Marijuana Use During Pregnancy and Breastfeeding: Implications for Neonatal and Childhood Outcomes

Counseling About Cannabis Use During Pregnancy and Lactation: A Qualitative Study of Patient and Clinician Perspectives

INTRODUCTION

Legalization in many jurisdictions has increased the prevalence of cannabis use, including during pregnancy and lactation. Accordingly, clinicians providing perinatal and infant care are increasingly required to counsel about this topic, even if they do not feel comfortable or prepared for this conversation. The aim of this research was to explore how prenatal clinicians and pregnant and lactating women interact with cannabis consumption.

METHODS

Using qualitative description, we conducted semi-structured interviews with 75 individuals in Canada: 23 clinicians who provide pregnancy and lactation care, and 52 individuals who made cannabis consumption decisions during pregnancy and/or lactation. Data were analyzed using inductive content analysis.

RESULTS

Three phases of the clinical encounter influenced decision-making about cannabis consumption: initiation of a discussion about cannabis, sense-making, and the outcome of the encounter. Patients and clinicians described similar ideals for a counseling encounter about cannabis consumption during pregnancy or lactation: open, patient-centered conversation grounded in an informed decision-making model to explore the benefits, risks, and alternatives to cannabis. While clinicians described these values as reflecting real clinical interactions, patients reported that in their experience, actual interactions did not live up to these ideals.

CONCLUSION

Clinicians and pregnant and lactating people report desiring the same things from a counseling interaction about cannabis: sharing of information, identification of values, and facilitation of a decision. Both groups endorse an open, nonjudgemental counseling approach that explores the reasons why a patient is considering cannabis consumption and reflects these reasons against available evidence and alternatives known to be safe.

Association of psychiatric and substance use disorders with cannabis use and cannabis use disorder during early pregnancy in northern California

AIMS

To estimate the strength of association between psychiatric disorders and substance use disorders (SUD), and cannabis use and cannabis use disorder (CUD) during early pregnancy.

DESIGN

Observational study.

SETTING

Kaiser Permanente Northern California, USA.

PARTICIPANTS

299 496 pregnancies from 227 555 individuals screened for cannabis use by self-report and a urine toxicology test at entrance to prenatal care in Kaiser Permanente Northern California during January 2011-December 2021 (excepting year 2020). The sample was 62.5% non-White, with a mean (standard deviation) age of 31.1 (5.5) years; 6.8% used cannabis; 0.2% had a CUD.

MEASUREMENTS

Exposure variables included electronic health record-based psychiatric diagnoses of attention deficit hyperactivity, anxiety, bipolar, depressive, personality, posttraumatic stress and psychotic disorders; and alcohol, opioid, stimulant and tobacco use disorders, during the two years prior to pregnancy up to the day before the prenatal substance use screening date. Outcome variables were any cannabis use, frequency of self-reported cannabis use and CUD during early pregnancy.

FINDINGS

Psychiatric disorder prevalence ranged from 0.2% (psychotic) to 14.3% (anxiety), and SUD ranged from 0.3% (stimulant/opioid) to 3.8% (tobacco). Psychiatric disorders were associated with cannabis use and CUD, with the strongest association for any use found for bipolar disorder (adjusted odds ratio [aOR] = 2.83; 95% confidence interval [CI] = 2.53-3.17) and the strongest association for CUD found for psychotic disorders (aOR = 10.01, 95% CI = 6.52-15.37). SUDs were associated with cannabis use and CUD, with the strongest association for any use found for tobacco use disorder (aOR = 4.03, 95% CI = 3.82-4.24) and the strongest association for CUD found for stimulant use disorder (aOR = 21.99, 95% CI = 16.53-29.26). Anxiety, bipolar, depressive disorders and tobacco use disorder were associated with greater odds of daily than monthly or less cannabis use.

CONCLUSIONS

Psychiatric disorders and substance use disorders appear to be associated with elevated odds of any and frequent cannabis use as well as cannabis use disorder during early pregnancy. In most cases, the associations with cannabis outcomes were stronger for substance use disorders than other psychiatric disorders.

Cannabis Use During Early Pregnancy Following Recreational Cannabis Legalization

Importance

It is unknown whether state recreational cannabis legalization (RCL) is related to increased rates of prenatal cannabis use or whether RCL-related changes vary with cannabis screening methods or the local policy environment.

Objective

To test whether RCL in California was associated with changes in prenatal cannabis use rates, whether changes were evident in both self-report and urine toxicology testing, and whether rates varied by local policies banning vs allowing adult-use retailers post-RCL.

Design, Setting, and Participants

This population-based time-series study used data from pregnancies in Kaiser Permanente Northern California universally screened for cannabis use during early pregnancy by self-report and toxicology testing from January 1, 2012, to December 31, 2019. Analyses were conducted from September 2022 to August 2024.

Exposures

California state RCL passage (November 9, 2016) and implementation of legal sales (January 1, 2018) were examined with a 1-month lag. Local policies allowing vs banning medical retailers pre-RCL and adult-use retailers post-RCL were also examined.

Main Outcomes and Measures

Any prenatal cannabis use was based on screening at entrance to prenatal care (typically at 8-10 weeks' gestation) and defined as (1) a positive urine toxicology test result or self-report, (2) a positive urine toxicology test result, or (3) self-report. Interrupted time series models were fit using Poisson regression, adjusting for age, race and ethnicity, and neighborhood deprivation index.

Results

The sample of 300 993 pregnancies (236 327 unique individuals) comprised 25.9% Asian individuals, 6.4% Black individuals, 26.0% Hispanic individuals, 37.7% White individuals, and 4.1% individuals of other, multiple, or unknown race, with a mean (SD) age of 30.3 (5.4) years. Before RCL implementation, rates of prenatal cannabis use rose steadily from 4.5% in January 2012 to 7.1% in January 2018. There was no change in use rates at the time of RCL passage (level change rate ratio [RR], 1.03; 95% CI, 0.96-1.11) and a statistically significant increase in rates in the first month after RCL implementation, increasing to 8.6% in February 2018 (level change RR, 1.10; 95% CI, 1.04-1.16). Results were similar when defining prenatal cannabis use by (1) a toxicology test or (2) self-report. In local policy analyses, the post-RCL implementation increase in use was only found among those in jurisdictions allowing adult-use cannabis retailers (allowed RR, 1.21; 95% CI, 1.10-1.33; banned RR, 1.01; 95% CI, 0.93-1.10).

Conclusions and Relevance

In this time-series study, RCL implementation in California was associated with an increase in rates of cannabis use during early pregnancy, defined by both self-report and toxicology testing, driven by individuals living in jurisdictions that allowed adult-use retailers.

Predictors of perinatal cannabis use in colorado and the association with depression during pregnancy

PURPOSE

To evaluate the prevalence and predictors of cannabis use and reasons for use during and/or after pregnancy among Colorado birthing individuals. To determine the independent association of self-reported depression during pregnancy and cannabis used.

METHODS

Data from Health eMoms, a statewide perinatal longitudinal electronic surveillance system were analyzed. Perinatal cannabis use was defined as any use during and/or after pregnancy. Bivariate associations of birthing individual and infant characteristics with use were estimated using chi-square tests. Multivariable logistic regression was used to assess the independent relationship between depression and reported cannabis use versus no reported cannabis use.

RESULTS

A weighted sample of 117,812 birthing individuals was analyzed from survey responses between 2018-2021. Among the 15,585 (13.3%) who reported perinatal cannabis use, 35.5% reported use during pregnancy and 87.3% reported post-partum use. Individuals with depression during pregnancy had 2.2 times higher adjusted odds (95% CI: 1.5. 3.3) of any perinatal cannabis use compared to those without depression. Among those who had any perinatal cannabis use, reported use for medical reasons was 92% during pregnancy, while 43% cited this as the reason for use 12-14 months post-partum.

CONCLUSION

Self-reported cannabis use during the perinatal period in a state with legalized recreational use was over 1 in 10. Use varied significantly by demographics and social factors with inconsistent perinatal guidance provided by healthcare professionals. Depression during pregnancy was significantly associated with use, illustrating the need for comprehensive mental health screening and therapeutic evidence-based interventions to support these individuals.

Prenatal Cannabis Exposure and Executive Function and Aggressive Behavior at Age 5 Years

Importance

Cannabis use during pregnancy is increasingly common in the US and may affect the development and behavior of preschool-aged children.

Objective

To prospectively investigate the association of prenatal cannabis exposure with executive function and aggressive behavior at age 5 years.

Design, Setting, Participants

This cohort study was conducted from 2016 through 2020. Data analysis was conducted from 2022 through 2024. Patients aged 16 through 50 years who were able to communicate in English and intended to deliver at the Ohio State University Wexner Medical Center were enrolled in a pregnancy research repository. Participants (n = 355) who gave consent for future contact and whose child(ren) was presumed to be alive were invited to participate again at child age 5 years (children born May 25, 2010, through February 7, 2016) and 250 children participated (70%).

Exposure

Cannabis exposure was measured prospectively by urine toxicology, maternal self-report, and obstetric record abstraction.

Main Outcomes and Measures

Executive function and aggressive behavior, measured via multimodal assessment by staff masked to exposure status. Outcomes were chosen a priori.

Results

Of 250 children, 80 were exposed to cannabis (32%). Use of tobacco, other drugs, and alcohol during pregnancy was common (22% to 39% each). Most families were living in poverty. There were 155 children who were Black/African American, non-Hispanic (62%); 11 were Hispanic (4%); 34 indicated more than one race or another race, non-Hispanic (14%); and 50 were White, non-Hispanic (20%). Age-corrected standard scores for children's attention and inhibitory control (National Institutes of Health Toolbox) were about 0.4 SDs lower for those exposed to cannabis compared with unexposed (β = -6.1 points; 95% CI, -10.8 to -1.4), following propensity score weighting and adjustment for confounders. Exposed children also exhibited poorer task-based planning ability and more observed aggression. Caregiver ratings of executive function and behavior and laboratory assessments of other aspects of executive functioning showed no differences by exposure status.

Conclusions and Relevance

Results from this contemporary US cohort where prenatal cannabis exposure was common and indicated that exposed children exhibited some differences in aspects of executive function and behavior relevant to long-term academic success and adaptive functioning. These results may be considered in refining clinical recommendations regarding cannabis use during pregnancy.

Cannabis Use during Pregnancy: An Update

The use of cannabis during pregnancy has emerged as a mounting cause for concern due to its potential adverse consequences on both the mother and her offspring. This review will focus on the dangers associated with prenatal exposure to cannabis, particularly those related to neurodevelopment. It will also discuss the features of maternal and placental functioning that are likely to have long-term effects on the offspring's development. The most pertinent and up-to-date materials can be found through a literature search. The literature emphasizes the substantial hazards associated with prenatal exposure to cannabis. These include impairments in cognitive function and difficulties in behavior in this particular instance. Structural and functional alterations in the brain can be noticed in offspring. The use of cannabis has been associated with an increased likelihood of experiencing pregnancy-related complications, such as giving birth prematurely and having a baby with a low birth weight. Additionally, it has been connected to potential negative effects on mental and emotional well-being. Studies have shown that when a pregnant woman is exposed to cannabis, it can negatively impact the functioning of the placenta and the growth of the fetus. This might potentially contribute to the development of placental insufficiency and restricted growth in the womb. Longitudinal studies reveal that children who were exposed to cannabis in the womb experience additional long-term developmental challenges, such as decreased cognitive abilities, reduced academic performance, and behavioral issues. In order to address the problem of cannabis usage during pregnancy, it is essential to adopt a comprehensive and coordinated strategy. This method should integrate and synchronize public health policy, education, and research initiatives. By implementing these targeted strategies, it is possible to mitigate potential health and welfare concerns for both present and future generations.

Reconsidering Breastfeeding Recommendations in the Context of Cannabis Use to Support Health Equity

The authors offer guidance to perinatal nurses and clinicians on how to assist patients who use cannabis and wish to breastfeed.

Neonatal outcomes associated with in utero cannabis exposure: a population-based retrospective cohort study

BACKGROUND

The full spectrum of associations between in utero cannabis exposure and adverse neonatal outcomes is still unclear.

OBJECTIVE

This study aimed to evaluate the associations between in utero cannabis exposure and neonatal outcomes.

STUDY DESIGN

This population-based retrospective cohort study of singleton births among Kaiser Permanente Northern California members (January 1, 2011-July 31, 2020) included parent-infant dyads in which the pregnant parent was screened for cannabis use as part of standard prenatal care, generally upon entrance into care. Data were ascertained from electronic health records. Generalized estimating equation models were adjusted for sociodemographic characteristics, other non-cannabis prenatal substance use, medical and mental health comorbidities, and adequacy of prenatal care. In utero cannabis exposure was defined as self-reported use since becoming pregnant and/or a positive urine toxicology test for cannabis at any time during pregnancy (yes/no; primary exposure). Frequency of use was self-reported and categorized as daily, weekly, monthly or less, never, or unknown (secondary exposure). Neonatal outcomes included low birthweight, small for gestational age, preterm birth, neonatal intensive care unit admission, and infant respiratory support.

RESULTS

Of 364,924 infants, 22,624 (6.2%) were exposed to cannabis in utero. After adjustment for potential confounders, including in utero exposure to other substances, in utero exposure to cannabis was associated with greater odds of low birthweight (adjusted odds ratio, 1.20; 95% confidence interval, 1.12-1.28), small for gestational age (adjusted odds ratio, 1.24; 95% confidence interval, 1.18-1.30), preterm birth (<37 weeks; adjusted odds ratio, 1.06; 95% confidence interval, 1.00-1.13), and neonatal intensive care unit admission (adjusted odds ratio, 1.06; 95% confidence interval, 1.01-1.11). There was a suggestive association with early preterm birth (<34 weeks; adjusted odds ratio, 1.11; 95% confidence interval, 1.00-1.23; P=.055), but no significant association with respiratory support (adjusted odds ratio, 1.07; 95% confidence interval, 0.97-1.18). Dose-response analysis found an increasing likelihood of low birthweight and small for gestational age with increasing frequency of prenatal cannabis use by the pregnant individual. Sensitivity analyses further supported an increased likelihood of low birthweight and small for gestational age, although associations with other outcomes did not reach statistical significance.

CONCLUSION

In utero cannabis exposure was associated with increased likelihood of low birthweight, small for gestational age, preterm birth, and neonatal intensive care unit admission. Clinicians should counsel individuals who are pregnant or considering pregnancy about the potential adverse neonatal health outcomes associated with prenatal cannabis use.

Risk Factors for Postpartum Depression and Severe Distress among Mothers of Very Preterm Infants at NICU Discharge

OBJECTIVE

To identify psychological, medical, and socioenvironmental risk factors for maternal postpartum depression (PPD) and severe psychological distress (SPD) at intensive care nursery discharge among mothers of very preterm infants.

STUDY DESIGN

We studied 562 self-identified mothers of 641 infants born <30 weeks who were enrolled in the Neonatal Neurobehavior and Outcomes in Very Preterm Infants Study (NOVI) conducted in nine university-affiliated intensive care nurseries. Enrollment interviews collected socioenvironmental data, depression, and anxiety diagnoses prior to and during the study pregnancy. Standardized medical record reviews ascertained prenatal substance use, maternal and neonatal medical complications. The Edinburgh Postnatal Depression Scale and Brief Symptom Inventory were administered at nursery discharge to screen for PPD and SPD symptoms, respectively.

RESULTS

Unadjusted analyses indicated mothers with positive screens for depression (n = 76, 13.5%) or severe distress (n = 102, 18.1%) had more prevalent prepregnancy/prenatal depression/anxiety, and their infants were born at younger gestational ages, with more prevalent bronchopulmonary dysplasia, and discharge after 40 weeks postmenstrual age. In multivariable analyses, prior depression or anxiety was associated with positive screens for PPD (risk ratio [RR]: 1.6, 95% confidence interval [CI]: 1.1-2.2) and severe distress (RR: 1.6, 95% CI: 1.1-2.2). Mothers of male infants had more prevalent depression risk (RR: 1.7, 95% CI: 1.1-2.4), and prenatal marijuana use was associated with severe distress risk (RR: 1.9, 95% CI: 1.1-2.9). Socioenvironmental and obstetric adversities were not significant after accounting for prior depression/anxiety, marijuana use, and infant medical complications.

CONCLUSION

Among mothers of very preterm newborns, these multicenter findings extend others' previous work by identifying additional indicators of risk for PPD and SPD associated with a history of depression, anxiety, prenatal marijuana use, and severe neonatal illness. Findings could inform designs for continuous screening and targeted interventions for PPD and distress risk indicators from the preconception period onward.

KEY POINTS

· Preconceptional and prenatal screening for postpartum depression and severe distress may inform care.. · Prior depression, anxiety, and neonatal complications predicted severe distress and depression symptoms at NICU discharge.. · Readily identifiable risk factors warrant continuous NICU screening and targeted interventions to improve outcomes..

Prenatal cannabis exposure and the risk for neuropsychiatric anomalies in the offspring: a systematic review and meta-analysis

OBJECTIVE

To evaluate the association between cannabis use during pregnancy and the risk for long-term neuropsychiatric pathology in the offspring.

DATA SOURCES

MEDLINE, EMBASE, and Cochrane library databases were systematically searched until January 22, 2024, with no language or date restrictions.

STUDY ELIGIBILITY CRITERIA

Studies were eligible for inclusion if they reported quantitative data on any long-term neuropsychiatric outcome in offspring whose mothers used cannabis during pregnancy for medical or recreational use, by any route and at any trimester, in comparison to offspring of women who abstained from cannabis use during pregnancy. All observational study designs were included in the analysis.

STUDY APPRAISAL AND SYNTHESIS METHODS

A systematic review and meta-analysis were performed according to the PRISMA and MOOSE guidelines. The data was extracted independently by 2 reviewers. The following offspring outcomes were of interest: attention-deficit/hyperactivity disorder (ADHD), autism spectrum disorder (ASD), depression, anxiety, psychotic disorders, as well as cannabis and other substance use. Odds ratios (OR) and 95% confidence intervals (CI) were pooled for each neuropsychiatric outcome in the offspring of women exposed to cannabis during pregnancy compared with nonexposed. Data were pooled using random-effects models.

RESULTS

Eighteen eligible observational studies were included in the systematic review, and 17 were included in the final quantitative analysis, representing 534,445 participants. After adjusting for confounders, the pooled OR for ADHD was 1.13 (95% CI 1.01-1.26); for ASD, the pooled OR was 1.04 (95% CI 0.74-1.46); for psychotic symptoms, the pooled OR was 1.29 (95% CI 0.97-1.72); for anxiety, the pooled OR was 1.34 (95% CI 0.79-2.29); for depression, the pooled OR was 0.72 (95% CI 0.11-4.57); and for offspring's cannabis use, the pooled OR was 1.20 (95% CI 1.01-1.42).

CONCLUSION

Prenatal cannabis exposure is not associated with an increased risk of ASD, psychotic symptoms, anxiety, or depression in offspring. However, it may slightly elevate the risk of ADHD and predispose offspring to cannabis consumption. Despite these findings, caution is warranted regarding cannabis use during pregnancy. Further research is imperative, especially given the increasing potency of cannabis in recent years.

Association of Cannabis with Apneic Episodes in a Breastfed Infant: A Case Study

Background: The use of cannabis and its perceived safety among pregnant and breastfeeding women has increased in the context of expanding legalization. Current guidelines recommend abstaining from the use of cannabis while pregnant or breastfeeding due to the potential for harm, although there is still much that is unknown in this field. Case Presentation: A 5-week-old infant presented with recurrent apneic episodes and a positive urine delta-9-tetrahydrocannabinol (THC) screening test. The infant's mother reported regular cannabis use for treatment of depression and anxiety while pregnant and breastfeeding. The infant was subsequently transitioned to formula feedings, and the infant's condition improved. Conclusion: Cannabis and its active metabolites can be transferred into breast milk and may have deleterious neurologic effects on infants. However, a causal relationship between cannabis exposure and short- or long-term neurologic sequelae has not yet been definitively established. Further studies are warranted to assess the safety of maternal cannabis use for breastfed infants.

The Risk of Ventricular Septal Defects Associated With Prenatal Marijuana Exposure: A Systematic Review and Meta-Analysis

With the recent legalization of marijuana across the United States, its usage in pregnant women has increased. The aim of this meta-analysis was to determine if prenatal marijuana use increases the likelihood of ventricular septal defects. The analysis was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. The search strategy identified 4 case-control studies that were ultimately included in the analysis with a combined 381,621 infant records. Quantitative analysis demonstrated prenatal marijuana usage significantly increases the likelihood of ventricular septal defects (odds ratio = 2.39, 95% confidence interval = 1.11-5.18).

Perinatal Cannabis Use and Cannabis Use during Breastfeeding: the Role of Health Care Workers

OBJECTIVE

This study aimed to estimate the proportion of perinatal women reporting a health care worker (HCW) discussed cannabis use during pregnancy or breastfeeding with them and to evaluate the association between HCWs' discussions and perinatal cannabis use and cannabis use while breastfeeding.

STUDY DESIGN

Data from Health eMoms (a longitudinal, state-representative survey of Colorado mothers, collected from 2018 to 2020 [n = 3,193]) were utilized in logistic regressions assessing the relationship between HCW discussions about cannabis and perinatal cannabis use and cannabis use while breastfeeding at two time points postpartum, adjusting for sociodemographic factors.

RESULTS

A total of 5.8% of the sample reported cannabis use either during their most recent pregnancy or while breastfeeding at 3 to 6 months' postpartum. A total of 67.8% of the sample reported an HCW-discussed cannabis at prenatal visits. Women reporting perinatal use were more likely to report HCW discussing cannabis compared with nonusers (82.2 vs. 65.3%, p < 0.01). There was not a significant association between HCW discussions and cannabis use while breastfeeding at either time point postpartum. Compared with nonusers, women using perinatally were more likely to report cannabis Web sites (28.9 vs. 6.5%), cannabis stores (15.7 vs. 3.8%), or word-of-mouth (28.4 vs. 17.1%) as trusted sources of cannabis-related information.

CONCLUSION

HCW discussions about cannabis use during pregnancy or breastfeeding are not universally reported. This study highlights the need for further encouragement of universal HCW discussions of cannabis use during pregnancy and breastfeeding, strengthening of messaging around cannabis use during these periods, and improved delivery of reliable cannabis-related health information to this population.

KEY POINTS

· HCW discussions of perinatal cannabis use are not universally reported by women.. · Women reporting perinatal use were more likely to report HCW discussions of cannabis.. · Women reporting perinatal cannabis use were more likely to trust word-of-mouth or cannabis stores or Web sites..

Systematic Review and Meta-analysis of the Relationship Between Exposure to Parental Substance Use and Attention-Deficit/Hyperactivity Disorder in Children

Attention-deficit/hyperactivity disorder (ADHD) is characterized by persistent patterns of inattention, hyperactivity, and impulsiveness. Among US children and adolescents aged 3-17 years, 9.4% have a diagnosis of ADHD. Previous research suggests possible links between parental substance use and ADHD among children. We conducted a systematic review and meta-analysis of 86 longitudinal or retrospective studies of prenatal or postnatal alcohol, tobacco, or other parental substance use and substance use disorders and childhood ADHD and its related behavioral dimensions of inattention and hyperactivity-impulsivity. Meta-analyses were grouped by drug class and pre- and postnatal periods with combined sample sizes ranging from 789 to 135,732. Prenatal exposure to alcohol or tobacco and parent substance use disorders were consistently and significantly associated with ADHD among children. Other parental drug use exposures resulted in inconsistent or non-significant findings. Prevention and treatment of parental substance use may have potential for impacts on childhood ADHD.

Association between maternal cigarette smoking cessation and risk of preterm birth in Western New York

BACKGROUND

Although many studies suggested the benefit of smoking cessation among pregnant women in reducing the risk of preterm birth (PTB), the timing of the effect of the cessation remains inconclusive.

OBJECTIVES

To examine the association of trimester-specific smoking cessation behaviours with PTB risk.

METHODS

We included 199,453 live births in Western New York between 2004 and 2018. Based on self-reported cigarette smoking during preconception and in each trimester, we created six mutually exclusive groups: non-smokers, quitters in each trimester, those who smoked throughout pregnancy, and inconsistent smokers. Risk ratios (RRs) and 95% confidence intervals (CIs) were estimated using Poisson regression to examine the association between smoking cessation and PTB. Effect modification by illegal drug use, maternal age, race and ethnicity and pre-pregnancy body mass index (BMI) was investigated multiplicatively by ratio of relative risk and additively by relative excess risk due to interaction (RERI).

RESULTS

Overall, 6.7% of women had a PTB; 14.1% smoked throughout pregnancy and 3.4%, 1.8% and 0.8% reported quitting smoking during the first, second and third trimesters, respectively. Compared to non-smokers, third-trimester cessation (RR 1.20, 95% CI 1.01, 1.43) and smoking throughout pregnancy (RR 1.27, 95% CI 1.21, 1.33) were associated with a higher PTB risk, while quitting smoking during the first or second trimester, or inconsistent smoking was not associated with PTB. A positive additive interaction was identified for maternal age and late smoking cessation or smoking throughout pregnancy on PTB risk (RERI 0.17, 95% CI 0.00, 0.36), and a negative interaction was observed for pre-pregnancy BMI ≥30 kg/m2 (ratio of relative risk 0.70, 95% CI 0.63, 0.78; RERI -0.42, 95% CI -0.56, -0.30).

CONCLUSION

Compared to non-smokers, smoking throughout pregnancy and third-trimester smoking cessation are associated with an increased risk of PTB, while quitting before the third trimester may not increase PTB risk.

The unseen patient: competing priorities between patients and providers when cannabis is used in pregnancy, a qualitative study

Objectives

This study aimed to explore competing priorities when cannabis is used during pregnancy from the perspective of providers and Black and Latina people. Maternal cannabis use is increasingly common, but patients and providers alike struggle to navigate it.

Methods

This pilot used qualitative, constructivist ground theory methods to conduct semi-structured, remote interviews between 16 November 2021, and 7 February 2022 with 7 Black and Latina people who used cannabis during pregnancy, and 10 providers between 15 March 2022, and 6 April 2022, all of who were in Southern California, U.S.

Results

We identified three main findings: (1) Providers reported barriers to caregiving and relationship building with patients due to maternal cannabis use stigma, (2) Providers prioritized the fetus despite patients' current health system challenges that drove cannabis use, and (3) Both patients and providers engaged in personal research beyond the healthcare system to better understand maternal cannabis use.

Discussion

Our findings indicate that challenges exist between people who use cannabis during pregnancy and providers. Both groups need accurate, sociocultural sensitive information about maternal cannabis use via a harm reduction lens.

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).

Intentions to Use Cannabis Postpartum: A Qualitative Study of Pregnant Individuals Who Used Cannabis During Early Pregnancy

Objective: To examine plans for postpartum cannabis use among pregnant individuals who used cannabis during early pregnancy. Materials and Methods: Eighteen virtual focus groups were conducted from November 17, 2021, to December 17, 2021, with 23 Black and 30 White pregnant adults in Kaiser Permanente Northern California, who self-reported prenatal cannabis use during early pregnancy. Focus groups were recorded, transcribed, and analyzed using thematic analysis. Results: The sample (N = 53) had a mean age of 30.3 years (standard deviation = 5.2) at recruitment; 70% reported daily, 25% weekly, and 6% ≤ monthly cannabis use at entrance to prenatal care. Some participants viewed cannabis as critical for coping with postpartum mental and physical health challenges, while others questioned whether cannabis use would fit with their parental lifestyle, and some planned to abstain altogether. Most planned to use cannabis postpartum, but with lower frequency than before pregnancy, and in ways consistent with harm reduction (e.g., smoking outside to avoid secondhand or thirdhand smoke exposure). Many were motivated to abstain from cannabis while breastfeeding, and some desired more data on the safety of cannabis and breastfeeding, or intended to "pump and dump," believing it would reduce potential transfer of Δ9-tetrahydrocannabinol (THC) to their infant. Responses from Black and White participants were generally similar, but White participants were more likely to report plans to use cannabis while breastfeeding and to want information about cannabis and breastfeeding. Conclusions: Pregnant individuals with prenatal cannabis use had varied plans for cannabis use postpartum. Many were motivated to abstain or use cannabis less frequently than pre-pregnancy, especially during lactation.

Maternal Cannabis Use during Lactation and Potential Effects on Human Milk Composition and Production: A Narrative Review

Cannabis use has increased sharply in the last 20 y among adults, including reproductive-aged women. Its recent widespread legalization is associated with a decrease in risk perception of cannabis use during breastfeeding. However, the effect of cannabis use (if any) on milk production and milk composition is not known. This narrative review summarizes current knowledge related to maternal cannabis use during breastfeeding and provides an overview of possible pathways whereby cannabis might affect milk composition and production. Several studies have demonstrated that cannabinoids and their metabolites are detectable in human milk produced by mothers who use cannabis. Due to their physicochemical properties, cannabinoids are stored in adipose tissue, can easily reach the mammary gland, and can be secreted in milk. Moreover, cannabinoid receptors are present in adipocytes and mammary epithelial cells. The activation of these receptors directly modulates fatty acid metabolism, potentially causing changes in milk fatty acid profiles. Additionally, the endocannabinoid system is intimately connected to the endocrine system. As such, it is probable that interactions of exogenous cannabinoids with the endocannabinoid system might modify release of critical hormones (e.g., prolactin and dopamine) that regulate milk production and secretion. Nonetheless, few studies have investigated effects of cannabis use (including on milk production and composition) in lactating women. Additional research utilizing robust methodologies are needed to elucidate whether and how cannabis use affects human milk production and composition.

Potentially modifiable risk and protective factors affecting mental and emotional wellness in pregnancy

Introduction

Impaired mental and emotional wellness often co-occurs with prenatal substance use, and both affect infant socio-emotional, cognitive, language, motor, and adaptive behavioral outcomes. Guided by the modified biopsychosocial framework, this study examined the role of common substance exposures during pregnancy (i.e., alcohol and cannabis), socio-cultural factors (social support during pregnancy, adverse childhood experiences), and reproductive health factors on maternal mental health (MMH).

Methods

Data were obtained from a prospective cohort study-Ethanol, Neurodevelopment, Infant, and Child Health (ENRICH-2), and included 202 pregnant persons. Alcohol and cannabis exposures were assessed through repeated prospective interviews and a comprehensive battery of drug and ethanol biomarkers. MMH outcomes were evaluated during the third trimester through the Perceived Stress Scale, Edinburgh Depression Scale, Generalized Anxiety Disorders-7, and Post-traumatic Stress Disorder Checklist for Diagnostic and Statistical Manual of Mental Disorders. Univariate and multivariable linear regression models evaluated significant predictors of MMH.

Results

Results of multivariable analysis indicate that both maternal adverse childhood experiences and alcohol exposure, even at low-to-moderate levels, during pregnancy were associated with poorer scores for most MMH measures, while higher level of social support and Spanish as the primary language at home (as a proxy of enculturation) had protective effects (all p's < 0.05).

Conclusion

These findings highlight the importance of assessing substance use, including periconceptional alcohol exposure, and mental health in pregnant persons as closely related risk factors which cannot be addressed in isolation. Our findings also emphasize a strong protective effect of socio-cultural factors on maternal mental and emotional wellbeing-a strong precursor to maternal-infant bonding and infant neurodevelopment.

Cannabis use, decision making, and perceptions of risk among breastfeeding individuals: the Lactation and Cannabis (LAC) Study

OBJECTIVE

Our primary objective was to understand breastfeeding individuals' decisions to use cannabis. Specifically, we investigated reasons for cannabis use, experiences with healthcare providers regarding use, and potential concerns about cannabis use.

METHODS

We collected survey data from twenty breastfeeding participants from Washington and Oregon who used cannabis at least once weekly. We documented individuals' cannabis use and analyzed factors associated with their decisions to use cannabis during lactation. Qualitative description was used to assess responses to an open-ended question about potential concerns.

RESULTS

Fifty-five percent of participants (n = 11) reported using cannabis to treat or manage health conditions, mostly related to mental health. Eighty percent of participants (n = 16) reported very few or no concerns about using cannabis while breastfeeding, although participants who used cannabis for medical purposes had significantly more concerns. Most participants (n = 18, 90%) reported receiving either no or unhelpful advice from healthcare providers. Four themes arose through qualitative analysis, indicating that breastfeeding individuals are: 1) identifying research gaps and collecting evidence; 2) monitoring their child's health and development; 3) monitoring and titrating their cannabis use; and 4) comparing risks between cannabis and other controlled substances.

CONCLUSIONS

Breastfeeding individuals reported cannabis for medical and non-medical reasons and few had concerns about cannabis use during breastfeeding. Breastfeeding individuals reported using a variety of strategies and resources in their assessment of risk or lack thereof when deciding to use cannabis. Most participants reported receiving no helpful guidance from healthcare providers.

Cannabis Smoking and Storage within the Home: A Cross-Sectional Survey of Pregnant Women and Women with Young Children

INTRODUCTION

Child cannabis exposure has increased in recent years - a trend that parallels changes to state cannabis legality. Yet, little is known about household cannabis practices. To address this gap, this study aimed to examine household cannabis practices among a geographically diverse sample of US women of reproductive age. We also examined variations in household cannabis practices across state cannabis policies.

METHODS

The study sample (N = 114) included pregnant women and women with young children in their home. In Spring of 2021, 114 women completed a single cross-sectional online survey that included demographic information and asked about cannabis use, household cannabis practices (e.g., indoor smoking, cannabis storage), and cannabis use risk perceptions. We analyzed data using descriptive statistics and Fisher's exact tests.

RESULTS

A total of 69.23% of women reported cannabis products were allowed in their home and 42.98% reported that smoking cannabis was permitted in one or more rooms. Self-reported cannabis use, as well as partner or family cannabis use were significantly associated with allowing cannabis products in the home (p < 0.001). There was no difference in cannabis smoking rules among women in states with legalized cannabis (47.73%) than those in states that had yet to legalize (40.00%), p = 0.339.

CONCLUSIONS

Amid rapidly shifting cannabis policies, further examination of household cannabis practices is needed. Public heath efforts should focus on reducing in-home cannabis exposure and promote safe storage and smoking practices for families with children in the home.

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.

Marijuana Use and Breastfeeding: A Survey of Newborn Nurseries

BACKGROUND AND OBJECTIVES

Marijuana use has increased nationally and is the most common federally illicit substance used during pregnancy. This study aimed to describe hospital practices and nursery director knowledge and attitudes regarding marijuana use and breastfeeding and assess the association between breastfeeding restrictions and provider knowledge, geographic region, and state marijuana legalization status. We hypothesized that there would be associations between geography and/or state legalization and hospital practices regarding breastfeeding with perinatal marijuana use.

METHODS

A cross-sectional, 31-question survey was sent electronically to the 110 US hospital members of the Academic Pediatric Association's Better Outcomes through Research for Newborns (BORN) network. Survey responses were analyzed using descriptive statistics to report frequencies. For comparisons, χ2 and Fisher exact tests were used to determine statistical significance.

RESULTS

Sixty-nine (63%) BORN nursery directors across 38 states completed the survey. For mothers with a positive cannabinoid screen at delivery, 16% of hospitals universally or selectively restrict breastfeeding. Most (96%) nursery directors reported that marijuana use while breastfeeding is "somewhat" (70%) or "very harmful" (26%). The majority was aware of the potential negative impact of prenatal marijuana use on learning and behavior. There were no consistent statistical associations between breastfeeding restrictions and provider marijuana knowledge, geographic region, or state marijuana legalization status.

CONCLUSIONS

BORN newborn clinicians report highly variable and unpredictable breastfeeding support practices for mothers with perinatal marijuana use. Further studies are needed to establish evidence-based practices and to promote consistent, equitable care of newborns with perinatal marijuana exposure.

Birth outcomes following in utero co-exposure to tobacco and marijuana

BACKGROUND

With recent changes in tobacco and marijuana use patterns, it becomes crucial to understand how the prenatal co-use of these substances impacts birth outcomes. The goal of this study was to examine the risk of adverse birth outcomes among infants born to women who used tobacco and marijuana concurrently throughout pregnancy compared to infants of women who used tobacco alone.

METHODS

This study involved a retrospective chart review of pregnant women identified via self-report or biochemical testing who used tobacco products alone (N = 71) or tobacco and marijuana simultaneously (N = 127) at any point throughout pregnancy. Differences in birth outcomes between these groups, including APGAR (appearance, pulse, grimace, activity, and respiration) scores, respiratory distress, neonatal intensive care unit admission, intrauterine growth restriction, birth weight, birth length, head circumference, gestational age, and length of hospital stay, were analyzed using linear regression and odds ratio analysis.

RESULTS

There were no significant differences in outcomes for infants of women who used tobacco and marijuana compared to infants of women who used tobacco alone during pregnancy. Rates of adverse birth outcomes were high among women who used tobacco compared to what would be expected in unexposed pregnancies.

CONCLUSIONS

Tobacco and marijuana co-use during pregnancy was not associated with an additional risk of adverse birth outcomes compared to tobacco use alone. Women should be educated on potential risks of marijuana, and especially, tobacco use during pregnancy. These results will inform clinical recommendations for pregnant women using tobacco and marijuana, aiming to decrease preventable adverse outcomes for patients and infants.

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.

Prenatal cannabinoid exposure: why expecting individuals should take a pregnancy pause from using cannabinoid products

Cannabinoid use in all populations is increasing as legalization across the United States continues. Concerningly, there is a lack of caution provided by medical providers to pregnant individuals as to the impact the use of cannabinoids could have on the developing fetus. Research continues in both the preclinical and clinical areas, and is severely needed, as the potency of delta-9-tetrahydrocannabinol (THC), the primary psychoactive component of cannabis, has increased dramatically since the initial studies were completed. Thus far, clinical studies raise compelling evidence for short term memory deficits, impulse control issues, and attention deficiencies following prenatal cannabinoid exposure (PCE). These changes may be mediated through epigenetic modifications that not only impact the current offspring but could carry forward to future generations. While additional studies are needed, a pregnancy pause from cannabinoid products should be strongly recommended by providers to ensure the optimal health and well-being of our future generations.

Academy of Breastfeeding Medicine Clinical Protocol #21: Breastfeeding in the Setting of Substance Use and Substance Use Disorder (Revised 2023)

Background: The Academy of Breastfeeding Medicine (ABM) revised the 2015 version of the substance use disorder (SUD) clinical protocol to review the evidence and provide updated literature-based recommendations related to breastfeeding in the setting of substance use and SUD treatments. Key Information: Decisions around breastfeeding are an important aspect of care during the peripartum period, and there are specific benefits and risks for substance-exposed mother-infant dyads. Recommendations: This protocol provides breastfeeding recommendations in the setting of nonprescribed opioid, stimulant, sedative-hypnotic, alcohol, nicotine, and cannabis use, and SUD treatments. Additionally, we offer guidance on the utility of toxicology testing in breastfeeding recommendations. Individual programs and institutions should establish consistent breastfeeding approaches that mitigate bias, facilitate consistency, and empower mothers with SUD. For specific breastfeeding recommendations, given the complexity of breastfeeding in mothers with SUD, individualized care plans should be created in partnership with the patient and multidisciplinary team with appropriate clinical support and follow-up. In general, breastfeeding is recommended among mothers who stop nonprescribed substance use by the time of delivery, and they should continue to receive ongoing postpartum care, such as lactation support and SUD treatment. Overall, enhancing breastfeeding education regarding substance use in pregnancy and lactation is essential to allow for patient-centered guidance.

Variation in Hospital Practices Regarding Marijuana Use in Pregnancy and Lactation

Background and Objectives: Evidence is lacking on the safety of marijuana (MJ) exposure on the fetus and neonate, and current guidelines vary across professional organizations. We examined variation in hospital practices regarding use of mother's own milk (MOM) in the setting of perinatal MJ exposure based on hospital location and state MJ legal designation. Methods: We conducted a cross-sectional electronic survey of U.S. perinatal health care workers on hospital policies and clinical practice regarding maternal MJ use from November 2021 to April 2022. We analyzed responses from those working in states with legal recreational MJ (REC), MJ legal for medical use only (MED), and illegal MJ (NON), based on legalization status as of 2021. Results: Two thousand six hundred eighty-three surveys were analyzed from 50 states and the District of Columbia, with 1,392 respondents from REC states, 524 from NON states, and 668 from MED states. Hospital policies and practices showed significant differences between facilities from REC and NON states. REC states were more likely to have policies allowing use of MOM from mothers using MJ after delivery and less likely to routinely include cannabinoids in toxicology testing. Hospital policies also varied within individual hospitals between well baby nurseries and neonatal intensive care units. Conclusions: Hospital practices vary widely surrounding provision of MOM in the presence of maternal MJ use, based on state legalization status and hospital unit of care. Clear guidelines across professional organizations regarding perinatal MJ exposure, regardless of legality, are warranted to improve consistency of care and patient education.

Adverse childhood experiences, antenatal stressful life events, and marijuana use during pregnancy: A population-based study

Cumulative exposure to adverse childhood experiences (ACEs) and antenatal stressful life events (ASLEs) are independently associated with marijuana use during pregnancy. However, research has not explored how both exposures may influence marijuana use jointly. Assessing the joint associations of ACEs and recent ASLEs on marijuana use can identify people who may benefit from early intervention. Data come from the Nevada Pregnancy Risk Assessment Monitoring System, 2017-2020 (N = 2483). We assessed eight measures of ACEs before age 18 and fourteen measures of ASLEs twelve months before giving birth. Generalized estimating equations estimated the direct and joint associations (additive and multiplicative interaction) of ACEs and ASLEs on marijuana use during pregnancy. 9.8% used marijuana during the most recent pregnancy. Compared to people who reported no ACEs, those reporting 1 ACE (adjusted prevalence ratio[aPR] = 1.96, 95% confidence interval [CI] = 1.30-2.94), 3 ACEs (aPR = 3.58, 95%CI = 2.69-4.77), and 4+ ACEs (aPR = 3.67, 95%CI = 2.36-5.72) were more likely to use marijuana. Compared to people reporting no ASLEs, those reporting 4+ ASLEs (aPR = 3.12, 95% CI = 1.64-5.92) were more likely to use marijuana. There was evidence of interaction for high ACE and ASLE exposure on an additive scale. ACEs and ASLEs were independently associated with marijuana use during pregnancy, and there was evidence of additive interaction. Screening for ACEs and ASLEs during pregnancy, referrals to appropriate behavioral health services, and trauma-informed approaches are important to address marijuana use during pregnancy.

Effects of a combination of cannabidiol and delta-9-tetrahydrocannabinol on key biological functions of HTR-8/SVneo extravillous trophoblast cells

In recent years, cannabis use has increased among pregnant women. In addition, the phytocannabinoids cannabidiol (CBD) and delta-9-tetrahydrocannabinol (THC) alone or in combination are being used for therapeutical applications. THC and CBD are able to cross the placenta and a lot remains unknown concerning their impact on angiogenesis and extravillous trophoblasts' (EVTs) migration and invasion, which are essential processes for placentation. Thus, in this study, the HTR-8/SVneo cell line was employed to evaluate the effects of CBD, THC and of their combination (1:1, 2 µM). Cannabinoids affected epithelial-mesenchymal transition, as showed by increased expression of the epithelial protein marker E-cadherin for CBD and CBD plus THC treatments, and decrease of mesenchymal intermediate filament vimentin for all treatments. The gene expression of the metalloproteinases MMP2 and MMP9, and of their inhibitors TIMP1 and TIMP2 was increased, except the latter for THC treatment. Moreover, CBD reduced cell migration and invasion, an effect that was enhanced by its combination with THC. CBD with or without THC also upregulated the gene expression of PGF, while the anti-angiogenic factor sFLT1 was increased for all treatments. VEGFA and FLT1 were not affected. Alone or combined CBD and THC also decreased tube segments' length. Additionally, ERK1/2 and STAT3 phosphorylation was increased in the CBD and CBD plus THC-treated cells, while THC only activated STAT3. AKT activation was only affected by CBD. This work demonstrates that the exposure to cannabinoid-based products containing CBD and/or THC, may interfere with key processes of EVTs differentiation. Therefore, crucial phases of placental development can be affected, compromising pregnancy success.

Cannabis use during pregnancy and its effect on the fetus, newborn and later childhood: A systematic review

INTRODUCTION

Cannabis and its derivatives are becoming increasingly popular in women's preferences during pregnancy in order to relieve nausea. The present study examines cannabis use during pregnancy and its effects on the fetus, newborn and later childhood.

METHODS

All primary studies were searched in the databases: PubMed, Scopus, Medline during the period June 2019 to August 2020. The keywords used were 'pregnancy', 'pregnant women', 'cannabis', 'marijuana', 'fetus', 'newborn', 'childhood', and combined with 'AND' and 'OR' Boolean operators. Inclusion criteria were: pregnant users of cannabis as the study group and pregnant non-users of cannabis as the control group; the articles could be in English or in Greek. The exclusion criteria were: unpublished studies, reviews, presentations at conferences, and animal studies.

RESULTS

From the systematic review of the literature, the study included 13 primary research studies in which it was found that the children of mother-user faced: disorders in the sleep cycle, memory problems, hyperactivity, increased chances of low birth weight, prematurity with lower Apgar score in the 1st and 5th minutes and hospitalization in an NICU, DNA methylation at the position CpG.32, and modifications in the brain, especially in the amygdala. In addition, girls had more aggressive behavior at the age of 18 months, shorter breastfeeding period, and neonatal death.

CONCLUSIONS

The use of cannabis during the gestation period by the mother, aggravates the physical and mental development of the fetus, the newborn and the later childhood.

Impulsivity and Alcohol Use during Pregnancy and Postpartum: Insights from Novel Methodological Approaches within the Context of the COVID-19 Pandemic

Impaired emotion regulation and impulsivity have been linked to substance use. This study evaluated the association between emotion regulation difficulties-specifically impulsivity-and substance use within the context of the COVID-19 pandemic among pregnant (n = 49) and postpartum (n = 20) women. Participants from a prospective cohort ENRICH-2 completed a baseline phone survey of COVID-19-related experiences and impulsivity followed by a 14-day (3x/day) mobile ecological momentary assessment (mEMA) of impulsivity and substance use. Between-subject (BS) and within-subject (WS) associations for baseline impulsivity and momentary impulsivity with respect to substance use were examined using mixed effects models. At the BS level, momentary impulsivity scores that were higher than the overall group average were positively associated with subsequent momentary reports of marijuana use (β = 1.25; p = 0.04) when controlling for pregnancy status and COVID-19-related stress. At the WS level, momentary impulsivity scores that were higher than an individual's average score were positively associated with subsequent reports of momentary alcohol use (β = 0.08; p = 0.04). This research supports the idea that impulsivity varies based on individual situations, such as stress associated with the COVID-19 pandemic, and may be an important correlate of substance use in pregnant and postpartum women. Future research might consider investigation of additional factors, which may serve to moderate or mediate the relationship between impulsivity and substance use.

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 use, cannabis use disorder and mental health disorders among pregnant and postpartum women in the US: A nationally representative study

BACKGROUND

Cannabis use and cannabis use disorder (CUD) are associated with mental health disorders, however the extent of this matter among pregnant and recently postpartum (e.g., new moms) women in the US is unknown. Associations between cannabis use, DSM-5 CUD and DSM-5 mental health disorders (mood, anxiety, personality and post-traumatic stress disorders) were examined among a nationally representative sample of pregnant and postpartum women.

METHODS

The 2012-2013 National Epidemiologic Survey on Alcohol and Related Conditions-III was used to examine associations between past-year cannabis use, CUD and mental health disorders. Weighted logistic regression models were used to estimate unadjusted and adjusted odds ratios (aORs). The sample (N=1316) included 414 pregnant and 902 postpartum women (pregnant in the past year), aged 18-44 years old.

RESULTS

The prevalence of past-year cannabis use and CUD was 9.8% and 3.2%, respectively. The odds of cannabis use (aORs range 2.10-3.87, p-values<0.01) and CUD (aORs range 2.55-10.44, p-values< 0.01) were higher among women with versus without any past-year mood, anxiety or posttraumatic stress disorders or any lifetime personality disorder. aORs for the association of cannabis use with specific mood, anxiety or personality disorders ranged from 1.95 to 6.00 (p-values<0.05). aORs for the association of CUD with specific mood, anxiety or personality disorders ranged from 2.36 to 11.60 (p-values<0.05).

CONCLUSIONS

From pregnancy up to one year postpartum is a critical period where women may be particularly vulnerable to mental health disorders, cannabis use and CUD. Treatment and prevention are essential.

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.

Principles of care for pregnant and parenting people with substance use disorder: the obstetrician gynecologist perspective

Substance use in pregnant and parenting persons is common, yet still underdiagnosed. Substance use disorder (SUD) is one of the most stigmatized and undertreated chronic medical conditions, and this is exacerbated in the perinatal period. Many providers are not sufficiently trained in screening or treatment for substance use, so gaps in care for this population persist. Punitive policies towards substance use in pregnancy have proliferated, lead to decreased prenatal care, do not improve birth outcomes, and disproportionately impact Black, Indigenous, and other families of color. We discuss the importance of understanding the unique barriers of pregnancy-capable persons and drug overdose as one of the leading causes of maternal death in the United States. We highlight the principles of care from the obstetrician-gynecologist perspective including care for the dyad, person-centered language, and current medical terminology. We then review treatment of the most common substances, discuss SUD during the birthing hospitalization, and highlight the high risk of mortality in the postpartum period.

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.

Treatment outcomes among pregnant women with cannabis use disorder

Cannabis use disorder (CUD) among pregnant women is on the rise in the United States. The American College of Obstetricians and Gynecologists have recommended against the use of cannabis during pregnancy and breastfeeding. However, limited research exists on CUD treatment in this vulnerable population. The purpose of this study was to examine factors that influence CUD treatment completion in pregnant women. Data from the 2010-2019 Treatment Episode Data Set-Discharges (TEDS-D) were used (n = 7,319 pregnant women who reported CUD and had no prior treatment history). Descriptive statistics, logistic regression, and classification tree analyses were conducted to assess treatment outcomes. Only 30.3% of the sample completed CUD treatment. Length of stay between 4 and 12 months was associated with a higher likelihood of CUD treatment completion. The odds of treatment completion were higher if the referral source was alcohol/drug use care provider (AOR = 1.60, 95% CI [1.01, 2.54]), other community referral (AOR = 1.65, 95% CI [1.38, 1.97]), and the court/criminal justice (AOR = 2.29, 95% CI [1.92, 2.72]) relative to being referred by individual/self. A relatively high proportion of CUD treatment completion (52%) was observed among pregnant women who had > 1 month of CUD treatment and were referred to the treatment program by the criminal justice system. For pregnant women, referrals from the justice system, community, and healthcare providers can increase the likelihood of successful CUD treatment outcomes. Developing targeted CUD treatments for pregnant populations is crucial due to increasing CUD rates, cannabis accessibility, and potency.

An equitable, community-engaged translational framework for science in human lactation and infant feeding-a report from "Breastmilk Ecology: Genesis of Infant Nutrition (BEGIN)" Working Group 5

Human milk is the ideal source of nutrition for most infants, but significant gaps remain in our understanding of human milk biology. As part of addressing these gaps, the Breastmilk Ecology: Genesis of Infant Nutrition (BEGIN) Project Working Groups 1-4 interrogated the state of knowledge regarding the infant-human milk-lactating parent triad. However, to optimize the impact of newly generated knowledge across all stages of human milk research, the need remained for a translational research framework specific to the field. Thus, with inspiration from the simplified environmental sciences framework of Kaufman and Curl, Working Group 5 of the BEGIN Project developed a translational framework for science in human lactation and infant feeding, which includes 5 nonlinear, interconnected translational stages, T1: Discovery; T2: Human health implications; T3: Clinical and public health implications; T4: Implementation; and T5: Impact. The framework is accompanied by 6 overarching principles: 1) Research spans the translational continuum in a nonlinear, nonhierarchical manner; 2) Projects engage interdisciplinary teams in continuous collaboration and cross talk; 3) Priorities and study designs incorporate a diverse range of contextual factors; 4) Research teams include community stakeholders from the outset through purposeful, ethical, and equitable engagement; 5) Research designs and conceptual models incorporate respectful care for the birthing parent and address implications for the lactating parent; 6) Research implications for real-world settings account for contextual factors surrounding the feeding of human milk, including exclusivity and mode of feeding. To demonstrate application of the presented translational research framework and its overarching principles, 6 case studies are included, each illustrating research gaps across all stages of the framework. Applying a translational framework approach to addressing gaps in the science of human milk feeding is an important step toward the aligned goals of optimizing infant feeding across diverse contexts as well as optimizing health for all.

Influence of prenatal cannabinoid exposure on early development and beyond

Public perception surrounding whether cannabis use is harmful during pregnancy often diverges greatly from the recommendations of doctors and healthcare providers. In contrast to the medical guidance of abstinence before, during, and after pregnancy, many women of reproductive age believe cannabis use during pregnancy is associated with little potential harm. Legalization and social cues support public perceptions that cannabis use during pregnancy is safe. Moreover, pregnant women may consider cannabis to be a safe alternative for treating pregnancy related ailments, including morning sickness. Compounding the problem is a lack of medical and federal guidance on safe, low, or high-risk levels of cannabis use. These issues mirror the continuing debate surrounding alcohol use and health, in particular, whether there are safe or lower risk levels of alcohol consumption during pregnancy. Clinical studies to date suffer from several limitations. First, most human studies are correlative in nature, meaning that causal associations cannot be made between in utero cannabis exposure and health and behavioral outcomes later in life. Due to obvious ethical constraints, it is not possible to randomly assign pregnant mothers to cannabis or other drug exposure conditions-a requirement needed to establish causality. In addition, clinical studies often lack quantitative information on maternal exposure (i.e., dose, frequency, and duration), include a small number of individuals, lack replication of outcome measures across cohorts, rely on self-report to establish maternal drug use, and suffer from unmeasured or residual confounding factors. Causal associations between maternal cannabis exposure and offspring outcomes are possible in preclinical cohorts but there is a large amount of heterogeneity across study designs and developmental differences between rodents and humans may limit translatability. In this review, we summarize research from human and preclinical models to provide insight into potential risks associated with prenatal cannabinoid exposure (PCE). Finally, we highlight gaps in knowledge likely to contribute to the growing divide between medical guidance and public attitudes regarding cannabis use during pregnancy.

Association of cannabis use during pregnancy with severe acute respiratory syndrome coronavirus 2 infection: a retrospective cohort study

BACKGROUND AND AIMS

Cannabis use is increasingly common among pregnant individuals and might be a risk factor for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. We aimed to test whether prenatal cannabis use is associated with increased risk of SARS-CoV-2 infection during pregnancy.

DESIGN

This is a retrospective cohort study.

SETTING

The study was conducted in California, USA.

PARTICIPANTS

A total of 58 114 pregnancies (with outcomes from 5 March 2020 to 30 September 2021) among 57 287 unique pregnant women aged 14-54 years who were screened for prenatal substance use, enrolled in Kaiser Permanente Northern California (KPNC) (a health-care system) and had not tested positive for COVID-19 prior to pregnancy onset.

MEASUREMENTS

We utilized data from the KPNC electronic health record. Cannabis use status (current, recently quit and non-user) was based on universal screenings during prenatal care (including urine toxicology testing and self-reported use on a self-administered questionnaire). SARS-CoV-2 infection [based on polymerase chain reaction (PCR) tests] was estimated in time-to-event analyses using Cox proportional hazard regression models adjusting for covariates. Secondary analyses examined differences in (a) SARS-CoV-2 testing rates and (b) SARS-CoV-2 infection rates among those tested.

FINDINGS

We observed 348 810 person-months of follow-up time in our cohort with 41 064 SARS-CoV-2 PCR tests and 6% (n = 2414) of tests being positive. At the start of follow-up, 7% of pregnant individuals had current use, 12% had recently quit and 81% did not use cannabis. Adjusting for covariates, current use was associated with lower rates of SARS-CoV-2 infection [adjusted hazard ratio (aHR) = 0.60, 95% confidence interval (CI) = 0.49-0.74 than non-use. Those who had recently quit did not differ from non-cannabis users in infection rates (aHR = 0.96, 95% CI = 0.86-1.08). Sensitivity analyses among patients who received a SARS-CoV-2 test also found lower odds of infection associated with current versus no cannabis use (aOR = 0.76, CI = 0.61-0.93).

CONCLUSIONS

Current cannabis use appears to be associated with a reduced risk of SARS-CoV-2 infection among pregnant individuals.

Tobacco and Cannabis Use During and After Pregnancy in California

OBJECTIVES

As the social and legal acceptance of cannabis use grows, health professionals must understand and mitigate the impact of cannabis use in the perinatal period. Here we compare the prevalence of tobacco and cannabis use during and after pregnancy in California, a state that recently legalized cannabis use.

METHODS

Measures of tobacco and cannabis use during and after pregnancy were obtained from California's Maternal and Infant Health Assessment, an annual population-based survey of California resident women with a live birth. To allow analysis of county-level variation, we pooled data from the 35 counties with the largest numbers of births from 2017 to 2019.

RESULTS

Cannabis use was more than twice as common as cigarette smoking among pregnant women (4.9% vs. 2.1%) in California. This difference was even more pronounced in some counties; for example, in Los Angeles, cannabis use was four times more prevalent than cigarette use. Either during or soon after birth, 7.3% of women in California reported cannabis use. Of those who smoked tobacco cigarettes prior to pregnancy, 73% quit before their third trimester of pregnancy, though 33.0% of these women reported a post-partum relapse in cigarette use.

CONCLUSIONS

States that have legalized cannabis must attend to the increasing prevalence of perinatal cannabis use, as well as concurrent use with tobacco and other substances. Efforts to support cannabis cessation should draw from successful public health approaches in tobacco control.

Pregnant individual's lived experience of cannabis use during the COVID-19 pandemic: a qualitative study

Introduction

Quantitative studies indicate that the COVID-19 pandemic has contributed to increased rates of prenatal cannabis use. However, little is known about how the pandemic has impacted cannabis use from the perspective of pregnant individuals themselves. Our objective was to characterize COVID-19-related changes in cannabis use among pregnant individuals who used cannabis during the pandemic.

Methods

We conducted 18 focus groups (from 11/17/2021 to 12/17/2021) with Black and White pregnant individuals aged 18+ who self-reported prenatal cannabis use during universal screening at entrance to prenatal care (at ~8 weeks gestation) in Kaiser Permanente Northern California. Virtual focus groups were transcribed and analyzed using thematic analysis.

Results

The sample of 53 pregnant individuals (23 Black, 30 White) was 30.3  years old (SD = 5.2) on average, and most (70%) self-reported daily versus weekly or monthly prenatal cannabis use. Major themes regarding the impact of the pandemic on cannabis use included increases in use (resulting from depression, anxiety, stress, boredom), and changes in social use (less sharing of smoked cannabis products), modes of use (from smoking to other modes due to respiratory concerns) and source (from storefront retailers to delivery).

Conclusion

Coping with mental health symptoms and stress were identified drivers of perceived pandemic-related increases in prenatal cannabis use in 2021. Pregnant individuals adapted their use in ways consistent with public health recommendations to decrease social contact and reduce or quit smoking to mitigate COVID-19 transmission and harms. Proactive, mental health outreach for pregnant individuals during future pandemic waves may reduce prenatal cannabis use.

Sex-dependent Effect of In-utero Exposure to Δ9-Tetrahydrocannabinol on Glucagon and Stathmin-2 in Adult Rat Offspring

OBJECTIVES

Administration of Δ⁹-tetrahydrocannabinol (Δ⁹-THC) to pregnant rats results in glucose intolerance, insulin resistance and reduced islet mass in female, but not male, offspring. The effects of Δ⁹-THC on other islet hormones is not known. One downstream target of the cannabinoid receptor, stathmin-2 (Stmn2), has recently been shown to suppress glucagon secretion, thereby suggesting Δ⁹-THC may also affect alpha-cell function. The aim of the present study was to determine the effects of in-utero Δ⁹-THC exposure on the profile of glucagon, insulin and Stmn2 in the rat offspring islet and serum.

METHODS

Pregnant Wistar rat dams were injected with Δ⁹-THC (3 mg/kg per day, intraperitoneally) or vehicle from gestational day 6 to birth. Offspring were euthanized at postnatal day 21 (PND21) or at 5 months (adult) to collect blood and pancreata.

RESULTS

At PND21, control and Δ⁹-THC-exposed offspring showed that Stmn2 had a strong colocalization with glucagon (Pearson's correlation coefficient ≥0.6), and a weak colocalization with insulin (Pearson's correlation coefficient <0.4) in both males and females, with no changes by either treatment or sex. In adult female offspring in the Δ⁹-THC group, intensity analysis indicated an increased insulin-to-glucagon (I/G; p<0.05) ratio and a decreased glucagon-to-Stmn2 (G/S; p<0.01) ratio, and no changes in these ratios in adult males. Furthermore, Δ⁹-THC did not alter fasting blood glucose and serum insulin levels in either male or female adult offspring. However, female Δ⁹-THC-exposed offspring exhibited an increased I/G ratio (p<0.05) and decreased G/S ratio in serum by adulthood (p<0.05).

CONCLUSION

Collectively, the reduced G/S ratio in both islet and serum in association with an increased serum I/G ratio has direct correlations with early glucose intolerance and insulin resistance observed exclusively in females' offspring in this prenatal cannabinoid model.

Perceptions About Cannabis Following Legalization Among Pregnant Individuals With Prenatal Cannabis Use in California

IMPORTANCE

As rates of prenatal cannabis use increase and cannabis legalization spreads across the US, studies are needed to understand the potential impacts of legalization from the perspectives of pregnant individuals who use cannabis.

OBJECTIVE

To characterize pregnant individuals' perspectives on legalization of cannabis for adult use in California (effective in 2018) in relation to prenatal cannabis use behaviors and beliefs.

DESIGN, SETTING, AND PARTICIPANTS

This qualitative study was conducted in Kaiser Permanente Northern California, a large health care system with universal screening for self-reported cannabis use at entrance to prenatal care. Eighteen semistructured focus groups were conducted from November 17 to December 17, 2021, using a secure video conferencing platform with Black and White pregnant participants who self-reported cannabis use during early pregnancy. Data were analyzed from March to June 2022.

MAIN OUTCOMES AND MEASURES

Video-recorded interviews were transcribed and analyzed using thematic analysis to identify major themes and subthemes.

RESULTS

Among 53 participants (mean [SD] age, 30.3 [5.2] years), 23 (43%) identified as non-Hispanic Black and 30 (57%) identified as non-Hispanic White; 16 participants (30%) reported continued cannabis use at the time of recruitment. Major themes regarding the perceived impact of legalization included easier access (via retailers and delivery), greater acceptance (including reduced stigma and more discussions about prenatal cannabis use with health care practitioners), and trust in cannabis retailers (including safety and effectiveness of diverse products sold and perceptions of cannabis retailer employees as knowledgeable, nonjudgmental, and caring). Responses were mixed about whether retailer marketing and advertising were associated with prenatal cannabis use and whether legalization resulted in reduced concerns about Child Protective Services involvement.

CONCLUSION AND RELEVANCE

The findings of this qualitative study suggest pregnant individuals perceive cannabis legalization as having reduced barriers to prenatal cannabis use and that legalization has created challenges and opportunities for supporting the health of pregnant individuals. The results of this qualitative study highlight key areas that can be further explored in future educational materials, public health campaigns, and policy adaptations to address increasing rates of prenatal cannabis use.