In search of social belonging: a qualitative study of drivers of alcohol use and barriers to alcohol reduction among pregnant women in South Africa

Abstract

Abstract Background Alcohol use during pregnancy remains a major public health concern in South Africa, particularly in communities with entrenched historical, social, and structural drivers of harmful drinking. Saldanha Bay, a peri-urban fishing community in the Western Cape, has among the highest reported rates of fetal alcohol spectrum disorder globally. Understanding the multilevel social and structural dynamics that sustain alcohol use in pregnancy is essential to inform contextually appropriate interventions. Methods Formative qualitative research to inform the adaptation of a peer-led intervention to reduce alcohol use during pregnancy was conducted between January and June 2025. We held two focus group discussions, one with healthcare providers ( n = 6) and one with community leaders ( n = 7) and conducted in-depth interviews with male partners of women who drank during pregnancy ( n = 15) and drinking peers (friends or family members; n = 16). We purposively recruited participants with support of a long-standing community partner and through snowball sampling. Data were collected in Afrikaans and English using semi-structured guides, audio-recorded, transcribed, translated, and analyzed thematically using NVivo. Analysis followed an iterative coding and memoing process, and reporting adhered to COREQ guidelines. Results Six interrelated themes emerged. First, couple-level dynamics, particularly male partner drinking, were perceived as the primary driver of continued alcohol use during pregnancy, with partner drinking heavily influencing maternal drinking behaviors. Trajectories ranged from mutual continuation to solidarity-driven reduction. Second, participants described that the need for social belonging and fear of isolation often outweighed pregnancy-related health motivations, especially in contexts where alcohol use is central to social life and pregnancies are unplanned. Third, intergenerational misinformation normalized and actively undermined medical advice during pregnancy and breastfeeding. Fourth, alcohol use functioned as a coping mechanism for stressors like poverty, violence, unplanned pregnancy, and partner absence; some participants described loss of control consistent with addiction. Fifth, there was strong expressed support for mentor-based interventions delivered by credible, relatable women with lived experience, ideally engaging partners and broader social networks. Sixth, participants emphasized that support should be community-based rather than clinic-based, combine group and individual support, and provide sustained engagement throughout pregnancy. Conclusions Family, peers and partners closest to women who use alcohol in pregnancy describe how addressing these issues in this context will require moving beyond individual behavior change to address intersecting relational and structural factors. Effective interventions must engage male partners, debunk family level myths and misinformation, and utilize trusted peers in non-stigmatized spaces and community-centered delivery models with sustained community support.