Prenatal cannabis screening and counseling practices by state recreational legalization status: A multi-state examination of PRAMS data (2017–2020)
Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe St., Baltimore, MD 21205, USA
Department of Nursing, Towson University, 8000 York Rd, Towson MD 21252, USA
Abstract
Objective
Despite increased recreational cannabis legalization (RCL) in the US in recent years, little is known about cannabis advice received at prenatal care visits. We aimed to examine cannabis screening and counseling occurring at prenatal care visits, including adherence of advice to current clinical guidelines and variations by RCL status.
Methods
In this repeated cross-sectional study, we used 2017–2020 Pregnancy Risk Assessment Monitoring System data for 9 states to calculate weighted prevalence estimates of cannabis screening and advice received during prenatal care. We also examined adherence to the American College of Obstetricians and Gynecology’s clinical guidelines for cannabis use during pregnancy, including variations across RCL and self-reported prenatal cannabis use via chi-squared tests.
Results
In the sample (weighted N = 742,491), 20.53 % received cannabis advice that was adherent to clinical guidelines. Women in states with RCL more frequently reported being asked about cannabis use (78.66 % vs. 62.30 %; P < 0.001), and reported being advised against cannabis use during pregnancy (44.29 % vs. 37.06 %; P < 0.001) and lactation (31.03 % vs. 25.50 %; P < 0.001) at a prenatal care visit than women residing in states without RCL. Similarly, women in states with RCL more frequently reported being advised to use cannabis prenatally (2.96 % vs 1.45 %, P < 0.001). Women who reported any prenatal cannabis use were more likely to report being advised to use cannabis at a prenatal care visit in comparison to those who did not report prenatal cannabis use (10.10 % vs 1.16 %, P < 0.001).
Conclusions
Given the variations in cannabis screening and advice occurring at prenatal care visits, findings underscore the importance of clinical practice that is consistent with current guidelines.
Untitled section
Keywords: Pregnancy, Substance use, Maternal health, Clinician advice, Health communication
Highlights
- •Women reporting cannabis use in pregnancy more frequently reported being advised to use at visits.
- •All women should be screened and counseled about risks of cannabis use during pregnancy.
- •Findings reinforce adherence to clinical guidance on cannabis use during pregnancy.
Article notes
Untitled section
Received 2025 Jul 25; Revised 2025 Sep 10; Accepted 2025 Sep 24; Collection date 2025 Dec.
1.Introduction
There is no evidence that supports the safety of prenatal cannabis use.(American College of Obstetricians and Gynecologists Comittee on Obstetric Practice, 2017). Despite this fact, cannabis is the most commonly used federally illicit substance during pregnancy in the United States (US) (Volkow et al., 2019). Decreasing risk perceptions of cannabis use during pregnancy (Jarlenski et al., 2017; Passey et al., 2014), perceived safety of cannabis use (McGinty et al., 2017), shifting social norms (Kolar et al., 2018), and recreational cannabis legalization (RCL)(Gnofam et al., 2019; Lee et al., 2020; Skelton et al., 2020) have been associated with increasing prevalence of cannabis use during pregnancy. At the federal level, cannabis remains a Schedule 1 substance in the US. Yet, 39 states and the District of Columbia have legalized cannabis for medical use and 24 states have legalized cannabis for adult recreational use. Importantly, changes to state-level cannabis policies add complexity to the implementation of clinical recommendations, particularly for perinatal care providers.
Although there is much to be learned about health effects of prenatal cannabis use, evidence is clear that the main psychoactive component of cannabis, ∆-9-tetrahydrocannabinol (THC), readily crosses the placenta (Volkow et al., 2017). Contemporary evidence also supports heightened risk for adverse maternal (Young-Wolff et al., 2024), neonatal (e.g., low birth weight, preterm birth)(Marchand et al., 2021; National Academies of Sciences and Medicine, 2017), and child neurodevelopmental outcomes of prenatal cannabis use(American College of Obstetricians and Gynecologists Comittee on Obstetric Practice, 2017; Ryan et al., 2018). One of the largest meta-analyses to date, conducted by Marchand et al. (2021), compared neonatal outcomes of infants with and without in utero cannabis exposure and found that exposed children had higher rates of preterm birth, admission to the neonatal intensive care unit, low birth weight, small for gestational age, poorer 1-minute Apgar scores, and smaller head circumferences (Marchand et al., 2021). The growing body of evidence supporting adverse health outcomes of perinatal cannabis use has led the American College of Obstetricians and Gynecologists (ACOG) and the American Academy of Pediatrics (AAP) to recommend that women abstain from cannabis use during pregnancy (American College of Obstetricians and Gynecologists Comittee on Obstetric Practice, 2017, Ryan et al., 2018). Guidelines also recommend that clinicians encourage women to stop using cannabis in favor of alternative therapies for which pregnancy-specific safety data exist and educate women about possible risks of cannabis exposure, including long-term neurobehavioral effects (Reece-Stremtan et al., 2015) and second-hand smoke exposure (Ryan et al., 2018). Additionally, the ACOG, the AAP, and the Academy for Breastfeeding Medicine (ABM) recommend that breastfeeding women abstain from cannabis use during lactation due to the pharmacokinetic properties of THC (i.e., lipophilic nature and long half-life of THC) and the high fat content of breastmilk (American College of Obstetricians and Gynecologists Comittee on Obstetric Practice, 2017, Reece-Stremtan et al., 2015, Ryan et al., 2018).
Effective clinician-directed screening, education, and communication has been linked to improved perinatal health outcomes, including outcomes among women with substance use disorders (Hostage et al., 2020; Shogren et al., 2017). Few studies, however, have examined cannabis-related communications between health care providers and pregnant women (Bartlett et al., 2020; Holland et al., 2016, Jarlenski et al., 2016; Skelton et al., 2024; Young-Wolff et al., 2020). These studies were mostly qualitative (Holland et al., 2016, Jarlenski et al., 2016; Skelton et al., 2024), included women reporting prenatal cannabis use only (Jarlenski et al., 2016), or examined online communications only (Young-Wolff et al., 2020). Nevertheless, existing evidence builds the case that women are dissatisfied with cannabis-related communication from their health care providers (Bayrampour et al., 2019; Holland et al., 2016; Skelton et al., 2024; Young-Wolff et al., 2020). Given this dissatisfaction, many women report seeking information from cannabis dispensaries and social media to make decisions about cannabis use during pregnancy (Jarlenski et al., 2017). The large increase in cannabis use among women of reproductive age (Brown et al., 2017), in combination with recent evidence demonstrating increased risks of adverse health outcomes of cannabis use during pregnancy underscore the need to examine cannabis screening and advice occurring at prenatal care visits.
The objectives of this study were to examine variations in cannabis screening, advice, and overall adherence to ACOG guidelines by cannabis use during pregnancy and by RCL status. We hypothesized that more women will be using cannabis during pregnancy when clinical care is non-adherent. Given that states with RCL allocate a portion of revenue from cannabis sales for public health efforts, we anticipate there may be heightened awareness of risks of prenatal cannabis use in these states. Therefore, we hypothesized that adherence to guidelines for cannabis use during pregnancy will be greater in states with RCL than in states without RCL.
2.Methods
2.1.Design
We conducted a secondary data analysis of repeated cross-sectional data from the 2017–2020 Pregnancy Risk Assessment Monitoring System (PRAMS) (Shulman et al., 2018) automated research file. PRAMS is a site-specific and population-based surveillance system implemented by state, territorial, or local health departments in partnership with the Centers for Diseases Control and Prevention (CDC) (Shulman et al., 2018). The overarching goal of PRAMS is to identify subpopulations of women and infants at risk for health problems, monitor changes in health status, and measure progress towards improving maternal and child health outcomes. The Towson University IRB determined this research to be exempt. This study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines.
2.2.Study sample
Using data from birth certificates, each participating PRAMS site uses stratified sampling to survey women with recent live births 2–6 months after delivery (Shulman et al., 2018). Annually, each site samples between 1000 and 3000 women via telephone or mail. A detailed description of the PRAMS methodology, including sampling methodology variations across sites, is published elsewhere (Shulman et al., 2018).
In addition to the annual PRAMS questionnaire, states may append optional supplements to obtain data on topics of emerging concern (e.g., Zika, maternal COVID-19 experiences). One of these supplements, used for the first time in 2017, is the Marijuana and Prescription Drug Use Supplement. A total of 10 states that used the PRAMS Marijuana Supplement between 2017 and 2021 met the Centers for Disease Control and Prevention’s threshold for data release (55 % and 50 % for 2017 and 2018–2021 data, respectively): Alaska, Illinois, Maine, North Dakota, New Jersey, New Mexico, New York, Pennsylvania, Virginia, and West Virginia. Although all 10 states used questions about cannabis-related screening, advice, and recommendations during prenatal care, there was substantial variability in the number of years states chose to ask these questions (eTable 1). In effort to preserve data, we opted to include annual data for each PRAMS site with at least one year of data for our outcome variable.
2.3.Measures
2.3.1.Cannabis screening and advice at prenatal care visits
In the Marijuana Supplement, cannabis screening and advice occurring at prenatal care visits is assessed via the following question: “During any of your prenatal care visits, did a doctor, nurse, or other health care worker do any of the following things? Please include if they asked you on a written form or in conversation. For each item, check No if they did not do this or Yes if they did.” This question included four items: Ask me if I was using marijuana, recommend that I use marijuana for any reason, advise me not to use marijuana, or advise me not to breastfeed my baby if I was using marijuana. Responses allowed for the calculation of a four-level response variable.
2.3.2.Adherence to clinical recommendations
Our primary outcome variable was adherence to current clinical recommendations for cannabis use during pregnancy. Current ACOG recommendations for cannabis use during pregnancy state the following: all women should be asked about cannabis use during early pregnancy, women reporting cannabis use should be counseled about potential adverse health consequences of continued use while pregnant, pregnant women should be encouraged to discontinue cannabis use, and marijuana use while breastfeeding should be discouraged (American College of Obstetricians and Gynecologists Comittee on Obstetric Practice, 2017). Guidance further states that obstetrician-gynecologists should be discouraged from prescribing or recommending cannabis use for medicinal purposes during pregnancy and lactation (American College of Obstetricians and Gynecologists Comittee on Obstetric Practice, 2017).
Using these guidelines and individual responses to the question about cannabis screening and advice occurring at prenatal care visits, we created an indicator variable representing adherence to ACOG guidelines. We operationalized this variable as an affirmative response to the following items: Ask me if I was using marijuana, advise me not to use marijuana, and advise me not to breastfeed my baby if I was using marijuana, and a negative response to the item, recommend that I use marijuana for any reason. We coded all other potential combinations as non-adherent.
2.3.3.Cannabis legalization
For each year of data, we created a dichotomous indicator variable (0 or 1) based on whether the state had RCL at the time. For states that legalized recreational cannabis during the study period, the enactment date (as opposed to the date retail sales began) was used as the demarcation date. This is because prior studies, including our own, demonstrate cannabis use patterns and policies change based on RCL use enactment date (Skelton et al., 2021; Young-Wolff et al., 2024) while retail sales can take years for implementation, with variation at the city or county level. Given the cross-sectional, retrospective nature of the PRAMS survey, we assessed whether the respondent’s gestation occurred entirely before or after legalization enactment using the infant’s date of birth and gestational age. Subsequently, if a woman’s pregnancy crossed the enactment date, the case was excluded from analyses. Virginia enacted RCL on July 1, 2021, and included outcomes variables after legalization only. In turn, all cases in Virginia crossed the enactment period and subsequently excluded from analysis. In total, this left 9 states - 2 states with RCL (Alaska and Maine) and 7 states without RCL (Illinois, North Dakota, New Jersey, New Mexico, New York, Pennsylvania, and West Virginia).
2.3.4.Cannabis use during pregnancy
PRAMS asks the following question about cannabis use, “At any time during the 3 months before you got pregnant OR during your most recent pregnancy did you use ‘marijuana’ or hash in any form?” Respondents who answer affirmatively are then asked, “During your most recent pregnancy, how often did you use marijuana products in an average month?”. We used responses to the latter question to create a binary variable for any cannabis use during pregnancy (any use/did not use).
2.4.Statistical analysis
PRAMS data are weighted to account for the complex sampling design, as well as non-response and non-coverage.(Shulman et al., 2018) First, we used descriptive statistics to compute weighted estimates of maternal sociodemographic characteristics. We then used Pearson ꭓ2 tests to examine differences in sociodemographic characteristics across women residing in states with and without RCL.
Next, we reported weighted prevalence estimates for each cannabis screening question and overall adherence to ACOG guidelines. Lastly, using Pearson’s ꭓ2, we examined variations in outcome variables across RCL status and whether the respondent reported any prenatal cannabis use. We used Stata 14.1 (StataCorp, College Station, TX) for all analyses and considered 2-sided significance at a threshold of alpha= 0.05. Data analysis was conducted in 2025.
3.Results
The analytic sample included 13,727 women who attended at least one prenatal care visit and delivered a live-born infant, representing 784,415 births. Table 1 displays overall maternal sociodemographic characteristics of the sample and stratified by RCL status. Overall, the sample was predominately White (70.81 %), 29 years of age or less (47.93 %) and had at least one prenatal care visit in the first trimester (88.63 %). There was sociodemographic variation among women residing in states with and without RCL. Women residing in states with RCL were significantly more likely to report cannabis use during pregnancy (10.66 % vs. 3.36 %) and to report both cannabis and tobacco use during pregnancy (4.06 % vs.1.26 %) compared to those residing in states without RCL (Table 1).
| Recreational Cannabis Legal | ||||
|---|---|---|---|---|
| Characteristic | Total (% (CI) | No (n = 12,134)b % (CI) | Yes (n = 1593)b % (CI) | P-valueC |
| Marital Status | ||||
| Married | 62.25 (60.98, 63.51) | 62.22 (60.92, 63.51) | 63.33 (60.46, 66.10) | 0.488 |
| Unmarried | 37.75 (36.49, 39.02) | 37.78 (36.49, 39.08) | 36.67 (33.90, 39.54) | |
| Maternal age (years) | ||||
| <19 | 3.36 (2.93, 3.85) | 3.36 (2.92, 3.86) | 3.51 (2.55, 4.81) | < 0.001 |
| 20–29 | 44.57 (43.29, 45.87) | 44.35 (43.03, 45.67) | 53.21 (50.26, 56.13) | |
| 30–34 | 30.85 (29.70, 32.01) | 30.93 (29.76, 32.13) | 27.56 (25.03, 30.23) | |
| >35 | 21.22 (20.22, 22.27) | 21.36 (20.32, 22.44) | 15.73 (13.71, 17.97) | |
| Household income | ||||
| < $20,000 | 21.68 (20.61, 22.79) | 21.68 (20.58, 22.82) | 21.75 (19.41, 24.28) | < 0.001 |
| $20,001-$40,000 | 17.53 (16.55, 18.56) | 17.38 (16.38, 18.43) | 23.39 (20.95, 26.02) | |
| $40,001-$85,000d | 20.93 (19.91, 22.00) | 20.79 (19.73, 21.88) | 26.62 (24.11, 29.29) | |
| ≥ $,85,001e | 39.86 (38.63, 41.09) | 40.16 (39.90, 41.42) | 28.25 (25.71, 30.93) | |
| Race | ||||
| White | 70.81 (69.69, 71.90) | 70.88 (69.74, 72.00) | 67.87 (66.4, 69.31) | < 0.001 |
| Black | 12.49 (11.69, 13.32) | 12.76 (11.94, 13.61) | 2.06 (1.33, 3.17) | |
| American Indian/Alaskan Native | 1.21 (1.08, 1.37) | 1.24 (1.10, 1.39) | 0.40 (0.16, 1.01) | |
| Otherf | 15.49 (14.64, 16.39) | 15.13 (14.25, 16.05) | 29.67 (28.53, 30.83) | |
| Ethnicity | ||||
| Hispanic | 20.25 (19.31, 21.22) | 20.69 (19.73, 21.68) | 3.39 (2.46, 4.65) | < 0.001 |
| Non-Hispanic | 79.75 (78.78, 80.69) | 79.31 (78.32, 80.27) | 96.61 (95.35, 97.54) | |
| Education | ||||
| High school diploma or GED | 35.08 (33.84, 36.35) | 35.08 (33.80, 36.37) | 35.21 (32.39, 38.15) | < 0.001 |
| Some college | 24.62 (23.55, 25.73) | 24.46 (23.36, 25.60) | 30.77 (28.17, 33.5) | |
| Bachelors degree | 22.40 (21.4, 23.44) | 22.43 (21.4, 23.49) | 21.49 (19.23, 23.94) | |
| Masters, doctoral, or professional degree | 17.89 (16.96, 18.86) | 18.03 (17.08, 19.02) | 12.52 (10.75, 14.54) | |
| WIC participation | ||||
| Yes | 31.57 (30.34, 32.83) | 31.59 (30.33, 32.88) | 30.63 (27.94, 33.45) | 0.536 |
| No | 68.43 (67.17, 69.66) | 68.41 (67.12, 69.67) | 69.37 (66.55, 72.06) | |
| Prenatal care payerg | ||||
| Medicaid | 36.89 (35.63, 38.17) | 36.82 (35.54, 38.13) | 39.43 (36.60, 42.33) | 0.103 |
| Privateh | 55.37 (54.09, 56.64) | 55.52 (54.21, 56.82) | 49.53 (46.61, 52.46) | < 0.001 |
| Self-payi | 3.67 (3.26, 4.14) | 3.77 (3.34, 4.24) | 0.12 (2.9e−04, 0.46) | < 0.001 |
| Governmentj | 1.84 (1.51, 2.25) | 1.72 (1.38, 2.14) | 6.77 (5.51, 8.29) | < 0.001 |
| 1st trimester prenatal care | ||||
| Yes | 88.63 (87.79, 89.43) | 88.59 (87.72, 89.41) | 90.28 (88.40, 91.89) | 0.102 |
| No | 11.37 (10.57, 12.21) | 11.41 (10.59, 12.28) | 9.72 (8.11, 11.6) | |
| Prenatal cigarette smokingk | ||||
| Yes | 7.24 (6.57, 7.97) | 7.12 (6.43, 7.87) | 11.82 (10.06, 13.84) | < 0.001 |
| No | 92.76 (92.03, 93.43) | 92.88 (92.13, 93.57) | 88.18 (86.16, 89.94) | |
| Parity | ||||
| Nullip | 38.53 (37.29, 39.79) | 38.51 (37.24, 39.80) | 39.21 (36.38, 42.11) | 0.081 |
| Primi | 33. 14 (31.93, 34.37) | 33.08 (31.84, 34.34) | 25.52 (32.74, 38.41) | |
| Multi | 28.33 (27.18, 29.51) | 28.41 (28.23, 29.61) | 25.27 (22.82, 27.88) | |
| Cannabis use in 3 monthsl prior to or during pregnancy | ||||
| Yes | 9.22 (8.47, 10.04) | 8.93 (8.16, 9.76) | 20.76 (18.41, 23.34) | < 0.001 |
| No | 90.78 (89.96, 91.53) | 91.07 (90.24, 91.84) | 79.24 (76.66, 81.59) | |
| Cannabis use during pregnancy | ||||
| Yes | 3.54 (3.08, 4.07) | 3.36 (2.89, 3.90) | 10.66 (8.99, 12.60) | < 0.001 |
| No | 96.46 (95.93, 96.92) | 96.64 (96.10, 97.11) | 89.34 (87.4, 91.01) | |
| Cannabis and tobacco use during pregnancy | ||||
| No | 90.54 (89.72, 91.29) | 90.77 (89.94, 91.54) | 81.55 (79.17, 83.72) | < 0.001 |
| Cannabis or tobacco | 8.12 (7.43, 8.89) | 7.97 (7.25, 8.75) | 14.39 (12.43, 16.60) | |
| Both | 1.33 (1.04, 1.69) | 1.26 (0.97, 1.64) | 4.06 (3.07, 5.35) | |
Across the entire sample, 20.53 % reported receiving cannabis advice and recommendations that was adherent to current clinical guidelines (Table 2). Of all women surveyed, almost two-thirds reported they were not advised against cannabis use during pregnancy (62.65 %, CI [61.34, 63.94]). There were statistically significant differences in clinical screening and recommendations received at prenatal care visits between women who reported cannabis use during pregnancy and those who did not report cannabis use during pregnancy (Table 2). Of women who reported cannabis use during pregnancy, only 26.06 % (CI [20.27,32.81] reported receiving advice consistent with current clinical guidelines and 10.10 % (CI [6.97,14.41] reported they were advised to use cannabis during a prenatal care visit.
| Any cannabis use during pregnancy | Recreational cannabis legal | ||||||
|---|---|---|---|---|---|---|---|
| Variable | Totalb % (CI)K | No (unweighted n = 12,943)b % (CI) | Yes (unweighted n = 784)b,c % (CI) | P valued | No (unweighted n = 12, 134)b % (CI) | Yes (unweighted n = 1593)b % (CI) | P valued |
| ACOG Adherencee | |||||||
| Non-adherent | 79.47 (78.35, 80.54) | 79.68 (78.54, 80.77) | 73.94 (67.19, 79.73) | 0.056 | 79.56 (78.42, 80.66) | 75.91 (73.24, 78.40) | 0.008 |
| Adherent | 20.53 (19.46, 21.65) | 20.32 (19.23, 21.46) | 26.06 (20.27, 32.81) | 20.44 (19.34, 21.58) | 24.09 (21.6, 26.76) | ||
| Asked about marijuana use (n = 12,552) | |||||||
| No | 37.41 (36.13, 38.70) | 38.1 (36.80, 39.42) | 19.05 (13.53, 26.14) | < 0.001 | 37.82 (36.52, 39.15) | 21.34 (18.98, 23.92) | < 0.001 |
| Yes | 62.59 (61.30, 63.87) | 61.90 (60.58, 63.20) | 80.95 (73.86, 86.47) | 62.18 (60.85, 63.48) | 78.66 (76.08, 81.02) | ||
| Recommend marijuana use (n = 12,557) | |||||||
| No | 98.51 (98.17, 98.79) | 98.84 (98.51, 99.09) | 89.90 (85.59, 93.03) | < 0.001 | 98.55 (98.2, 98.84) | 97.04 (95.84, 97.91) | < 0.001 |
| Yes | 1.49 (1.21, 1.83) | 1.16 (0.91, 1.49) | 10.10 (6.97, 14.41) | 1.45 (1.16, 1.80) | 2.96 (2.09, 4.16) | ||
| Advised not to use marijuana (n = 12,481) | |||||||
| No | 62.65 (61.34, 63.94) | 63.11 (61.78, 64.42) | 50.50 (43.26, 57.71) | < 0.001 | 62.83 (61.49, 64.15) | 55.71 (52.70, 58.67) | < 0.001 |
| Yes | 37.35 (36.06, 38.66) | 36.89 (35.58, 38.22) | 49.50 (42.29, 56.74) | 37.17 (35.85, 38.51) | 44.29 (41.33, 47.30) | ||
| Advised not to breastfeed while using marijuana (n = 12,432) | |||||||
| No | 74.38 (73.19, 75.53) | 74.93 (73.73, 76.10) | 59.74 (52.58, 66.50) | < 0.001 | 74.52 (73.30, 75.70) | 68.97 (66.10, 71.70) | < 0.001 |
| Yes | 25.62 (24.47, 26.81) | 25.07 (23.90, 26.27) | 40.26 (33.50, 47.42) | 25.48 (24.30, 26.70) | 31.03 (28.30, 33.90 | ||
Overall cannabis communication received during prenatal care visits was more adherent to ACOG guidelines in states with RCL in comparison to women residing in states without RCL (24.09 % and 20.44 % (P = 0.008), respectively).
4.Discussion
In this repeated cross-sectional analysis using PRAMS Marijuana Supplement data from 2017 to 2020, we found significant variations in cannabis-related screening and advice occurring at prenatal care visits by prenatal cannabis use and state recreational cannabis legality. For example, 26.06 % of women who reported cannabis use during pregnancy received advice consistent with current clinical guidelines. Women in states without RCL were less frequently screened for cannabis use at a prenatal care visit in comparison to women residing in states with RCL (62.18 % and 78.66 %, respectively). In contrast, women in states with RCL were more likely to report being advised against cannabis use during pregnancy (44.29 % vs. 37.17 %) and lactation (31.03 % vs. 25.5 %) during a prenatal care visi
Clinician-directed screening has been directly linked with positive perinatal health outcomes. Thus, it is critical that prenatal care clinicians are able to effectively identify risky behaviors, including cannabis use in pregnant women, educate women on the risks of cannabis use during pregnancy, and make treatment and resource referrals, as appropriate. In this study, however, only three out of every five women reported being asked about cannabis use at a prenatal care visit. As uptake of cannabis use during pregnancy is uncommon,(Skelton and Benjamin-Neelon, 2021, Skelton et al., 2020) patient-provider discussions about cannabis use should begin at the first prenatal care visit and follow national clinical guidance, which includes screening for cannabis use in early pregnancy and discouraging cannabis use in pregnant women (American College of Obstetricians and Gynecologists Comittee on Obstetric Practice, 2017, Badowski and Smith, 2020, Ryan et al., 2018). Although this study assess overall adherence to ACOG guidelines, other clinical organizations are aligned with advising against cannabis use during pregnancy and lactation (Reece-Stremtan et al., 2015, Ryan et al., 2018, Zoorob and Quinlan, 2024), given associated adverse health outcomes. Each organization has a unique set of recommendations. For example, the American Academy of Family Physicians developed a mnemonic, WEED, for addressing cannabis use during pregnancy (Zoorob and Quinlan, 2024). This includes the following: welcoming questions about cannabis use, exploring alternatives to cannabis for pregnancy-specific ailments, explaining harms of cannabis use, and delivering a harm-reduction message for those unwilling to abstain while pregnant (Zoorob and Quinlan, 2024). Nevertheless, to ensure all patients receive educational information about risks of cannabis use during pregnancy and lactation, prenatal care clinics could consider providing educational materials and resources about cannabis use during pregnancy to all patients, regardless of disclosure of cannabis use.
Prior evidence has reported that clinicians cite lack of sufficient evidence on the maternal, fetal, and neonatal health effects of perinatal and postpartum cannabis exposure (Brooks et al., 2017). Uncertainty about outcomes may lead clinicians to avoid discussing cannabis use with their patients (Brooks et al., 2017). A recent qualitative study found that many prenatal care providers were unsure how to respond to patient disclosure of cannabis use and as such, focused on punitive consequences (e.g., involvement of child protective services), ultimately failing to discuss potential adverse health effects of use (Holland et al., 2016). Another study found that when pregnant women disclosed cannabis use to their healthcare provider they did not receive counseling or information about the health risks of prenatal cannabis use (Woodruff et al., 2021). In our study, we found that of women who reported prenatal cannabis use, only 36.89 % were advised not to use while pregnant. Ultimately, the lack of patient-provider communication about cannabis use during prenatal care visits is a missed opportunity for intervention and risk reduction. Future research in this area could examine continuing clinician education on the health-related risks of cannabis use as a way to increase provider confidence and adherence to clinical guidelines. Importantly, the onus of education about risks of perinatal cannabis use should not fall on clinicians alone. Further, states with retail cannabis dispensaries should ensure allocation of cannabis sales tax revenue for targeted education for pregnant women consuming cannabis as well as tailored public health campaigns about the risks of cannabis use during pregnancy and lactation.
Indeed, prenatal cannabis use is a complex perinatal health issue, as women who use cannabis during pregnancy are more likely to experience nausea and vomiting during pregnancy (Roberson et al., 2014; Young-Wolff et al., 2019) and report having mental health issues, such as depression, stress, or anxiety (Allen et al., 2020). Unfortunately, many women do not feel comfortable disclosing cannabis use to their healthcare providers for fear of judgement and punitive consequences of disclosure, such as child protective services (CPS) involvement and potential separation from their children (Skelton et al., 2024; Woodruff et al., 2021). Nevertheless, it is imperative that women are appropriately screened and counseled about potential health risks of cannabis use during pregnancy. As a way to increase disclosure of cannabis use by pregnant women, clinicians could ask about gastrointestinal and mental health symptoms as a segue to describing treatments with known safety data for these conditions.
Future research on patient-provider cannabis communications is needed using a health equity lens, where discrepancies in patient-provider interactions are examined across patient sociodemographic characteristics (e.g., race, insurance provider, age, ethnicity) so that health inequities in screening, recommendations, and ultimately, reporting, may be addressed. Future studies should also examine screening and advice received at prenatal care visits and frequency of cannabis use during pregnancy, including when cessation occurred in response to advice, as this is not able to be examined using PRAMS data. Lastly, future studies should aim to examine the extent to which different mandatory reporting laws (i.e. notification of social worker and/or child protective services), insurance policies for reporting and testing, and hospital policies are associated with cannabis screening and patient-provider communications occurring during prenatal care visits.
4.1.Limitations
This study is one of the first to examine cannabis-related screening and advice received at prenatal care visits with a large, multi-state sample of women in the US. Nonetheless, these findings should be interpreted in the context of study limitations. First, the PRAMS data collection methods are reliant on both self-report and retrospective recall. Thus, social desirability bias likely resulted in conservative estimates in this analysis, particularly for self-reported cannabis use before and during pregnancy. Additionally, women may not have accurately reported advice received. The. PRAMS Marijuana Supplement did not ask women to report their source of information at prenatal care visits (e.g., obstetrician-gynecologist, midwife, nurse) and subsequently, we cannot make recommendations specific to perinatal clinician group(s). It is also important to note that many health systems require universal drug screening at one or more prenatal care visits; the PRAMS Marijuana Supplement does not ask questions about this method of screening. Lastly, given limitations of the PRAMS dataset, including the small number of states that opted to include questions from the Marijuana Supplement and met the CDC’s threshold for data release Marijuana Supplement, this analysis is descriptive in nature and not a nationally representative sample. Although we initially intended to look at variations in cannabis legalization exposure (i.e., medical vs. recreational), only a single state enacted medical cannabis legalization over the study period. We excluded respondents whose gestation crossed a RCL enactment date, which eliminated all cases for Virginia as they only had 2021 data. As mentioned previously, a limitation of the PRAMS dataset is the small number of states that opted to use the PRAMS Marijuana Supplement and met the CDC response rate threshold for data release. Subsequently, there was substantial variation in sociodemographic characteristics among those respondents in states with and without RCL. Notably, Hispanic respondents are under-represented in this study compared to vital statistics data, which is likely attributable to the inclusion of Alaska. As more states consider RCL, establishing baseline trends in cannabis use, especially among pregnant and postpartum women, alongside other important perinatal outcomes is imperative.
5.Conclusions
This study provides new evidence about cannabis screening and advice occurring during prenatal care visits and in turn, has important implications for future patient-clinician communications We found significant differences between reported cannabis screening and advice for prenatal cannabis use occurring at prenatal care visits across women residing in states with and without RCL as well as by prenatal cannabis use status. Our findings underscore the necessity of prenatal care clinicians as vital partners in screening for and addressing cannabis use before, during, and after pregnancy through non-punitive education about the health risks associated with cannabis use. Given the absence of safety data on prenatal cannabis use, clinicians should follow national guidance from prenatal and pediatric health organizations, which include screening for cannabis use in early pregnancy, discouraging cannabis use in pregnant women, and advising against cannabis use while breastfeeding.
Financial disclosure
The authors have no financial relationships relevant to this article to disclose.
Funding
The Health Resources and Services Administration (HRSA), Department of Health and Human Services (HHS) provided financial support for this study. The award provided 100 % of total costs and totaled $118,943.00. The contents are those of the author. They may not reflect the policies of HRSA, HHS, or the U.S. Government.
Declaration of Competing Interest
The authors declare there are no conflicts of interest to report, financial or otherwise.
Acknowledgments
We thank the PRAMS Working Group, which includes the PRAMS Team, Division of Reproductive Health, CDC and the following PRAMS sites for their role in conducting PRAMS surveillance and allowing the use of their data: PRAMS Alaska, PRAMS Illinois, PRAMS Maine, PRAMS North Dakota, PRAMS New Jersey, PRAMS New Mexico, PRAMS New York, PRAMS Pennsylvania, and PRAMS West Virginia.
References
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