Stigma, Silence, and Substance Use: A Qualitative Study of Barriers to Care Among Pregnant Women in Nigeria

Abstract

While substance use during pregnancy poses significant risks to maternal and fetal health globally, limited qualitative evidence exists on how cultural stigma and silence function as barriers to healthcare access in Sub-Saharan African contexts, particularly Nigeria. This qualitative study aimed to explore the lived experiences of pregnant women with substance use issues in Nigeria, examining how stigma and silence shape healthcare-seeking behaviors and treatment access. Using a descriptive qualitative design informed by phenomenological approaches, we conducted in-depth semi-structured interviews with 100 pregnant women across four Nigerian states (Lagos, Kano, Rivers, and Borno) and eight focus group discussions between March and September 2023. Participants were recruited through purposive and snowball sampling. Data were analyzed using Braun and Clarke's six-phase thematic analysis approach. Thematic analysis identified five interconnected barriers: (1) pervasive cultural stigma surrounding substance use during pregnancy; (2) silence as both a coping mechanism and barrier to care; (3) healthcare provider inadequacies including judgmental attitudes and insufficient addiction training; (4) limited access to specialized treatment services; and (5) negative family and community influences on help-seeking behaviors. Participants reported intense fear of disclosure, discrimination, and social ostracization, which significantly deterred engagement with appropriate care. A majority (93%) experienced shame and guilt, while 89% faced financial constraints to accessing services. Stigma and silence constitute formidable, multilayered barriers requiring comprehensive interventions targeting cultural attitudes, healthcare provider training, and service availability to improve maternal and fetal health outcomes in Nigeria. This study contributes in-depth qualitative understanding of the mechanisms through which stigma operates at individual, interpersonal, and structural levels in the Nigerian context.