Brief description of the studied documents

Twenty documents from nine countries were reviewed; Botswana, Croatia, Egypt, India, The Netherlands, North Macedonia, Poland, Portugal and Spain. Two national-level drug policy/program/action plan documents were retrieved from the following countries: Croatia, Portugal and Spain. The highest number (n = 5) of documents reviewed was from Poland. Three relevant drug policy documents were found from The Netherlands and one from North Macedonia. No drug policy-specific document was found for Botswana; however, a member of the research team reviewed the country's alcohol and health policies. Except for The Netherlands, all countries mention women, pregnancy, and motherhood-related concerns in a common drug policy document or national strategies. Only the Netherlands has a specific document directed towards pregnant women, a factsheet produced by the Dutch Association for Obstetrics and Gynaecology, “Vulnerable pregnant women and protection of the unborn child” which is part of a series about (domestic) violence, abuse, neglect, exploitation and other types of harm that may be inflicted onto someone in a power-imbalanced relationship [23].

Original publication of all these documents was in the last decade, except for “Counteracting drug addiction,” a drug demand reduction policy report from Poland, published in 2005 [24], and the Dutch policy, published in 1995 [25]. Five of the nine countries (Egypt, India, Croatia, Spain, and Poland) updated/ revised their drug policy in recent years [26,27,28,29,30,31]. North Macedonia brought out its latest drug policy in 2021 [32]. Two countries (Portugal and Botswana) have not updated their policies in the last ten years [33,34,35]. In most countries (n = 5), the Ministry of Health was responsible for publication of drug policy reports. However, different ministries in India, Poland, and Botswana have issued drug/alcohol policy documents, namely the Ministry of Social Justice and Empowerment, the Ministry of Finance/Trade, and the Ministry of Education. Spain has specific Ministerial involvement for drug policy measures and implementation, the Government Delegation for the National Drug Plan [36]. All nine countries intend to use the state budget to implement drug programs.

Table 1 provides further details.

Table 1 Description of national drug policy/programs/action plansContent analysis of the national policy/programs/strategies

We describe the results of the conventional content analysis as per “women,” “pregnancy,” and “children” sensitive/responsive texts in the reports.

We identified 19 unique codes from the content analysis. The recurrent and similar codes were combined to generate 11 major themes. The excerpts from the policy documents were quoted and presented in Table 2.

Table 2 Themes, Codes and Excerpts for “Women-sensitive Policy”

Several policy documents discussed the need to recognize and address special issues in women with drug use. Vulnerability, shame, blame, stigma, gender role, and gender violence were specifically mentioned.

Needs assessment refers to a practice for estimating the nature and magnitude of a health or social problem in a community/state/country where there is the intent to ameliorate or otherwise respond to that problem. The drug policy documents we reviewed described the need to conduct surveys among women and at-risk populations, not only to understand the problem but also to design acceptable and effective strategies to address it. Spain’s policy, in addition to the importance of conducting drug surveys, discusses a gender-responsive analytical framework to understand and integrate the needs of women with drug misuse.

The prevention strategies discussed in the documents included both universal actions, such as raising awareness in the general population, and the need for selective and indicated prevention programs and interventions targeting women.

Drug policy measures from various countries emphasize the role of gender-sensitive treatment. India’s National Action Plan for Drug Demand Reduction (2018–2025) talks about the provision of treatment in closed custodial settings and combined women with other vulnerable populations [26].

Policy measures are needed to develop and promote interventions and strategies to address housing, education, vocational training and employment. These interventions can be grouped as strategies for social reintegration. North Macedonia’s national health policy talks about providing social and economic opportunities [32].

Supply reduction means using strategies to disrupt the production and supply of illicit drugs. Interrupting drug trafficking along the shipping, air, and road transport routes is one supply reduction measure. The relationship between women and the drug trade is complex. Women’s participation in the drug supply chain can be attributed to vulnerability and oppression, where they are forced to be involved out of fear or exploitation. Another narrative explains the involvement in the drug trade as their own decision. Women may be involved in trafficking to sustain their drug consumption or be victims of in-person trafficking [4].

The national policies recognized the need for workforce training and capacity building in gender-responsive prevention and treatment. The training need extends to non professional voluntary workers and peer groups.

Several national policies mentioned the need for inter-ministerial, inter-sectoral, and international collaborations to achieve the objectives of the policy documents. The Spanish National Strategy on Addictions states as a strategic objective, “Guarantee quality integrated care” which includes the coordination of resources for women who suffer gender-based violence and their children [31].

Periodic surveillance is required to inform policymakers about existing drug policies’ effectiveness and limitations. Only a few of the countries’ policies reiterated the importance of gender-sensitive indicators for monitoring the implementation and outcome of the policy measures.

Policies are guiding principles chosen by a government and dictate the strategies and action plans to address a particular issue, e.g. control and regulation of psychoactive drugs.

Resource allocation refers to assigning available resources to various uses.

We discovered five major themes from nine different codes from the content analysis of the policy text concerning pregnant women. Four of the five themes have already been discussed while discussing women-sensitive policy. The only new theme that emerged in this section is the custody of children of women with drug misuse. Please see Table 3 for the excerpts from the policy documents, codes and themes.

Table 3 Themes, codes and excerpts for “pregnant women & children-sensitive policy”

Universal prevention, such as education/awareness generation of pregnant women and their partners regarding the harmful effects of drugs on fetal development. Some policy texts broadened the scope of prevention by incorporating prevention of exposure to psychoactive substances during pregnancy, further preventing the fetal neurobehavioral and developmental consequences. As mentioned earlier, Spanish policy promotes screening, early identification, and brief interventions for alcohol in “…sexual and reproductive care services, family planning, pre-pregnancy visits, and obstetrics, as well as sexually transmitted infection units” [31].

This was largely discussed in the context of gender-sensitive treatment, in the context of women and pregnant women together, or with an exclusive focus on pregnant women. The Portuguese policy also aspires to deliver a seamless and integrated model at all levels of care.

Child custody refers to a child's care, control, and maintenance through a legal mandate. The court aims to look after a child's best interest in deciding custody rights. Penalties for substance use in pregnancy can include loss of custody, compulsory treatment, and fines. [23, 40]. Fear of loss of custody can lead to some women avoiding seeking treatment [20].

Training of human resources was discussed with the need for specialized gender, and youth sensitive training on the prevention and treatment of drug misuse. For example, the Indian drug demand reduction policy stated, “Specialized training for those who work with vulnerable groups, such as patients with psychiatric co-morbidities, children and women, including pregnant women.” [27].

A few national drug policies expressed the need for coordination between various levels of service delivery systems: prevention, treatment, and harm reduction and also collaboration between services for women, pregnant women, and their children [27, 32, 33].

The content analysis of policy documents that pertained to children revealed 20 unique codes and 10 major themes. Most themes (n = 7) were similar to those captured and already described under the women/gender-sensitive policy matters, such as needs assessment, prevention, treatment, supply reduction, training, collaboration and coordination, and policy. Additional themes discovered were legislation (to protect children), resource allocation, research, and harm reduction. Below we discussed only those themes exclusive to “children”/“children with a parent who uses drugs.” The excerpts supporting the codes and additional themes were presented in Table 3.

Legislation signifies creating and implementing laws to prevent the production/manufacture/cultivating, possessing, selling, purchasing, transporting, storing, and/or consume any psychoactive substances. It aims to reduce the supply/access to drugs to those who use drugs.

Research is an integral component of drug policy. Preventive intervention research is important in this particular context of drug policies on children. Prevention may target the at-risk population, which is known as selective prevention. Portuguese policy alludes to the commitment to conducting risk-factor research.

Harm reduction refers to policies, programs, and practices that minimize drug use’s negative health, social and legal impacts. Harm reduction was cited in the Spanish national strategy, not for children, but for adults in order to protect the children in the family i.e., to minimize harm to others.

Summative quantitative analysis

Figure 1 depicts the number of times a particular theme occurred during the content analysis. Because the themes were different for three categories (e.g., women, pregnant women, children) and we wanted to check the relative frequency of occurrence of a particular theme in a specific category, we presented the “theme count” category-wise.

Fig. 1

Summative analysis of the category-wise theme frequency (occurrence of a particular theme in the policy documents)

For women-specific content analysis, special issues/concerns in women with drug misuse, need assessment, and prevention were the three most frequent themes; for the children-specific policies, prevention, training, and treatment comprised the three most occurring themes. For pregnant women's sensitive policy texts, prevention, treatment, and child custody were the highest-occurring themes.

Thematic map

Figure 2 illustrates the thematic map to visualize the cross-connections between common and unique themes (specific to the target population) discovered during the content analysis. All policies/programs are envisioned to prevent and treat drug misuse among women, pregnant women, and children. They emphasized the importance of needs assessment to understand the magnitude and patterns of the problem. The prevention can be universal (that is desirable for everybody in the eligible population, e.g., raising awareness and education at the population level), selective (identifying and addressing concerns of the vulnerable population), and indicated (early detection of risk factors and condition, and providing intervention to prevent future development of SUD). However, some policies reported the need for supply reduction and legislation to protect children and women (and the unborn children of pregnant women) as preventive measures. The policies talked about training and capacity building of human resources to deliver gender-sensitive care. Special psychosocial concerns in women with drug misuse, such as the stigma, blame, gender-based violence, and typical gender-role, must be examined and addressed in a gender-sensitive prevention and treatment program. Following treatment, national drug policies envisage providing socio-economic opportunities for the social reintegration of women with drug misuse. Drug policies deliberated on the child custody issues for pregnant women with drug misuse and linked this with the treatment. Implementing the policy measures will require inter-ministerial and international collaboration and coordination.

Fig. 2

Thematic map for visualizing inter-relationships between concepts and among main themes and subthemes. Green colored boxes are themes common to women, pregnant women, and children. Orange colored boxes are themes unique to women. Pink colored boxes contain unique theme for pregnant women. Blue colored boxes are children-specific themes

The performance of policies must be periodically monitored by gender-sensitive indicators and adapted to the changing needs and demands.

Adherence of the national policy/programs/strategies to the adapted checklist for gender-sensitive policy

Each author rated their own country’s policy reports. According to the ratings of the country’s gender-sensitive policy, there is limited adherence to international guidelines and lessons learned on gender equality and women’s empowerment, and engendering results chain which ensures outcome, output, and activities are in sync with the specific need in women and for pregnancy, and motherhood. Five and six out of nine members responded with different grades of disagreements (regarding their country’s policy adherence) on the likert scale for these two items, respectively.

Very little agreement was reached regarding the provision of gender-responsive indicators (agreement = 2/9) and targets and adequate and sustainable financial resources to implement the components of the policy (agreement = 1/9). The adherence is relatively better for the background situation and context analysis (agreement = 6/9), consideration of differential impact and strategies (agreement = 7/9), targeted approach to reach out to this special population (agreement = 7/9), envisioning equality and women empowerment (agreement = 7/9), improving access and participation in interventions (agreement = 6/9), and monitoring and evaluation of the implementation of the policy measures (agreement = 7/9). The agreement includes those who at least “somewhat agreed” to the checklist items. See Fig. 3 for finer details.

Fig. 3

Adherence of national policies with the adapted check-list for gender-sensitive policy