Attitudes toward alcohol use during pregnancy among women recruited from alcohol-serving venues in Cape Town, South Africa: A mixed-methods study

Background: The Western Cape Province of South Africa has one of the highest rates of fetal alcohol spectrum disorder (FASD) globally. Effective prevention of FASD requires understanding women's attitudes about alcohol use during pregnancy and whether these attitudes translate into behavior. Objective: The goal of this mixed-methods study was to describe attitudes toward alcohol use during pregnancy and examine how these attitudes influence drinking behaviors during pregnancy. Method: Over a five month period, 200 women were recruited from alcohol-serving venues in a township in Cape Town; a sub-set of 23 also completed in-depth interviews. Potential gaps between attitudes and behavior were described, and logistic regression models examined predictors of harmful attitudes toward alcohol use during pregnancy. Interviews were reviewed and coded for emergent themes. Results: Most women (n = 176) reported at least one pregnancy. Among these, the majority (83%) had positive preventive attitudes, but more than half of these still reported alcohol use during a previous pregnancy. The strongest predictors of harmful attitudes were a history of physical or sexual abuse and drinking during a previous pregnancy. Qualitative analysis revealed several themes that contributed to alcohol use during pregnancy: 1) having an unplanned pregnancy; 2) drinking because of stress or to cope with abuse/trauma; 3) reliance on the venue for support; 4) socialization; and 5) feelings of invincibility. Conclusions: The findings highlight an attitude-behavior gap and suggest that positive preventive attitudes are insufficient to elicit FASD preventive behavior. Interventions are needed that go beyond education to build intrinsic motivation and structural support to refrain from alcohol use during pregnancy.