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Published in final edited form as: Addict Behav. 2019 Aug 7;99:106082. doi: 10.1016/j.addbeh.2019.106082

Cannabis Use Among Women of Reproductive Age in the United States: 2002–2017

Omayma Alshaarawy a, James C Anthony b
PMCID: PMC6791768  NIHMSID: NIHMS1537512  PMID: 31421581

Abstract

Background:

In this study of cannabis use in large nationally representative samples of United States (US) women aged 12–44 years, we evaluate variation by pregnancy month and by trimester. We also evaluate cannabis dependence, which might explain why some women continue using cannabis during pregnancy.

Methods:

Large nationally representative samples drawn for the US National Surveys on Drug Use and Health included 12–44-year-old women asked about pregnancy month, cannabis use, and cannabis dependence (n = 381,199). For this research, we produced month-specific estimates across four-time intervals (2002–2005, 2006–2009, 2010–2013, 2014–2017).

Results:

Overall from 2002–2017, estimates for non-pregnant women and for pregnant women in Trimester 1 indicate 7%−8% had used cannabis at least once in the 30 days prior to assessment. For pregnancy Month 1, the corresponding estimate is 11%, double Month 3 estimate of 5%. This degree of month-to-month variation is not seen for pregnant women in Trimesters 2 and 3, for whom estimates are 3% and 2%, respectively. Among women using cannabis during pregnancy, an estimated 19% have cannabis dependence, versus an expected value of 13% among non-pregnant women (p<0.05).

Conclusion:

Evidence of a possibly ameliorative pregnancy-associated reduction of cannabis use prevalence was seen by Month 3 during pregnancy. Cannabis dependence may help account for cannabis use early during pregnancy. Identification and outreach to reproductive age women with cannabis dependence might decrease prenatal cannabis exposure.

Keywords: Cannabis, Marijuana, Dependence, Pregnancy, Women, NSDUH

1. Introduction

Recent United States (US) cannabis use prevalence estimates show modest increases over time (Alshaarawy & Anthony, 2017; Anthony, Lopez-Quintero, & Alshaarawy, 2016). This increase has raised concerns regarding cannabis effects on health, including pregnancy outcomes (Metz et al., 2017). Previous studies have shown an increase in cannabis use prevalence among US women of reproductive age from 2002 to 2014 (Brown et al., 2017). Studying pregnant women only, Agrawal et al. have reported an increase in cannabis use estimates from 2002 to 2016 (Agrawal et al., 2018). Most recently, Volkow et al. have reported higher cannabis use estimates for the first trimester of pregnancy compared to the later trimesters (Volkow, Han, Compton, & McCance-Katz, 2019).

There is a large body of evidence on effects of prenatal exposure to maternal tobacco cigarette smoking and alcohol drinking (Bhuvaneswar, Chang, Epstein, & Stern, 2007; Pereira, Da Mata, Figueiredo, de Andrade, & Pereira, 2017). Studies on cannabis use and pregnancy outcomes are much less frequent (El Marroun et al. 2018). Pre-clinical studies confirm that the highly lipophilic delta 9-tetrahydrocannabinol (THC), the main active constituent in cannabis, can cross the placental barrier (Fride et al., 2009; Hutchings, Martin, Gamagaris, Miller, & Fico, 1989). Functional cannabinoid receptors have been detected at gestational week 14 in the human embryo (Biegon & Kerman, 2001) with potential THC-mediated neuronal effects in the developing fetus (Tortoriello et al., 2014). Suggested associations link prenatal cannabis use with various reproductive outcomes including low birth weight, stillbirth, and neurocognitive-behavioral problems (Leemaqz et al., 2016).

Study of cannabis prenatal effects can be challenging because of uncertainties about accuracy of self-reports, varying routes of administration, uncertain doses and cannabinoid ratios, and concurrent use of tobacco, alcohol, or other drugs, as well as shared or co-varying psychosocial determinants of adverse pregnancy outcomes (Campolongo, Trezza, Ratano, Palmery, & Cuomo, 2011). Also, the timing of cannabis use relative to weeks from conception and stage of prenatal development might influence pregnancy and neonatal outcomes (Schneider, 2009).

With this background in mind, we were motivated to contribute new US epidemiological estimates on cannabis use before and during pregnancy, with a refined temporal look at month of pregnancy, as can be observed in cross-sectional samples of pregnant women. Several crucial organs develop within the first few weeks of gestation (Moore, Persaud & Torchia, 2018). Recent data suggest that 45% of the pregnancies in the US were unintended (Finer & Zolna, 2016). If detrimental maternal exposures coincide with critical periods of organogenesis, they can increase developmental risks (Holbrook & Rayburn, 2014). This more refined approach complements a more frequently used trimester-by-trimester approach.

The study estimates are from recent US nationally representative sample surveys of women, with standardized assessments of recently active cannabis use and cannabis dependence among non-pregnant women of reproductive age, and among pregnant women stratified by trimester/month of pregnancy. A positive association between cannabis dependence and cannabis use persistence has been reported in previous studies (Kosty, Seeley, Farmer, Stevens & Lewinsohn, 2017). Here we hypothesize that cannabis dependence might act as reinforcer and explain why pregnant women do not stop using cannabis even when they know they are pregnant.

2. Methods

For this research, the population under study was specified to be non-institutionalized civilian residents of the US, with multi-stage area probability samples drawn annually for the US National Surveys on Drug Use and Health (NSDUH), 2002–2017. The survey over-sampled specific subgroups, and analysis weights take into account the over-sampling as well as post-stratification adjustments for non-response. Participation levels for NSDUH 2002–2017 were ~70% (United States, 2014). The institutional review board at Michigan State University ruled that this study did not constitute human subjects research since it involves analyses of de-identified data.

After sampling, participants were recruited and assessed cross-sectionally. The assessments were from an Audio Computer Assisted Self Interview system (ACASI). ACASI modules assessed age, race/ethnicity, and pregnancy status of women 12–44 years of age. All self-identified pregnant women have been asked about the month of pregnancy.

In an ACASI module administered before the pregnancy items, participants were asked about cannabis use. Recently active cannabis use was defined as using cannabis in the 30 days prior to NSDUH interview. In NSDUH, assessments for cannabis dependence map closely to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria (American Psychiatric Association, 1994; DSM-IV). Respondents who used cannabis on 6 or more days in the 12 months prior to the interview were categorized as having cannabis dependence if they reported a positive response to three or more of the following six dependence criteria: 1) Spent a great deal of time over a period of a month getting, using, or getting over the effects of the substance, 2) Unable to keep set limits on substance use or used more often than intended, 3) Needed to use substance more than before to get desired effects or noticed that using the same amount had less effect, 4) Unable to cut down or stop using the substance every time he or she tried or wanted to, 5) Continued to use substance even though it was causing problems with emotions, nerves, mental health, or physical problems, and 6) Reduced or gave up participation in important activities due to substance use.

For the present investigation and for a fine-grained month-by-month look at cannabis use during pregnancy, the study’s estimation steps involved use of the NSDUH Restricted-use Data Analysis System (R-DAS, https://rdas.samhsa.gov/#/). These estimates are for analysis-weighted prevalence percentages, with Taylor series linearization used to derive 95% confidence (Vsevolozhskaya & Anthony, 2014). To thwart re-identification of participants, the NSDUH public use data files do not include variables on pregnancy month. Logistic regression modelling was conducted as a sensitivity analysis using the downloadable NSDUH public use data files which contain information on pregnancy status and trimester of pregnancy. First, past 30-day cannabis use was regressed on NSDUH year indicator to estimate the odds ratios of cannabis use for each NSDUH year stratified by pregnancy status and pregnancy trimester. We then used logistic regression modelling to estimate the association of cannabis dependence and pregnancy status among past 30-day cannabis users. Estimates were additionally adjusted for age subgroups (12–17, 18–25, and 26–44 years), race/ethnicity (non-Hispanic White, non-Hispanic Black, Hispanic, all others), education (less than high school, high school and above high school) and family income ($0–$19 999, $20 000–$49 999, $50 000–$74 999, ≥$75 000).

3. Results

The majority of the study sample were non-Hispanic Whites. There were no significant race/ethnicity differences between pregnant and non-pregnant women. Pregnant women were younger and more likely to have more than high school education compared to non-pregnant women (data are not shown in table/figure). Aggregation of samples across 2002–2017 indicates that one-in-12-to-13 non-pregnant women of reproductive age used cannabis during the 30 days prior to assessment (7.9%; 95% CI = 7.8, 8.1). Among pregnant women, the aggregate 2002–2017 estimate is just 4.0% (Figure 1).

Figure 1:

Figure 1:

Open in a new tab

Estimated prevalence of past 30-day cannabis use among women aged 12–44 years stratified by pregnancy status and by trimester of pregnancy. Data for the United States based on the R-DAS online analysis system of the National Surveys of Drug Use and Health, 2002–2017.

Estimates in red are from pooled analysis of the 2002–2017 aggregate data.

Estimates for recently active cannabis use show a trend of increased prevalence for non-pregnant and pregnant women of reproductive age in the US (Figure 1). Stratified by pregnancy trimester, past 30-day cannabis use prevalence has increased among women in Trimester 1 but not in Trimesters 2 and 3 (Figure 1). For pregnant women in Trimester 1, the 2002–2005 estimate is 5.6% (95% CI = 4.3, 7.1) compared to 8.1 % (95% CI = 6.4, 10.2) in 2014–2017. For pregnant women in Trimester 2, the 2002–2005 estimate is 2.7 % (95% CI = 1.8, 4.1) compared to 3.2% (95% CI = 2.3, 4.4) in 2014–2017. Similarly, cannabis use prevalence estimates show a relatively stable trend for pregnant women in Trimester 3.

To investigate in more detail, we turned to the NSDUH downloadable public use data files and regressed the log odds of cannabis use on an indicator variable for NSDUH year. The resulting estimates suggest that among pregnant women, the increase was evident in the first trimester, but not in the other trimesters (Supplemental Table 1).

From 2002–2017, one of every 10 pregnant women in Month 1 had used cannabis in the 30 days before the date of assessment (Figure 2). There is a noteworthy variation in the estimated prevalence of cannabis use across the three months of the first trimester. The estimated prevalence of cannabis use for Month 1 (10.7%) is twice the the estimate for Month 3 (4.6%, with p < 0.05), but there is no similar variation seen in the month-wise estimates for Trimesters 2 and 3. Of note is that one of every 50 pregnant women seen in the final month of pregnancy used cannabis in the 30 days prior to NSDUH interview.

Figure 2:

Figure 2:

Open in a new tab

Estimated prevalence of past 30-day cannabis use among women aged 12–44 years stratified by month of pregnancy status. Data for the United States based on the R-DAS online analysis system of the National Surveys of Drug Use and Health, 2002–2017.

Estimates in red are from pooled analysis of the 2002–2017 aggregate data.

Figure 3 displays cannabis dependence stratified by pregnancy status. A tangibly larger cannabis dependence estimate is seen for cannabis-using pregnant women (19.2%; 95% CI = 15.5, 23.6) compared to cannabis-using non-pregnant women (12.7%; 95% CI = 12.3%, 13.2%). Trimester-specific estimates (Figure 3) and month-specific estimates (Figure 4) indicate no substantial variation in cannabis dependence prevalence across these subgroups of cannabis-using pregnant women.

Figure 3:

Figure 3:

Open in a new tab

Estimated prevalence of cannabis dependence among past 30-day cannabis-using women aged 12–44 years stratified by pregnancy status and by trimester of pregnancy. Data for the United States based on the R-DAS online analysis system of the National Surveys of Drug Use and Health, 2002–2017.

All of these estimates are from pooled analysis of the 2002–2017 aggregate data.

Figure 4:

Figure 4:

Open in a new tab

Estimated prevalence of cannabis dependence among past 30-day cannabis-using pregnant women (12–44 years) stratified by the month of pregnancy. Data for the United States based on the R-DAS online analysis system of the National Surveys of Drug Use and Health, 2002–2017.

All of these estimates are from pooled analysis of the 2002–2017 aggregate data.

Consistent with estimates in Figure 3, the odds of cannabis dependence were modestly larger for cannabis-using pregnant women versus cannabis-using non-pregnant women (Multivariable-adjusted odds ratio = 1.37, 95% CI = 1.07, 1.77, Supplemental table 2). The odds of cannabis dependence were higher among women in the first and second trimester, compared to non-pregnant women. However, adjusting for covariates attenuated the association towards the null.

4. Discussion

In this study of non-pregnant and pregnant women who participated in recent nationally representative sample surveys in the US, past 30-day cannabis use prevalence has increased overtime. Among pregnant women, this increase was evident in the first trimester and the first month of pregnancy. We also found evidence of considerable variability in the estimated prevalence of recent cannabis use across the months of the first trimester of pregnancy when fetuses might be most susceptible to damage from drugs (Volkow, Compton, & Wargo, 2017). A potentially ameliorative pregnancy-associated reduction of cannabis use was observed in Month 3 of pregnancy. Pregnancy might be a motivation to cannabis use cessation, and pregnant women quit using once they found out they are pregnant. Most women in the US recognize their pregnancy and initiate prenatal care by the twelfth gestational week (Ayoola, Nettleman, Stommel, & Canady, 2010). However, this reduction can be also attributed to other factors such as the unwillingness to acknowledge cannabis use once a woman’s pregnancy status becomes apparent even with the use of confidential self-interviewing systems. We also found larger odds of cannabis dependence among cannabis-using pregnant women in a comparison with the corresponding odds for cannabis-using non-pregnant women. One possible interpretation is that the presence or a recent history of cannabis dependence helps explain why some pregnant women use cannabis while pregnant.

Consistent with prior studies, this study’s estimates indicate that cannabis use prevalence has increased among pregnant and non-pregnant women of reproductive age (Brown et al., 2017, Agrawal et al., 2018). Month-specific estimates presented in Fig. 2 show relative stability of the over-time estimates for Months 2–3, which leads to an inference that the Trimester 1 increase involves Month 1 of the pregnancy. This evidence might be indicative of the general increasing trend for non-pregnant women. We note that more than 40% of US pregnancies are unplanned (Finer & Zolna, 2016). Any first trimester effect (or putative Month 1 effect) might be due to women using cannabis before they realize they are pregnant.

Historically, cannabis has been mentioned in the herbal medicine pharmacopeia and folklore for its potential utility when nausea occurs during early pregnancy (Dickson et al, 2018). There is some evidence that pregnant women with severe nausea during pregnancy are more likely to use cannabis (Roberson, Patrick, & Hurwitz, 2014; Westfall, Janssen, Lucas, & Capler, 2006, Young-Wolff et al., 2019). In the current study, we did not observe an increase in cannabis use estimates in the months when pregnancy nausea peaks. Although medical cannabis is approved for the treatment of nausea and vomiting in some states, Volkow et al. have found that clinician-recommended cannabis use was low among pregnant women (Volkow, Han, Compton, & McCance-Katz, 2019).

Several limitations of the study merit attention. Of note is reliance on self-report measures with no toxicological assays. Self-reports might lead to misclassification errors, including differential misclassification such that pregnant women might be less likely to disclose cannabis use. We suspect that this measurement error is constrained in the NSDUH and in other computer-assisted self-interview population surveys, as compared with interviewer-administered surveys, or in contexts such as prenatal clinic assessment. Nevertheless, we acknowledge this potential limitation, even when an ACASI approach is used (Buchan, Tims, & Diamond, 2002).

Another limitation involves the cross-sectional nature of the NSDUH design. A future prospective design can be used to increase study rigor and to reduce uncertainty about the hypothesized influence of cannabis dependence on continued cannabis use after pregnancy onset is known. In addition, the prevalence of cannabis dependence was assessed in the 12 months prior to NSDUH interview. Therefore, we cannot ascertain whether pregnant women had cannabis dependence during or before pregnancy.

Counterbalanced with limitations of this type are some important strengths, which include multiple nationally representative samples with standardized assessment protocols for recently active cannabis use as well as cannabis dependence. In addition, the NSDUH approach identified women month by month during pregnancy, with cannabis use recall over the span of no more than 30 days. That is, there was no requirement for long-term recall, as has been more typical in retrospective reports over the entire span of pregnancy, or across pregnancy trimesters, often with measurements taken at or soon after the birthdate or during pre-natal care visits. The NSDUH module on cannabis and other drug use precedes the module of items on pregnancy. We speculate that cannabis under-reporting might be a larger problem in studies with reversal of that sequence.

Consistent with prior studies, cannabis use has increased among women of reproductive age. Among pregnant women, the increase in cannabis use prevalence was observed as early as Month 1 of pregnancy. Studies investigating the effects of prenatal cannabis use might need to account for the month of cannabis use during pregnancy as we observed considerable variations across Months 1–3 that cannot be seen when the customary trimester approach is used. The Month 1–3 estimates may be of special interest as pre-clinical studies identified the expression of cannabinoid-1 receptors in the developing brain as early as Months 1–2 interval (Fernandez-Ruiz, Berrendero, Hernandez, & Ramos, 2000).

In addition, the odds of cannabis dependence were higher among cannabis-using pregnant women compared to cannabis-using non-pregnant women. There were no variations by the trimester or month of pregnancy. These findings indicate the importance of cannabis dependence screening among women of reproductive age during general health services to provide the appropriate counseling and referral. The Substance Abuse and Mental Health Services administration also offers a confidential and anonymous source of information for persons seeking treatment facilities in the US. Prior data, however, indicate that substance-using reproductive-age women were less likely to receive treatment (Terplan, McNamara, & Chisolm, 2012), attributable to social stigma, economic disadvantages or fear of legal liability (Stone, 2015). Research is needed to overcome challenges to treatment access among women of reproductive age.

Supplementary Material

1

Highlights.

  • Cannabis use has increased among non-pregnant and pregnant women early in their pregnancy.

  • Considerable variations are seen in cannabis use estimates across the months of Trimester 1 but not in Trimesters 2 and 3.

  • A cannabis dependence syndrome may help account for cannabis use during pregnancy.

Acknowledgments

Role of Funding Sources

The current work has been funded by the NIH/NCCIH R00AT009156 to (OA) and NIH/NIDA K05DA015799 (JCA) and by Michigan State University. The funding body had no role in the design of the study, collection and analysis of data or the decision to publish. The content is the sole responsibility of the authors and does not represent the official views of Michigan State University, or the National Institutes of Health.

Footnotes

Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

Declarations of interest: none

Conflict of Interest

Both authors declare that they have no conflicts of interest.

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