Intentions to Use Cannabis Postpartum: A Qualitative Study of Pregnant Individuals Who Used Cannabis During Early Pregnancy

Abstract

Objective:

To examine plans for postpartum cannabis use among pregnant individuals who used cannabis during early pregnancy.

Materials and Methods:

Eighteen virtual focus groups were conducted from November 17, 2021, to December 17, 2021, with 23 Black and 30 White pregnant adults in Kaiser Permanente Northern California, who self-reported prenatal cannabis use during early pregnancy. Focus groups were recorded, transcribed, and analyzed using thematic analysis.

Results:

The sample (N = 53) had a mean age of 30.3 years (standard deviation = 5.2) at recruitment; 70% reported daily, 25% weekly, and 6% ≤ monthly cannabis use at entrance to prenatal care. Some participants viewed cannabis as critical for coping with postpartum mental and physical health challenges, while others questioned whether cannabis use would fit with their parental lifestyle, and some planned to abstain altogether. Most planned to use cannabis postpartum, but with lower frequency than before pregnancy, and in ways consistent with harm reduction (e.g., smoking outside to avoid secondhand or thirdhand smoke exposure). Many were motivated to abstain from cannabis while breastfeeding, and some desired more data on the safety of cannabis and breastfeeding, or intended to “pump and dump,” believing it would reduce potential transfer of Δ⁹-tetrahydrocannabinol (THC) to their infant. Responses from Black and White participants were generally similar, but White participants were more likely to report plans to use cannabis while breastfeeding and to want information about cannabis and breastfeeding.

Conclusions:

Pregnant individuals with prenatal cannabis use had varied plans for cannabis use postpartum. Many were motivated to abstain or use cannabis less frequently than pre-pregnancy, especially during lactation.

Introduction

Cannabis use during pregnancy is a growing public health issue. Rates and frequency of prenatal cannabis use have risen in recent years,^1,2 despite growing evidence of potential harm for mothers and their children exposed to cannabis in utero.^3–8 Studies suggest that some individuals who use cannabis during pregnancy perceive it to be a relatively safe and effective way to manage mental and physical symptoms, such as depression, stress, sleep problems, pain, and morning sickness.^9–11 Prenatal cannabis use is most common during the first trimester of pregnancy, and many pregnant individuals quit or decrease their use during their second and third trimesters.^12,13

Cannabis use during the postpartum period has been less well studied. Pregnant individuals often resume cannabis use after giving birth,^14–17 but little is known about factors that impact the decision to use cannabis during the postpartum period.^18,19 Initial research suggests that postpartum individuals report using cannabis for the same reasons they used before pregnancy, including for fun or to get high, for symptom management (e.g., depression, anxiety, chronic pain), and to cope with postpartum depression or the stress of having an infant.^20,21

Breastfeeding may also play a central role in individuals' decision-making around cannabis use postpartum. Studies indicate that some individuals abstain from cannabis during breastfeeding or express and discard milk (“pump and dump”) in an attempt to reduce infant exposure to cannabis, despite research demonstrating cannabis can stay in breast milk up to 6 days.²² Further, others who use cannabis may choose not to initiate or to quit breastfeeding.²¹

Cannabinoids are highly lipophilic and Δ⁹-tetrahydrocannabinol (THC) and cannabidiol (CBD) can rapidly accumulate in breast milk after maternal cannabis use (within 1–4 hours), including inhaling, edibles, and topicals, and can remain present in breast milk for up to 6 days.^16,22–26 In addition, individuals who use cannabis more frequently or with higher doses have a greater accumulation of THC in their breast milk.²⁴ Initial data also suggest that cannabis may negatively impact breast milk supply^22,27,28 and alter the composition of milk.²⁹ Notably, the amount of THC transferred to breast milk may vary with maternal pharmacokinetics, with some infants potentially getting greater exposure than others after maternal cannabis use.¹⁶ Research suggests that given the length of time that THC is detectable in breast milk, “pumping and dumping” may not prevent exposure to THC for breastfeeding babies.²²

Understanding the factors that impact pregnant individuals' intentions to use cannabis postpartum is critical for developing more tailored and effective education, prevention, and intervention strategies to assist pregnant individuals who would like to abstain or use cannabis less frequently during lactation and the postpartum period. This focus group study directly addresses this knowledge gap by examining the various factors pregnant individuals who use cannabis consider when deciding whether to use cannabis postpartum.

Materials and Methods

This study took place in Kaiser Permanente Northern California (KPNC), a large integrated health care system serving >4.5 million diverse members,³⁰ and was approved by the KPNC Institutional Review Board. English-speaking non-Hispanic Black and non-Hispanic White pregnant adults (the racial/ethnic groups with the highest prevalence of prenatal cannabis use in KPNC³¹) who self-reported using cannabis during universal screening at entrance to prenatal care (at ∼8 weeks gestation) were eligible; those who self-reported daily or weekly use (versus less than or equal to monthly) were prioritized.

After chart reviews were done to confirm that the patient was still pregnant, patients were emailed and given the chance to decline participation. Next, patients were called, verbally consented to participate, and asked whether (and when) they had quit cannabis use. Participants were informed that their participation would not impact their clinical care and their responses would not be connected in any way to their electronic health record.

We employed a combination of deductive and inductive approaches in our analysis. The open-ended focus group guide allowed participants to express, describe, and discuss with each other their various opinions and experiences related to intentions to use cannabis postpartum. We developed the script based on the existing literature and results from our previous cannabis research, as well as input from the study team, which included clinical psychologists, obstetrician/gynecologists, and a sociologist.

Patients were told that the study team was interested in understanding how patients make decisions about using cannabis during pregnancy and postpartum. They were asked questions related to their prenatal cannabis use and this study focused on responses to a question about plans to use cannabis after pregnancy. Patients were asked specifically whether they planned to change how they use cannabis after giving birth, and prompts included how, why, increase/decrease, and thoughts on cannabis and breastfeeding. Patients received a $50 gift card for participating. Virtual focus groups were conducted using a Health Insurance Portability and Accountability Act-compliant video-conferencing software from November 17, 2021, to December 17, 2021, and repeat focus groups were not carried out.

The average length of the 18 focus groups was 73.4 minutes (range 42–92 minutes). Participants and focus group leaders were race concordant, given that people with shared experiences may be more open with one another when discussing sensitive topics.^32,33 Senior author (T.R.F), female postdoctoral fellow and qualitative methodologist, conducted the focus group with White individuals and co-author (A.G.), female licensed clinical psychologist, conducted the focus group with Black individuals. No relationship was established between the focus group leaders and the participants before study commencement, and no one was present besides the participants and focus group leaders.

Our team utilized thematic analysis^34,35 to analyze the data. After each focus group, facilitators wrote field notes describing notable ideas and themes, as described by participants, and as the focus groups continued, the degree to which and the ways in which the responses of participants related to each other across the groups. We also had weekly debriefing meetings during which we discussed and documented the themes and more specific codes we were identifying in the focus groups, and found that thematic saturation had been achieved after the 18th focus group.^36,37

Focus groups were video recorded and professionally transcribed. Once all the focus group recordings were transcribed, three of the authors (A.A., sociologist/qualitative methodologist, T.R.F., qualitative methodologist, and K.C.Y.-W., clinical psychologist and addiction researcher) drafted the initial codebook that consisted of a branching series of themes, codes, and subcodes, which was based on the iterative themes and codes developed as described above. A larger group of authors (K.C.Y.-W., E.I. [clinical psychologist and mental health researcher], A.A., M.B.D. [senior project manager], and T.R.F.) coded the same two transcripts individually to test the codebook. The codebook was further revised until consensus was achieved on the themes, codes, and subcodes that would appropriately categorize the data. The 16 remaining transcripts were coded independently in NVivo Qualitative Analysis Software (Release 1.6.1)³⁸ by the 5 team members noted above. Transcripts were not returned to participants for comment and participants did not provide feedback on the findings.

For this study, we focused on quotes and themes in the coded data related to discussions about anticipated postpartum cannabis use. We carefully reviewed and compared the coded data on this topic to examine whether there were differences in themes and subthemes among Black and White participants. We used descriptive statistics to summarize patient sociodemographics and cannabis use behaviors. This study followed the Consolidated Criteria for Reporting Qualitative Research (see Supplementary Data)³⁹ guidelines to ensure that data collection and analysis were systematic and verifiable.

Results

Eighteen focus groups were conducted with 53 patients, with focus group sizes ranging from 1 to 6 participants.³⁸ Additional details on recruitment and participant rates are available elsewhere.^38,40 The sample was 43% Black and 57% White, with a mean age of 30.3 (5.2) years; 17%, 47% and 36% were in their first, second, and third trimesters, respectively, at recruitment (Table 1).

Table 1.

Age and Cannabis Use Characteristics Among Participants Overall and by Race

	Participant characteristics
	Overall		White		Black
	N	%	N	%	N	%
Age categories
21–30	30	56.6	15	50.0	15	65.2
31–40	23	43.4	15	50.0	8	34.7
Trimester at phone recruitment
First or second	34	64.2	22	73.3	12	52.2
Third	19	35.8	8	26.7	11	47.8
Frequency of prenatal cannabis use
Daily	37	69.8	23	76.7	14	60.9
Weekly or monthly	16	30.2	7	23.3	9	39.1
Quit cannabis use by the time of recruitment
Yes	37	69.8	21	70.0	16	69.6
No	16	30.2	9	30.0	7	30.4

At entrance to prenatal care, 70% reported daily, 25% weekly, and 6% ≤ monthly prenatal cannabis use. Most (n = 37; 70%) reported stopping cannabis use by the time of recruitment, and of those, most (n = 31; 84%) reported quitting during their first trimester. Compared to White participants, Black participants were younger, more likely to be in their third (vs. first or second) trimester at the time of study recruitment, and less likely to self-report daily (vs. weekly or ≤monthly) prenatal cannabis use at entrance to prenatal care (Table 1).

Our thematic analysis identified three primary themes related to postpartum cannabis use: (1) Cannabis use and postpartum health; (2) cannabis use and the parental transition; and (3) cannabis use when breastfeeding. Corresponding quotations for each theme are presented in Tables 2–4. No difference in themes 1 or 2 was identified by participant race; differences in theme 3 by race are described below.

Table 2.

Themes and Subthemes Related to Cannabis Use and Postpartum Health Among Pregnant Individuals Who Used Cannabis During Early Pregnancy

Theme 1: Cannabis use and postpartum health
Subthemes	Salient quotes
Cannabis use seen as helpful for postpartum health and well-being
Black	“But a lot of times it would be at night after that long day of getting off work, coming home with the baby. And it was like, ‘Oh, I just need something to, to relax.’ So, it happened gradually after about six months. And I only breastfed up until like three months, so it didn't affect that.”
White	“For me, I was a user before with chronic pain issues. You know, it's either that or narcotic medication, which screwed up my stomach in my 20s. So I guess there's just not an option for me personally. So I mean, it's as needed. I know from experience, you know, your baby is like always either asleep on you or you're trying to breastfeed. There's really not a lot of time to yourself. So you know, it's not something that's, ‘Oh, it's my time to do this. I've got to do this.’ It's kind of, you know, when you can, when it's needed, type of deal. So who knows how it will change for me, but I have no plans for any specific changes at all.”
White	“I know postpartum [depression] hits a lot of women really hard, and I've thought about how it [cannabis] could help because I definitely don't want to go on medication if I do have really bad postpartum … I was kind of going back and forth about whether I would introduce it [cannabis] back into my life. I might wait until my baby's several—like six months old. I don't know. Just for now I'm kind of saying no.”
Concerns about secondhand or thirdhand smoke exposure
Black	“For, for me, I plan on going back but not gonna be smoking combustibles ‘cause I do agree that the smell is a little bit off-putting for me. And I'm trying to not continue that, and I don't really want to have smoke in my baby's face. But like a vaporizer where it doesn't really produce a lot of smoke … I will go back to smoking, but it will probably be the way I will probably consume it, so a little bit less often or a dab pen. I have a dab pen, too, that I will probably go back to using.”
White	“I probably would not smoke joints or anything when I will be around my baby. Maybe if I'm at work and I'm on a lunch break, I probably would use it then. I'll choose that to be like my smoking time, but maybe more edibles will probably be my go-to option or dabbing more as well.”
	“Yeah, I think I would be open to it. I think one of the biggest transitions for my household is like, me and my partner, we used to smoke in the house. And so that's kind of one of the biggest transitions for us is like going outside and whatever the weather might be kind of thing. So, for that reason, too, I just don't know how often I might be wanting to do that once the baby is here. But yeah, I think that's a piece of our scenario that we're thinking through as well.”

Table 3.

Themes and Subthemes Related to Cannabis Use and the Parental Transition Among Pregnant Individuals Who Used Cannabis During Early Pregnancy

Theme 2: Cannabis use and the parental transition
Subthemes	Salient quotes
Unclear fit of cannabis with parental lifestyle
Black	“In the back of my mind, I also wonder if it's one of those things that, like, after I haven't done it for so long, am I still going to like it? Am I going to become super-paranoid? Has this changed everything? You know, how am I going to feel being pregnant and then being a mom—being, not pregnant, but, like, having a baby and then being high. Like, you know, some, you know, paranoia does happen at times. But I—you know, I am looking forward to that day.”
White	“Oh, I'm just saying, you know, thinking about yes, there are certain moments where I probably would want to, but at the same time, taking care of a baby, I imagine is going to be all-consuming and I'm probably going to need my wits about me, and I probably won't be able to take a sleep gummy and get my solid eight hours through the night. So, that won't really be a good idea anyway. So, that might just make the decision for me as far as most of my usage goes.”
Desire to abstain or use less frequently than before pregnancy
Black	“I feel like it's not really something that I need—not saying I needed it before, but I got used to not having it, so even if I do go back to smoking, it'll probably only be like on occasions and, you know, I won't go back to like everyday use ‘cause I'm already used to just not using it and just going through my day naturally.”
	“For me, after this pregnancy, I'll probably just give it all up like to be honest … the smell bothers me right now. So, just imagine having a newborn baby, and you're trying to focus and—with a clear brain and not be like, you know, having the smells around your kid, all that extra stuff. I'm already kind of like out on the outs of it ‘cause I'm just like, ‘Yeah, this is coming to an end.’ But I feel like after I have the baby, it's like it's just a wrap for me.”
	“…it will be nice to just take one hit and, and just be done for the day sort of thing or for a few hours versus smoking back to back to back, you know, all day long ‘cause my—‘cause my tolerance is so high.”
	“I think I'm just done completely. I was wanting to stop before I got pregnant anyway and me getting pregnant was like the best motivation. So, I was like, ‘Okay then, I really don't have to smoke anymore.’”
White	“I definitely don't want to be a regular, everyday smoker like I used to be, you know, especially with a baby and, you know, all of that. I want to make sure that I am 100 percent present and fully aware all the time.”
	“I think every once in a while, I'll partake, but probably not the first year, I won't go back. I don't think I'll ever go back to how heavily I used, like, how I was using before, but every once in a while, I'm just like, you know, here and there.”
	“So after my ‘condition,’ [pregnancy] they call it, I don't see that there's anything wrong with me smoking. Obviously, it's going to be different, and it's going to be a lot lighter, especially adjusting to having an infant. I'm not going to want to be altered in my mind. So I'm not going to get myself high, you know, while I'm taking care of her and things like that, because that's all going to be new because this is my first baby. But for me, myself, I liked smoking. Smoking to me was like drinking a glass of wine. So I don't see anything wrong with that.”

Table 4.

Subthemes Related to Specific Plans for Postpartum Cannabis Use and Breastfeeding Among Pregnant Individuals Who Used Cannabis During Early Pregnancy

Theme 3: Postpartum cannabis use and breastfeeding by race
Subthemes	Salient quotes
Cannabis use seen as compatible with breastfeeding
Black	“I just had to. I don't know if it was ‘cause it [cannabis] helps with a lot of things that I deal with like my appetite, too, and just if I get headaches here and there. And I was nursing here. I would try to wait a little while, you know, after I would smoke. But I didn't have any reservations [about using cannabis while breastfeeding child from previous pregnancy].
White	“But I mean, babies have endocannabinoid systems, so your breast milk has CBD in it. You don't actually consume enough amount of THC in one sitting that it would actually get your baby high. You would have to smoke like two pounds at one time for it to transfer through your breast milk. And you'd pass out from THC overload before then.”
	“I plan on breastfeeding and I will continue. I will continue to smoke while I breastfeed.”
“Pump and Dump” as a harm reduction strategy
Black	n/a
White	“Yeah. I'll probably go back. Obviously, like I plan on breastfeeding as long as she lets me, you know, and she wants to. I'm going to breastfeed her. So obviously, there's going to be that consideration, and I'm going to still be moderate about it and probably do the whole pump and dump and that sort of thing so that I make sure that she gets the best quality breast milk.”
	“Me and my boyfriend have already been planning on like how we can work around smoking and breastfeeding. If women are able to go out and have a beer or two with their friends and then come back and pump and dump or even work around schedules where they're pumping before they go out, that way the milk that is being produced later on doesn't either alcohol content or very low to where they aren't having to dump a huge amount, then why would it work any different for marijuana?”
Desire for information on cannabis and breastfeeding
Black	n/a
White	“I think through breastfeeding I was going to attempt to stay away from it or—although it does stay in your system longer—maybe just use very, like, lightly, which, at that point, I would assume my tolerance would be a lot less anyway, so I wouldn't need as much. I'm not sure yet. I'm a little undecided. I don't know what I'll do.”
	“Yeah, I definitely am planning on breastfeeding. Yeah, I have the same kind of concerns though, it's like, I don't really know how the cannabis use translates into the breast milk and what impact that has on the baby. Again, we just need more science, I guess; more studies about it.”
	“I have a lot of questions before I make a plan because I've heard a lot of different contradictory information about breastfeeding. So, I definitely have some questions and we have our last Kaiser class this Thursday, and it's all on breastfeeding, so I'm planning on asking tomorrow in class. Until then, I haven't made a plan, but it would be nice.”
Plans to abstain from cannabis use during lactation
Black	“Oddly enough, I'm not really concerned while I'm pregnant about using edibles. But for some reason, I always have this paranoia that using edibles—because I, I breastfed all of—all of my kids, I have this like phobia that I'm like I'm getting the baby high through the breast milk if I'm using edibles. So, like literally when I'm done with the nine months and, you know, we start with the breastfeeding, I just stop. [laughs] So, it's, it's a little bit weird, but once I'm done breastfeeding, then that's when I go, you know, back to my, my regular, you know, every-now-and-then use. But I don't know. I just always thought that that was a little bit weird for me, why I don't think that it really does anything for them while I'm carrying them. But breast milk … I don't know. I just feel like it's the equivalent of just getting the baby high directly or something.”
	“I think it's more direct, too. Like, when the baby's in utero, you can't see what's really going on versus when the baby is in your arms, you can actually see the baby and how it's responding. It's a little different. Now, it's, it's more real to you.”
	“Yeah. Like, I'm planning to breastfeed. Now, a glass of champagne would be nice … but as far as smoking, no. I mean, they say it stays in your system long. So, yeah, I will just take all that into consideration.”
	“I get paranoid about something like that. Like, ‘What if it dries your milk up or what if you can't like breastfeed properly or something like that because of the marijuana.’ I don't know, because I want to try to breastfeed too. I'll probably be the first one to try in my family. None of my female family member ever breastfed. So, I don't know if it's because they continued to smoke after. I'm not sure. I'm the first one that's going to try, but I want to be able to breastfeed my kid or child. So, if that means that I'm not smoking anymore, I'm not smoking anymore.”
	“I'm a smoker. Like I'm not going to lie. I'm looking forward to being able to smoke again, but I know I'm going to breastfeed. So I'm still going to be pushed off for a little bit longer. But at the end, I will be back to smoking.”
	“I feel like my breast milk should be at its highest quality with all the natural nutrients that it already has when it's being produced, versus having extra additives like cannabis in it, because you never know, you know, what it could give the baby or anything like that either…. Like, my fiancé is all, ‘Oh, as soon as the baby comes out, we've got to start back smoking, especially so you can sleep and have more patience.’ But I'm like, ‘No, we're not.’ I'm like, ‘I'm going to be breastfeeding and pumping, too…’”
	“One of my coworkers, she was telling me, ‘You don't want to eat chocolate, and you don't want to eat this, and you don't want to eat that while you're breastfeeding, because you're going to be giving your baby gas from the chocolate and from certain meats and stuff like that.’ So I'm, like … I can only imagine what I'm giving my baby if I'm using cannabis and I'm breastfeeding, you know?”
White	“Yeah. So, I was just planning on breastfeeding for about a year or so, you know feel it out, and then, yeah, not using cannabis at all during that time because I know that it can enter the milk and stay in the milk for a pretty long time. I think it was like three months, because it's so fat soluble. So, it would be after definitely.”
	“I always joke about it with my partner and we talk about it all the time where I'm like, ‘I can't wait till I'm done breastfeeding because then we're going to smoke a joint together.’ I intend to breastfeed, but then the therapist said the same thing about how marijuana smoke, like one joint to us could be like eight joints to the baby. So I definitely—like you guys, the same. I don't want to smoke every day, but I do want it for that like relief or relaxation or even help with sleep, but definitely after breastfeeding.”
	“My plan is to breastfeed however long I can do it for, and then, as soon as I'm done breastfeeding, I'm going to get back to my bong. It's just that I have a fear of my baby getting drug tested and them finding THC in my baby and then, you know, I'm this horrible mother that gave their baby pot. Like you know, it is again a stigma and all these things.”

Theme 1: Cannabis use and postpartum health

Cannabis seen as helpful for postpartum health and well-being

Several participants described plans to return to their pre-pregnancy patterns of cannabis use immediately after delivery. Anticipated reasons for postpartum cannabis use included using as needed for postpartum stress and chronic pain, and to be more available for their child by taking better care of themselves (e.g., by using cannabis to improve mood). One participant noted perceived benefits she anticipated from postpartum cannabis use, “It's super beneficial. I mean, being a new mom, we're going to be severely stressed. We're going to be tired, sleep-deprived, our bodies are still going to be hurting from recovery while expected to fully care and support for a brand new person that can't do anything for themselves and if we are able to have that little hit or two of relief to lower our stress and lower the body pain, it'll actually allow us to be more available and there for our child.”

Concerns about secondhand or thirdhand smoke exposure

Many participants reported they planned to change the way they used cannabis during the postpartum period to minimize risks of exposing their child to secondhand or thirdhand smoke. Specific examples of harm reduction strategies included switching from smoking cannabis to other modes (e.g., vaping), using cannabis at work instead of at home, and smoking cannabis outside versus inside the home. One participant described anticipated changes in personal hygiene to protect the baby from cannabis smoke, “But obviously, you know, sanitation issues, personal hygiene, you're definitely gonna have to be making sure you're keeping your hands clean, that you're not getting any smoke residue or anything on the baby.”

Theme 2: Cannabis use and the parental transition

Unclear fit of cannabis with parental lifestyle

Several participants were undecided or expressed ambivalence about whether or not to use cannabis postpartum. Several wondered whether cannabis use would feel different as a parent and questioned whether their reduced desire to use cannabis during pregnancy would persist into the postpartum period. One participant wondered, “Who knows by that time if I will even want to use it again?” Some also questioned whether there might be new negative effects of using cannabis as a mom (e.g., increased paranoia). Others had concerns about whether they would be able to care for their child if they were using cannabis. One noted, “I definitely don't want to be a regular, every day smoker like I used to be, you know, especially with a baby and, you know, all of that. I want to make sure that I am 100 percent present and fully aware all the time.”

Desire to abstain or use less frequently than pre-pregnancy

Many participants described a desire to return to cannabis postpartum, but did not want to use as frequently as they had pre-pregnancy. Several did not plan to return to cannabis use at all. Stated reasons for cutting down or maintaining abstinence included not needing cannabis anymore (i.e., after quitting during pregnancy), reduced tolerance, dislike of the smell of cannabis smoke, and wanting to be present and attentive to their child. One participant noted, “[My use] will probably be less … just because, you know, I haven't been using. So, I feel like my tolerance is going to be pretty low and also at this point I feel like I've also been able to like cope mentally without it more.”

Theme 3: Cannabis use and breastfeeding

Cannabis use seen as compatible with breastfeeding

There was no difference in Black and White participants' reported intentions to breastfeed; however, plans to use cannabis while breastfeeding differed among Black and White participants. While one Black participant noted that in a previous pregnancy she had used cannabis while breastfeeding to help with appetite and headaches, no participant in the Black groups discussed future plans to use cannabis while breastfeeding, preferring instead to wait until breastfeeding was done before using cannabis.

In contrast, some White participants stated they planned to use cannabis while breastfeeding, perceiving a lack of harm for their baby. One White participant mentioned that social media contributed to their perception that cannabis use and breastfeeding is safe: “I wouldn't judge anyone that does decide to breastfeed and use cannabis. I see on social media all the time “cannamoms” and them using stuff. So, I definitely look at a lot of that to see how their babies are doing. Yeah, I guess I'm open to it.”

“Pump and dump” as a harm reduction strategy

Several White participants noted one can “pump and dump” breast milk (i.e., pump breast milk and throw it away instead of feeding it to baby) and believed this method could be effective for reducing risks associated with cannabis use and breastfeeding.

A few White participants made direct comparisons to alcohol use, with one patient stating, “Obviously alcohol and cannabis aren't the same things, but now there's a lot more studies coming out where you don't always have to pump and dump depending on what you've been drinking … if you have a beer with dinner the night before, you don't have to freak out for a whole 24 hours. And there's been quite a few moms posted about cannabis use while breastfeeding, or it's one of those things where they've smoked to go to sleep, and the next morning … you just dump that morning milk, but they're not too concerned, and they've never seen a problem.”

Desire for information on cannabis and breastfeeding

Several White participants reported being unsure about whether or not they would use cannabis during lactation. These participants desired more information on the health risks of cannabis use and breastfeeding, the relative harms of cannabis vs. prescription drugs in breast milk, and whether “pump and dump” was a safe option for cannabis use. One participant described how the lack of information impacts her plans for postpartum use, “I'm planning to breastfeed. I don't feel like I have enough information. I'm thinking about it. I also like, you know, is pump and dump a possibility, potentially? I'm also concerned about postpartum depression, so I would prefer, if that happened, to be able to treat that in a more natural way.”

Plans to abstain from cannabis use during lactation

Among participants who planned to breastfeed, all Black participants and some White participants anticipated not using cannabis during lactation. Many viewed lactation as a well-defined time period when they would be especially open to abstaining from cannabis; however, most reported plans to use immediately after breastfeeding ends. One participant expressed that she would be okay if her child could not latch because it would mean she could return to cannabis use sooner, “If somebody was talking about their experience with the child didn't latch on and they weren't able to breastfeed and I was like, ‘That's fine, because then I'll be able to smoke.’ But for me, it's just like, you know, if he does latch on, then I will still continue to get that up until I'm able to wean him off and then I will [use cannabis].”

Reasons for not wanting to use cannabis during breastfeeding included fear of getting the child high through the breast milk; cannabis staying in the body for a long time and reaching the child through breast milk; concerns that cannabis use could negatively impact the child's latch or lower milk supply; and a desire to have the highest quality breast milk that does not include cannabis additives, smoke, or THC (the primary psychoactive cannabinoid found in cannabis).^41–43 One participant described her concerns, “Do you put THC in your breast—like, it's going to come out in your breast milk. Your baby is drinking THC. Like … ‘Why is your baby crying?’ ‘Oh, the baby needs smoke.’”

Notably, several Black participants perceived cannabis use while breastfeeding to be more harmful than prenatal cannabis use. Stated reasons included concerns that THC more directly reaches the baby through breast milk versus in utero, and that the potential risks would feel more real when one could actually see and hold their baby.

One participant who continued to use cannabis during pregnancy described preparing to quit in the third trimester, “I'm pretty much planning to do kind of like I did with the first pregnancy where once I hit, you know, my third trimester I'm going to try to quit, and just cut off immediately, just because I really want to breastfeed. So I want to have some time to allow my body to detox before the baby comes, although I think that like it would be really hard for me to like quit right after like going into labor. Like I'm going to be so stressed. Like it'll just be terrible. So I'm just kind of giving myself that time to prepare.”

Discussion

This qualitative study examined plans for using cannabis postpartum among pregnant individuals who self-reported cannabis use during early pregnancy. Most participants had quit cannabis use by the time of study recruitment and they reported varied plans for using cannabis postpartum. A few participants described plans to use cannabis immediately after birth to help cope with physical and mental health symptoms, such as stress and pain. Others were ambivalent or undecided about whether they would use cannabis postpartum, questioning whether cannabis use would be less pleasurable or would be inconsistent with their role as a parent. Several participants planned to maintain their abstinence achieved during pregnancy indefinitely.

Similar to other recent studies, our findings suggest that the postpartum period may be a unique period of time when some individuals are highly motivated to reduce their pre-pregnancy frequency of cannabis use or to use in ways that reduce potential risks for their infants (e.g., limiting secondhand or thirdhand smoke exposure).⁴¹ These harm-reduction strategies are in line with recommendations from the American Academy of Pediatrics advising that breastfeeding individuals should be cautioned about infant exposure to passive smoke.⁷

Clinicians working with pregnant patients who use cannabis could ask them about their goals for cannabis use during the postpartum period, and provide resources and support to those who want to abstain or use less frequently postpartum. Given the high demands on postpartum individuals, prevention approaches that support patients' mental health and provide skills for managing the unique stresses of the postpartum period, along with appropriate referrals for postpartum depression, may be especially helpful. For patients who choose to use cannabis postpartum, a harm reduction, collaborative approach that works with individuals to meet their goals for using cannabis postpartum in ways that minimize exposure to secondhand or thirdhand smoke and avoid parenting while impaired may be helpful.

This study also found that breastfeeding was a strong motivator for temporarily abstaining from cannabis use postpartum. Of interest, while participants reported intentions to make decisions around cannabis use based on breastfeeding plans, the opposite was not true (i.e., participants did not mention not breastfeeding or ending breastfeeding early to use cannabis). Studies to date on the potential risks of cannabis and breastfeeding have primarily focused on quantifying the amount of cannabinoids in breast milk, and the bioavailability of THC and CBD in infants is less understood.²² Cannabinoids are slowly eliminated from fat stores and regular exposure to THC, even low levels, may lead to an accumulation of cannabinoids in the child,⁴⁴ potentially impacting normal brain development.²⁴

However, data are lacking on the short- and long-term health effects for infants exposed to cannabis through breast milk. The limited existing studies on the potential harms from cannabis exposure through breast milk are conflicting, and additional research is critically needed.^14,17,45,46 With increasing potency of cannabis (percentage of THC) in recent years,⁴⁷ high-quality contemporary research that examines mode of cannabis administration and potency will be important to better understand the potential risks of cannabis during lactation.

With the recognition of potential for harm and insufficient data to evaluate the effects of cannabis on infants during lactation and breastfeeding, the American College of Obstetricians and Gynecologists (ACOG) discourages cannabis use during lactation and breastfeeding. Consistent with these recommendations, our findings highlight lactation as a time where many individuals are motivated to abstain from cannabis use. Given that some participants desired additional information about the safety of breastfeeding and cannabis, and others cited nonevidence-based information (e.g., through social media platforms), clinicians could support pregnant patients by asking them about their intentions to use cannabis postpartum, providing education that THC can be found in breast milk for up to 6 days and can accumulate in breast milk through modes other than smoking (i.e., edibles), and describing potential risks of using during breastfeeding.

Importantly, given the substantial health benefits of breastfeeding,⁴⁸ ACOG does not recommend the discontinuation of breastfeeding for individuals who use cannabis.⁴ While studies on the association between cannabis use postpartum and breastfeeding duration are mixed,^12,15,49 recent data suggest that postpartum individuals who use cannabis are less likely to breastfeed and have a shorter breastfeeding duration if they perceive cannabis use during breastfeeding to be unsafe versus safe.⁴⁹ Thus, it is critical that clinicians also advise patients who have firmly decided to use cannabis postpartum that breastfeeding is still recommended even if using cannabis. More research on the safety of cannabis use and breastfeeding and definitive data on the effectiveness of intended harm reduction strategies, including “pumping and dumping,” can help individuals to make more informed decisions about cannabis use and lactation.

Differences by Race

While there was no difference in intentions to breastfeed among Black versus White participants, there were notable differences related to plans for using cannabis and breastfeeding by race. Some White participants reported that they planned to use cannabis and breastfeed, either seeing no potential harm or describing strategies they perceived would reduce or eliminate potential harm, such as “pump and dump,” despite data indicating that cannabis can stay in the breast milk up to 6 days.²² Other White participants desired more information about the safety of cannabis and breastfeeding to make a more informed decision.

In contrast, while many Black participants reported plans to breastfeed, none indicated that they wanted more information about the safety of cannabis and breastfeeding or described plans to use cannabis while breastfeeding, preferring to wait to use cannabis until after breastfeeding is finished. The lack of difference among Black and White participants in intentions to breastfeed is notable and differs from epidemiologic data, indicating higher rates of breastfeeding among White versus Black U.S.-born individuals.⁵⁰

Overall, Black participants were more likely to make a distinction between the safety of cannabis use during pregnancy versus during breastfeeding, anticipating that the transfer of THC and other potentially harmful aspects of cannabis would seem more tangible after the baby was born. This was exemplified by a Black participant who described her plan to quit using cannabis in the third trimester to “detox” in preparation for lactation, and additional research is needed to understand this novel finding.

It is noteworthy that a recent study using Pregnancy Risk Assessment Monitoring System data from nine states found that pregnant non-Hispanic Black individuals were disproportionately given medical advice to not breastfeed if using cannabis.⁵¹ While no patient in our study stated that they would avoid breastfeeding to use cannabis postpartum, Black participants were more likely to report that cannabis use while breastfeeding was not safe. It is also possible that Black participants felt less comfortable expressing intent to use cannabis while breastfeeding.

In our study, compared to White participants, Black participants were younger, more likely to be in their third trimester at the time of study recruitment, and less likely to self-report daily (vs. weekly or less than or equal to monthly) prenatal cannabis use during early pregnancy. Differences in these characteristics may have also contributed to differences in perspectives on breastfeeding and cannabis use among White versus Black participants. No other difference was found between responses from White and Black participants. It will be important to replicate these findings in future qualitative and quantitative studies and to conduct additional research to examine factors that may contribute to differences in plans to use cannabis while breastfeeding by race.

Strengths and limitations

This study captured a range of participant experiences, achieved thematic saturation, and identified several important differences among Black versus White participants. However, focus groups were limited to insured Black and White pregnant patients who self-reported cannabis use during early pregnancy in a state where cannabis is legal for adult use, and we did not collect information on participants' education level or socioeconomic status or parity.

Additional studies are needed with individuals of other races/ethnicities, uninsured pregnant patients, those living in other states, those who use cannabis less frequently, and those who quit cannabis use before pregnancy. We did not purposefully sample participants based on prenatal cannabis use frequency or current cannabis use status at the time of the focus groups and we are unable to evaluate differences in themes by these factors. Finally, pregnant individuals who did not feel comfortable disclosing prenatal cannabis use at entrance to standard prenatal care would not have been identified as potentially eligible for this study.

Conclusions

Our results have important implications for clinical practice and can be used to better support patients during the postpartum period. Findings suggest that pregnant individuals' concerns about potential harms of cannabis use postpartum can impact whether and how they intend to use cannabis postpartum. Most planned to use cannabis postpartum but with less frequency than pre-pregnancy, and many planned to defer cannabis use until breastfeeding was finished. The perception that cannabis use while breastfeeding was safe or apprehension that postpartum mental and physical health would be challenging to navigate without cannabis was a factor associated with plans to use cannabis immediately postpartum.

Clinicians can educate pregnant patients about ways to reduce potential harms associated with postpartum cannabis use, including eliminating secondhand and thirdhand smoke exposure, avoiding parenting while impaired, and abstaining from cannabis use during lactation. Patients should also be educated that “pump and dump” may not prevent infant exposure to THC through breast milk.²² Finally, patients who choose to use cannabis postpartum should be counseled that cannabis use is not a contraindication to breastfeeding, and taught strategies for potential harm reduction.

Disclaimer

The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of data; preparation, review, or approval of the article; or decision to submit the article for publication.

Author Disclosure Statement

No competing financial interests exist.

Funding Information

This study was supported by an NIH NIDA K01 Award (Grant No. DA043604; K.C.Y.-W.), a Kaiser Permanente Northern California Division of Research Health Equity Supplement (K.C.Y.-W), and The Permanente Medical Group (TPMG) Delivery Science Fellowship Program (T.F.). The funding sources were not involved in data collection, analysis, interpretation, writing, or decision to submit the article for publication.