Cannabis Use During Pregnancy: The Importance of a Life Course Health Disparities Framework

Research by Allen et al. (1)—published in this issue—provides several important contributions, but none stands out more clearly than the finding that roughly one in three women reporting cannabis use prior to becoming pregnant continue to use cannabis during pregnancy. This is a disconcerting discovery, particularly in light of evidence that prenatal cannabis exposure is related to key neonatal (2) and, potentially, longer-term deleterious developmental outcomes (3). Here we extend the significance of this research by considering its importance within the context of a health disparities research framework (4, 5) and a life course perspective (6).

As defined by Braveman (7), the term health disparities refers to instances of “worse health among socially disadvantaged people and, in particular, members of disadvantaged racial/ethnic groups and economically disadvantaged people within any racial/ethnic group” (p. 6). In the present case, a health disparities research framework begs the question: Are there differences in perinatal cannabis use risk among members of disadvantaged groups in the United States? And, indeed, close inspection of the findings by Allen et al. (1) suggests that a health disparities lens would further strengthen the study’s contribution.

For example, simple arithmetic—using raw numbers provided by the authors—allows us to cautiously make two disparity-related observations. The first relates to differences in educational attainment, which is a well-established socioeconomic determinant of health (8–11). Namely, we see that rates of cannabis use during pregnancy were markedly lower among women with at least some college education (30%; 164/539) as compared to those with a high school diploma or less (43%; 199/458). Given the links between education and income, this seems to be consistent with Allen et al. (1)’s finding that exposure to stressful life events related to financial hardship is associated with risk of continued cannabis use during pregnancy. Taken together, these findings suggest that careful attention to socioeconomic disadvantage should be part of prevention/intervention efforts.

We also see some evidence of racial/ethnic disparities; namely, we see that rates of cannabis use during pregnancy were substantially elevated among American Indian/Alaska Native (AI/AN) participants (48%; 62/129) compared to rates among White, Black, and Hispanic participants (ranging from 28–35%). These comparisons, relying upon smaller subsamples, warrant caution in interpretation; however, it does appear that—while rates of continued use during pregnancy are alarming across all groups—the pattern of continued use while pregnant is particularly pressing among AI/NA participants.

Evidence of health disparities necessarily leads to consideration of the importance of contextual factors that may be drivers of risk among disadvantaged groups (12, 13). It is not sufficient that we simply identify higher rates of cannabis use during pregnancy among a particular group; we must also strive to understand and address likely causal mechanisms that operate within commonly identified social determinants. One approach could be to first examine the degree to which stressful life events may be more prevalent among a particular group and then to assess if the link between stressors and perinatal use may be especially robust among individuals experiencing specific components of social disadvantage.

One final point relates to the employment of a life course perspective. Allen et al. (1) provide a compelling rationale for focusing on proximal life events, given that less is understood about how such factors influence substance use. However, to garner a fuller understanding of perinatal cannabis use risk, it is vital we also consider the importance of early life (e.g., in utero, infancy, toddlerhood) and the potency of lifelong stressors. Elder’s (14) seminal work using a life course perspective underscores the importance of understanding the lives of individuals as unfolding over time, such that experiences at one moment in life (e.g., childhood trauma) may be related to behaviors at a later period (e.g., cannabis use while pregnant).

Others have applied this framework specifically to substance use (6, 15), but the core insight remains: Our experiences, from the time we are in utero through adulthood, have the potential to shape our behavior and our well-being. As we consider the evidence related to perinatal cannabis use—and develop programs to target this issue (16, 17)—it is vital we consider how distal and proximal stressors, including those related to social disadvantage, influence perinatal cannabis use over time.