Pregnant Women's Current and Intended Cannabis Use in Relation to Their Views Toward Legalization and Knowledge of Potential Harm

Predictors for cannabis cessation during pregnancy: a 10-year cohort study

The aim of this study is to determine factors associated with cannabis discontinuation, to assess the impact of mental health and addiction interventions on cannabis discontinuation during pregnancy and to investigate the neonatal impact of cannabis discontinuation. This is a 10-year cohort study in a tertiary hospital in Barcelona, Spain, including women with self-reported cannabis use during pregnancy. Main outcome was cannabis discontinuation based on biological sample testing. Secondary outcomes were neonatal intensive care unit (NICU) admission, preterm birth, birth weight and bottle-feeding. When cannabis use was detected during pregnancy, 32 out of 81 (38.3%) discontinued cannabis during pregnancy vs. four out of 61 (6.6%) when detected at birth (p < .001). Multivariate binary logistic regression showed that null parity (OR: 6.95, p = .011), detection of cannabis use during pregnancy (OR: 5.35, p = .018) and early detection and referral to mental health care for counseling on cannabis cessation and interventions on the first trimester (OR: 25.46, p < .001) increased cannabis discontinuation. Risk for preterm birth <37 weeks (11.4% vs. 30.8%) and NICU admission (25.7% vs. 54.2%) were lower when discontinuation. Early detection of cannabis use during pregnancy, cessation counseling with mental health interventions, and null parity are predictors for cannabis discontinuation during pregnancy.

Factors Associated with Provider Counseling Against Breastfeeding in the Setting of Marijuana Use: A Population-Based Survey

INTRODUCTION

The purpose of this study was to explore patient demographic factors associated with counseling against breastfeeding and concurrent marijuana use.

METHODS

A cross-sectional study derived using data from the Centers for Disease Control and Prevention administered Pregnancy Risk Assessment Monitoring System (PRAMS) in collaboration with state and local health departments. This study sample included survey participants whose responses indicate they received counseling discouraging breastfeeding with concurrent marijuana use. Bivariate and multivariate regression analyses assessed the relationship between factors associated with counseling against breastfeeding and concurrent marijuana use.

RESULTS

Of the 10,911 participants in this sample, 9,695 participants who answered the question about receiving counseling discouraging breastfeeding while using marijuana were included in the analysis (89% response rate for the total sample). Twenty nine percent of participants were advised by a provider not to breastfeed while using marijuana. Participants who received this counseling were more likely to be people of color, age less than or equal to 29, with a high school education or less, unmarried, report governmental or no insurance prepregnancy, and report marijuana use postpartum. In the multivariate analysis, age less than or equal to 20 (P = .001), being unmarried (P = .023), and marijuana use postpartum (P = .034) remained associated with counseling against breastfeeding.

DISCUSSION

Our results suggest that individuals are being counseled differently. Unmarried and young people (age <20 years) were more likely to report receiving counseling against breastfeeding with concurrent marijuana use. Given the growing national acceptability of marijuana use, the known benefits of breastfeeding, and the unclear risks of marijuana in human milk, there is a need to standardize counseling to avoid a missed opportunity to educate breastfeeding populations who use marijuana and to reduce the risk of counseling based on providers' personal attitudes and biases not aligned with evidence-based guidelines.

Cannabidiol Exposure During Gestation Leads to Adverse Cardiac Outcomes Early in Postnatal Life in Male Rat Offspring

Introduction: Studies indicate that ∼7% of pregnant individuals in North America consume cannabis in pregnancy. Pre-clinical studies have established that maternal exposure to Δ9-tetrahydrocannabinol (THC; major psychoactive component in cannabis) leads to fetal growth restriction and impaired cardiac function in offspring. However, the effects of maternal exposure to cannabidiol (CBD; major non-euphoric constituent) on cardiac outcomes in offspring remain unknown. Therefore, our objective is to investigate the functional and underlying molecular impacts in the hearts of offspring exposed to CBD in pregnancy. Methods: Pregnant Wistar rats were exposed to either 3 or 30 mg/kg CBD or vehicle control i.p. daily from gestational day 6 to term. Echocardiography was used to assess cardiac function in male and female offspring at postnatal day (PND) 21. Furthermore, quantitative polymerase chain reaction (qPCR), immunoblotting, and bulk RNA-sequencing (RNA-seq) were performed on PND21 offspring hearts. Results: Despite no differences in the heart-to-body weight ratio, both doses of CBD led to reduced cardiac function exclusively in male offspring at 3 weeks of age. Underlying this, significant alterations in the expression of the endocannabinoid system (ECS; e.g., decreased cannabinoid receptor 2) were observed. In addition, bulk RNA-seq data demonstrated transcriptional pathways significantly enriched in mitochondrial function/metabolism as well as development. Conclusion: Collectively, we demonstrated for the first time that gestational exposure to CBD, a constituent perceived as safe, leads to early sex-specific postnatal cardiac deficits and alterations in the cardiac ECS in offspring.

Perceptions of Cannabis Use and Its Benefits and Risks Among Breastfeeding Mothers

Background

Approximately 5% of breastfeeding women report using cannabis. Little is understood about perceived benefits and risks of cannabis use; thus, this study aimed to fill this gap.

Methods

An anonymous online survey was conducted from 2018 to 2019 among breastfeeding women (n = 1516) who used cannabis. Data collected included demographics, frequency and timing of cannabis use, perceived effects in infants, and repercussions experienced. Analyses included descriptive statistics; chi-square and t-tests were used to test differences between groups (SPSSv28). A subset (n = 413) left open-text responses about cannabis and its perceived risks and benefits. Content analysis and ATLAS.ti were used for open-ended responses.

Results

Two-thirds (67%) of participants were "not at all" concerned that cannabis use while breastfeeding affected their baby. Only 3% attributed symptoms in their infants to cannabis use; symptoms were perceived as positive or negative. Interestingly, 45% (n = 603) altered timing of cannabis use relative to breastfeeding to avoid exposing their infant to cannabis. Most mothers (85.8%) reported no changes in their breast milk supply. Few respondents were investigated by Child Protective Services (6.9%) or arrested (3.8%) for cannabis use. In open-ended responses, three themes emerged about the perceptions of cannabis use while breastfeeding: (1) cannabis preferred to address medical concerns, (2) positive impact of cannabis on quality of life for mothers and their children, and (3) concerns about negative consequences.

Conclusion

Breastfeeding mothers who used cannabis reported positive perceptions of cannabis as a safer alternative to medications, yet concerns existed about legal repercussions. Understanding maternal perceptions may be useful in developing successful approaches to counseling mothers about cannabis use.

Tobacco or marijuana use and infertility: a committee opinion

In the United States, approximately 21% of adults report some form of tobacco use, although 18% report marijuana use. Although the negative impact of tobacco use in pregnancy is well documented, the impact of tobacco and marijuana on fertility and reproduction is less clear. This committee opinion reviews the potential deleterious effects of tobacco, nicotine, and marijuana use on conception, ovarian follicular dynamics, sperm parameters, gamete mutations, early pregnancy, and assisted reproductive technology outcomes. It also reviews the current status of tobacco smoking cessation strategies. This document replaces the 2018 American Society for Reproductive Medicine Practice Committee document entitled Smoking and Infertility: a committee opinion (Fertil Steril 2018).

Parental factors predicting social deviance and psychological outcomes in offspring: Evidence from the Avon Longitudinal Study of Parents and Children (ALSPAC)

Objective: The objective of the present study was to examine whether exposure to prenatal psychoactive substances is associated with psychological outcomes and deviant behaviour. Methods: This was a secondary analysis of 7,769 mother-child dyads in the Avon Longitudinal Study of Parents and Children (ALSPAC) who were followed until the children were aged approximately 12 years. Parental characteristics and maternal use of various substances were collected in pregnancy and entered as predictors of psychological outcomes in childhood and deviant behaviours in early adolescence. The psychological outcomes were IQ, social cognition, working memory and inhibition, while the deviant behaviours were threatening others, truancy and cruelty to animals. Weighted logistic regression models were used to predict deviant behaviours and weighted linear regression for the psychological outcomes. Results: High prenatal alcohol exposure predicted truancy and cruelty to animals. Tobacco exposure predicted lower IQ, a greater social communication deficit, lower working memory, truancy and threatening others. Illicit drugs predicted a higher social communication deficit and truancy. All prenatal substance exposures remained significant after adjustment for peer influences and covariate imbalance. Conclusion: Alcohol, tobacco and illicit drugs were associated with deviant behaviours in early adolescence and these behaviours were preceded by psychological deficits in childhood. The present study supports the guideline that no amount of alcohol is safe to consume in pregnancy and that tobacco and illicit drugs should be avoided.

Is legal recreational cannabis associated with cannabis use during pregnancy, beliefs about safety, and perceived community stigma?

BACKGROUND

Among pregnant and recently pregnant people we investigated whether legal recreational cannabis is associated with pregnancy-related cannabis use, safety beliefs, and perceived community stigma.

METHODS

In 2022, we surveyed 3571 currently and recently pregnant English- or Spanish-speaking adults in 37 states. Primary outcomes included cannabis use during pregnancy and two continuous scale measures of beliefs about safety and perceived community stigma. Using generalized linear models and mixed effects ordinal logistic regression with random effects for state, we assessed associations between legal recreational cannabis and outcomes of interest, controlling for state-level and individual-level covariates and specifying appropriate functional form.

RESULTS

Those who reported cannabis use during pregnancy were more likely to believe it is safe and to perceive community stigma compared to those who did not report use during pregnancy. Legal recreational cannabis was not associated with cannabis use during pregnancy, continuation or increase in use, frequency of use, or safety beliefs. Legal recreational cannabis was associated with lower perceived community stigma (coefficient: -0.07, 95% CI: -0.13, -0.01), including among those who reported use during (coefficient = -0.22, 95% CI: -0.40, -0.04) and prior to but not during (coefficient = -0.19, 95% CI: -0.37, -0.01) pregnancy.

CONCLUSION

Findings do not support concerns that legal recreational cannabis is associated with cannabis use during pregnancy or beliefs about safety. Legal recreational cannabis may be associated with lower community stigma around cannabis use during pregnancy, which could have implications for pregnant people's disclosure of use and care-seeking behavior.

Incidence of postpartum depression in low-income cannabis users with and without a history of depression

While past research has linked cannabis use in pregnancy with a history of depression, sparse literature exists on cannabis use during pregnancy and postpartum depression (PPD). In this study, we aimed to better understand the association between PPD and cannabis use during pregnancy in those with and without a history of depression. This was a retrospective cohort study of patients who received prenatal care at a single institution between January 2017 and December 2019. Patient demographics, obstetric history, depression history, substance use history, and Edinburgh Postnatal Depression Scale (EPDS) scores were extracted from patients' medical records. Modified Poisson Regression with robust standard errors was used to estimate the relative risk (RR) of screening positive for PPD, adjusting for age at delivery, race/ethnicity, insurance type, marital status, and smoking history. Among the 799 subjects meeting inclusion criteria, 15.9% used cannabis during pregnancy. There was an increased risk of screening positive for PPD among prenatal cannabis users compared to non-users (aRR = 1.60, 95% CI: (1.05, 2.45)). Among individuals with a history of depression, the adjusted relative risk of screening positive for symptoms of PPD at the postpartum visit was 1.62 times greater in cannabis users compared to non-users (95% CI: (1.02, 2.58)). Prenatal cannabis use is associated with screening positive for PPD, particularly in those individuals with a history of depression. These results should discourage women with depression from self-medicating with cannabis in pregnancy and provide additional support to the existing recommendations to abstain from prenatal cannabis use.

The impact of pregnancy and associated hormones on the pharmacokinetics of Δ9-tetrahydrocannabinol

INTRODUCTION

(-)-Δ9-tetrahydrocannabinol (THC) is the main psychoactive component of cannabis. Cannabis is the most widely used drug of abuse by pregnant individuals, but its maternal-fetal safety is still unclear. The changes in THC disposition during pregnancy may affect THC safety and pharmacology.

AREAS COVERED

This review summarizes the current literature on THC metabolism and pharmacokinetics in humans. It provides an analysis of how hormonal changes during pregnancy may alter the expression of cannabinoid metabolizing enzymes and THC and its metabolite pharmacokinetics. THC is predominately (>70%) cleared by hepatic metabolism to its psychoactive active metabolite, 11-OH-THC by cytochrome P450 (CYP) 2C9 and to other metabolites (<30%) by CYP3A4. Other physiological processes that change during pregnancy and may alter cannabinoid disposition are also reviewed.

EXPERT OPINION

THC and its metabolites disposition likely change during pregnancy. Hepatic CYP2C9 and CYP3A4 are induced in pregnant individuals and in vitro by pregnancy hormones. This induction of CYP2C9 and CYP3A4 is predicted to lead to altered THC and 11-OH-THC disposition and pharmacodynamic effects. More in vitro studies of THC metabolism and induction of the enzymes metabolizing cannabinoids are necessary to improve the prediction of THC pharmacokinetics in pregnant individuals.

Marijuana Use among Pregnant and Nonpregnant Women of Reproductive Age, 2013-2019

BACKGROUND

Marijuana is the most commonly used federally illicit substance among reproductive-age women in the United States. Updated information on marijuana use in this population can inform clinical and public health interventions.

METHODS

Data from the 2013-2019 National Survey on Drug Use and Health was used to report weighted prevalence estimates of marijuana use in the past month, past 2-12 months, and past year among women aged 18-44 years with self-reported pregnancy status. Bivariate analyses and general linear regression models with Poisson distribution using appropriate survey procedures identified factors associated with past-year marijuana use by pregnancy status.

RESULTS

Among pregnant women, 4.9% (95% confidence interval [CI]: 4.1-5.6) reported marijuana use in the past month, 10.4% (95% CI: 9.3-11.5) in the past 2-12 months, and 15.2% (95% CI: 13.9-16.6) in the past year. Among nonpregnant women, 11.8% (95% CI: 11.5-12.0) reported marijuana use in the past month, 7.8% (95% CI: 7.6-8.0) in the past 2-12 months, and 19.5% (95% CI: 19.2-19.9) in the past year. After adjusting for sociodemographic characteristics, past-year marijuana use was 2.3-5.1 times more likely among pregnant, and 2.1 to 4.6 times more likely among nonpregnant women who reported past-year tobacco smoking, alcohol use, or other illicit drug use compared to those reporting no substance use.

CONCLUSIONS

Pregnant and nonpregnant women reporting marijuana use, alone or with other substances, can benefit from substance use screening and treatment facilitation.

Nausea and vomiting of pregnancy and prenatal cannabis use in a Michigan sample

BACKGROUND

Nausea and vomiting of pregnancy, also referred to as morning sickness, affects more than 70% of all pregnancies. Symptoms range from mild to severe and, in some cases, can be debilitating, resulting in a reduced quality of life. Moreover, prenatal cannabis use prevalence has doubled in the United States, and cannabis potency, measured by the concentration of delta-9-tetrahydrocannabiniol, has increased from 10% in 2009 to 14% in 2019. State-level recreational legalization of cannabis may contribute to the liberalization of its use and reduced risk perception. Furthermore, the relatively recent discovery of cannabinoid hyperemesis syndrome may contribute to the mischaracterization of morning sickness in individuals who use cannabis during pregnancy. Although cannabis has well-documented antiemetic properties, there is insufficient research on the topic. Therefore, it is essential to establish a tangible understanding of the association between nausea and vomiting of pregnancy and prenatal cannabis use.

OBJECTIVE

This study aimed to estimate the degree to which nausea and vomiting of pregnancy might be associated with prenatal cannabis use in a sample of pregnant people in Michigan, a state where recreational cannabis use became legal in December 2018.

STUDY DESIGN

This was a prospective study of participants from the Michigan Archive for Research on Child Health, a population-based pregnancy cohort that was recruited using a probability-based sampling approach. Participants were recruited from 22 prenatal clinics located throughout Michigan's lower peninsula. Cross-sectional analyses were performed for data available between October 2017 and January 2022.

RESULTS

Among this sample of Michigan pregnant people, 14% (95% confidence interval, 11%-16%) reported cannabis use. Participants who experienced increasing morning sickness severity had higher odds of using cannabis (adjust odds ratio, 1.2; 95% confidence interval, 1.1-1.2). When the sample was restricted to first-trimester morning sickness and cannabis use, the results remained statistically robust. When the direction of the association was reversed, an increase in morning sickness severity was detected among participants who used cannabis during pregnancy (ßadjusted, 0.2; 95% confidence interval, 0.1-0.2). Lastly, the association between prepregnancy cannabis use and first-trimester morning sickness was investigated. Study findings suggest an increase in morning sickness severity among people who used cannabis in the 3 months before pregnancy compared with those who did not use cannabis (ßadjusted, 0.1; 95% confidence interval, 0.003-0.200).

CONCLUSION

Study findings indicated a link between nausea and vomiting of pregnancy and prenatal cannabis use. Moreover, this study revealed that using cannabis in the 3 months before pregnancy is associated with first-trimester morning sickness severity. The strengths of our study contribute to the scant epidemiologic evidence in this area of research. More fine-grained, time-specific data on nausea and vomiting of pregnancy and prenatal cannabis use are necessary to draw inferences about cause-effect relationships. Our study might provide a basis to discourage cannabis use during pregnancy until more evidence is collected.

Reported Reasons for Cannabis Use Before and After Pregnancy Recognition

OBJECTIVES

Cannabis use is cautioned against during pregnancy, yet many pregnant people continue to use. This study aimed to evaluate the patterns and reasons for cannabis use before and after conception in pregnant people who screened positive for cannabis use at initiation of prenatal care.

METHODS

Pregnant patients at 1 prenatal practice in Baltimore, MD, who either self-reported cannabis use or tested positive on urine toxicology were approached for enrollment. Those who consented were given an anonymous survey with multiple choice questions regarding frequency and reasons for use before and after pregnancy recognition. Fisher exact, χ 2 test, and analysis of variance were used for analysis.

RESULTS

Of 117 pregnant people approached, 105 enrolled in the study. Of the 105 respondents, 40 (38.1%) reported complete abstinence after pregnancy recognition, whereas 65 (61.9%) reported continued use. Of the respondents who continued cannabis use, 35 (53.8%) had decreased frequency of use or quit, 26 (40%) reported no change in frequency of use, and 4 (6.2%) reported increase in frequency of use. Those who considered their use medical or mixed before pregnancy were 4 times as likely to continue use compared with those who considered their use nonmedical (66.7% vs 33.3%; odds ratio, 4.0; 95% confidence interval, 1.3-12.8). Respondents who continued use after pregnancy recognition were significantly more likely to discuss their use with their obstetrician (89.2% vs 50%, P < 0.001).

CONCLUSIONS

Reasons for use frequently changed after recognition of pregnancy. Most people who continued use during pregnancy reported that their reasons were for symptom control.

Making informed choices about cannabis use during pregnancy and lactation: A qualitative study of information use

BACKGROUND

Cannabis use during pregnancy and lactation continues to increase as some perceive cannabis to be helpful for symptom management and coping. As such, pregnant and lactating people are faced with challenging decisions, weighing benefits against the potential risks of cannabis use. To help clinicians facilitate informed choices, we explored the self-identified information needs of pregnant and lactating people who are deciding whether or not to use cannabis. We aimed to describe the modes and sources of their information-seeking and their satisfaction with the information they found.

METHODS

We interviewed 52 people in Canada who made the decision to start, stop, or continue using cannabis during pregnancy and lactation. Participants were recruited from advertisements in prenatal clinics and on social media. We utilized an inductive approach to analysis focused on information used in decision-making about cannabis use, including the process of seeking and evaluating that information.

RESULTS

Participants were deliberate in their search for information, most commonly seeking information on risks of use. Information sources were mainly online material or people in their social networks. Clinicians were not commonly described as a knowledgeable or supportive source of information. Overwhelmingly, participants described the information they found as insufficient and emphasized the need for more comprehensive and trustworthy sources of information.

CONCLUSIONS

Participants identified distinct and unmet information needs associated with their decision to use cannabis. They described a desire for clear evidence about the impact of cannabis use, including information about how to balance the benefits they perceived from cannabis use with the risks of harm.

Maternal Childhood Maltreatment, Internal Working Models, and Perinatal Substance Use: Is There a Role for Hyperkatifeia? A Systematic Review

The parent-infant relationship is critical for socioemotional development and is adversely impacted by perinatal substance use. This systematic review posits that the mechanisms underlying these risks to mother-infant relationships center on 3 primary processes: (1) mothers' childhood maltreatment experiences; (2) attachment styles and consequent internal working models of interpersonal relationships; and (3) perinatal substance use. Further, the review considers the role of hyperkatifeia, or hypersensitivity to negative affect which occurs when people with substance use disorders are not using substances, and which drives the negative reinforcement in addiction. The authors performed a systematic review of articles (published 2000-2022) related to these constructs and their impact on mother-infant relationships and offspring outcomes, including original clinical research articles addressing relationships between these constructs, and excluding case studies, reviews, non-human animal studies, intervention studies, studies with fewer than 30% female-sex participants, clinical guidelines, studies limited to obstetric outcomes, mechanistic/biological studies, and studies with methodological issues precluding interpretation. Overall 1844 articles were screened, 377 were selected for full text review, and data were extracted from 157 articles. Results revealed strong relationships between mothers' childhood maltreatment experiences, less optimal internal working models, and increased risk for perinatal substance use, and importantly, all of these predictors interacted with hyperkatifeia and exerted a marked impact on mother-infant relationships with less data available on offspring outcomes. These data strongly support the need for future studies addressing the additive impact of maternal childhood maltreatment experiences, suboptimal internal working models, and perinatal substance use, with hyperkatifeia as a potential moderator, and their interacting effects on mother-infant socioemotional outcomes.

Cannabis and Pregnancy: A Review

Importance

Prenatal cannabis use is rising and is a major public health issue. Cannabis use in pregnancy and during lactation has been associated with increased maternal and offspring morbidity and mortality.

Objective

This review aims to summarize the existing literature and current recommendations for cannabis use during pregnancy or lactation.

Evidence Acquisition

A PubMed, Cochrane Library, and Google Scholar literature search using the following terms was performed to gather relevant data: "cannabis," "cannabinoid," "delta-9-tetrahydrocannabinol," "THC," "cannabidiol," "fetal outcomes," "perinatal outcomes," "pregnancy," and "lactation."

Results

Available studies on cannabis use in pregnancy and during lactation were reviewed and support an association with increased risk of preterm birth, neonatal intensive care unit admission, low birth weight, and small-for-gestational-age infants.

Conclusion and Relevance

There is a critical need for research on the effects of cannabis use in pregnancy and during lactation. This is a necessary first step before furthering patient education, developing interventions, and targeting antenatal surveillance to ameliorate the adverse impacts on maternal and fetal health.

Cannabis for morning sickness: areas for intervention to decrease cannabis consumption during pregnancy

BACKGROUND

Cannabis use during pregnancy is increasing, with 19-22% of patients testing positive at delivery in Colorado and California. Patients report using cannabis to alleviate their nausea and vomiting, anxiety, and pain. However, preclinical and clinical data highlight harmful effects to offspring physiology and behavior following fetal cannabis exposure. This narrative review identifies potential areas for intervention to decrease cannabis consumption during pregnancy.

METHODS

A combination of keywords, including "cannabis", "cannabis", "weed", "pregnancy", "morning sickness", "child protective services", and "budtender" were searched in databases such as PubMed and Google Scholar, as well as in social media forums, governmental webpages, and other publicly available sources.

RESULTS

The literature search identified several areas for intervention to reduce cannabis use during pregnancy, including physician and pharmacist training, engagement with pregnant patients, regulation of dispensary workers, and the role of child protective services.

DISCUSSION

This comprehensive review identifies multiple areas for improvement to benefit pregnant patients. Recommendations are independent and can be implemented simultaneously by the identified groups. Limitations of this research includes the relatively limited availability of data focused specifically on cannabis consumption during pregnancy and the complexity of the sociopolitical field of substance use during pregnancy.

CONCLUSIONS

Cannabis consumption during pregnancy is increasing and causes harm to the developing fetus. To educate pregnant patients about these risks, we must address the gaps in education from multiple contact points.

Women are Taking the Hit: Examining the Unique Consequences of Cannabis Use Across the Female Lifespan

Cannabis use has risen dramatically in recent years due to global decriminalization and a resurgence in the interest of potential therapeutic benefits. While emerging research is shaping our understanding of the benefits and harms of cannabis, there remains a paucity of data specifically focused on how cannabis affects the female population. The female experience of cannabis use is unique, both in the societal context and because of the biological ramifications. This is increasingly important given the rise in cannabis potency, as well as the implications this has for the prevalence of Cannabis Use Disorder (CUD). Therefore, this scoping review aims to discuss the prevalence of cannabis use and CUD in women throughout their lifespan and provide a balanced prospective on the positive and negative consequences of cannabis use. In doing so, this review will highlight the necessity for continued research that goes beyond sex differences.

Impact of Prenatal Cannabis Use Disorder on Perinatal Outcomes

OBJECTIVES

With legislative changes to cannabis legalization and increasing prevalence of use, cannabis is the most commonly used federally illicit drug in pregnancy. Our study aims to assess the perinatal outcomes associated with prenatal cannabis use disorder.

METHODS

We conducted a retrospective cohort study using California linked hospital discharge-vital statistics data and included singleton, nonanomalous births occurring between 23 and 42 weeks of gestational age. χ 2 Test and multivariable logistic regression were used for statistical analyses.

RESULTS

A total of 2,380,446 patients were included, and 9144 (0.38%) were identified as using cannabis during pregnancy. There was a significantly increased risk for adverse birthing person outcomes, including gestational hypertension (adjusted odds ratio [AOR], 1.19; 95% confidence interval [CI], 1.06-1.34; P = 0.004), preeclampsia (AOR, 1.16; 95% CI, 1.0-1.28; P = 0.006), preterm delivery (AOR, 1.45; 95% CI, 1.35-1.55; P < 0.001), and severe maternal morbidity (AOR, 1.22; 95% CI, 1.02-1.47; P = 0.033). Prenatal cannabis use disorder was also associated with an increased risk of neonatal outcomes including respiratory distress syndrome (AOR, 1.16; 95% CI, 1.07-1.27; P < 0.001), small for gestational age (AOR, 1.47; 95% CI, 1.38-1.56; P < 0.001), neonatal intensive care unit admission (AOR, 1.24; 95% CI, 1.16-1.33; P < 0.001), and infant death (AOR, 1.86; 95% CI, 1.44-2.41; P < 0.001). There was no statistically significant difference in stillbirth (AOR, 0.96; 95% CI, 0.69-1.34; P = 0.80) and hypoglycemia (AOR, 1.22; 95% CI, 1.00-1.49; P = 0.045).

CONCLUSIONS

Our study suggests that prenatal cannabis use disorder is associated with increased maternal and neonatal morbidity and mortality. As cannabis use disorder in pregnancy is becoming more prevalent, our findings can help guide preconception and prenatal counseling.

Addressing cannabis consumption among patients with hyperemesis gravidarum

Severe nausea and vomiting of pregnancy and hyperemesis gravidarum affect up to 3% of all pregnant people, causing substantial maternal and neonatal morbidity, suffering, and financial cost. Evidence supports the association of cannabis consumption with symptoms of severe nausea and vomiting of pregnancy or hyperemesis gravidarum as the general public has come to believe that cannabis is a natural, safe antiemetic. Cannabis consumption in pregnancy is discouraged strongly by the Surgeon General of the United States and the American College of Obstetricians and Gynecologists because of evidence of potential harms. Symptoms of intractable, severe nausea and vomiting of pregnancy or hyperemesis gravidarum associated with cannabis consumption may be unrecognized cannabinoid hyperemesis syndrome, and this syndrome may be more common than previously thought. Cannabis consumption is especially detrimental when causing or exacerbating debilitating symptoms such as the intense, persistent, recurrent, or cyclic vomiting and associated dehydration and other sequelae of cannabinoid hyperemesis syndrome. Open discussion of cannabis consumption during pregnancy is very challenging for patients and maternity care providers in our current environment of variable legal status across states and variable degrees of personal and societal acceptance. Evidence-based medical knowledge, guidance, tools, and skills are needed to differentially diagnose and treat cannabinoid hyperemesis syndrome in pregnancy. Researchers, clinicians, and medical specialty organizations must work together to strengthen the evidence base and develop or refine the necessary guidelines and tools for maternity care provider skill development, and to increase public and patient awareness of cannabinoid hyperemesis syndrome, specifically during pregnancy.

Cannabinoids and the placenta: Receptors, signaling and outcomes

Cannabis use during pregnancy is increasing. The improvement of pregnancy-related symptoms including morning sickness and management of mood and stress are among the most reported reasons for its use. Δ9-tetrahydrocannabinol (Δ9-THC) and cannabidiol (CBD) are the most abundant cannabinoids found within the cannabis flower. The concentration of these components has drastically increased in the past 20 years. Additionally, many edibles contain only one cannabinoid and are marketed to achieve a specific goal, meaning there are an increasing number of pregnancies that are exposed to isolated cannabinoids. Both Δ9-THC and CBD cross the placenta and can impact the fetus directly, but the receptors through which cannabinoids act are also expressed throughout the placenta, suggesting that the effects of in-utero cannabinoid exposure may include indirect effects from the placenta. In-utero cannabis research focuses on short and long-term fetal health and development; however, these studies include little to no placenta analysis. Prenatal cannabinoid exposure is linked to small for gestational age and fetal growth-restricted babies. Compromised placental development is also associated with fetal growth restriction and the few studies (clinical and animal models) that included placental analysis, identify changes in placental vasculature and function in these cannabinoid-exposed pregnancies. In vitro studies further support cannabinoid impact on cell function in the different populations that comprise the placenta. In this article, we aim to summarize how phytocannabinoids can impact placental development and function. Specifically, the cannabinoids and their actions at the different receptors are described, with receptor localization throughout the human and murine placenta discussed. Findings from studies that included placental analysis and how cannabinoid signaling may modulate critical developmental processing including cell proliferation, angiogenesis and migration are described. Considering the current research, prenatal cannabinoid exposure may significantly impact placental development, and, as such, identifying windows of placental vulnerability for each cannabinoid will be critical to elucidate the etiology of fetal outcome studies.

Systematic Review: Polysubstance Prevalence Estimates Reported during Pregnancy, US, 2009-2020

INTRODUCTION

The objective of this systematic review is to describe polysubstance studies and their prevalence estimates among pregnant people in the US.

METHODS

This review was not subject to protocol preparation or registration with the International Prospective Register of Systematic Reviews (PROSPERO) because outcome data were not reported. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Checklist was followed. Four scientific literature databases were used to identify articles published from January 1, 2009 to June 3, 2020 reporting prenatal exposure to two or more substances in the US. A standardized process of title and abstract screening followed by a two-phase full-text review was used to assess study eligibility.

RESULTS

A total of 119 studies were included: 7 case-control studies, 7 clinical trials, 76 cohort studies, and 29 cross-sectional studies. Studies varied with respect to study design, time period, region, sampling and participant selection, substances assessed, and method of exposure ascertainment. Commonly reported polysubstance prevalence estimates among studies of pregnant people included combinations with alcohol, marijuana, and/or tobacco/nicotine. The range of prevalence estimates was wide (alcohol 1-99%; marijuana 3-95%; tobacco/nicotine 2-95%).

DISCUSSION

Polysubstance use during pregnancy is common, especially with alcohol, marijuana, and/or tobacco/nicotine. Future research to assess polysubstance use during pregnancy could help better describe patterns and ultimately help mitigate its effects on maternal and infant health outcomes.

Effects of prenatal cannabis exposure on developmental trajectory of cognitive ability and brain volumes in the adolescent brain cognitive development (ABCD) study

Although cannabis use during pregnancy is increasing widely, the effects of cannabis on developmental trajectories, such as whether its effects during pregnancy remain the same between time points or gradually increase, are unclear. This study aimed to examine whether cannabis use during pregnancy affects the process of change in cognition and brain volume. Data from two-time points measured longitudinally were analyzed. We used data from the Adolescent Brain and Cognitive Development Study. Participants included 11,876 children aged 9-11 years participated at baseline, and 10,414 participated at 2-year follow-up from 22 sites across the United States. We explored the associations between prenatal cannabis exposure and cognitive abilities and brain volumes developmental trajectories. Among 11,530 children with valid data for prenatal cannabis exposure, 10,833 had no prenatal cannabis use, and 697 had cannabis use during their pregnancy. There was a significant interaction between time points and cannabis use during pregnancy on visuo-perceptual processing ability (b = -0.019, p = .009) and intracranial volumes (b = -6338.309, p = .009). We found that the effects of exposure to cannabis during pregnancy are not uniform at all times and may gradually become more apparent and magnified as development progresses.

Feasibility and acceptability of collecting umbilical cord tissue for prenatal cannabis research: A mixed-methods research study

BACKGROUND

Large-scale longitudinal studies with biological samples are needed to examine the associations between prenatal cannabis use and birth and developmental outcomes.

OBJECTIVES

The aim of this study was to understand the feasibility and acceptability of collecting umbilical cord tissue for the purpose of cannabis use testing in a community sample.

DESIGN

This is a mixed methods research study consisted of a prospective cohort study and a qualitative descriptive study.

METHODS

This study was conducted in Vancouver, British Columbia between January 2021 and August 2022. Participants were recruited during pregnancy, and the umbilical cord tissues were collected at birth and tested for the presence of cannabinoids. After the completion of the study, participants completed an online open-ended questionnaire about their overall experience. Data were analyzed using descriptive and thematic analyses.

RESULTS

Among the 85 eligible individuals, 57 people (67%) consented to the study. The cord tissue was collected for 39 participants (68.4%). The collection rates for participants with vaginal, elective, and emergency cesarean delivery were 73.0%, 71.4%, and 53.8%, respectively, and for those with spontaneous and induced labor were 81.5% and 50%, respectively. Four (7.0%) and seven participants (12.3%) reported prenatal cannabis use in direct and probing self-report questions, respectively. The agreement between any self-report and cord tissue test was moderate (kappa 0.53, 95% confidence interval 0.06-0.99). Qualitative findings were classified into five themes.

CONCLUSION

The collection of cord tissue was perceived acceptable by most participants. Implementation of collection protocols for complex labors, a central hospital unit to liaise direct communications and active participants' involvement might increase the feasibility of future studies.

Pregnant and lactating people's strategies to mitigate the risk of cannabis consumption

BACKGROUND

Multiple studies have demonstrated that pregnant and lactating people who use cannabis perceive a variety of benefits from that use, offering some explanation of why rates of use continue to increase.

OBJECTIVES

The aim of this study was to explore pregnant and lactating people's perceptions of the risks of cannabis use and understand what steps, if any, they take to mitigate these risks.

DESIGN

Qualitative description.

METHODS

We analyzed semi-structured interviews with 52 Canadians who made the decision to start, stop, or continue using cannabis during pregnancy or lactation between 2019 and 2021. Data collection iterated with analysis. We used a conventional (inductive) approach to content analysis.

RESULTS

Perception of risk was found to be an essential component of decision-making about cannabis use. We identified a cycle of "risk identification," "management," and "observation" of effects. First, the pregnant or lactating person assesses the risks and weighs them against the perceived benefits of cannabis use. Second, they take action to minimize risks, with some choosing abstinence. Others, often those who were using cannabis to manage symptoms, continued cannabis use but devised a variety of other risk mitigation strategies such as, decreasing the amount or frequency of their use, changing the form of cannabis, and strategically timing their use with caregiving responsibilities. The final stage of the cycle involves seeking information about whether or not the initial perceived risk has manifested after implementing mitigation strategies, through observations and clinical information about the pregnancy or child.

CONCLUSION

Participants consistently engaged in deliberation about the risks and benefits associated with their perinatal cannabis use. Nearly all implemented strategies intended to minimize risk. Our results highlight the need for more research to inform clear public health messaging about risk mitigation to minimize the potential harms of perinatal cannabis use. This work informs clinicians about patient-perceived risks and mitigation strategies which could in turn help inform shared decision-making conversations.

"Ganja Mamas": Online discussions about cannabis use in pregnancy

BACKGROUND

Nearly 5 % of pregnant women in the United States use cannabis. However, expecting mothers often do not seek counsel from their healthcare providers about prenatal cannabis use due to stigma and legal ramifications. Instead, cannabis-using pregnant women turn to each other to learn. Online message boards have become a safe place for parents to seek answers anonymously in real-time. The objective of this study was to examine the information-seeking/giving behaviors of cannabis-using pregnant women on an online community forum.

METHODS

We extracted 151 original messages and 1260 corresponding comments posted over a 7-day period from Whattoexpect.com's "Ganja Mamas" forum. We iteratively developed a codebook with 16 categories to reflect information-seeking behavior. N = 131 unique forum members posted questions for comment.

RESULTS

Approximately half, 46.56 %, reported their geographic location (24 states), and 40.46 % reported gestational age. The top topics for which members sought out information were testing, state-specific questions, postpartum, child protective services (CPS), hospital-specific questions, birth announcements, methods of cannabis use, quitting, breastfeeding/pumping, pregnancy symptoms, mental health, general health and pregnancy, and quantity of cannabis use. The second phase of analysis was based on members' responses. Clustered codes indicated how the respondents were using the forum: (1) interviewing and geographic location, (2) knowledge, experience, and reassurance, (3) congratulations and relief, and (4) concealing cannabis use and symptoms.

CONCLUSIONS

Our results demonstrate that mothers on an online cannabis forum are seeking information about location-specific experiences pertaining mostly to testing and child protective services. Additionally, mothers are responding by geographic-specific interviewing, and are expressing relief and reassurance in response to members' experiences.

Effect of maternal adverse childhood experiences (ACE) and cannabis use on pregnancy outcomes

This study aimed to characterize the relationship between cannabis use, ACE score, and pregnancy outcomes. Pregnant patients in Baltimore, MD, completed the 17-point ACE checklist. Charts of the birth parent and neonate were reviewed for urine toxicology testing at initiation of care and delivery, prenatal care metrics, and birth statistics. Multivariable logistic regression analysis was performed to assess the relationship between ACE score, cannabis use, and pregnancy outcomes. Of 256 birth parents, 87 (34.0%) tested positive for cannabis at initial visit and 39 (15.2%) tested positive for cannabis at delivery. Testing positive for cannabis at initial visit or delivery was associated with higher ACE score (15.1 vs 13.7, p = 0.04; 16.2 vs 13.8, p = 0.01). Of those who tested positive for cannabis at initial visit, 39/87 (45.0%) tested positive at delivery. Continued cannabis use at delivery was associated with lower maternal weight gain (7.9 kg vs 13.3 kg, p = 0.003), fewer prenatal visits (7 vs 8, p = 0.010), and numerically higher mean ACE score. Cannabis use at delivery was associated with 10% lower birthweight (2665 g vs 3014 g p < 0.05) but not with pre-term birth. Total ACE score was not significantly associated with any birth outcome. Worse pregnancy outcomes were associated with cannabis use throughout pregnancy but not with cannabis use at prenatal care initiation. The interplay of ACE and continued cannabis use during pregnancy warrants further research on the physiologic effects of cannabis and interventions to decrease substance use during pregnancy.

Perspectives from women who engaged in prenatal and postpartum cannabis use in a U.S. State with legal non-medical use

Evidence suggests fetal risks are associated with cannabis use during pregnancy. Yet, insights into women's decision-making and cannabis use during pregnancy are limited. This study explored these concepts with postpartum women who used cannabis during and after pregnancy. We conducted interviews with 15 women (4 self-identifying a race other than White and 4 self-identifying Hispanic ethnicity) who: 1) lived in the Puget Sound region of Washington State, 2) reported past-year cannabis use on a routine screen, and 3) had documented pregnancy and delivery March 2015-May 2017. Semi-structured interviews asked about decision-making and cannabis use during pregnancy and postpartum. We used template analysis for coding and analysis. The key findings included that women: 1) gathered information about cannabis use during pregnancy primarily through internet searches and discussions with peers; 2) were reluctant to talk with health care providers about cannabis; 3) used cannabis while pregnant to treat health issues, including morning sickness, pain, and mental health conditions; 4) were comfortable with their decision to use cannabis while pregnant, but had questions about long-term effects; and 5) tried to mitigate transmission through breastmilk. Women decided about cannabis during pregnancy based on their experience, health symptoms, and information gathered from the internet and peers, often without guidance from their health care provider. Results point to opportunities for providers to become informed about and engage in discussion with patients about cannabis use during preconception, pregnancy, and postpartum.

Cannabis use among pregnant women under different legalization frameworks in the United States

Background: Cannabis use in pregnancy is associated with adverse neonatal outcomes, yet its use among pregnant women in the United States has increased significantly.Objectives: This cross-sectional study explored how cannabis use in pregnant women varied between different cannabis legalization frameworks, that is, permitted use of cannabidiol (CBD)-only, medical cannabis, and adult-use cannabis.Methods: Behavioral Risk Factor Surveillance System data from 2017 to 2020 was utilized with respondents classified by their state's policies into CBD-only, medical, and adult-use groups. Outcome measures included prevalence of use and usage characteristics (frequency, method of intake, and reason for use) among pregnant women. Logistic regression models were estimated to evaluate the association between legal status and prevalence of use.Results: The unweighted dataset included 1,992 pregnant women. Recent cannabis use was reported by (weighted proportions): 2.4% (95%CI: 0-4.4) of respondents in the CBD-only group, 7.1% (95%CI: 4.0-10.1) in the medical group and 6.9% (95%CI: 3.0-10.9) in the adult-use group. Compared to the CBD-only group, respondents in the medical and adult-use groups were 4.5-fold (adjusted; 95%CI: 1.4-14.7; p = .01) and 4.7-fold (adjusted; 95%CI: 1.3-16.2; p = .02) more likely to use cannabis. Across all groups, smoking was the most common method of intake and over 49% of users reported using partially or entirely for adult-use purposes.Conclusions: The increased use with legalization motivates further research on the impacts of cannabis as a therapeutic agent during pregnancy and supports the need for increased screening and patient counseling regarding the potential effects of cannabis use on fetal development.

Intention to Breastfeed and Paternal Influence on Pregnant Mothers Exclusively Using Marijuana Compared with Other Substances

Objective: To determine intention to breastfeed (ITBF) rates among mothers exclusively using marijuana (eMJ) compared with electronic cigarettes (eEcig), tobacco products (eTob), or multisubstances (MS), nonusers (NU), and the influence of paternal presence and paternal substance use. Study Design: Cross-sectional study of parental survey responses merged with electronic birth certificates. Accounting for clinical and social determinants of health, analyses of ITBF included (1) all mothers, (2) single mothers, and (3) mothers with fathers. Results: Among all mothers (n = 1,073), eMJ, eTob, and MS users had lower odds of ITBF compared with NU. Only eMJ users had lower odds of ITBF for those without paternal presence. However, in those mothers with a paternal presence, odds of ITBF were similar to NU for eMJ, eTob, and MS users when accounting for paternal factors, including paternal substance use. Conclusion: Women exclusively using MJ have lower ITBF compared with NU. However, paternal presence mitigated this effect, independent of parental MJ use. The presence of fathers may represent a unique predictor for increased ITBF in MJ using mothers.

Peri-Pregnancy Cannabis Use and Autism Spectrum Disorder in the Offspring: Findings from the Study to Explore Early Development

The association of autism spectrum disorder (ASD) with self-reported maternal cannabis use from 3 months pre-conception to delivery ("peri-pregnancy") was assessed in children aged 30-68 months, born 2003 to 2011. Children with ASD (N = 1428) were compared to children with other developmental delays/disorders (DD, N = 1198) and population controls (POP, N = 1628). Peri-pregnancy cannabis use was reported for 5.2% of ASD, 3.2% of DD and 4.4% of POP children. Adjusted odds of peri-pregnancy cannabis use did not differ significantly between ASD cases and DD or POP controls. Results were similar for any use during pregnancy. However, given potential risks suggested by underlying neurobiology and animal models, further studies in more recent cohorts, in which cannabis use and perception may have changed, are needed.

Outcomes of Cannabis Use During Pregnancy Within the American Association of Birth Centers Perinatal Data Registry 2007-2020: Opportunities Within Midwifery-Led Care

BACKGROUND

Healthcare providers require data on associations between perinatal cannabis use and birth outcomes.

METHODS

This observational secondary analysis come from the largest perinatal data registry in the United States related to the midwifery-led birth center model care (American Association of Birth Centers Perinatal Data Registry; N = 19 286). Births are planned across all birth settings (home, birth center, hospital); care is provided by midwives and physicians.

RESULTS

Population data show that both early and persistent self-reports of cannabis use were associated with higher rates of preterm birth, low-birth-weight, lower 1-minute Apgar score, gestational weight gain, and postpartum hemorrhage. Once controlled for medical and social risk factors using logistic regression, differences for childbearing people disappeared except that the persistent use group was less likely to experience "no intrapartum complications" (adjusted odds ratio [aOR] = 0.49; 95% confidence interval [CI], 0.32-0.76; P < .01), more likely to experience an indeterminate fetal heart rate in labor (aOR = 3.218; 95% CI, 2.23-4.65; P < .05), chorioamnionitis (aOR = 2.8; 95% CI, 1.58-5.0; P < .01), low-birth-weight (aOR = 1.8; 95% CI, 1.08-3.05; P < .01), and neonatal intensive care unit (NICU) admission (aOR = 2.4; 95% CI, 1.30-4.69; P < .05).

CONCLUSIONS

Well-controlled data demonstrate that self-reports of persistent cannabis use through the third trimester are associated with an increased risk of low-birth-weight and NICU admission.

Pregnancy Outcomes Associated With Use of Tobacco and Marijuana

Tobacco and marijuana are the most common drugs of abuse among pregnant women. Cigarettes have been extensively studied and increase the risk of miscarriage, preterm birth, premature rupture of membranes, placental dysfunction, low birth rate, stillbirth, and infant mortality. There are sparse data on the specific effects of electronic cigarettes and smokeless tobacco in pregnancy. Literature on marijuana in pregnancy is limited by confounding, bias, and the retrospective nature of studies that do not capture contemporary trends in use. However, several studies suggest an association between marijuana and fetal growth restriction, low birth weight, and neurodevelopmental differences in offspring.

Trends in Cannabis Polysubstance Use During Early Pregnancy Among Patients in a Large Health Care System in Northern California

IMPORTANCE

Rates of prenatal cannabis use are increasing alongside perceptions that cannabis is a harmless therapeutic for pregnancy-related ailments, while rates of prenatal use of alcohol and tobacco are decreasing. It is important to examine whether cannabis use during pregnancy is increasing similarly among patients with and patients without co-occurring substance use.

OBJECTIVES

To examine trends in cannabis polysubstance use during pregnancy and to test differences in cannabis use over time among pregnant individuals who use only cannabis vs those who use cannabis and other substances.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional time-series study used data from 367 138 pregnancies among 281 590 unique pregnant patients universally screened for prenatal substance use as part of standard care in Kaiser Permanente Northern California from January 1, 2009, to December 31, 2018. Statistical analysis was performed from October 5, 2021, to April 18, 2022.

EXPOSURES

Time (calendar year).

MAIN OUTCOMES AND MEASURES

Use of substances during early pregnancy was assessed via universal screening with a self-administered questionnaire (for cannabis, alcohol, stimulants, and nicotine) and/or positive results of a urine toxicology test (for cannabis, alcohol, stimulants, and pharmaceutical opioids), and data were extracted from the electronic health record.

RESULTS

The study sample of 367 138 pregnancies from 281 590 unique pregnant patients (median gestation at time of screening, 8.6 weeks [IQR, 7.3-10.6 weeks]) was 25.9% Asian or Pacific Islander, 6.6% Black, 25.8% Hispanic, 38.0% non-Hispanic White, and 3.6% other race or ethnicity; 1.1% were aged 11 to 17 years, 14.9% were aged 18 to 24 years, 61.9% were aged 25 to 34 years, and 22.1% were aged 35 years or older; and the median neighborhood household income was $70 455 (IQR, $51 563-$92 625). From 2009 to 2018, adjusted rates of use of only cannabis during pregnancy (no other substances) increased substantially from 2.39% (95% CI, 2.20%-2.58%) in 2009 to 6.30% (95% CI, 6.00%-6.60%) in 2018, increasing at an annual relative rate of 1.11 (95% CI, 1.10-1.12). The rate of use of cannabis and 1 other substance also increased (annual relative rate, 1.04 [95% CI, 1.03-1.05]), but not as rapidly (P < .001 for difference), while the rate of use of cannabis and 2 or more other substances decreased slightly (annual relative rate, 0.97 [95% CI, 0.96-0.99]). Adjusted rates of prenatal use of cannabis and alcohol (1.04 [95% CI, 1.03-1.06]) and cannabis and stimulants (1.03 [95% CI, 1.01-1.06]) increased over time, while rates of prenatal use of cannabis and nicotine (0.97 [95% CI, 0.96-0.98]) decreased.

CONCLUSIONS AND RELEVANCE

In this cross-sectional time-series study, rates of prenatal cannabis use during early pregnancy increased significantly more rapidly among patients without co-occurring substance use, which could reflect increased acceptability of cannabis and decreased perceptions of cannabis-related harms. Furthermore, increased rates of use of cannabis with alcohol and stimulants warrant continued monitoring.

Clinician responses to cannabis use during pregnancy and lactation: a systematic review and integrative mixed-methods research synthesis

BACKGROUND

Perinatal cannabis use is increasing, and clinician counselling is an important aspect of reducing the potential harm of cannabis use during pregnancy and lactation. To understand current counselling practices, we conducted a systematic review and integrative mixed-methods synthesis to determine "how do perinatal clinicians respond to pregnant and lactating patients who use cannabis?"

METHODS

We searched 6 databases up until 2021-05-31. Eligible studies described the attitudes, perceptions, or beliefs of perinatal clinician about cannabis use during pregnancy or lactation. Eligible clinicians were those whose practice particularly focusses on pregnant and postpartum patients. The search was not limited by study design, geography, or year. We used a convergent integrative analysis method to extract relevant findings for inductive analysis.

RESULTS

Thirteen studies were included; describing perspectives of 1,366 clinicians in 4 countries. We found no unified approach to screening and counselling. Clinicians often cited insufficient evidence around the effects of perinatal cannabis use and lacked confidence in counselling about use. At times, this meant clinicians did not address cannabis use with patients. Most counselled for cessation and there was little recognition of the varied reasons that patients might use cannabis, and an over-reliance on counselling focussed on the legal implications of use.

CONCLUSION

Current approaches to responding to cannabis use might result in inadequate counselling. Counselling may be improved through increased education and training, which would facilitate conversations to mitigate the potential harm of perinatal cannabis use while recognizing the benefits patients perceive.

Physician Communication and Perceived Stigma in Prenatal Cannabis Use

Cannabis has long been widely used throughout the prenatal period. However, motives for prenatal cannabis use (PCU) have not been comprehensively examined. Stigmatization has been identified as a barrier to therapeutic cannabis use and related physician communication. Such stigma may be particularly salient in the context of PCU. One hundred and three women who reported current or past pregnancy were recruited online. Participants completed a survey querying prenatal experiences, substance use, and attitudes toward PCU. PCU was reported by 35 (34%) respondents. Treating nausea and vomiting of pregnancy was the most frequently reported reason for PCU (89%), and 24 (69%) reported substituting cannabis for pharmaceutical drugs. Sixty-two percent of PCU participants and 31% of non-PCU participants indicated discomfort discussing PCU with their physician, and 74% of PCU participants and 27% of non-PCU participants indicated they would not disclose PCU to their physician if it occurred in future pregnancies. Our findings suggest that PCU may reflect primarily therapeutic motives of relieving symptoms of morning sickness, nausea, low appetite, pain, and substituting for other prescription medications. Respondents reported discomfort discussing PCU with physicians, which was more pronounced among respondents with lived experience of PCU. Findings suggest PCU might best be evaluated within a therapeutic framework and highlight the importance of efforts to enhance patient-caregiver communication regarding PCU.

Pregnant People's Perspectives On Cannabis Use During Pregnancy: A Systematic Review and Integrative Mixed-Methods Research Synthesis

Introduction

Rates of perinatal cannabis use are rising, despite clinical evidence about the potential for harm. Accordingly, pregnant and lactating people who perceive a benefit from cannabis use may have a difficult time making informed decisions about cannabis use.

Methods

We conducted a systematic review of mixed‐methods research to synthesize existing knowledge on the perspectives of pregnant people and their partners about cannabis use in pregnancy. Six health and social science databases were searched up until May 30, 2021. There were no methodological, time, or geographic limits applied. We employed a convergent integrative approach to the inductive analysis of findings from all studies.

Results

We identified 26 studies describing views of 17,781 pregnant and postpartum people about cannabis use in pregnancy. No studies describing the views of partners were identified, and only one study specifically addressed the perspectives of lactating people. Comparative analysis revealed that whether cannabis was studied alone or grouped with other substances resulted in significant diversity in descriptions of participant decision‐making priorities and perceptions of risks and benefits. Studies of cannabis alone demonstrated a complex decision‐making process whereby perceived benefits are balanced against the available information about risk, which is often unclear and uncertain. Clear and helpful information was difficult to identify, and health care providers were not described as a helpful and trusted resource for decision‐making.

Discussion

Decision‐making about cannabis use is difficult for pregnant and lactating people who perceive a benefit from this use, although this decisional difficulty is seldom reflected in studies that examine cannabis as one of multiple substances that pregnant or lactating people may use. Our review suggests several approaches clinicians may take to encourage open and supportive conversations to facilitate informed decisions about cannabis use during the perinatal period.

Factors that shape pregnant women's perceptions regarding the safety of cannabis use during pregnancy

Background

Cannabis use among pregnant women has increased. We surveyed pregnant women in rural Pennsylvania to examine cannabis use and opinions regarding its safety during pregnancy. We examined associations between challenges of pregnancy (e.g., exhaustion, pain, nausea) and cannabis use.

Methods

A cross-sectional survey was administered to a convenience sample of English-speaking pregnant women receiving prenatal care at Geisinger, May–June 2019. Principal component analysis (PCA) was used to construct three scores (overwhelmed/exhausted, happy/optimistic, and health worries) based on 10 questions regarding common experiences during pregnancy (e.g., nausea/vomiting, pain, exhaustion, mood). A score based on four questions regarding cannabis safety during pregnancy was also constructed.

Results

From a maximum of 300 surveys distributed, 284 were completed (95%). Most participants were white (87%), married (49%) or living with a partner (38%), and had private health insurance (62%). Most women indicated it was unsafe to use alcohol and tobacco products during pregnancy (> 90%), but that proportion dropped to 82% and 63% regarding recreational cannabis and medical cannabis, respectively. Only women with prior cannabis use (23% of sample) continued to do so during pregnancy: 57% of women reporting daily cannabis use prior to pregnancy continued to use cannabis during pregnancy with 33% reporting daily use. Two thirds of users during pregnancy indicated they were self-medicating for: nausea (90%), anxiety (70%), insomnia (30%), and pain management (30%). Many (56%) of the women who used cannabis during pregnancy believed it is safe. Younger women and women who were overwhelmed/exhausted or less happy/optimistic were more likely to believe cannabis use is safe. Women valued healthcare provider advice more than advice from family and friends. Study strengths include a high response rate. Weaknesses include self-report and that is was a convenience sample; however, the demographics of the sample were similar to past studies.

Conclusion

Women with a history of cannabis use, especially daily use, are at risk of continuing during pregnancy and should receive counseling. Younger women and women with greater stressors during pregnancy also are at greater risk. Screening for prior use and for stressors may identify patients that would benefit from enhanced counseling.

Beliefs about marijuana use during pregnancy and breastfeeding held by residents of a Latino-majority, rural region of California

Marijuana use among pregnant and breastfeeding women is on the rise and carries risks for infant health and well-being. Decisions to use marijuana while pregnant and breastfeeding are motivated by beliefs that use poses minimal risk to infants and offers benefits to maternal users. Misperceptions and usage trend higher among disadvantaged populations. This study surveyed 401 community residents on beliefs about risks and benefits of marijuana use by pregnant and breastfeeding women. The study utilized techniques to enhance recruitment of Latino and disadvantaged residents of rural communities in California, a state where recreational marijuana use is legal. Analyses revealed substantial endorsement of beliefs about benefits and low risks of marijuana use while pregnant and breastfeeding, many of which run counter to current evidence. Misperceptions were particularly prevalent for cannabis users and male respondents. Trends in valid beliefs, while modest, were higher for Latinos and parents.

The Volume and Tone of Twitter Posts About Cannabis Use During Pregnancy: Protocol for a Scoping Review

Background

Cannabis use has increased in Canada since its legalization in 2018, including among pregnant women who may be motivated to use cannabis to reduce symptoms of nausea and vomiting. However, a growing body of research suggests that cannabis use during pregnancy may harm the developing fetus. As a result, patients increasingly seek medical advice from online sources, but these platforms may also spread anecdotal descriptions or misinformation. Given the possible disconnect between online messaging and evidence-based research about the effects of cannabis use during pregnancy, there is a potential for advice taken from social media to affect the health of mothers and their babies.

Objective

This study aims to quantify the volume and tone of English language posts related to cannabis use in pregnancy from January 2012 to December 2021.

Methods

Modeling published frameworks for scoping reviews, we will collect publicly available posts from Twitter that mention cannabis use during pregnancy and use the Twitter Application Programming Interface for Academic Research to extract data from tweets, including public metrics such as the number of likes, retweets, and quotes, as well as health effect mentions, sentiment, location, and users’ interests. These data will be used to quantify how cannabis use during pregnancy is discussed on Twitter and to build a qualitative profile of supportive and opposing posters.

Results

The CHEO Research Ethics Board reviewed our project and granted an exemption in May 2021. As of December 2021, we have gained approval to use the Twitter Application Programming Interface for Academic Research and have developed a preliminary search strategy that returns over 3 million unique tweets posted between 2012 and 2021.

Conclusions

Understanding how Twitter is being used to discuss cannabis use during pregnancy will help public health agencies and health care providers assess the messaging patients may be receiving and develop communication strategies to counter misinformation, especially in geographical regions where legalization is recent or imminent. Most importantly, we foresee that our findings will assist expecting families in making informed choices about where they choose to access advice about using cannabis during pregnancy.

Trial Registration

Open Science Framework 10.17605/OSF.IO/BW8DA; www.osf.io/6fb2e

International Registered Report Identifier (IRRID)

PRR1-10.2196/34421

Measuring cannabis-related knowledge, attitudes, perceptions, motivations, and influences among women of reproductive age: a scoping review

Background

Cannabis use among women of reproductive age has increased substantially in recent decades. Understanding reasons for cannabis use in this population is critical for cannabis use prevention efforts. Thus, this scoping review aimed to identify and synthesize current measures on reasons for cannabis use in women of reproductive age.

Methods

We searched PubMed, PyschINFO, CINAHL, and Google Scholar for relevant studies published in English between January 2010 and April 2021. Peer-reviewed, quantitative studies reporting on measures of cannabis-related knowledge, attitudes, perceptions, motivations, and influences among women of reproductive age were eligible for inclusion. We excluded studies not focused on women of reproductive age and studies reporting cannabis use prevalence data only.

Results

We included 11 studies (10 primary studies and 1 review) with varying subpopulation samples of women, including non-pregnant women (n = 2), women experiencing infertility (n = 1), pregnant women (n = 4), postpartum women (n = 3), and women in the perinatal period (n = 1). Measurement topic areas included information received from health care professionals, attitudes, perceptions and experiences about cannabis use, knowledge of potential harms, and motivations for cannabis use. Most studies including measures of risk perceptions were conducted among pregnant or postpartum women (n = 4). A single study measured influences of cannabis use; no studies measured social or peer influences of use. Most studies (n = 7) created their own measures, with 2 studies using secondary data via measures from population-based surveillance systems in the United States, and one using a previously validated instrument. Recommendations for future research were centered around addressing knowledge gaps of health effects of cannabis use across different time periods, and etiology of cannabis use.

Conclusions

We found vast measurement gaps in current measures of antecedents of cannabis use among women of reproductive age, providing clear direction for future research in this area. Findings necessitate psychometric evaluation of existing measures to ascertain validity and reliability, as well as development of additional measures of women’s cannabis-related attitudes, perceptions, motivations, and influences. This work is critical to guide not only epidemiologic studies, but cannabis-related prevention work as well.

Supplementary information

The online version contains supplementary material available at 10.1186/s12905-022-01673-6.

Birth Outcomes of Neonates Exposed to Marijuana in Utero: A Systematic Review and Meta-analysis

IMPORTANCE

While some studies have found an association between marijuana use and adverse neonatal outcomes, results have not been consistent across all trials.

OBJECTIVE

To assess available data on neonatal outcomes in marijuana-exposed pregnancies.

DATA SOURCES

PubMed, Medline, ClinicalTrials.gov, Cochrane, Scopus, and Web of Science were searched from each database's inception until August 16, 2021.

STUDY SELECTION

All interventional and observational studies that included pregnant women who were exposed to marijuana compared with pregnant women who were not exposed to marijuana and that reported neonatal outcomes were included.

DATA EXTRACTION AND SYNTHESIS

Reporting followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses guideline. Data were extracted by 2 authors for all outcomes, which were pooled using a random-effects model as mean difference or risk ratio (RR) and 95% CI. Data were analyzed from August through September 2021.

MAIN OUTCOMES AND MEASURES

All outcomes were formulated prior to data collection. Outcomes included incidence of birth weight less than 2500 g, small for gestational age (defined as less than the fifth percentile fetal weight for gestational age), rate of preterm delivery (defined as before 37 weeks' gestation), gestational age at time of delivery, birth weight, incidence of neonatal intensive care unit (NICU) admission, Apgar score at 1 minute, Apgar score at 5 minutes, incidence of an Apgar score less than 7 at 5 minutes, fetal head circumference, and fetal length.

RESULTS

Among 16 studies including 59 138 patients, there were significant increases in 7 adverse neonatal outcomes among women who were exposed to marijuana during pregnancy vs those who were not exposed during pregnancy. These included increased risk of birth weight less than 2500 g (RR, 2.06 [95% CI, 1.25 to 3.42]; P = .005), small for gestational age (RR, 1.61 [95% CI, 1.44 to 1.79]; P < .001), preterm delivery (RR, 1.28 [95% CI, 1.16 to 1.42]; P < .001), and NICU admission (RR, 1.38 [95% CI, 1.18 to 1.62]; P < .001), along with decreased mean birth weight (mean difference, -112.30 [95% CI, -167.19 to -57.41] g; P < .001), Apgar score at 1 minute (mean difference, -0.26 [95% CI, -0.43 to -0.09]; P = .002), and infant head circumference (mean difference, -0.34 [95% CI, -0.63 to -0.06] cm; P = .02).

CONCLUSIONS AND RELEVANCE

This study found that women exposed to marijuana in pregnancy were at a significantly increased risk of some adverse neonatal outcomes. These findings suggest that increasing awareness about these risks may be associated with improved outcomes.

Preconception cannabis use: An important but overlooked public health issue

Cannabis is the most commonly used federally illicit drug among pregnant women in the United States, and the prevalence and frequency of prenatal cannabis use are increasing. The preconception period – typically thought of as the 3-12 months immediately preceding pregnancy – is a distinct and critical period for women’s health that has often been overlooked when examining prenatal cannabis use. Given that substance use behaviors typically develop before pregnancy, and risk factors associated with prenatal cannabis use are often present prior to conception, preventive approaches to addressing prenatal cannabis use would benefit from focusing on women who use cannabis prior to pregnancy. In order to ensure preconception cannabis use is brought to the forefront of cannabis prevention efforts, we recommend additional research, patient education, and clinician training focused on preconception cannabis use.

Association of Comorbid Behavioral and Medical Conditions With Cannabis Use Disorder in Pregnancy

IMPORTANCE

Prenatal cannabis use continues to increase, yet studies of the demographic, psychiatric, and medical characteristics associated with cannabis use in pregnancy are limited by size and use of self-report, and often do not consider cannabis use disorder (CUD) or concomitant substance use disorders (SUDs). Understanding the factors associated with CUD in pregnancy is paramount for designing targeted interventions.

OBJECTIVE

To examine the prevalence of co-occurring psychiatric and medical conditions of US pregnant individuals hospitalized with and without CUD by concomitant SUDs.

DESIGN, SETTING, AND PARTICIPANTS

The study analyzed restricted hospital discharge data from the 2010 to 2018 Healthcare Cost and Utilization Project State Inpatient Databases in 35 states. Data were analyzed from January to August 2021. Weighted linear regressions tested whether the prevalence of psychiatric and medical conditions differed between individuals with and without a CUD diagnosis at hospitalization. Inpatient hospitalizations of pregnant patients aged 15 to 44 years with a CUD diagnosis were identified. Pregnant patients aged 15 to 44 years without a CUD diagnosis were identified for comparison. Patients were further stratified based on concomitant SUD patterns: (1) other SUDs, including at least 1 controlled substance; (2) other SUDs, excluding controlled substances; and (3) no other SUDs.

EXPOSURES

CUD in pregnancy.

MAIN OUTCOMES AND MEASURES

Prevalence of demographic characteristics, psychiatric disorders (eg, depression and anxiety), and medical conditions (eg, epilepsy and vomiting).

RESULTS

The sample included 20 914 591 hospitalizations of individuals who were pregnant. The mean (SD) age was 28.24 (5.85) years. Of the total number of hospitalizations, 249 084 (1.19%) involved CUD and 20 665 507 (98.81%) did not. The proportion of prenatal hospitalizations involving CUD increased from 0.008 in 2010 to 0.02 in 2018. Analyses showed significant differences in the prevalence of almost every medical and psychiatric outcome examined between hospitalizations with and without CUD diagnoses, regardless of concomitant SUDs. Elevations were seen in depression (0.089; 95% CI, 0.083-0.095), anxiety (0.072; 95% CI, 0.066-0.076), and nausea (0.036; 95% CI, 0.033-0.040]) among individuals with CUD only at hospitalization compared with individuals with no SUDs at hospitalization.

CONCLUSIONS AND RELEVANCE

Considerable growth was observed in the prevalence of CUD diagnoses among individuals hospitalized prenatally and in the prevalence of depression, anxiety, nausea, and other conditions in individuals with CUD at hospitalization. This study highlights the need for more screening, prevention, and treatment, particularly in populations with co-occurring CUD and psychiatric disorders. Research on the determinants and outcomes associated with CUD during pregnancy is needed to guide clinicians, policy makers, and patients in making informed decisions.

Reasons for cannabis use during pregnancy and lactation: a qualitative study

BACKGROUND

Cannabis use among pregnant and lactating people is increasing, despite clinical evidence showing that cannabis use may be associated with low birth weight and childhood developmental deficits. Our objective was to understand why pregnant and lactating people use cannabis and how these motivations change across perinatal stages.

METHODS

Using qualitative, constructivist grounded theory methodology, we conducted telephone and virtual interviews with 52 individuals from across Canada. We selected participants using maximum variation and theoretical sampling. They were eligible if they had been pregnant or lactating within the past year and had decided to continue, cease or decrease their cannabis use during the perinatal period.

RESULTS

We identified 3 categories of reasons that people use cannabis during pregnancy and lactation: sensation-seeking for fun and enjoyment; symptom management of chronic conditions and conditions related to pregnancy; and coping with the unpleasant, but nonpathologized, experiences of life. Before pregnancy, participants endorsed reasons for using cannabis in these 3 categories in similar proportions, with many offering multiple reasons for use. During pregnancy, reasons for use shifted primarily to symptom management. During lactation, reasons returned to resemble those expressed before pregnancy.

INTERPRETATION

In this study, we showed that pregnant and lactating people use cannabis for many reasons, particularly for symptom management. Reasons for cannabis use changed across reproductive stages. The dynamic nature of the reasons for use across stages speaks to participant perception of benefits and risks, and perhaps a desire to cast cannabis use during pregnancy as therapeutic because of perceived stigma.

Marijuana, Opioid, and Alcohol Use Among Pregnant and Postpartum Individuals Living With HIV in the US

Importance

Amid the opioid epidemic and evolving legal and social changes with marijuana, little is known about substance use among pregnant and postpartum people living with HIV.

Objectives

To evaluate trends in marijuana, alcohol, and opioid use during pregnancy and the first year postpartum among US people living with HIV and the differences in substance use based on marijuana legalization status.

Design, Setting, and Participants

Data from the Surveillance Monitoring for Antiretroviral Toxicities (SMARTT) study of the Pediatric HIV/AIDS Cohort Study were analyzed. SMARTT-enrolled, pregnant people living with HIV at 22 US sites from January 1, 2007, to July 1, 2019, with self-reported substance use data available in pregnancy, 1 year postpartum, or both were assessed.

Exposures

Calendar year and state marijuana legalization status.

Main Outcomes and Measures

The prevalence of any use of each of the following substances was calculated by calendar year, separately for pregnancy and postpartum: marijuana, alcohol, opioid, and concomitant alcohol and marijuana. Log binomial models were fit using general estimating equations to evaluate the mean annual change, accounting for repeat pregnancies. The study also evaluated differences in substance use by state recreational or medical marijuana legalization status.

Results

Substance use data were available for 2926 pregnancies from 2310 people living with HIV (mean [SD] age, 28.8 [6.1] years; 822 [28.1%] Hispanic, 1859 [63.5%] non-Hispanic Black, 185 [6.3%] White, 24 [0.8%] of more than 1 race, 24 [0.8%] of other race or ethnicity [individuals who identified as American Indian, Asian, or Native Hawaiian or other Pacific Islander], and 12 [0.4%] with unknown or unreported race or ethnicity). Between 2007 and 2019, marijuana use during pregnancy increased from 7.1% to 11.7%, whereas alcohol and opioid use in pregnancy were unchanged. Postpartum alcohol (44.4%), marijuana (13.6%), and concomitant alcohol and marijuana (10.0%) use were common; marijuana use increased from 10.2% to 23.7% from 2007 to 2019, whereas postpartum alcohol use was unchanged. The adjusted mean risk of marijuana use increased by 7% (95% CI, 3%-10%) per year during pregnancy and 11% (95% CI, 7%-16%) per year postpartum. Postpartum concomitant alcohol and marijuana use increased by 10% (95% CI, 5%-15%) per year. Differences in substance use were not associated with recreational legalization, but increased marijuana use was associated with medical marijuana legalization.

Conclusions and Relevance

In this cohort study, opioid use among pregnant people living with HIV remained stable, whereas marijuana use during pregnancy and postpartum increased over time and in states with legalized medical marijuana. These patterns of increasing marijuana use among pregnant and postpartum people living with HIV suggest that enhanced clinical attention is warranted, given the potential maternal and child health implications of substance use.

Serious psychological distress and cannabis use among pregnant women in the United States: Findings from the National Survey of Drug Use and Health, 2015-2018

BACKGROUND

Cannabis use in pregnancy has been shown to be associated with a past diagnosis of mental health disorders. This study aimed to evaluate the association between serious psychological distress (SPD) and cannabis use in pregnant women in the United States.

METHODS

Using cross-sectional data from the 2015-2018 National Survey on Drug Use and Health (NSDUH), we compared likelihood of cannabis use among pregnant women who reported acute, recent or no SPD based on the Kessler K-6 Distress Scale. Weighted analyses were conducted to describe study population and differences in cannabis use patterns in women with SPD compared to those without. Multivariate logistic regression models were fit to determine whether the relationship between SPD and cannabis use differed by acute, recent or no SPD status.

RESULTS

Our final study sample consisted of 2,277,425 pregnant women. In adjusted analyses, pregnant women with any SPD (acute or recent) had 3.1 (95% confidence interval: 2.1, 4.5) times the odds of being current cannabis users compared to pregnant women without SPD. Compared to those with no SPD, pregnant women adjusted with acute SPD had 3.9 (2.5, 6.1) the adjusted odds and recent SPD had 2.4 (1.3, 4.4) times the odds of being current cannabis users. Cannabis use rates in each trimester were significantly higher in women with SPD compared to women without.

CONCLUSION

Women who report recent or acute SPD are significantly more likely to use cannabis during all trimesters of pregnancy than those who report no SPD.

Marijuana liberalization policies and perinatal health

We studied the effect of marijuana liberalization policies on perinatal health with a multiperiod difference-in-differences estimator that exploited variation in effective dates of medical marijuana laws (MML) and recreational marijuana laws (RML). We found that the proportion of maternal hospitalizations with marijuana use disorder increased by 23% (0.3 percentage points) in the first three years after RML implementation, with larger effects in states authorizing commercial sales of marijuana. This growth was accompanied by a 7% (0.4 percentage points) decline in tobacco use disorder hospitalizations, yielding a net zero effect over all substance use disorder hospitalizations. RMLs were not associated with statistically significant changes in newborn health. MMLs had no statistically significant effect on maternal substance use disorder hospitalizations nor on newborn health and fairly small effects could be ruled out. In absolute numbers, our findings implied modest or no adverse effects of marijuana liberalization policies on the array of perinatal outcomes considered.