Patient Perceptions of Prenatal Cannabis Use and Implications for Clinicians

Pregnant and Recently Pregnant People's Views on Policies That Punish Pregnant People Who Use Cannabis

OBJECTIVE

To explore recently/currently pregnant people's experiences and views about cannabis use during pregnancy and their associated support for policies that punish pregnant people who use cannabis.

METHODS

A market research firm administered a survey (May-June 2022) to pregnant and recently pregnant people ages 18-49 regarding their attitudes about cannabis use policies and practices. We used multivariable regression to assess whether cannabis use and beliefs are associated with support for punishing people who use cannabis.

RESULTS

3,571 people initiated the survey, 3,569 completed support for punishment items. More participants (32%) agreed that cannabis use should be illegal for pregnant people than for everyone (17%); 30% agreed that using cannabis during pregnancy is child abuse; most agreed that pregnant people should be able to talk with their doctor about cannabis use without worrying about getting in trouble (72%) and that doctors and nurses should get consent from the pregnant person before testing their urine for cannabis (52%), although uncertainty was high (22%-39%) across items. Cannabis use pre-pregnancy (-0.39, 95% CI, -0.46, -0.32) and during pregnancy (-0.42, 95% CI, -0.49, -0.35) was associated with less support for punishment. Agreeing that use during pregnancy is safe for the baby (-0.47, 95% CI, -0.58, -0.36) and that people who use cannabis during pregnancy can be great parents (-0.55, 95% CI -0.63, -0.46) were associated with less support for punishment.

CONCLUSIONS

While recently/currently pregnant people's perspectives about cannabis use during pregnancy were complex and varied by policy, most supported policies and practices that protect the patient-provider relationship.

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

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

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.

Prenatal Cannabis Use and Maternal Pregnancy Outcomes

Importance

Many studies have evaluated whether in utero cannabis exposure is associated with fetal and neonatal outcomes, yet little is known about whether prenatal cannabis use is associated with maternal health outcomes during pregnancy.

Objective

To evaluate whether prenatal cannabis use is associated with maternal health outcomes during pregnancy.

Design, Setting, and Participants

This population-based retrospective cohort study included pregnancies in Northern California from January 2011 to December 2019 that lasted 20 weeks or longer and were screened for prenatal cannabis use.

Exposures

Prenatal cannabis use was defined as any self-reported use during early pregnancy or a positive toxicology test result based on universal screening at entrance to prenatal care (approximately 8-10 weeks' gestation). Self-reported frequency of use (daily, weekly, monthly or less, never, unknown), use defined only by self-report, and use defined only by toxicology test results were examined.

Main Outcomes and Measures

Electronic health record data were used to define the following outcomes: gestational hypertension, preeclampsia, eclampsia, gestational diabetes, gestational weight gain greater and less than guidelines, placenta previa, placental abruption, placenta accreta, and severe maternal morbidity. Adjusted risk ratios (aRRs) were calculated using a modified Poisson regression.

Results

The sample (n = 316 722 pregnancies; 250 221 unique individuals) included 84 039 (26.5%) Asian/Pacific Islander, 20 053 (6.3%) Black, 83 145 (26.3%) Hispanic, and 118 333 (37.4%) White individuals; the mean (SD) age was 30.6 (5.4) years. Overall, 20 053 (6.3%) screened positive for prenatal cannabis use; 2.9% were positive by self-report, 5.3% by toxicology testing, and 1.8% by both. The frequency of cannabis use was 1930 (0.6%) daily, 2345 (0.7%) weekly, 4892 (1.5%) monthly or less, and 10 886 (3.4%) unknown. Prenatal cannabis use was associated with greater risk of gestational hypertension (aRR, 1.17; 95% CI, 1.13-1.21), preeclampsia (aRR, 1.08; 95% CI, 1.01-1.15), weight gain less than (aRR, 1.05; 95% CI, 1.01-1.08) and greater than (aRR, 1.09; 95% CI, 1.08-1.10) guidelines, and placental abruption (aRR, 1.19; 95% CI, 1.05-1.36). The pattern of results was similar when defining prenatal cannabis use only by self-report or only by toxicology testing, and associations between the frequency of prenatal cannabis use and outcomes varied with outcome.

Conclusions and Relevance

The results of this cohort study suggest that prenatal cannabis use was associated with several adverse maternal health outcomes during pregnancy. Continued research is needed to understand whether characteristics of prenatal cannabis use (eg, dose, mode, and timing) moderate these associations.

Perinatal Tetrahydrocannabinol Compromises Maternal Care and Increases Litter Attrition in the Long-Evans Rat

The marijuana legalization trend in the U.S. will likely lead to increased use by younger adults during gestation and postpartum. The current study examined the hypothesis that delta-9-tetrahydrocannabinol (THC) would disrupt voluntary maternal care behaviors and negatively impact offspring development. Rat dams were gavaged with 0, 2, 5, or 10 mg/kg THC from the 1st day of gestation through the 21st postnatal day. Somatic growth and developmental milestones were measured in the offspring, and maternal pup retrieval tests were conducted on postnatal days 1, 3, and 5. THC did not affect body growth but produced transient delays in the righting reflex and eye opening in offspring. However, there was significant pup mortality due to impaired maternal care. Dams in all THC groups took significantly longer to retrieve their pups to the nest and often failed to retrieve any pups. Serum levels of THC and metabolites measured at this time were comparable to those in breastfeeding women who are chronic users. Benchmark doses associated with a 10% reduction of pup retrieval or increased pup mortality were 0.383 (BMDL 0.228) and 0.794 (BMDL 0.442) mg/kg THC, respectively. The current findings indicate that maternal care is an important and heretofore overlooked index of THC behavioral toxicity and should be included in future assessments of THC's health risks.

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.

Prenatal delta-9-tetrahydrocannabinol exposure alters fetal neurodevelopment in rhesus macaques

Prenatal cannabis use is associated with adverse offspring neurodevelopmental outcomes, however the underlying mechanisms are relatively unknown. We sought to determine the impact of chronic delta-9-tetrahydrocannabinol (THC) exposure on fetal neurodevelopment in a rhesus macaque model using advanced imaging combined with molecular and tissue studies. Animals were divided into two groups, control (n = 5) and THC-exposed (n = 5), which received a daily THC edible pre-conception and throughout pregnancy. Fetal T2-weighted MRI was performed at gestational days 85 (G85), G110, G135 and G155 to assess volumetric brain development. At G155, animals underwent cesarean delivery with collection of fetal cerebrospinal fluid (CSF) for microRNA (miRNA) studies and fetal tissue for histologic analysis. THC exposure was associated with significant age by sex interactions in brain growth, and differences in fetal brain histology suggestive of brain dysregulation. Two extracellular vesicle associated-miRNAs were identified in THC-exposed fetal CSF; pathway analysis suggests that these miRNAs are associated with dysregulated axonal guidance and netrin signaling. This data is indicative of subtle molecular changes consistent with the observed histological data, suggesting a potential role for fetal miRNA regulation by THC. Further studies are needed to determine whether these adverse findings correlate with long-term offspring neurodevelopmental health.