The transition to parenthood, opportunity to drink, drinking, and alcohol use disorder

The associations between marital status (single, married, divorced, widowed), or transitions across marital statuses, and alcohol use and alcohol use disorder (AUD) have been widely studied and documented (Chilcoat and Breslau, 1996, Leonard and Eiden, 2007, Leonard and Rothbard, 1999, Miller-Tutzauer et al., 1991). Though research is relatively limited in low-income countries or non-European diaspora settings, the pattern of associations documented thus far is consistent across settings: remaining unmarried increases the risk of hazardous alcohol use, and transitions out of marriage (through divorce or widowhood) also increase that subsequent risk. Associations between becoming a parent and alcohol use or the onset of AUD are less clear. Research tends to suggest that parenthood is protective against developing AUD (Chilcoat and Breslau, 1996, Fergusson et al., 2012), however, findings vary by age and gender (Borschmann et al., 2019, Little et al., 2009). One reason interpretations are not as clear is that studies rarely match lifetime histories of transitions into parenthood with lifetime histories of alcohol use to investigate the specific postpartum change in the risk of AUD. Another reason is that alcohol use and disorder may reduce the chances of becoming a parent in many settings. We overcome these two limitations by using unique new life history measures from Nepal – a setting of near universal marriage and childbearing – to assess models of the postpartum changes in odds of alcohol use and AUD, independent of marital transitions.

Mechanisms producing associations between marital transitions and alcohol use or disorder are also clearer than those connecting parenthood to alcohol use and disorder. Transitions from being single to becoming married increase social support, with widely documented benefits for mental health, including reduced rates of substance use disorders such as AUD (Kendler et al., 2016). Transitions out of marriage, through either divorce or widowhood, not only remove that social support, but they also introduce a stressful experience, likely to increase substance use disorders such as AUD (Kendler et al., 2017). Prior studies of the substance use consequences of childbearing point toward a lower likelihood of AUD following parenthood for women, but some potential for increased drinking following parenthood for men (Kendler et al., 2019, Leggat et al., 2021). Research on the mental health consequences of parenthood has focused more on major depressive disorder (MDD) or major depressive episodes (MDE) than on alcohol use and AUD. In fact, the literature connecting transitions into motherhood with MDD is voluminous and robust and focuses on postpartum depression (O’hara and Swain, 1996, Shorey et al., 2018). There is evidence that the transition to fatherhood also confers an increased risk of paternal postpartum MDD (Cameron et al., 2016, Matthey et al., 2000, Paulson and Bazemore, 2010). A small literature examines elevated risks of mothers’ postpartum alcohol and substance use, closely linking these behaviors to maternal MDD (Chapman and Wu, 2013, Ross and Dennis, 2009). Little research focuses on fathers’ postpartum risks of alcohol use or disorder, though in addition to research on fathers’ MDD there is research on fathers’ postpartum anxiety (Leach et al., 2016). It is possible that other disorders, like MDD or anxiety, increase AUD risks in both mothers and fathers. It is also possible that risk factors identified for postpartum maternal substance use, such as unemployment, being single, or smoking, also increase fathers’ AUD (Chapman and Wu, 2013). Most striking, however, is that the literature rarely considers the possibility that the same overall psychological stresses that may produce postpartum MDD in mothers might also produce postpartum AUD in fathers because men are more likely to respond to stress with AUD than with MDD (Scott et al., 2018).

Individuals experience a process of increased exposure to drinking before transitioning to AUD. Though risk factors related to transitions through stages of alcohol involvement have been identified in adolescents (Del Valle Tena et al., 2019), studies of this process in adults have been limited (Wells et al., 2011 is one exception). By using a population sample from a setting with a large fraction of adults who face restrictions on access to alcohol, we are able to identify family experiences that increase or reduce subsequent access to alcohol, drinking, and AUD. Many religions include proscriptions against access to alcohol and alcohol use, but in Hindu Nepal, these religious rules were also civil laws until 1962 (Adhikari, 1998, Dhital et al., 2001, Höfer, 1979, Maskey, 1996). These laws made access to alcohol illegal for ethnic groups representing nearly half of the total population (Cole et al., 2021), greatly limiting production and distribution of alcohol and creating variance in the opportunity to drink, ever drinking, and AUD. We have previously shown that ethnic prohibitions created ethnicity differences in opportunity and actual drinking, but not in the transition from drinking to AUD (Cole et al., 2021). Previous analysis also revealed tremendous gender differences in alcohol use, with women so unlikely to use alcohol that AUD was rarely observed among women in Nepal (Cole et al., 2021, Scott et al., 2021).

Overall, Nepal serves as an important population to advance the study of family events and alcohol use because marriage and parenthood are nearly universal and restrictions on access to alcohol create variance in adult transitions to alcohol use and disorder. The context of widespread parentally arranged marriages reduces the likelihood that prior mental disorders or substance misuse behaviors limit entry into marriage or parenthood (Ghimire et al., 2006). This setting provides an opportunity to assess the independent role of family events relative to other key predictors established before childbearing (birth cohort, gender, ethnicity, and education) as in recent research on depression (Axinn et al., 2020b). However, due to low levels of alcohol use among women, we constrained our examination of women’s postpartum alcohol use to opportunities to drink and the initiation of drinking.

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