Table 3.

Marijuana Counseling Domains: Definitions and Examples

Domain	Definition and Example
No counseling	No health care provider response to patient’s marijuana use or disclosure; health care provider may assess last  use if patient quit since confirming pregnancy but offers no information or counseling regarding marijuana  use.
	OB: Any smoking, drinking, or drugs? PT: I smoked marijuana a month ago to 2 months ago. OB: And how  much did you used to smoke? PT: Marijuana? OB: No, cigarettes. PT: Ah a pack would last me for 2 weeks.  OB: Alright Ms. X. So again it is your first time seeing us, um, so we are going to do a number of tests that we  do for everybody on their first pregnancy visit.
Punitive	Counseling focused on the legal ramifications of patient’s marijuana use; patient wamed child protective  services will be contacted or informing patient that urine drug screening will be performed (at visit; at  delivery).
	OB: Um, the issue with marijuana specifically is just that it is illegal. So at the time of delivery, they will do  a urine drug test because you have a history of using it. If it is positive, at the time of delivery, they will often  have you, like force you to talk to the child protective services because it is a risk factor.
Medical	Counseling focused on medical risks of marijuana use such as comparing the negative outcomes of smoking  tobacco (small gestational age, preterm birth, asthma); includes discussions regarding nausea and  suggestions of using or prescribing medications for nausea in place of marijuana.
	OB: We do know it can affect size of the babies and things like that. And we want your baby to develop as  healthy as possible. And you know how it alters your mind when you have it, how it makes you feel, so think  about what it is doing to the baby that is not even formed quite yet. It gets the effects as well. And we don’t  want to do that to the baby.
Helpful and  supportive	Counseling included offering resources such as social work or counseling referrals, providing encouragement  and support to quit; health care provider notes intention to follow-up with patient on quit efforts.
	OB: If you find yourself in a position where you feel like you can’t stop using…there are lots of avenues that  we can help you explore to…keep you clean and sober…So let us know if there is anything we can do to help.
Unclear	Counseling is not specific, health care provider expressed uncertainty of effects of marijuana use during  pregnancy, patients advised to quit without providing information on risks or other educational information.
	OB: Ok, so our goal is to keep you off of everything during pregnancy.

OB, obstetrician; PT, patient.