Through a mixed-methods approach, we explored the perspective of mental health clinicians who work with patients who use cannabis during pregnancy. Survey results demonstrated that ESS perceive patients’ diverse motivations for use and rely primarily on peers for information. Qualitative themes highlighted that ESS leverage expertise in complementary areas and intentionally plan initial clinical encounters to introduce, assess, and intervene around prenatal cannabis use. ESS also emphasize that psychotherapeutic factors (therapeutic rapport, patient readiness, and mental health) contribute to patient engagement. Both qualitative and survey results indicated that ESS find patient-centered interventions such as MI, harm reduction, and psychoeducation to be the most helpful in addressing cannabis use with patients.

For therapeutic factors, such as rapport and patient readiness, the perspectives of ESS clinicians are consistent with current literature on psychotherapy factors in substance use treatment (Flora, 2013, Meier et al., 2005) and complement the experiences of patients who use cannabis during pregnancy. Focus groups with pregnant patients engaging in cannabis use demonstrate that the clinician approach, including rapport and a nonjudgmental stance, plays a role in patients willingness to discuss their use with their clinician (Foti et al., 2023). Our study found that clinicians use patients’ motivations and needs to better understand the context of their cannabis use, which felt more personal and helpful compared to a more general recommendation. This strategy appeared consistent with both rapport-building and acknowledging patients’ anecdotal experiences with cannabis use. Other settings might consider prioritizing rapport-building alongside standardized assessments and psychoeducation. Many physicians are likely aware of interventions such as MI and harm reduction to explore a patient’s readiness to not use cannabis (Groff et al., 2023). Training in and incorporating MI and harm reduction strategies throughout prenatal care and across disciplines might further facilitate behavior change. Relatedly, clinicians highlighted how harm reduction interventions complemented the ES program’s patient-centered approach. Pregnancy offered a unique opportunity to change cannabis use. ESS worked with patients to consider harm reduction strategies they had never considered before, such as delaying use or replacing use with other activities. Other clinicians might leverage and highlight pregnancy as an opportunity for patients to change their cannabis use, particularly for those who may not have considered making a change previously.

Prior qualitative work with pregnant patients also indicates patients’ motives to self-medicate with cannabis to relieve pregnancy symptoms, particularly nausea, appetite, and stress (Chang et al., 2019, Foti et al., 2023); other quantitative studies show that pregnant patients with nausea and vomiting, depression and anxiety, have elevated rates of prenatal cannabis use (Young-Wolff et al., 2018, Young-Wolff et al., 2020). Our results similarly found ESS recognize patients’ diverse motives for use and are intentional about introducing strategies (e.g., psychoeducation, wellness, sleep hygiene, stress management) that offer patients alternative ways to manage their symptoms without cannabis. The ES program uniquely creates a structure to address prenatal substance use and mental health as a routine part of prenatal care. Other systems may consider how creating similar organizational structures could support clinicians who work with patients using cannabis during pregnancy. Such efforts may also foster a multidisciplinary perspective to treating pregnancy symptoms and facilitating referrals for additional support during pregnancy. Recruiting clinicians with diverse training and providing access to interventions (e.g., sleep, stress management, mental health), in addition to substance use interventions, could engage patients who might be otherwise reluctant to directly address their cannabis use during pregnancy.

Our results are consistent with prior research that suggests pregnant individuals who use cannabis rely on experiences of friends and family to learn about cannabis and desire clear and evidence-based information (Jarlenski et al., 2016, Macario and Thomas, 2022, Taneja et al., 2022). Similarly, ESS reported encounters with patients who turned to peers for information and to navigate potential gaps in knowledge about cannabis’ effects. This finding suggests peer-to-peer support and/or interventions might appeal to many pregnant patients. Additionally, clinicians might consider that patients may weigh peers' opinions over clinical recommendations. Clinicians may not always discuss cannabis use with pregnant patients, even when patients disclose use, focus on the legal consequences instead of the health effects (Holland et al., 2016, Woodruff et al., 2021). Further research is warranted to examine how clinicians may be perceived as more accessible and trusted resources for health information about cannabis use during pregnancy, bolstered with patient-centered interventions.

The present findings must be considered in light of study limitations. The sample was limited to a small group of mental health clinicians working in a specialized prenatal substance use screening and intervention program embedded within prenatal care at KPNC. The perspectives of these clinicians may not generalize to those who work with pregnant patients outside of KPNC or in other settings (e.g., specialty addiction treatment). Importantly, while KPNC encompasses a diverse patient population, the sample of clinicians in our study was primarily female, White, and middle-aged. This has important implications for how clinicians may be navigating conversations around cannabis use, and the willingness of patients to engage openly with a provider. Furthermore, results may be limited in generalizability to providers of other backgrounds. Nevertheless, study participants had extensive expertise working with patients who use cannabis during pregnancy and offered critical clinical insights. Study participants were also providing clinical services within a state that has legalized cannabis use. Experiences of clinicians who work with pregnant patients in states with different cannabis policies may differ, particularly those with stricter reporting guidelines for Child Protective Services (CPS) than California. Even in states where cannabis is legal, concerns about CPS reporting in the context of prenatal cannabis use remain, particularly for low-income and minoritized individuals (Ceasar et al., 2023). Yet, focus groups on cannabis legalization do demonstrate that patients are more open to having conversations about their prenatal cannabis use with their clinicians after legalization (Young-Wolff et al., 2022).