions related to smoking among pregnant and postpartum women in a low-income, multiethnic setting.
      ] which women perceived as more harmful for the baby than the substance use itself [
      • Borland T.
      • Babayan A.
      • Irfan S.
      • Schwartz R.
      Exploring the adequacy of smoking cessation support for pregnant and postpartum women.
      ,
      • McLeod D.
      • Benn C.
      • Pullon S.
      • et al.
      The midwife’s role in facilitating smoking behaviour change during pregnancy.
      ]. The withdrawal symptoms and cravings as a consequence of the addiction to the substance [
      • Britton G.R.
      • Collier R.
      • McKitrick S.
      • et al.
      CE: Original research: The experiences of pregnant smokers and their providers.
      ,
      • Leppo A.
      ‘Subutex is safe’: perceptions of risk in using illicit drugs during pregnancy.
      ,
      • Van Scoyoc A.
      • Harrison J.A.
      • Fisher P.A.
      Beliefs and behaviors of pregnant women with addictions awaiting treatment initiation.
      ,
      • Grant A.
      • Morgan M.
      • Mannay D.
      • Gallagher D.
      Understanding health behaviour in pregnancy and infant feeding intentions in low-income women from the UK through qualitative visual methods and application to the COM-B (capability, opportunity, motivation-behaviour) model.
      ] that in some instances lead them to feelings of loss of control [
      • Arborelius E.
      • Nyberg K.
      How should midwives discuss smoking behaviour in pregnancy with women of low educational attainment?.
      ] were also a source of concern. Additionally, women were concerned about the effect of abstinence on their relationships [
      • Britton G.R.
      • Collier R.
      • McKitrick S.
      • et al.
      CE: Original research: The experiences of pregnant smokers and their providers.
      ,
      • Leppo A.
      ‘Subutex is safe’: perceptions of risk in using illicit drugs during pregnancy.
      ,
      • Van Scoyoc A.
      • Harrison J.A.
      • Fisher P.A.
      Beliefs and behaviors of pregnant women with addictions awaiting treatment initiation.
      ,
      • Grant A.
      • Morgan M.
      • Mannay D.
      • Gallagher D.
      Understanding health behaviour in pregnancy and infant feeding intentions in low-income women from the UK through qualitative visual methods and application to the COM-B (capability, opportunity, motivation-behaviour) model.
      ], since using is a common habit within their partner and/or wider social circle, whereby reported that they “feel left out of some situations with my friends” [
      • Nichter M.
      • Nichter M.
      • Adrian S.
      • Goldade K.
      • Tesler L.
      • Muramoto M.
      Smoking and harm-reduction efforts among postpartum women.
      ]“There was a couple of times I just tried stopping, just getting sick. I would get a day into the sickness and it would just get to the point where it’s just… I’m running out the door [to get more drugs.]” [
      • Van Scoyoc A.
      • Harrison J.A.
      • Fisher P.A.
      Beliefs and behaviors of pregnant women with addictions awaiting treatment initiation.
      ]
      Regarding smoking, women were concerned about gaining too much weight if they attempted quitting [
      • Nichter M.
      • Nichter M.
      • Adrian S.
      • Goldade K.
      • Tesler L.
      • Muramoto M.
      Smoking and harm-reduction efforts among postpartum women.
      ,
      • Dunn C.L.
      • Pirie P.L.
      • Lando H.A.
      Attitudes and perceptions related to smoking among pregnant and postpartum women in a low-income, multiethnic setting.
      ]. Since smoking was their main coping mechanisms for stress [
      • Britton G.R.
      • Collier R.
      • McKitrick S.
      • et al.
      CE: Original research: The experiences of pregnant smokers and their providers.
      ,
      • Nichter M.
      • Nichter M.
      • Muramoto M.
      • et al.
      Smoking among low-income pregnant women: an ethnographic analysis.
      ,
      • Nichter M.
      • Nichter M.
      • Adrian S.
      • Goldade K.
      • Tesler L.
      • Muramoto M.
      Smoking and harm-reduction efforts among postpartum women.
      ,
      • Dunn C.L.
      • Pirie P.L.
      • Lando H.A.
      Attitudes and perceptions related to smoking among pregnant and postpartum women in a low-income, multiethnic setting.
      ], women reported that they would probably resort to food as means of getting comfort when not being able to use cigarettes [
      • Nichter M.
      • Nichter M.
      • Muramoto M.
      • et al.
      Smoking among low-income pregnant women: an ethnographic analysis.
      ,
      • Dunn C.L.
      • Pirie P.L.
      • Lando H.A.
      Attitudes and perceptions related to smoking among pregnant and postpartum women in a low-income, multiethnic setting.
      ]. When speaking about illicit drug use, women were especially concerned about their mental health [
      • Leppo A.
      ‘Subutex is safe’: perceptions of risk in using illicit drugs during pregnancy.
      ] and their perception that their life would feel dull without the effects of the drugs [
      • Leppo A.
      ‘Subutex is safe’: perceptions of risk in using illicit drugs during pregnancy.
      ].“I either eat or smoke…. I make the choice, I don’t want to get big, so I’ll go smoke” [
      • Nichter M.
      • Nichter M.
      • Adrian S.
      • Goldade K.
      • Tesler L.
      • Muramoto M.
      Smoking and harm-reduction efforts among postpartum women.
      ].
      Category 1.2: Perceived benefits obtained from substance abstinence
      Within this sub-category, women spoke about practical benefits for their life, such as hygiene and money saving aspects [
      • Bauld L.
      • Graham H.
      • Sinclair L.
      • et al.
      Barriers to and facilitators of smoking cessation in pregnancy and following childbirth: literature review and qualitative study.
      ,
      • Arborelius E.
      • Nyberg K.
      How should midwives discuss smoking behaviour in pregnancy with women of low educational attainment?.
      ,
      • McLeod D.
      • Benn C.
      • Pullon S.
      • et al.
      The midwife’s role in facilitating smoking behaviour change during pregnancy.
      ]. But the main benefits identified by the women were related to their own and their baby’s health [
      • Crawford-Williams F.
      • Steen M.
      • Esterman A.
      • Fielder A.
      • Mikocka-Walus A.
      “My midwife said that having a glass of red wine was actually better for the baby”: a focus group study of women and their partner’s knowledge and experiences relating to alcohol consumption in pregnancy Fiona.
      ,
      • Sheridan K.
      Substance-using pregnant and parenting adolescent girls: considerations for preventive intervention using a resilience lens.
      ,
      • McLeod D.
      • Benn C.
      • Pullon S.
      • et al.
      The midwife’s role in facilitating smoking behaviour change during pregnancy.
      ,
      • Grant A.
      • Morgan M.
      • Gallagher D.
      • Mannay D.
      Smoking during pregnancy, stigma and secrets: visual methods exploration in the UK.
      ,
      • Nichter M.
      • Nichter M.
      • Muramoto M.
      • et al.
      Smoking among low-income pregnant women: an ethnographic analysis.
      ,
      • Fergie L.
      • Coleman T.
      • Ussher M.
      • Cooper S.
      • Campbell K.A.
      Pregnant smokers’ experiences and opinions of techniques aimed to address barriers and facilitators to smoking cessation: a qualitative study.
      ,
      • Nichter M.
      • Nichter M.
      • Adrian S.
      • Goldade K.
      • Tesler L.
      • Muramoto M.
      Smoking and harm-reduction efforts among postpartum women.
      ]. Additionally, some emotional benefits for the women were also identified. Women felt a sense of relief from the guilt of using substances [
      • Sheridan K.
      Substance-using pregnant and parenting adolescent girls: considerations for preventive intervention using a resilience lens.
      ,
      • Grant A.
      • Morgan M.
      • Gallagher D.
      • Mannay D.
      Smoking during pregnancy, stigma and secrets: visual methods exploration in the UK.
      ,
      • Nichter M.
      • Nichter M.
      • Muramoto M.
      • et al.
      Smoking among low-income pregnant women: an ethnographic analysis.
      ], and felt that they were giving a good example to their children by remaining substance free [
      • Nichter M.
      • Nichter M.
      • Adrian S.
      • Goldade K.
      • Tesler L.
      • Muramoto M.
      Smoking and harm-reduction efforts among postpartum women.
      ]. Furthermore, some women spoke about developing an increased perception of willpower and self-efficacy as consequence of their achievements during their process towards abstinence [
      • Bauld L.
      • Graham H.
      • Sinclair L.
      • et al.
      Barriers to and facilitators of smoking cessation in pregnancy and following childbirth: literature review and qualitative study.
      ,
      • Sheridan K.
      Substance-using pregnant and parenting adolescent girls: considerations for preventive intervention using a resilience lens.
      ,
      • Nichter M.
      • Nichter M.
      • Muramoto M.
      • et al.
      Smoking among low-income pregnant women: an ethnographic analysis.
      ,
      • Pletsch P.K.
      • Morgan S.
      • Pieper A.F.
      Context and beliefs about smoking and smoking cessation.
      ].
      For some women, being pregnant or having other children was already motivation enough to attempt quitting, engage in harm reducing actions or to abstain from drugs completely [
      • Crawford-Williams F.
      • Steen M.
      • Esterman A.
      • Fielder A.
      • Mikocka-Walus A.
      “My midwife said that having a glass of red wine was actually better for the baby”: a focus group study of women and their partner’s knowledge and experiences relating to alcohol consumption in pregnancy Fiona.
      ,
      • Sheridan K.
      Substance-using pregnant and parenting adolescent girls: considerations for preventive intervention using a resilience lens.
      ,
      • Grant A.
      • Morgan M.
      • Gallagher D.
      • Mannay D.
      Smoking during pregnancy, stigma and secrets: visual methods exploration in the UK.
      ,
      • Fergie L.
      • Coleman T.
      • Ussher M.
      • Cooper S.
      • Campbell K.A.
      Pregnant smokers’ experiences and opinions of techniques aimed to address barriers and facilitators to smoking cessation: a qualitative study.
      ]. Some women reported that “No one is more special than my baby” [
      • Nichter M.
      • Nichter M.
      • Muramoto M.
      • et al.
      Smoking among low-income pregnant women: an ethnographic analysis.
      ] adopting a moral responsibility towards prioritising their baby’s wellbeing which facilitated that they remained substance free [
      • Crawford-Williams F.
      • Steen M.
      • Esterman A.
      • Fielder A.
      • Mikocka-Walus A.
      “My midwife said that having a glass of red wine was actually better for the baby”: a focus group study of women and their partner’s knowledge and experiences relating to alcohol consumption in pregnancy Fiona.
      ,
      • Gamble J.
      • Grant J.
      • Tsourtos G.
      Missed opportunities: a qualitative exploration of the experiences of smoking cessation interventions among socially disadvantaged pregnant women.
      ,
      • Sheridan K.
      Substance-using pregnant and parenting adolescent girls: considerations for preventive intervention using a resilience lens.
      ,
      • Raymond N.
      • Beer C.
      • Glazebrook C.
      • Sayal K.
      Pregnant women’s attitudes towards alcohol consumption.
      ,
      • Nichter M.
      • Nichter M.
      • Muramoto M.
      • et al.
      Smoking among low-income pregnant women: an ethnographic analysis.
      ].“There’s a baby inside you. You know you’ve got to do it.” [
      • Grant A.
      • Morgan M.
      • Gallagher D.
      • Mannay D.
      Smoking during pregnancy, stigma and secrets: visual methods exploration in the UK.
      ] [Smoking]
      “My kid at 5 telling me that he doesn’t want me to die, it was heartbreaking” [
      • Bauld L.
      • Graham H.
      • Sinclair L.
      • et al.
      Barriers to and facilitators of smoking cessation in pregnancy and following childbirth: literature review and qualitative study.
      ] [Smoking]
      “The only reason why I quit was because I was pregnant, so I mean, if I hadn’t fallen pregnant, I’d probably still be smoking cigarettes now”
      Another factor associated with the pregnancy that acted as a facilitator was the pregnancy-related sickness, women found that smoking or drinking alcohol during their pregnancy made them feel sick resulting in women decreasing their substance use [
      • Bauld L.
      • Graham H.
      • Sinclair L.
      • et al.
      Barriers to and facilitators of smoking cessation in pregnancy and following childbirth: literature review and qualitative study.
      ,
      • Nichter M.
      • Nichter M.
      • Muramoto M.
      • et al.
      Smoking among low-income pregnant women: an ethnographic analysis.
      ,
      • Fergie L.
      • Coleman T.
      • Ussher M.
      • Cooper S.
      • Campbell K.A.
      Pregnant smokers’ experiences and opinions of techniques aimed to address barriers and facilitators to smoking cessation: a qualitative study.
      ,
      • Grant A.
      • Morgan M.
      • Mannay D.
      • Gallagher D.
      Understanding health behaviour in pregnancy and infant feeding intentions in low-income women from the UK through qualitative visual methods and application to the COM-B (capability, opportunity, motivation-behaviour) model.
      ].“Look, I don’t want to be like a reformed bitch of smoking, but the smoke is just making me sick.” [
      • Nichter M.
      • Nichter M.
      • Muramoto M.
      • et al.
      Smoking among low-income pregnant women: an ethnographic analysis.
      ]
      Theme 2: Feelings of shame and guilt
      In most of the studies, women referred to feelings of guilt and shame due to their substance use [
      • Bauld L.
      • Graham H.
      • Sinclair L.
      • et al.
      Barriers to and facilitators of smoking cessation in pregnancy and following childbirth: literature review and qualitative study.
      ,
      • Crawford-Williams F.
      • Steen M.
      • Esterman A.
      • Fielder A.
      • Mikocka-Walus A.
      “My midwife said that having a glass of red wine was actually better for the baby”: a focus group study of women and their partner’s knowledge and experiences relating to alcohol consumption in pregnancy Fiona.
      ,
      • Arborelius E.
      • Nyberg K.
      How should midwives discuss smoking behaviour in pregnancy with women of low educational attainment?.
      ,
      • Nichter M.
      • Nichter M.
      • Muramoto M.
      • et al.
      Smoking among low-income pregnant women: an ethnographic analysis.
      ,
      • Nichter M.
      • Nichter M.
      • Adrian S.
      • Goldade K.
      • Tesler L.
      • Muramoto M.
      Smoking and harm-reduction efforts among postpartum women.
      ,
      • Dunn C.L.
      • Pirie P.L.
      • Lando H.A.
      Attitudes and perceptions related to smoking among pregnant and postpartum women in a low-income, multiethnic setting.
      ,
      • Morris M.
      • Seibold C.
      • Webber R.
      Drugs and having babies: an exploration of how a specialist clinic meets the needs of chemically dependent pregnant women.
      ]. These negative feelings in combination with the external pressure from their social environment acted as barriers to abstaining from substance use for some women whereby “you feel even worse and in the end it becomes too much” [
      • Arborelius E.
      • Nyberg K.
      How should midwives discuss smoking behaviour in pregnancy with women of low educational attainment?.
      ] resulting in women’s stress levels increasing which lead to increased use of the substance as a coping strategy [
      • Arborelius E.
      • Nyberg K.
      How should midwives discuss smoking behaviour in pregnancy with women of low educational attainment?.
      ,
      • Dunn C.L.
      • Pirie P.L.
      • Lando H.A.
      Attitudes and perceptions related to smoking among pregnant and postpartum women in a low-income, multiethnic setting.
      ].I just can’t stand it. Sometimes I’ll even try to turn the guilt off, and it’s like it’s still in my head and, you know, what I’m doing and I don’t know why, it’s just so hard for me to quit. Oh, and the baby will kick when I’m smoking, it almost makes me like cry because it’s just like, I shouldn’t. [
      • Nichter M.
      • Nichter M.
      • Muramoto M.
      • et al.
      Smoking among low-income pregnant women: an ethnographic analysis.
      ] [Smoking]

      4.2 External factors

      Theme 3: Knowledge and information
      Category 3.1: Knowledge about the risks of substance use
      Many women discussed a lack of accurate knowledge about the risks women were taking when using substances during pregnancy. One factor that contributes to the generalised lack of accurate knowledge is the use of anecdotal evidence as a source of information and justification for substance use. Regardless of the substance, women often discussed their previous pregnancies or people they knew or heard of that had used substances during their pregnancy who had a healthy baby [
      • Bauld L.
      • Graham H.
      • Sinclair L.
      • et al.
      Barriers to and facilitators of smoking cessation in pregnancy and following childbirth: literature review and qualitative study.
      ,
      • Britton G.R.
      • Collier R.
      • McKitrick S.
      • et al.
      CE: Original research: The experiences of pregnant smokers and their providers.
      ,
      • Crawford-Williams F.
      • Steen M.
      • Esterman A.
      • Fielder A.
      • Mikocka-Walus A.
      “My midwife said that having a glass of red wine was actually better for the baby”: a focus group study of women and their partner’s knowledge and experiences relating to alcohol consumption in pregnancy Fiona.
      ,
      • Leppo A.
      ‘Subutex is safe’: perceptions of risk in using illicit drugs during pregnancy.
      ,
      • Sheridan K.
      Substance-using pregnant and parenting adolescent girls: considerations for preventive intervention using a resilience lens.
      ,
      • Arborelius E.
      • Nyberg K.
      How should midwives discuss smoking behaviour in pregnancy with women of low educational attainment?.
      ,
      • Raymond N.
      • Beer C.
      • Glazebrook C.
      • Sayal K.
      Pregnant women’s attitudes towards alcohol consumption.
      ,
      • Grant A.
      • Morgan M.
      • Gallagher D.
      • Mannay D.
      Smoking during pregnancy, stigma and secrets: visual methods exploration in the UK.
      ,
      • Nichter M.
      • Nichter M.
      • Muramoto M.
      • et al.
      Smoking among low-income pregnant women: an ethnographic analysis.
      ,
      • Van Scoyoc A.
      • Harrison J.A.
      • Fisher P.A.
      Beliefs and behaviors of pregnant women with addictions awaiting treatment initiation.
      ,
      • Dunn C.L.
      • Pirie P.L.
      • Lando H.A.
      Attitudes and perceptions related to smoking among pregnant and postpartum women in a low-income, multiethnic setting.
      ]. Generalising these individual cases might be contributing to the creation of misconceptions about the risks. Furthermore, using these counter examples as justification might also be used as a coping mechanism to reduce the guilt associated with their substance abuse.I drank a little bit with my first child and I carried on doing that with my second and third pregnancies. My first child is absolutely fine. [
      • Raymond N.
      • Beer C.
      • Glazebrook C.
      • Sayal K.
      Pregnant women’s attitudes towards alcohol consumption.
      ] [Alcohol]
      “So far from what I’ve seen, any girl that I know that’s done dope throughout their pregnancy, their kids are really overachievers. Which, I’m not trying to say, ‘use meth, it’ll make your kids smart.’ I’m just saying that the ones that I do know, there’s nothing wrong with their kids.” [
      • Van Scoyoc A.
      • Harrison J.A.
      • Fisher P.A.
      Beliefs and behaviors of pregnant women with addictions awaiting treatment initiation.
      ] [Illicit drugs]
      Women reported misconceptions about the risks of substance use, which were likely a consequence of using unreliable sources to obtain information in combination with the anecdotal evidence explained above. For instance, only heavy use was perceived as dangerous by many women [
      • Crawford-Williams F.
      • Steen M.
      • Esterman A.
      • Fielder A.
      • Mikocka-Walus A.
      “My midwife said that having a glass of red wine was actually better for the baby”: a focus group study of women and their partner’s knowledge and experiences relating to alcohol consumption in pregnancy Fiona.
      ,
      • Leppo A.
      ‘Subutex is safe’: perceptions of risk in using illicit drugs during pregnancy.
      ,
      • Raymond N.
      • Beer C.
      • Glazebrook C.
      • Sayal K.
      Pregnant women’s attitudes towards alcohol consumption.
      ,
      • Grant A.
      • Morgan M.
      • Gallagher D.
      • Mannay D.
      Smoking during pregnancy, stigma and secrets: visual methods exploration in the UK.
      ,
      • Nichter M.
      • Nichter M.
      • Muramoto M.
      • et al.
      Smoking among low-income pregnant women: an ethnographic analysis.
      ,
      • Fergie L.
      • Coleman T.
      • Ussher M.
      • Cooper S.
      • Campbell K.A.
      Pregnant smokers’ experiences and opinions of techniques aimed to address barriers and facilitators to smoking cessation: a qualitative study.
      ,
      • Barbosa-Leiker C.
      • Burduli E.
      • Smith C.L.
      • Brooks O.
      • Orr M.
      • Gartstein M.
      Daily cannabis use during pregnancy and postpartum in a state with legalized recreational cannabis.
      ,
      • Van Scoyoc A.
      • Harrison J.A.
      • Fisher P.A.
      Beliefs and behaviors of pregnant women with addictions awaiting treatment initiation.
      ,
      • Dunn C.L.
      • Pirie P.L.
      • Lando H.A.
      Attitudes and perceptions related to smoking among pregnant and postpartum women in a low-income, multiethnic setting.
      ,
      • Grant A.
      • Morgan M.
      • Mannay D.
      • Gallagher D.
      Understanding health behaviour in pregnancy and infant feeding intentions in low-income women from the UK through qualitative visual methods and application to the COM-B (capability, opportunity, motivation-behaviour) model.
      ] and hence “If you drink in moderation and you're sensible, then I don't think it affects the fetus” [
      • Raymond N.
      • Beer C.
      • Glazebrook C.
      • Sayal K.
      Pregnant women’s attitudes towards alcohol consumption.
      ]. The distinction between heavy and light use was made by the women in a subjective way, and in many cases, it was not based on medical evidence. For example, light alcohol use was defined by women as “one sip of wine” [
      • Crawford-Williams F.
      • Steen M.
      • Esterman A.
      • Fielder A.
      • Mikocka-Walus A.
      “My midwife said that having a glass of red wine was actually better for the baby”: a focus group study of women and their partner’s knowledge and experiences relating to alcohol consumption in pregnancy Fiona.
      ], “one or two [drinks]” [
      • Crawford-Williams F.
      • Steen M.
      • Esterman A.
      • Fielder A.
      • Mikocka-Walus A.
      “My midwife said that having a glass of red wine was actually better for the baby”: a focus group study of women and their partner’s knowledge and experiences relating to alcohol consumption in pregnancy Fiona.
      ], “drink in moderation” [
      • Raymond N.
      • Beer C.
      • Glazebrook C.
      • Sayal K.
      Pregnant women’s attitudes towards alcohol consumption.
      ]; whereas women defined light smoking as “four a day” [
      • Dunn C.L.
      • Pirie P.L.
      • Lando H.A.
      Attitudes and perceptions related to smoking among pregnant and postpartum women in a low-income, multiethnic setting.
      ], “an odd fag [cigarette] now and then” [
      • Grant A.
      • Morgan M.
      • Gallagher D.
      • Mannay D.
      Smoking during pregnancy, stigma and secrets: visual methods exploration in the UK.
      ], “under ten cigarettes a day” [
      • Nichter M.
      • Nichter M.
      • Muramoto M.
      • et al.
      Smoking among low-income pregnant women: an ethnographic analysis.
      ] or women considered illicit drug use safe when used “in low and steady doses” [
      • Leppo A.
      ‘Subutex is safe’: perceptions of risk in using illicit drugs during pregnancy.
      ,
      • Van Scoyoc A.
      • Harrison J.A.
      • Fisher P.A.
      Beliefs and behaviors of pregnant women with addictions awaiting treatment initiation.
      ]. Further, certain substances were seen as more dangerous than others [
      • Britton G.R.
      • Collier R.
      • McKitrick S.
      • et al.
      CE: Original research: The experiences of pregnant smokers and their providers.
      ,
      • Crawford-Williams F.
      • Steen M.
      • Esterman A.
      • Fielder A.
      • Mikocka-Walus A.
      “My midwife said that having a glass of red wine was actually better for the baby”: a focus group study of women and their partner’s knowledge and experiences relating to alcohol consumption in pregnancy Fiona.
      ,
      • Leppo A.
      ‘Subutex is safe’: perceptions of risk in using illicit drugs during pregnancy.
      ,
      • Nichter M.
      • Nichter M.
      • Muramoto M.
      • et al.
      Smoking among low-income pregnant women: an ethnographic analysis.
      ,
      • Barbosa-Leiker C.
      • Burduli E.
      • Smith C.L.
      • Brooks O.
      • Orr M.
      • Gartstein M.
      Daily cannabis use during pregnancy and postpartum in a state with legalized recreational cannabis.
      ,
      • Dunn C.L.
      • Pirie P.L.
      • Lando H.A.
      Attitudes and perceptions related to smoking among pregnant and postpartum women in a low-income, multiethnic setting.
      ] “alcohol was really bad, but there was no proof that meth did anything to the babies” [
      • Van Scoyoc A.
      • Harrison J.A.
      • Fisher P.A.
      Beliefs and behaviors of pregnant women with addictions awaiting treatment initiation.
      ], and some women thought that the consequences of quitting could be worse than the consequences of using [
      • Britton G.R.
      • Collier R.
      • McKitrick S.
      • et al.
      CE: Original research: The experiences of pregnant smokers and their providers.
      ,
      • Leppo A.
      ‘Subutex is safe’: perceptions of risk in using illicit drugs during pregnancy.
      ,
      • Nichter M.
      • Nichter M.
      • Muramoto M.
      • et al.
      Smoking among low-income pregnant women: an ethnographic analysis.
      ,
      • Van Scoyoc A.
      • Harrison J.A.
      • Fisher P.A.
      Beliefs and behaviors of pregnant women with addictions awaiting treatment initiation.
      ]. Some women also believed that the properties of the substance might benefit the baby [
      • Crawford-Williams F.
      • Steen M.
      • Esterman A.
      • Fielder A.
      • Mikocka-Walus A.
      “My midwife said that having a glass of red wine was actually better for the baby”: a focus group study of women and their partner’s knowledge and experiences relating to alcohol consumption in pregnancy Fiona.
      ,
      • Raymond N.
      • Beer C.
      • Glazebrook C.
      • Sayal K.
      Pregnant women’s attitudes towards alcohol consumption.
      ,
      • Van Scoyoc A.
      • Harrison J.A.
      • Fisher P.A.
      Beliefs and behaviors of pregnant women with addictions awaiting treatment initiation.
      ], with a women reporting that “babies that have been drug exposed may be more gifted, more creative, and more beautiful.” [
      • Van Scoyoc A.
      • Harrison J.A.
      • Fisher P.A.
      Beliefs and behaviors of pregnant women with addictions awaiting treatment initiation.
      ]. Other women thought that the risks are exaggerated [
      • Bauld L.
      • Graham H.
      • Sinclair L.
      • et al.
      Barriers to and facilitators of smoking cessation in pregnancy and following childbirth: literature review and qualitative study.
      ,
      • Britton G.R.
      • Collier R.
      • McKitrick S.
      • et al.
      CE: Original research: The experiences of pregnant smokers and their providers.
      ,
      • Leppo A.
      ‘Subutex is safe’: perceptions of risk in using illicit drugs during pregnancy.
      ,
      • Arborelius E.
      • Nyberg K.
      How should midwives discuss smoking behaviour in pregnancy with women of low educational attainment?.
      ,
      • Raymond N.
      • Beer C.
      • Glazebrook C.
      • Sayal K.
      Pregnant women’s attitudes towards alcohol consumption.
      ,
      • Nichter M.
      • Nichter M.
      • Muramoto M.
      • et al.
      Smoking among low-income pregnant women: an ethnographic analysis.
      ,
      • Van Scoyoc A.
      • Harrison J.A.
      • Fisher P.A.
      Beliefs and behaviors of pregnant women with addictions awaiting treatment initiation.
      ,
      • Dunn C.L.
      • Pirie P.L.
      • Lando H.A.
      Attitudes and perceptions related to smoking among pregnant and postpartum women in a low-income, multiethnic setting.
      ,
      • Morris M.
      • Seibold C.
      • Webber R.
      Drugs and having babies: an exploration of how a specialist clinic meets the needs of chemically dependent pregnant women.
      ], believing that the consequences of substance use on the fetus are “things that are fixable” [
      • Bauld L.
      • Graham H.
      • Sinclair L.
      • et al.
      Barriers to and facilitators of smoking cessation in pregnancy and following childbirth: literature review and qualitative study.
      ] once the baby is born [
      • Bauld L.
      • Graham H.
      • Sinclair L.
      • et al.
      Barriers to and facilitators of smoking cessation in pregnancy and following childbirth: literature review and qualitative study.
      ,
      • Britton G.R.
      • Collier R.
      • McKitrick S.
      • et al.
      CE: Original research: The experiences of pregnant smokers and their providers.
      ,
      • Van Scoyoc A.
      • Harrison J.A.
      • Fisher P.A.
      Beliefs and behaviors of pregnant women with addictions awaiting treatment initiation.
      ]. These misconceptions can act as barriers as women rationalise their substance use and decrease the feelings of guilt that women report feeling.“I don’t want that to sound nasty, but like having a small baby, the baby will grow, he can put on weight. . . and doctors are amazing now like. . . there’s more chance of the baby developing a cleft lip as well, that could be fixed with surgery.” [Smoking] [
      • Bauld L.
      • Graham H.
      • Sinclair L.
      • et al.
      Barriers to and facilitators of smoking cessation in pregnancy and following childbirth: literature review and qualitative study.
      ]
      Another barrier to remaining abstinent is that some women believe “nothing will happen to you” [
      • Dunn C.L.
      • Pirie P.L.
      • Lando H.A.
      Attitudes and perceptions related to smoking among pregnant and postpartum women in a low-income, multiethnic setting.
      ] and “nothing happens to the baby either” [
      • Dunn C.L.
      • Pirie P.L.
      • Lando H.A.
      Attitudes and perceptions related to smoking among pregnant and postpartum women in a low-income, multiethnic setting.
      ] and so they do not feel susceptible to the potential harms of the substances [
      • Bauld L.
      • Graham H.
      • Sinclair L.
      • et al.
      Barriers to and facilitators of smoking cessation in pregnancy and following childbirth: literature review and qualitative study.
      ,
      • Britton G.R.
      • Collier R.
      • McKitrick S.
      • et al.
      CE: Original research: The experiences of pregnant smokers and their providers.
      ,
      • Arborelius E.
      • Nyberg K.
      How should midwives discuss smoking behaviour in pregnancy with women of low educational attainment?.
      ,
      • Raymond N.
      • Beer C.
      • Glazebrook C.
      • Sayal K.
      Pregnant women’s attitudes towards alcohol consumption.
      ,
      • Grant A.
      • Morgan M.
      • Gallagher D.
      • Mannay D.
      Smoking during pregnancy, stigma and secrets: visual methods exploration in the UK.
      ,
      • Nichter M.
      • Nichter M.
      • Muramoto M.
      • et al.
      Smoking among low-income pregnant women: an ethnographic analysis.
      ,
      • Van Scoyoc A.
      • Harrison J.A.
      • Fisher P.A.
      Beliefs and behaviors of pregnant women with addictions awaiting treatment initiation.
      ,
      • Dunn C.L.
      • Pirie P.L.
      • Lando H.A.
      Attitudes and perceptions related to smoking among pregnant and postpartum women in a low-income, multiethnic setting.
      ]. In these cases, despite having some knowledge or awareness of the risks, women share the belief that this cannot happen to them, that “it only happens to other people”.
      On the other hand, having more accurate knowledge about the risks of substance use acted as a facilitator to prevent substance use during pregnancy [
      • Bauld L.
      • Graham H.
      • Sinclair L.
      • et al.
      Barriers to and facilitators of smoking cessation in pregnancy and following childbirth: literature review and qualitative study.
      ,
      • Britton G.R.
      • Collier R.
      • McKitrick S.
      • et al.
      CE: Original research: The experiences of pregnant smokers and their providers.
      ,
      • Crawford-Williams F.
      • Steen M.
      • Esterman A.
      • Fielder A.
      • Mikocka-Walus A.
      “My midwife said that having a glass of red wine was actually better for the baby”: a focus group study of women and their partner’s knowledge and experiences relating to alcohol consumption in pregnancy Fiona.
      ,
      • Gamble J.
      • Grant J.
      • Tsourtos G.
      Missed opportunities: a qualitative exploration of the experiences of smoking cessation interventions among socially disadvantaged pregnant women.
      ,
      • Leppo A.
      ‘Subutex is safe’: perceptions of risk in using illicit drugs during pregnancy.
      ,
      • Sheridan K.
      Substance-using pregnant and parenting adolescent girls: considerations for preventive intervention using a resilience lens.
      ,
      • Arborelius E.
      • Nyberg K.
      How should midwives discuss smoking behaviour in pregnancy with women of low educational attainment?.
      ,
      • Raymond N.
      • Beer C.
      • Glazebrook C.
      • Sayal K.
      Pregnant women’s attitudes towards alcohol consumption.
      ,
      • Grant A.
      • Morgan M.
      • Gallagher D.
      • Mannay D.
      Smoking during pregnancy, stigma and secrets: visual methods exploration in the UK.
      ,
      • Nichter M.
      • Nichter M.
      • Muramoto M.
      • et al.
      Smoking among low-income pregnant women: an ethnographic analysis.
      ,
      • Fergie L.
      • Coleman T.
      • Ussher M.
      • Cooper S.
      • Campbell K.A.
      Pregnant smokers’ experiences and opinions of techniques aimed to address barriers and facilitators to smoking cessation: a qualitative study.
      ,
      • Nichter M.
      • Nichter M.
      • Adrian S.
      • Goldade K.
      • Tesler L.
      • Muramoto M.
      Smoking and harm-reduction efforts among postpartum women.
      ,
      • Van Scoyoc A.
      • Harrison J.A.
      • Fisher P.A.
      Beliefs and behaviors of pregnant women with addictions awaiting treatment initiation.
      ]. In the case of alcohol, for instance, since the information about its risks can be contradictive and confusing, women tended to “go for the safety aspect, so because I'm not 100% sure, I just completely abstain to be on the safe side. [Alcohol]” [
      • Raymond N.
      • Beer C.
      • Glazebrook C.
      • Sayal K.
      Pregnant women’s attitudes towards alcohol consumption.
      ].
      In the case of smoking, besides being aware of the risks of the smoking itself [
      • Britton G.R.
      • Collier R.
      • McKitrick S.
      • et al.
      CE: Original research: The experiences of pregnant smokers and their providers.
      ,
      • Gamble J.
      • Grant J.
      • Tsourtos G.
      Missed opportunities: a qualitative exploration of the experiences of smoking cessation interventions among socially disadvantaged pregnant women.
      ,
      • Nichter M.
      • Nichter M.
      • Muramoto M.
      • et al.
      Smoking among low-income pregnant women: an ethnographic analysis.
      ,
      • Nichter M.
      • Nichter M.
      • Adrian S.
      • Goldade K.
      • Tesler L.
      • Muramoto M.
      Smoking and harm-reduction efforts among postpartum women.
      ,
      • Dunn C.L.
      • Pirie P.L.
      • Lando H.A.
      Attitudes and perceptions related to smoking among pregnant and postpartum women in a low-income, multiethnic setting.
      ], having knowledge about the risks of passive smoking [
      • Bauld L.
      • Graham H.
      • Sinclair L.
      • et al.
      Barriers to and facilitators of smoking cessation in pregnancy and following childbirth: literature review and qualitative study.
      ,
      • Dunn C.L.
      • Pirie P.L.
      • Lando H.A.
      Attitudes and perceptions related to smoking among pregnant and postpartum women in a low-income, multiethnic setting.
      ] and the influence of smoking on breastmilk [
      • Nichter M.
      • Nichter M.
      • Adrian S.
      • Goldade K.
      • Tesler L.
      • Muramoto M.
      Smoking and harm-reduction efforts among postpartum women.
      ] also acted as facilitators.“It gets not only into your lungs, but it gets into your bloodstream and everything, so why wouldn’t it get into your milk and go to the baby?” [
      • Nichter M.
      • Nichter M.
      • Adrian S.
      • Goldade K.
      • Tesler L.
      • Muramoto M.
      Smoking and harm-reduction efforts among postpartum women.
      ] [Smoking]
      Despite the fact that many women resort to counter examples and misinformation about the risks to rationalise their use and reduce their feelings of guilt, most of them are aware that there are certain risks associated to their behaviour [
      • Bauld L.
      • Graham H.
      • Sinclair L.
      • et al.
      Barriers to and facilitators of smoking cessation in pregnancy and following childbirth: literature review and qualitative study.
      ,
      • Britton G.R.
      • Collier R.
      • McKitrick S.
      • et al.
      CE: Original research: The experiences of pregnant smokers and their providers.
      ,
      • Crawford-Williams F.
      • Steen M.
      • Esterman A.
      • Fielder A.
      • Mikocka-Walus A.
      “My midwife said that having a glass of red wine was actually better for the baby”: a focus group study of women and their partner’s knowledge and experiences relating to alcohol consumption in pregnancy Fiona.
      ,
      • Gamble J.
      • Grant J.
      • Tsourtos G.
      Missed opportunities: a qualitative exploration of the experiences of smoking cessation interventions among socially disadvantaged pregnant women.
      ,
      • Leppo A.
      ‘Subutex is safe’: perceptions of risk in using illicit drugs during pregnancy.
      ,
      • Sheridan K.
      Substance-using pregnant and parenting adolescent girls: considerations for preventive intervention using a resilience lens.
      ,
      • Arborelius E.
      • Nyberg K.
      How should midwives discuss smoking behaviour in pregnancy with women of low educational attainment?.
      ,
      • Raymond N.
      • Beer C.
      • Glazebrook C.
      • Sayal K.
      Pregnant women’s attitudes towards alcohol consumption.
      ,
      • Nichter M.
      • Nichter M.
      • Muramoto M.
      • et al.
      Smoking among low-income pregnant women: an ethnographic analysis.
      ,
      • Fergie L.
      • Coleman T.
      • Ussher M.
      • Cooper S.
      • Campbell K.A.
      Pregnant smokers’ experiences and opinions of techniques aimed to address barriers and facilitators to smoking cessation: a qualitative study.
      ,
      • Barbosa-Leiker C.
      • Burduli E.
      • Smith C.L.
      • Brooks O.
      • Orr M.
      • Gartstein M.
      Daily cannabis use during pregnancy and postpartum in a state with legalized recreational cannabis.
      ,
      • Nichter M.
      • Nichter M.
      • Adrian S.
      • Goldade K.
      • Tesler L.
      • Muramoto M.
      Smoking and harm-reduction efforts among postpartum women.
      ,
      • Van Scoyoc A.
      • Harrison J.A.
      • Fisher P.A.
      Beliefs and behaviors of pregnant women with addictions awaiting treatment initiation.
      ,
      • Grant A.
      • Morgan M.
      • Mannay D.
      • Gallagher D.
      Understanding health behaviour in pregnancy and infant feeding intentions in low-income women from the UK through qualitative visual methods and application to the COM-B (capability, opportunity, motivation-behaviour) model.
      ]. This awareness led some women in these studies to take action in order to minimise the harms produced by their use [
      • Nichter M.
      • Nichter M.
      • Muramoto M.
      • et al.
      Smoking among low-income pregnant women: an ethnographic analysis.
      ,
      • Fergie L.
      • Coleman T.
      • Ussher M.
      • Cooper S.
      • Campbell K.A.
      Pregnant smokers’ experiences and opinions of techniques aimed to address barriers and facilitators to smoking cessation: a qualitative study.
      ,
      • Nichter M.
      • Nichter M.
      • Adrian S.
      • Goldade K.
      • Tesler L.
      • Muramoto M.
      Smoking and harm-reduction efforts among postpartum women.
      ,
      • Van Scoyoc A.
      • Harrison J.A.
      • Fisher P.A.
      Beliefs and behaviors of pregnant women with addictions awaiting treatment initiation.
      ,
      • Dunn C.L.
      • Pirie P.L.
      • Lando H.A.
      Attitudes and perceptions related to smoking among pregnant and postpartum women in a low-income, multiethnic setting.
      ]. In some instances, these changes were in line with common recommendations, whereas with others they were in response to their own perception of what was best for the baby.
      The most commonly reported strategy to reduce harm was trying to abstain or cutting down the substance use [
      • Bauld L.
      • Graham H.
      • Sinclair L.
      • et al.
      Barriers to and facilitators of smoking cessation in pregnancy and following childbirth: literature review and qualitative study.
      ,
      • Crawford-Williams F.
      • Steen M.
      • Esterman A.
      • Fielder A.
      • Mikocka-Walus A.
      “My midwife said that having a glass of red wine was actually better for the baby”: a focus group study of women and their partner’s knowledge and experiences relating to alcohol consumption in pregnancy Fiona.
      ,
      • McLeod D.
      • Benn C.
      • Pullon S.
      • et al.
      The midwife’s role in facilitating smoking behaviour change during pregnancy.
      ,
      • Nichter M.
      • Nichter M.
      • Muramoto M.
      • et al.
      Smoking among low-income pregnant women: an ethnographic analysis.
      ,
      • Nichter M.
      • Nichter M.
      • Adrian S.
      • Goldade K.
      • Tesler L.
      • Muramoto M.
      Smoking and harm-reduction efforts among postpartum women.
      ,
      • Van Scoyoc A.
      • Harrison J.A.
      • Fisher P.A.
      Beliefs and behaviors of pregnant women with addictions awaiting treatment initiation.
      ,
      • Dunn C.L.
      • Pirie P.L.
      • Lando H.A.
      Attitudes and perceptions related to smoking among pregnant and postpartum women in a low-income, multiethnic setting.
      ]. Cutting down to levels considered “not that much.”
      • Dunn C.L.
      • Pirie P.L.
      • Lando H.A.
      Attitudes and perceptions related to smoking among pregnant and postpartum women in a low-income, multiethnic setting.
      ] was perceived as a positive solution to balance the baby’s needs with their own needs, and it was advised by healthcare professionals when unable to abstain completely [
      • Nichter M.
      • Nichter M.
      • Muramoto M.
      • et al.
      Smoking among low-income pregnant women: an ethnographic analysis.
      ,
      • Dunn C.L.
      • Pirie P.L.
      • Lando H.A.
      Attitudes and perceptions related to smoking among pregnant and postpartum women in a low-income, multiethnic setting.
      ]. Women also tried to compensate with other health behaviours [
      • Crawford-Williams F.
      • Steen M.
      • Esterman A.
      • Fielder A.
      • Mikocka-Walus A.
      “My midwife said that having a glass of red wine was actually better for the baby”: a focus group study of women and their partner’s knowledge and experiences relating to alcohol consumption in pregnancy Fiona.
      ,
      • McLeod D.
      • Benn C.
      • Pullon S.
      • et al.
      The midwife’s role in facilitating smoking behaviour change during pregnancy.
      ,
      • Nichter M.
      • Nichter M.
      • Muramoto M.
      • et al.
      Smoking among low-income pregnant women: an ethnographic analysis.
      ,
      • Nichter M.
      • Nichter M.
      • Adrian S.
      • Goldade K.
      • Tesler L.
      • Muramoto M.
      Smoking and harm-reduction efforts among postpartum women.
      ,
      • Van Scoyoc A.
      • Harrison J.A.
      • Fisher P.A.
      Beliefs and behaviors of pregnant women with addictions awaiting treatment initiation.
      ,
      • Dunn C.L.
      • Pirie P.L.
      • Lando H.A.
      Attitudes and perceptions related to smoking among pregnant and postpartum women in a low-income, multiethnic setting.
      ] such as “eating more frequently” [
      • Van Scoyoc A.
      • Harrison J.A.
      • Fisher P.A.
      Beliefs and behaviors of pregnant women with addictions awaiting treatment initiation.
      ] and “sleep every night” [
      • Van Scoyoc A.
      • Harrison J.A.
      • Fisher P.A.
      Beliefs and behaviors of pregnant women with addictions awaiting treatment initiation.
      ], and keeping themselves busy and distracted whereby “instead of smoking, doing the kids’ sandwiches” [
      • Fergie L.
      • Coleman T.
      • Ussher M.
      • Cooper S.
      • Campbell K.A.
      Pregnant smokers’ experiences and opinions of techniques aimed to address barriers and facilitators to smoking cessation: a qualitative study.
      ] or doing exercise to release stress [
      • Fergie L.
      • Coleman T.
      • Ussher M.
      • Cooper S.
      • Campbell K.A.
      Pregnant smokers’ experiences and opinions of techniques aimed to address barriers and facilitators to smoking cessation: a qualitative study.
      ]. Other women limited relationships with other users [
      • Van Scoyoc A.
      • Harrison J.A.
      • Fisher P.A.
      Beliefs and behaviors of pregnant women with addictions awaiting treatment initiation.
      ]. Women also reported changing their habit to what they considered safer [
      • Bauld L.
      • Graham H.
      • Sinclair L.
      • et al.
      Barriers to and facilitators of smoking cessation in pregnancy and following childbirth: literature review and qualitative study.
      ,
      • Nichter M.
      • Nichter M.
      • Muramoto M.
      • et al.
      Smoking among low-income pregnant women: an ethnographic analysis.
      ,
      • Van Scoyoc A.
      • Harrison J.A.
      • Fisher P.A.
      Beliefs and behaviors of pregnant women with addictions awaiting treatment initiation.
      ], for example switching substance [
      • Van Scoyoc A.
      • Harrison J.A.
      • Fisher P.A.
      Beliefs and behaviors of pregnant women with addictions awaiting treatment initiation.
      ] or type of administration [
      • Van Scoyoc A.
      • Harrison J.A.
      • Fisher P.A.
      Beliefs and behaviors of pregnant women with addictions awaiting treatment initiation.
      ]. Although not always adaptive, these behaviours show that women have some motivation to change their habits and therefore considered them facilitators.“We posted a big sign on the front door saying, ‘No Drugs.’” [
      • Van Scoyoc A.
      • Harrison J.A.
      • Fisher P.A.
      Beliefs and behaviors of pregnant women with addictions awaiting treatment initiation.
      ],
      “I was just like, well, ok, in the morning I can just drink coffee instead [of using methamphetamine].’’ When this didn’t work, she tried switching to drinking alcohol, “I will just replace that [methamphetamine] with X amount, with alcohol” [
      • Van Scoyoc A.
      • Harrison J.A.
      • Fisher P.A.
      Beliefs and behaviors of pregnant women with addictions awaiting treatment initiation.
      ]

      Category 3.2: Sources and quality of information

      On several occasions, women reported a lack of sources of information regarding the risks of the substance they were using [
      • Bauld L.
      • Graham H.
      • Sinclair L.
      • et al.
      Barriers to and facilitators of smoking cessation in pregnancy and following childbirth: literature review and qualitative study.
      ,
      • Crawford-Williams F.
      • Steen M.
      • Esterman A.
      • Fielder A.
      • Mikocka-Walus A.
      “My midwife said that having a glass of red wine was actually better for the baby”: a focus group study of women and their partner’s knowledge and experiences relating to alcohol consumption in pregnancy Fiona.
      ,
      • Leppo A.
      ‘Subutex is safe’: perceptions of risk in using illicit drugs during pregnancy.
      ,
      • Raymond N.
      • Beer C.
      • Glazebrook C.
      • Sayal K.
      Pregnant women’s attitudes towards alcohol consumption.
      ,
      • Barbosa-Leiker C.
      • Burduli E.
      • Smith C.L.
      • Brooks O.
      • Orr M.
      • Gartstein M.
      Daily cannabis use during pregnancy and postpartum in a state with legalized recreational cannabis.
      ,
      • Nichter M.
      • Nichter M.
      • Adrian S.
      • Goldade K.
      • Tesler L.
      • Muramoto M.
      Smoking and harm-reduction efforts among postpartum women.
      ,
      • Van Scoyoc A.
      • Harrison J.A.
      • Fisher P.A.
      Beliefs and behaviors of pregnant women with addictions awaiting treatment initiation.
      ,
      • Grant A.
      • Morgan M.
      • Mannay D.
      • Gallagher D.
      Understanding health behaviour in pregnancy and infant feeding intentions in low-income women from the UK through qualitative visual methods and application to the COM-B (capability, opportunity, motivation-behaviour) model.
      ]. There was a perceived lack of evidence about the risks reported by women [
      • Leppo A.
      ‘Subutex is safe’: perceptions of risk in using illicit drugs during pregnancy.
      ,
      • Barbosa-Leiker C.
      • Burduli E.
      • Smith C.L.
      • Brooks O.
      • Orr M.
      • Gartstein M.
      Daily cannabis use during pregnancy and postpartum in a state with legalized recreational cannabis.
      ,
      • Van Scoyoc A.
      • Harrison J.A.
      • Fisher P.A.
      Beliefs and behaviors of pregnant women with addictions awaiting treatment initiation.
      ] “I’ve actually heard they don’t exactly know what is safe and what isn’t. Because they don’t know they say not to do it [Alcohol]” [
      • Crawford-Williams F.
      • Steen M.
      • Esterman A.
      • Fielder A.
      • Mikocka-Walus A.
      “My midwife said that having a glass of red wine was actually better for the baby”: a focus group study of women and their partner’s knowledge and experiences relating to alcohol consumption in pregnancy Fiona.
      ], and in many cases, women spoke about not having specific information [
      • Bauld L.
      • Graham H.
      • Sinclair L.
      • et al.
      Barriers to and facilitators of smoking cessation in pregnancy and following childbirth: literature review and qualitative study.
      ,
      • Nichter M.
      • Nichter M.
      • Adrian S.
      • Goldade K.
      • Tesler L.
      • Muramoto M.
      Smoking and harm-reduction efforts among postpartum women.
      ] about “what damage does [Smoking] actually do to the placenta, you know, proper sort of medical facts” [
      • Herbec A.
      • Beard E.
      • Brown J.
      • Gardner B.
      • Tombor I.
      • West R.
      The needs and preferences of pregnant smokers regarding tailored internet-based smoking cessation interventions: a qualitative interview study.
      ].“If I was given more information, you know, per scientific research studies, I could maybe make a more informed decision” [
      • Barbosa-Leiker C.
      • Burduli E.
      • Smith C.L.
      • Brooks O.
      • Orr M.
      • Gartstein M.
      Daily cannabis use during pregnancy and postpartum in a state with legalized recreational cannabis.
      ] [Cannabis]
      Another reported issue that acts as barrier is the poor communication between healthcare professionals and women about substance use. Women reported only being asked about their substance use at their booking visit “there was no other conversation about it” [
      • Crawford-Williams F.
      • Steen M.
      • Esterman A.
      • Fielder A.
      • Mikocka-Walus A.
      “My midwife said that having a glass of red wine was actually better for the baby”: a focus group study of women and their partner’s knowledge and experiences relating to alcohol consumption in pregnancy Fiona.
      ] or if there was discussion it was on very limited occasions [
      • Bauld L.
      • Graham H.
      • Sinclair L.
      • et al.
      Barriers to and facilitators of smoking cessation in pregnancy and following childbirth: literature review and qualitative study.
      ,
      • Crawford-Williams F.
      • Steen M.
      • Esterman A.
      • Fielder A.
      • Mikocka-Walus A.
      “My midwife said that having a glass of red wine was actually better for the baby”: a focus group study of women and their partner’s knowledge and experiences relating to alcohol consumption in pregnancy Fiona.
      ,
      • Gamble J.
      • Grant J.
      • Tsourtos G.
      Missed opportunities: a qualitative exploration of the experiences of smoking cessation interventions among socially disadvantaged pregnant women.
      ,
      • Barbosa-Leiker C.
      • Burduli E.
      • Smith C.L.
      • Brooks O.
      • Orr M.
      • Gartstein M.
      Daily cannabis use during pregnancy and postpartum in a state with legalized recreational cannabis.
      ,
      • Nichter M.
      • Nichter M.
      • Adrian S.
      • Goldade K.
      • Tesler L.
      • Muramoto M.
      Smoking and harm-reduction efforts among postpartum women.
      ]. The discussions about their substance use were very superficial and generalised, and lacked practical advice [
      • Bauld L.
      • Graham H.
      • Sinclair L.
      • et al.
      Barriers to and facilitators of smoking cessation in pregnancy and following childbirth: literature review and qualitative study.
      ,
      • Britton G.R.
      • Collier R.
      • McKitrick S.
      • et al.
      CE: Original research: The experiences of pregnant smokers and their providers.
      ,
      • Nichter M.
      • Nichter M.
      • Muramoto M.
      • et al.
      Smoking among low-income pregnant women: an ethnographic analysis.
      ], leaving women with poor understanding of the risks [
      • Bauld L.
      • Graham H.
      • Sinclair L.
      • et al.
      Barriers to and facilitators of smoking cessation in pregnancy and following childbirth: literature review and qualitative study.
      ,
      • Nichter M.
      • Nichter M.
      • Adrian S.
      • Goldade K.
      • Tesler L.
      • Muramoto M.
      Smoking and harm-reduction efforts among postpartum women.
      ,
      • Dunn C.L.
      • Pirie P.L.
      • Lando H.A.
      Attitudes and perceptions related to smoking among pregnant and postpartum women in a low-income, multiethnic setting.
      ].“My doctor just tells me that it’s really important for me to quit. Well, I know that already, and I want to quit too. If it were so easy, I would have done it already. So when he says that to me, I just say, “Okay,” and that’s the end of the conversation” [
      • Nichter M.
      • Nichter M.
      • Muramoto M.
      • et al.
      Smoking among low-income pregnant women: an ethnographic analysis.
      ] [Smoking]
      Further, on several occasions women spoke about receiving conflicting information from different sources [
      • Borland T.
      • Babayan A.
      • Irfan S.
      • Schwartz R.
      Exploring the adequacy of smoking cessation support for pregnant and postpartum women.
      ,
      • Crawford-Williams F.
      • Steen M.
      • Esterman A.
      • Fielder A.
      • Mikocka-Walus A.
      “My midwife said that having a glass of red wine was actually better for the baby”: a focus group study of women and their partner’s knowledge and experiences relating to alcohol consumption in pregnancy Fiona.
      ,
      • Gamble J.
      • Grant J.
      • Tsourtos G.
      Missed opportunities: a qualitative exploration of the experiences of smoking cessation interventions among socially disadvantaged pregnant women.
      ,
      • Herbec A.
      • Beard E.
      • Brown J.
      • Gardner B.
      • Tombor I.
      • West R.
      The needs and preferences of pregnant smokers regarding tailored internet-based smoking cessation interventions: a qualitative interview study.
      ,
      • Raymond N.
      • Beer C.
      • Glazebrook C.
      • Sayal K.
      Pregnant women’s attitudes towards alcohol consumption.
      ,
      • Barbosa-Leiker C.
      • Burduli E.
      • Smith C.L.
      • Brooks O.
      • Orr M.
      • Gartstein M.
      Daily cannabis use during pregnancy and postpartum in a state with legalized recreational cannabis.
      ,
      • Grant A.
      • Morgan M.
      • Mannay D.
      • Gallagher D.
      Understanding health behaviour in pregnancy and infant feeding intentions in low-income women from the UK through qualitative visual methods and application to the COM-B (capability, opportunity, motivation-behaviour) model.
      ], including amongst different healthcare professionals [
      • Bauld L.
      • Graham H.
      • Sinclair L.
      • et al.
      Barriers to and facilitators of smoking cessation in pregnancy and following childbirth: literature review and qualitative study.
      ,
      • Borland T.
      • Babayan A.
      • Irfan S.
      • Schwartz R.
      Exploring the adequacy of smoking cessation support for pregnant and postpartum women.
      ,
      • Britton G.R.
      • Collier R.
      • McKitrick S.
      • et al.
      CE: Original research: The experiences of pregnant smokers and their providers.
      ,
      • Gamble J.
      • Grant J.
      • Tsourtos G.
      Missed opportunities: a qualitative exploration of the experiences of smoking cessation interventions among socially disadvantaged pregnant women.
      ,
      • Herbec A.
      • Beard E.
      • Brown J.
      • Gardner B.
      • Tombor I.
      • West R.
      The needs and preferences of pregnant smokers regarding tailored internet-based smoking cessation interventions: a qualitative interview study.
      ,
      • McLeod D.
      • Benn C.
      • Pullon S.
      • et al.
      The midwife’s role in facilitating smoking behaviour change during pregnancy.
      ,
      • Nichter M.
      • Nichter M.
      • Muramoto M.
      • et al.
      Smoking among low-income pregnant women: an ethnographic analysis.
      ,
      • Barbosa-Leiker C.
      • Burduli E.
      • Smith C.L.
      • Brooks O.
      • Orr M.
      • Gartstein M.
      Daily cannabis use during pregnancy and postpartum in a state with legalized recreational cannabis.
      ,
      • Nichter M.
      • Nichter M.
      • Adrian S.
      • Goldade K.
      • Tesler L.
      • Muramoto M.
      Smoking and harm-reduction efforts among postpartum women.
      ], and also, there were occasions in which family or friends of the woman would act as source of information [
      • Leppo A.
      ‘Subutex is safe’: perceptions of risk in using illicit drugs during pregnancy.
      ,
      • Morris M.
      • Seibold C.
      • Webber R.
      Drugs and having babies: an exploration of how a specialist clinic meets the needs of chemically dependent pregnant women.
      ].“So like my GP I didn’t really get a definitive answer…Whereas when I went to my midwife, for my antenatal appointment that was clearly communicated from day one…” [
      • Crawford-Williams F.
      • Steen M.
      • Esterman A.
      • Fielder A.
      • Mikocka-Walus A.
      “My midwife said that having a glass of red wine was actually better for the baby”: a focus group study of women and their partner’s knowledge and experiences relating to alcohol consumption in pregnancy Fiona.
      ].
      “My doctor, he doesn’t like that I use marijuana at all. […] And once I was pregnant, he’s like, ‘You’ve got to stop.’ And I did stop when we talked about it. But then when I told him my OB’s decision to let me linger a bit, at least until I’m like 20 weeks or so to see if the morning sickness goes away […] He doesn’t like it, but my OB doctor totally understands.” [
      • Barbosa-Leiker C.
      • Burduli E.
      • Smith C.L.
      • Brooks O.
      • Orr M.
      • Gartstein M.
      Daily cannabis use during pregnancy and postpartum in a state with legalized recreational cannabis.
      ]
      Theme 4: Experiences within healthcare system
      Category 4.1: Relationship with healthcare professionals
      Women expressed feeling judged and stigmatised for their substance use during their antenatal care [
      • Borland T.
      • Babayan A.
      • Irfan S.
      • Schwartz R.
      Exploring the adequacy of smoking cessation support for pregnant and postpartum women.
      ,
      • Britton G.R.
      • Collier R.
      • McKitrick S.
      • et al.
      CE: Original research: The experiences of pregnant smokers and their providers.