Prenatal substance use during the COVID-19 pandemic in the United Kingdom: associations with depression, anxiety, and pandemic stressors

Introduction The COVID-19 pandemic was associated with high levels of depression and anxiety among pregnant individuals in the UK, as shown previously in the EPPOCH cohort. However, the relationships between these psychological burdens, pandemic-related stressors, and substance use in the prenatal period have not been systematically investigated. Methods To address this gap, we conducted a cross-sectional analysis of baseline EPPOCH data ( n = 3,292; June–November 2020). Participants reported alcohol, tobacco, cannabis, and illicit drug use before and after recognition of pregnancy, alongside validated measures of depression, anxiety, pregnancy-related anxiety, and pandemic stressors. Linear regression models examined associations between mental health, COVID-19 stressors, and substance use after pregnancy recognition. A qualitative thematic analysis of 380 open-ended responses explored perceptions of substance use post-pregnancy recognition. Results Alcohol was the most commonly used substance before pregnancy. Following pregnancy recognition, tobacco (8.75%), and alcohol (8.60%) were the most frequently reported substances, followed by cannabis (1.49%) and illicit drugs (0.12%). Tobacco use after pregnancy recognition was associated with higher levels of depressive symptoms and pandemic stressors, including perceived personal health threat and not receiving necessary care. Prenatal co-use of substances was associated with higher depressive symptoms and pandemic-related financial difficulties. Qualitative themes included continued substance use until pregnancy detection, vaping as a perceived safer-use strategy, and midwifery advice influencing prenatal substance use decisions. Discussion In this large UK pregnancy cohort recruited during the COVID-19 pandemic, substance use following pregnancy recognition-particularly tobacco-was linked to depression and pandemic-related stressors. These findings highlight the importance of equipping midwives and other healthcare professionals with clear, evidence-based guidance on prenatal substance use, particularly during global health crises.