Substance Use Among Young Mothers: An Analysis of Facebook Posts

Introduction

Substance use among young pregnant women is common and a significant public health concern. While pregnancy is associated with significant reductions in alcohol, cigarettes, and other drug use, both alcohol and illicit drug use remain frequent problems during pregnancy. National surveys reveal that among women aged 15-44 years who are early in their pregnancy, 16.5% report alcohol use in the past month, 10.8% report heavy episodic drinking (ie, binge drinking; ≥4 drinks in a row), and 11.5% report illicit drug use. Compared with young adult and adult women, adolescent women report the highest rates of illicit drug use during pregnancy [1].

The American College of Obstetricians and Gynecologists has recommended routine screening and brief interventions for substance use during pregnancy. Marijuana use is emerging as an area of particular concern for childbearing women—for whom marijuana is the most commonly reported illicit drug [1]—given the associated risks for both mothers and infants. For instance, cannabis users are at increased risk of depression, and children exposed to marijuana prenatally have impaired outcomes across several cognitive domains [2,3]. Among a national sample of adolescents aged 12-17 years, 6.5% reported current marijuana use, and 12.0% reported use in the past year [1]. When compared with nonpregnant adolescent girls, pregnant adolescent girls reported rates of marijuana use that were twice as high as nonpregnant peers (6.45% vs 14%, respectively) [4]. Studies have demonstrated that pregnant and nonpregnant women more commonly perceive regular marijuana use as having no risk to their health [5], which may be attributed to remaining areas of uncertainty in the literature regarding effects of marijuana use on the developing fetus, such as fetal growth [6,7]. This discrepancy between perceived safety and physician-identified risk is one of several obstacles that may exist for disclosure of stigmatized behaviors during pregnancy. Technology can help to overcome such barriers. Social media posts can provide insight into young women’s perceptions of substance use that complements data from traditional qualitative research, providing direct observations of their posted views. With the widespread availability of smartphones and internet access, social media has changed the landscape of information gathering and sharing with respect to substance use among adolescents [8,9]. This study aims to characterize the frequency and content of Facebook posts regarding substance use in the year before pregnancy and during pregnancy among young mothers.

Methods

Facebook posts were mined from 43 young pregnant women (age 16-24 years) who were recruited as a convenience sample and consented from 2 Midwest primary care clinics that serve a predominantly low-income community. The text-based Facebook posts authored by consented women were extracted using the Facebook application programming interface (API). Posts were extracted at study recruitment (typically in the first trimester) and again later in pregnancy (typically in the second or third trimester). At study recruitment, women also provided demographic information, estimated date of delivery, and the date they recalled discovering they were pregnant. During each data extraction, study participants logged on to their Facebook account to grant access, and access was lost once they signed out. Natural language processing was used to identify posts related to substance use by searching posts by keywords (eg, drunk, drugs, pot, and meth) and their morphological variants. Keywords included common synonyms and brand names for alcohol, tobacco, and illicit drugs and were supplemented by internet searching for colloquial synonyms and slang. Additional words were added from synonyms of derivationally related forms from a lexical database, WordNet [10]. Multimedia Appendix 1 provides a full list of keywords that were searched. These identified posts were separated by time stamp into prepregnancy and pregnancy posts. Facebook posts that occurred during pregnancy were identified by a timestamp occurring after the subject’s last menstrual period (LMP), which was imputed from the estimated date of delivery. Facebook posts that occurred within the year prior to pregnancy were identified by a timestamp occurring <1 year prior to the LMP. Substance-related post frequency was compared before and after subjects discovered they were pregnant, using the paired sample t test. Using mixed-methods techniques and an inductive framework, 2 investigators (DO and GTW) coded and identified major themes around substance use. Notably, only English-language posts were coded. Codes were derived iteratively, and a formal codebook was established after consensus or discussion between at least 2 investigators, with a third investigator (TC) resolving any disagreements. Posts were not required to identify self-use by the subject to be coded as substance-related. Outcome measures include the frequency of posts and major themes expressed regarding substance use before and during pregnancy. This study was approved by the Institutional Review Board of the University of Michigan (HUM00104989).

Results

Quantitative Results

This study included 43 young women aged 16-24 years. Table 1 presents participants’ characteristics. Facebook posts were last extracted at a median of 33 weeks gestational age. Approximately 2% of posts were in Spanish and not analyzed. Facebook posts revealed that young women are discussing the use of substances, predominantly marijuana, alcohol, and tobacco (cigarettes, hookah), before and during pregnancy (Table 2). Overall, 70% (30/43) of subjects posted about substances during the 1 year prior to pregnancy through the end of pregnancy. Furthermore, 56% (24/43) of subjects posted about substances during their pregnancies.

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The average total Facebook posting frequency (not restricted to posts about substance use) did not appear to change appreciably throughout pregnancy. However, the number of posts about substance use appeared to decrease after pregnancy compared with before pregnancy, most markedly after the date on which participants found out that they were pregnant (Figures 1 and 2). The paired sample t test supported a mean difference in substance-related post frequency between the periods before and after subjects discovered their pregnancies (t₄₂=2.3, P=.03).

Qualitative Results

Posts that reference substance use in the year prior to pregnancy (Table 3) predominantly focused on use or anticipated use of substances by subjects (118/158, 75% of substance-related posts; “i'm bout 3 shots from drunk tf”). Posts were unlikely to contain an overt value judgment about substance use, but generally referred to substance use in a positive or neutral tone (“I do love my vodka lol”). The most common themes of posts were cravings for substance use (“man i'm up, need to find weed and smoke asap. i fucking hate credit cards bruh”) and references about intoxication (eg, high, drunk, etc; “ima lil tipsy bih right now [4 smiling face with horns emojis]”). Posts describing social substance use (such as use with a friend or at a party) again typically described self-use by subjects (29/32 posts) but often suggested comradery-building (“someone come threw and smoke…i mean shit, we'll become friends! lmao!”).

Fewer substance-related posts during pregnancy (Table 4) described substance use by subjects (28/76, 37%) than in the year prior to pregnancy (118/158, 75%). Of posts describing self-use during pregnancy, the majority was written before subjects discovered they were pregnant (18/28, 64%). The most common theme was discussion of negative aspects of substance use (posts discussing abstinence from substance use were also included in this theme). These posts described the dangers of substance use among pregnant women and their concerns about use around their family or themselves during pregnancy (“i hate it when people who smoke cigarettes come all up in my face and talk to me. if you don't get yo nicotine tobacco smelling ass breath out my face...... ugh.”). Some of these posts demonstrated ambivalence about the types of substance use (“smoking does kill but we ain't talking about weed”) or complete abstinence (“4 days no drinking 4 days no squares and 3 days no weed!”). Another common theme was a discussion of social aspects of substance use. These posts often referred to the social challenges of abstinence (ie, lack of social interaction that includes substance use; “where are the people that know how 2 communicate? can have good conversation w/a sense of humor w/o being drunk or high? too many negative nancy's around here, positive vibes only!”). Furthermore, major themes included craving substances (less common than in the year prior to pregnancy) and references to intoxication (most commonly referring to intoxication in others).

Discussion

Principal Findings

We characterized Facebook posts regarding substance use in the year before pregnancy and during pregnancy among a sample of young mothers. We found that the frequency of posts related to substances decreased after subjects discovered they were pregnant; this may represent a decline in the presence of substance use among the lives of young women when they become pregnant or may represent a social stigma of discussing substance use while pregnant. We are not aware of prior research that captures the total or substance-related social media posting frequency throughout pregnancy, though a cross-sectional study showed pregnant women frequently check social media [11].

Pregnancy is a window of opportunity that prompts the majority of women to either reduce or abstain from alcohol and substance use for the remainder of their pregnancy [12]. Many of the substance-related Facebook posts we identified during pregnancy reflected this increased focus on abstinence from and negative consequences of substance use. However, a subset of women continue using substances during pregnancy [1,4]. Our sample of pregnant young women often discussed substance use in ways that highlighted the need for continued interventions to support their abstinence from substances during pregnancy. For instance, women in our sample often expressed a loss of social support because they were not able to participate in the social use of substances; this is similar to a prior qualitative study of Australian women who identified social alcohol consumption as motivation for continued use throughout pregnancy [13]. Unique to this study, some of the posts suggested social abandonment instead of simple loss of social activities: “bitches don't hit you up to check on you if you ain't got a bottle or a blunt.” This finding may reflect a study population with fewer baseline social resources and is amplified by the vivid verbiage found in Facebook posts throughout our sample. Furthermore, although the women in our sample appeared to have knowledge about the need to abstain from substance use during pregnancy, they often expressed some ambivalence about the need to avoid all substances at all times, particularly marijuana. Reportedly, marijuana use during pregnancy is on the rise [14], increasing by 62% over the past decade; this increase has been attributed, in part, to an increased perception of the safety of marijuana use during pregnancy [4,5]. Clinicians should acknowledge the role of substance use in the lives of youth and find ways to ensure these young women are supported and empowered to make healthy decisions during pregnancy.

Disclosure of sensitive topics, such as substance use during pregnancy, is challenging because of social stigma, but can be facilitated by the use of technology. Social media posts by young women can provide valuable insight into their perceptions of substance use during the vulnerable time of pregnancy, with observations unencumbered by a formal research setting. Such information can be used toward preventive efforts in reducing use during pregnancy by identifying the circumstances around why substances are used (ie, social support and addiction) and assist in targeting resources and programs for at-risk mothers.

Limitations

Although this study represents a novel investigation of substance use, it has a number of limitations. Despite an extensive database of search terms, it is possible that some posts were missed owing to posts with nonsemantic use of words that refer to risk-taking behaviors or novel slang not found during internet searching. However, search terms were identified using a variety of methods that included modern youth-centered vernacular. In addition, some posts related to substance use may be posted through pictures only, which were not analyzed in this study. Posts were extracted at 2 times in pregnancy (at enrollment and a later date in the second or third trimester), and anticipated extraction of posts could have introduced a potential desirability bias; this is felt to be less likely as the research team is only a small part of a much larger audience that would be anticipated to read the posts. Moreover, the quantitative analysis of post frequency is limited by the small sample size and a relatively low proportion of substance-related posts. However, the qualitative data collected provides important nuance and context to these dangerous behaviors among a high proportion of young mothers in our diverse sample. Finally, although our sample included a diverse range of race or ethnicities, findings from our small study may not be generalizable to larger populations of youth.

Conclusions

Our evaluation of Facebook posts reveals that young pregnant women are discussing the use of substances, predominantly alcohol and marijuana. Providers that care for young pregnant mothers can anticipate and acknowledge the possible loss of social interaction related to substance use and support women in remaining abstinent throughout pregnancy. Future work that explores youth-centered interventions to prevent and treat substance use before and during pregnancy among young, at-risk mothers could improve outcomes for both mothers and their children.