While the federal government still categorizes cannabis as an illicit Schedule 1 substance , states are increasingly legalizing cannabis use, with 18 U.S. states and the District of Columbia legalizing adult recreational cannabis use and 36 states legalizing medical cannabis use as of May 2021 . These states include California, where voters approved medical cannabis use in 1996 and recreational cannabis use in 2016, with retail sales of recreational cannabis beginning on January 1, 2018 . As cannabis legalization spreads, many health professionals are concerned about negative health effects of possible increases in cannabis use , with particular fears focused on potential fetal harms from cannabis use in pregnancy . Studies investigating potential harms from cannabis use in pregnancy have documented a robust association between cannabis smoking and low birth weight . Some studies find increased risk of pre-term birth or small-for-gestational age associated with cannabis use in pregnancy , but others have not found these associations . Some studies have found associations between prenatal cannabis use and adverse neurocognitive outcomes and increased psychopathology in exposed children, especially when maternal cannabis use occurred after pregnancy recognition . However, most studies of harms associated with cannabis use in pregnancy suffer from methodological weaknesses, including an inability to adequately control for potential confounders including poverty and poly-substance use including tobacco . In light of concerns about cannabis use in pregnancy, mobile vertical rack in 2019 the U. S. Surgeon General recommended total abstinence from cannabis for pregnant people .
The American College of Obstetricians and Gynecologists recommends that prenatal care providers ask all pregnant people about their substance use, including cannabis, and that “women reporting cannabis use should be counseled about concerns regarding potential adverse health consequences of continued use during pregnancy” . However, adherence to these recommendations appears low . A few studies have examined pregnant people’s perspectives on and experiences with cannabis use in pregnancy. These studies have documented that pregnant people are uncertain but concerned about potential risks to their fetus from prenatal cannabis use , and that they seek information on risks and benefits of cannabis use in pregnancy from the internet as well as from friends and family . This research has also found that pregnant people would like to discuss cannabis with their healthcare providers but may be dissuaded due to concerns about being reported to child protective services and potentially being separated from their newborn . Many pregnant people report receiving no counseling and education on health aspects of prenatal cannabis use from their healthcare providers , even after disclosing cannabis use . Instead, providers may emphasize legal consequences of use during pregnancy, rather than health-related aspects . Most of this research, however, was conducted in states and in time periods where recreational cannabis was illegal . A recent national study focusing on general contexts found that people who use cannabis were more likely to disclose use to their healthcare providers in states where such use is legal.But research in the U.S. to date has not yet examined patient-provider interactions regarding cannabis use during pregnancy in a context of legalized recreational cannabis.
To fill these gaps, we conducted a qualitative study of people who used cannabis during pregnancy in California after legalization of recreational cannabis, to explore their experiences of their interactions with providers about cannabis. In May-August 2019, we conducted in-depth interviews for a qualitative study that sought to explore perspectives, decision-making, and experiences of pregnant and postpartum Californians who use cannabis regularly, in the context of legal recreational cannabis. This analysis focuses on participants’ experiences disclosing and discussing cannabis use with providers. A group of community advisors with expertise in prenatal care, preterm birth prevention, substance use disorder treatment, and community-informed research helped refine our interview guide, plan and conduct recruitment outreach, and interpret results. Study participants were eligible if they were currently pregnant or had been pregnant within the last year; had used cannabis regularly in the last year or in the year before their most recent pregnancy; were 18 years or older; lived in California; and were Englishspeaking. Because research has shown that people who use cannabis during pregnancy in the U.S. come from all racial/ethnic groups and socio-economic positions , we aimed to recruit a heterogenous participant group, recruiting via cannabis dispensaries, healthcare providers, and social media. Several cannabis dispensaries in the San Francisco Bay Area posted or distributed study flyers. Providers in prenatal health and substance use disorder treatment clinics also posted flyers and/or referred patients to the study. On Facebook and Instagram, we recruited via local “cannamoms” groups and local cannabis user groups. We tracked demographic details of recruited participants on a spreadsheet and checked regularly to be sure that a range of racial/ethnic groups, socio-economic positions, and recruitment sources were represented. This led us to adjust recruitment after one month: after 9 of our first 14 participants reported that they were referred from a statewide group prenatal parenting program for Black women, we paused further participation from those in this program to ensure that we had a more demographically diverse sample. Interested participants took part in a 15-minute phone call with study staff for eligibility screening, verbal consent, and scheduling, followed later by an in-depth phone interview of up to one hour.
The first author conducted all interviews. A flexible interview guide allowed us to cover domains relevant to our study questions while also exploring participants’ priorities and diverse experiences. Here, we report on interview domains covering participants’ patterns of cannabis use before and during pregnancy and disclosure and/or discussion of cannabis use in pregnancy with healthcare providers. Participants were given a $50 gift card in remuneration. Interviews were audio-recorded and transcribed verbatim. One participant declined to be recorded; for that interview, we used extensive notes taken during the conversation to inform development of themes, but did not use any direct quotations. We continued recruiting and interviewing until no new themes emerged in our interviews, suggesting we had reached thematic saturation . We conducted coding of transcripts via a two-step process: “chunking” text according to interview domains, and then detailed close coding within domains . We then conducted thematic analysis of the coded text, using deductive and inductive methods. The first author conducted all coding and led all authors and community advisors in interpretation of results and articulation of major themes, through discussing codes and interview excerpts, followed by revising themes. We selected representative quotes from across the sample to illustrate each theme; the 15 quotes presented here come from 12 different participants reflecting a range of racial/ethnic groups, ages, and educational backgrounds. The study protocol was reviewed and approved by the University of California, San Francisco Institutional Review Board. All participants used cannabis at least weekly before pregnancy; most reported daily cannabis use, vertical grow rack both before and during pregnancy. More than half reported having reduced or stopped cannabis use upon pregnancy recognition. Some reported a mix of reducing and stopping; of these, some stopped using cannabis early in pregnancy but started again later ; others reduced early in pregnancy and then stopped or planned to stop a month or so before their due date.
A few reported that their use stayed about the same in pregnancy as before, or even increased during pregnancy. Most reported using cannabis to ease pregnancy-related symptoms of nausea/vomiting or lack of appetite, pain, or insomnia, or to cope with stress or trauma; some reported using to relax and enjoy themselves with others. This study finds that pregnant people who use cannabis in California continue to report barriers to open discussion of this use with their prenatal providers, despite state legalization of recreational cannabis. While a recent study found that pregnant people do find verbal screening for alcohol, tobacco, and other drugs acceptable and are willing to disclose their substance use to prenatal providers , previous research has found that pregnant people fear that providers’ knowledge of their use will lead to judgment and punishment, particularly reporting to CPS . Consistent with the older body of research, most participants in the current study reported being unwilling to disclose their cannabis use, due to fears of CPS reporting and potential consequences such as parent-child separation. Previous studies have suggested that such fears lead pregnant people who use drugs to physically avoid and/or emotionally disengage from prenatal care . Here, we extend those previous findings by identifying that pregnant people’s fears of being judged and reported to CPS by providers create barriers to comprehensive and compassionate discussions about cannabis use in pregnancy, even in the context of legal recreational cannabis. It is important to note that our participants’ fears of negative repercussions were centered around CPS report for cannabis use during pregnancy, not around the legal status of cannabis use per se. While few people are criminally prosecuted for substance use during pregnancy, about 1 % of all newborns are reported to CPS related to maternal substance use during pregnancy, including cannabis use . In our study, fears of CPS involvement were reported by participants across racial/ethnic groups, but in actuality there are stark racial inequities in this reporting, with providers reporting 4–5 times more Black than white newborns.While legalization of cannabis may reduce some racial inequities imposed by the racist “War on Drugs” , state legalization does not change the federal status of cannabis as a Schedule 1 substance, nor does it necessarily change the CPS reporting policy in the state; further, CPS reporting policies do not necessarily distinguish between legal and illegal substances . California has not changed their CPS reporting policy since legalizing cannabis . Our research suggests legalizing cannabis for recreational purposes does not resolve the barriers that CPS reporting requirements impose on patient-provider discussion of cannabis use in pregnancy. Our finding that few participants reported their providers asking about cannabis echoes previous research finding that providers consider cannabis use in pregnancy to be lower priority to address with patients than other substances used in pregnancy , and that many providers do not respond to pregnant patients’ disclosure of cannabis use . This silence may be sending a health message: our study concords with prior research suggesting that some patients interpret providers’ silence on the topic as an indication that cannabis is safe to use in pregnancy . Provider silence on cannabis use in pregnancy is inconsistent with ACOG-recommended practices and educational messages and may limit opportunities for nuanced and patient-centered discussions about risks and benefits of continued use.
Even when they do occur, though, patient-provider discussions of cannabis may not be nuanced and patient-centered. In our study, participants who discussed cannabis use with their providers reported hearing a wide range of health/risk messages, from endorsement of cannabis use, to recommended harm-reduction strategies, to what they experienced as threats of CPS reports. The spectrum of messages may reflect some providers’ attempts to acknowledge patients’ range of options on cannabis use in pregnancy . However, the inconsistency may also reflect providers’ uncertainty in the face of nascent and sometimes conflicting evidence on health effects of cannabis use in pregnancy . While this study was not designed to examine providers’ motivations for raising the possibility of a CPS report, this study strongly suggests that patients often interpret providers’ discussion of possible CPS report as a threat. Future research should examine providers’ behavior-change philosophies and approaches related to cannabis use in pregnancy, as well as their reasons for and approaches to discussing possible CPS involvement. This work has important implications. First, state-level legalization of cannabis does not address the CPS reporting policies that more commonly punish people who use cannabis during pregnancy. People concerned about pregnant people facing punishment for their cannabis use should focus on changing CPS reporting policies and not only general-population legalization policies. Second, in their committee opinion on cannabis and pregnancy, ACOG included a recommendation that providers inform patients “of the potential ramifications of a positive screen result [for cannabis], including any mandatory reporting requirements” . The findings from this study suggest that this recommendation, as currently phrased, may have unintended consequences, and thus, perhaps should be revised. Further, this study suggests that ACOG’s statement that “Seeking obstetric–gynecologic care should not expose a woman to criminal or civil penalties for marijuana use” overlooks the realities of widespread CPS reporting policies and practices and the lived experiences and perceptions of pregnant people who use cannabis.