• Structural violence, stigma and gendered labour exploitation trap women in cycles of addiction, trauma and neglected maternal healthcare
• Drug use is normalised as survival within exploitative work/family systems
• Family support, structured rehab/parenting progs., trauma-informed gender-responsive intervention, pivotal for recovery and reintegration

Many incarcerated Sri Lankan mothers whose substance abuse is entwined with contexts of structural violence, gendered labour exploitation, intergenerational trauma, the normalisation of substance use and addiction in families and workplaces, poverty, exploitation, domestic violence, and systemic neglect, note that stigma including social stigma and marginalisation, the fear of withdrawal, trauma, and maternal guilt and psychological burden, hindered timely healthcare access for themselves and their children.

These findings were made in a research on ‘Mothering from the margins: Lived experiences of incarcerated substance-abusing mothers and the developmental risks faced by their children in Sri Lanka’ which was authored by K. Dayasiri and G. Gunarathna (both attached to the Kelaniya University’s Medical Faculty’s Paediatrics Department), and published in the British Medical Journal Paediatrics Open Journal 2025.

Children of incarcerated and substance-abusing mothers are at elevated risk of neglect, developmental delays, and psychosocial harm. In low- and middle-income countries (LMICs), support systems for children of imprisoned mothers are often fragmented or non-existent. Maternal substance abuse is frequently linked to histories of trauma, poverty, and gender-based violence (GBV).

Children of incarcerated, substance-abusing mothers represent one of the most vulnerable yet overlooked populations in global public health. Parental incarceration alone poses profound risks to child development, but, when compounded with maternal substance abuse, the effects on children’s physical, emotional and cognitive wellbeing are often severe and lasting. These children are disproportionately affected by disrupted caregiving, inconsistent access to healthcare, increased exposure to trauma, and socioeconomic instability. In addition to the effects of incarceration, parental substance use – especially during the prenatal period – has been associated with neuro-developmental delays, behavioural problems, and cognitive deficits in children. Postnatal substance use by caregivers can further impair attachment, emotional regulation, and access to essential healthcare services.

Globally, women comprise an increasing proportion of the prison population, with many incarcerated for drug-related offences. In Sri Lanka also, this trend is evident, with a significant number of incarcerated women being primary caregivers of young children (R Khan’s ‘Women’s vulnerability for drug-related offences in Sri Lanka: With special reference to a low-income area in Colombo’). Many of these women have a history of drug dependency, often stemming from complex interactions between poverty, trauma, intimate partner violence (IPV), and the lack of economic opportunities. Children born into these environments face a high risk of poor nutrition, delayed development, limited schooling, and neglect or abuse. Their basic rights to safety, health and nurturing are frequently compromised even before their mothers are imprisoned.

Substance abuse among women in Sri Lanka, particularly those from low-income urban settings, is a growing concern (A Hapangama, DGBMS Dasanyake, KALA Kuruppuarachchi, A Pathmeswaran and HJd Silva’s ‘Substance use disorders and their correlates among inmates in a Sri Lankan prison’). The absence of integrated child protection frameworks and supportive caregiving policies exacerbates the health risks to children. Children born to such mothers may start life already disadvantaged: many are exposed to in-utero substance use, receive inadequate prenatal and postnatal care, and lack stable caregiving. On maternal incarceration, children are usually cared for by elderly grandparents or extended family, often in poor conditions with minimal institutional oversight. These caregiving arrangements are informal, fragmented, and rarely supported by trained professionals. In many cases, there is no structured follow-up to monitor the child’s physical and developmental milestones or to ensure access to vaccinations, nutrition programmes or psychosocial support. The burden placed on caregivers – who may be ill, impoverished or overwhelmed – further undermines the consistency of care. 

Barriers to healthcare access

Participants frequently reported delays or avoidance in seeking antenatal, postnatal and paediatric healthcare due to stigma, the fear of judgement and withdrawal symptoms. Negative experiences in health facilities discouraged continued engagement with services.

“When I went to the clinic, some expectant women whispered behind my back. They treated me differently. So I stopped going”.– participant number 23.

Substance use during pregnancy was often concealed due to the fear of legal or social repercussions. This avoidance of care posed direct risks to both maternal and child health, particularly in the early developmental period.

Intergenerational substance abuse

Many described being raised in households where substance abuse was normalised. Exposure began in early childhood, often involving family members such as parents or spouses.

“I grew up in a house where my father, mother and uncles were always using. It never seemed like something bad until I got addicted myself” – participant number seven. “Both my father and husband are drug users. I wanted to change my husband, but I couldn’t. I got dragged into it instead” – participant number 41.

This pattern reflects an entrenched intergenerational cycle, where drug use is socially learnt and normalised from a young age. In some cases, mothers began using drugs as teenagers, often under the influence of peers or intimate partners.

Social stigma and marginalisation

Social exclusion was a recurrent theme. Participants reported being denied housing, employment or community reintegration due to their identity as drug users.

“No one wants to rent a house to someone like me. I can’t get a job, so I do whatever I can to survive” – participant number 19. “I was a prostitute and had many problems on the street. We didn’t have money. My friend introduced me to drugs to help me survive the night life” - participant number 37.

Economic vulnerability often led women to informal or exploitative work, such as sex work or spa-based employment, where drug use was normalised or even encouraged for performance.

Maternal guilt and psychological burden

Participants expressed deep emotional pain over the consequences of their substance use on their children. Feelings of guilt, shame, and helplessness were common, particularly in relation to missed developmental milestones and disrupted parenting. “I know that I’ve hurt my child, but every time I try to quit, the stress makes me use it again”. “One of the worst things is losing a good time with your child. It can affect their development”. “My child is having problems with speech. He didn’t get much time with either of us”.

Some mothers reported missing important child health appointments, including immunisation schedules, due to incarceration or drug dependence.

“I missed the vaccination sessions for my child. I think that my mother did them all”.

This psychological burden was compounded by the fear that their children, now in the care of elderly grandparents, might face abuse or neglect.

Coping strategies and resilience

Despite the adversities, many displayed resilience and a strong motivation to change. Those with family support or who had access to structured rehabilitation or parenting programmes expressed greater optimism about the future.

“My mother takes care of my child while I’m in prison. When I get out, I want to change and be there for my child”- participant number 26. “I work in a spa and drugs helped me do the job properly. But I want a different life for my kids”.

Structural vulnerability and gendered pathways to drug use

Structural vulnerability and gendered risk include addiction as a response to trauma and exploitation, GBV and survival economies, and inadequate institutional responses. 

Structural determinants such as poverty, GBV, exploitative labour, and inadequate housing create gendered pathways into substance use. Most women began using drugs not recreationally, but functionally, to survive, endure trauma or sustain precarious employment. For instance, spa workers and sex workers described drug use as a means to dissociate during work or manage night shifts.

Substance use as symptom and strategy

Substance use as a coping mechanism includes emotional numbing or stress relief, functional use to endure work or abuse, and dependency shaped by chronic trauma. 

Rather than viewing substance use merely as deviant behaviour, participants framed it as both a symptom of systemic neglect and a coping strategy. Emotional regulation, escape from violence, and increased stamina for night work were commonly cited motivations. This complicates linear narratives of addiction and points toward the need for trauma-informed and gender-responsive intervention models.

The family as both risk and resource

Family dynamics are central to both the risk of addiction and the possibility of recovery. On the one hand, familial substance use modeled drug-related behaviour exposed children to high-risk environments. On the other hand, grandmothers and occasionally mothers-in-law emerged as protective figures, caring for children and enabling the temporary continuity of parenting during incarceration. This duality suggests the importance of family-based interventions rather than individual-focused models.

Parenting from the margins

Participants described deep emotional connections to their children, despite prolonged physical separation. Many mothers viewed incarceration as both a rupture and a possible turning point. However, the institutional settings rarely offered parenting support programmes. The lack of developmental monitoring, poor record-keeping and mental health services for mothers contributed to feelings of alienation and helplessness. Social, emotional, and structural barriers faced by incarcerated substance-abusing mothers intersect. Their narratives pointed to a cycle of trauma, addiction, stigma, and marginalisation, compounded by inadequate systemic support. Yet, the resilience displayed by many also highlights pathways for recovery and reintegration.

The fear of withdrawal, influences of the family and friends, and psychological stress were perceived to be driving forces for substance abuse in mothers. Maternal fear of withdrawal symptoms and social stigma were major barriers to seeking timely healthcare. The intergenerational effects of substance abuse were evident, with a subset of children identified as being at risk of neglect or abuse, further compounding their vulnerabilities.

Driving forces behind substance abuse by incarcerated mothers

The driving forces behind substance abuse were multifactorial. Family influence played a key role, with many exposed to drug use through substance-abusing partners or relatives. Physiological dependence, particularly the fear of withdrawal symptoms, was a strong motivator for continued use. Work-related pressures, especially in exploitative or physically demanding jobs like spa work or manual labour, prompted substance use to maintain energy or endurance. Social influences such as peer pressure and emotional or intimacy-related factors, including using drugs to initiate or sustain relationships, also contributed. Psychological distress including depression, anxiety, and trauma led some women to self-medicate with drugs. Finally, relational dynamics such as co-dependency and an inability to stop a partner’s drug use, further entrenched substance abuse behaviours.

Discussion 

Profound challenges are faced by incarcerated, substance abusing mothers in safeguarding the physical and developmental wellbeing of their children. Systemic neglect, stigma, poverty, and gendered vulnerabilities intersect to compromise both maternal and child health. Barriers to healthcare access recur. Mothers described avoiding antenatal and postnatal care due to the fear of judgement, stigma, and inadequate support within health institutions. In the Sri Lankan context, where substance use among women is harshly stigmatised and often criminalised, care settings may serve more as sites of social exclusion than support. Participants described being shamed by health workers or fellow patients, leading to disengagement from essential services. This underscores the urgent need for training frontline healthcare providers in stigma reduction and the development of non-punitive, trauma-informed models of maternal care. In addition, the establishment of integrated programmes that simultaneously address maternal substance use and child development has shown promise in improving health outcomes for both mothers and their children. Such programmes offer comprehensive, family-centred interventions that promote recovery, parenting skills and child safety, and may be especially relevant in LMIC settings like Sri Lanka where formal support systems are limited.

Many engaged in survival sex work, spa-based employment or informal labour markets that exposed them to unsafe environments and normalised drug use. For some, drugs had become a coping mechanism to deal with trauma, domestic violence or the demands of exploitative labour. Others were introduced to substances by partners or family members, reflecting deeply entrenched cycles of intergenerational addiction. Once addicted, the incarcerated mothers faced multiple barriers to seeking help including stigma, the fear of child separation, limited access to rehabilitation services, and legal repercussions.

Intergenerational substance abuse reflected deeply entrenched patterns of familial drug use. Many reported growing up in homes where drug use was normalised by fathers, husbands or uncles. For some, early exposure began during adolescence through peer pressure or intimate partners. Familial transmission of substance abuse is not merely through genetics but through social modelling and normalisation. This pattern suggests that interventions must extend beyond the individual to target family dynamics and community-level risk factors.

Social stigma and marginalisation emerged as a significant structural barrier. Participants recounted being denied housing, employment, or support due to their identity as drug users and former sex workers. In many cases, survival strategies such as spa work or transactional sex were closely tied to drug use, either as a means of coping with exploitation or as a requirement for performance. These experiences highlight the gendered nature of addiction in low-resource settings, where poverty and violence push women into high-risk, low-agency environments. Rehabilitation efforts must therefore be gender-sensitive and address the socioeconomic drivers of addiction, not merely its symptoms.

Maternal guilt and psychological burden were expressed. Participants mourned lost time with their children, developmental setbacks and broken maternal bonds. The psychological weight of knowing that their children may suffer neglect or abuse in their absence created feelings of helplessness and despair. Yet, despite these burdens, many expressed a desire to change – demonstrating that incarceration, while punitive, could also serve as a potential turning point. This reinforces the value of prison-based parenting and mental health programmes that can facilitate emotional healing and promote child-focused rehabilitation.

Coping strategies and resilience were particularly powerful. Mothers who had strong family support – especially from their own mothers – were more optimistic about rebuilding their lives and reconnecting with their children. Others cited the desire to ‘be there’ for their children as a motivation to pursue recovery. These findings suggest that even in the context of trauma, incarceration and addiction, there exists a potential for change and reintegration. This reinforces the argument for post-release support programmes that enable parenting continuity, family reunification, and structured rehabilitation.

Addiction, parenting, and incarceration must be viewed through a structural lens. Substance use among these women was rarely about recreation; rather, it was a survival mechanism in response to violence, emotional pain, and exploitative labour. Addiction was both a symptom and a strategy – offering temporary relief while compounding long-term harm. Interventions must therefore be trauma-informed, grounded in harm reduction and situated within broader social protection policies that address housing, employment and IPV. Additionally, the dual role of the family as both risk and resource is highlighted. While many were introduced to drugs by family members, others relied on those same family systems – particularly grandmothers – to care for their children during incarceration. This duality underscores the importance of family-based interventions, where recovery and child protection are pursued in tandem. Strengthening kinship care systems, training caregivers, and monitoring child development within these informal arrangements could enhance outcomes for affected children.

Conclusion 

Healthcare access is undermined by stigma, the fear of withdrawal and systemic neglect in the Sri Lankan prisons and healthcare systems. Intergenerational addiction and structural vulnerabilities play a role in perpetuating maternal substance use. There are both risk and resilience factors within familial caregiving, particularly the pivotal role of grandmothers.

Intersecting challenges are faced by substance-abusing incarcerated mothers in Sri Lanka and there are consequential risks to child health and development. The findings point to urgent gaps in maternal healthcare, child protection, and rehabilitation services, shaped by stigma, poverty and systemic neglect. Yet, within these narratives of trauma are also stories of resilience and hope. Addressing these issues requires trauma-informed, gender-responsive and family-centred interventions that extend beyond incarceration. Policymakers must prioritise holistic care models that support both mothers and children, breaking intergenerational cycles of addiction and disadvantage while promoting recovery, dignity and child wellbeing.

There is an urgent need for trauma-informed, family-centred interventions for incarcerated mothers and their children in LMICs. Child protection policies should integrate developmental monitoring and caregiver support into informal care arrangements. Prison-based parenting programmes and gender-sensitive rehabilitation services are valuable in terms of breaking cycles of addiction and disadvantage.