Moving Toward Health and Social Equity for Women Who Use Cannabis During Preconception, Pregnancy and Lactation

Expanding legalization and growing social acceptability and accessibility of cannabis will potentially increase use of cannabis among women before, during, and after pregnancy. Using repeated cross-sectional data from the Pregnancy Risk Assessment Monitoring System (PRAMS) between 2004 and 2018, Skelton and colleagues¹ compared maternal cannabis use at two time points during the preconception, prenatal and postpartum periods among women living in two states that legalized recreational use (Maine and Alaska) and two that legalized only medicinal or decriminalized recreational use (Vermont and New Hampshire). The authors used a difference-in-difference analyses over time, contrasting changes in intervention and comparison states, an important strength relative to earlier studies of the issue. Consistent with prior research, results indicated that the prevalence of cannabis use before and during pregnancy increased over time in both intervention and comparison states. In the two states legalizing recreational cannabis use, preconception and postpartum cannabis use, but not prenatal use, increased significantly relative to comparison states.

However limitations of the study design, most noted by the authors, include available data for only four states, asynchronous time periods, low response rates, short follow-up periods, overlapping medical legalization in control states, differences in the characteristics of women in intervention vs control states, and retrospectively self-reported data on cannabis use. These design issues limit both the ability to generalize across states legalizing recreational cannabis and to inform causal interpretation. Earlier research by Skelton found a significantly higher prevalence of prenatal cannabis use among women who lived in states that had legalized cannabis for recreational use, but that study used a single year of 2016 PRAMS data, without the difference-in-difference approach, and with a different combination of states.²

Increased prevalence of cannabis use among pregnant women in recent years and growing evidence of associated adverse effects on fetal, neonatal and neurodevelopmental outcomes are cause for substantial concern.³ The US Surgeon General, American College of Obstetricians and Gynecologists, and the American Academy of Pediatrics strongly advise against cannabis use during pregnancy and lactation. Yet, pregnant women remain uncertain about the relative harms of prenatal cannabis use and many seek out anecdotal advice from peers and online communities supportive of cannabis when choosing whether to use (or continue to use) cannabis during pregnancy.⁴ Adding to the confusion, cannabis retailers tout cannabis as a safe, natural and effective way to manage pregnancy symptoms. In one study, 69%⁵ of cannabis retailers recommended use for nausea and vomiting in pregnancy in response to a simulated call from a pregnant woman. Many women using cannabis during pregnancy believe cannabis carries little risk, and perceive it as a natural substitute for prescribed medications used to treat mental health and pregnancy-related symptoms.⁶

As legalization of cannabis for recreational use continues to expand across the US, we urgently need additional research to better understand whether state legalization leads to increases in prevalence, frequency, or intensity of cannabis use among women before, during, and after pregnancy. Further, legalization has been accompanied by expansion of alternative methods of cannabis administration (e.g., high potency vaping and edibles) and extensive product diversification. We also need studies to determine whether pregnant and lactating women switch or add new methods of cannabis administration following legalization, and to evaluate the impact of their use. Certain methods of prenatal cannabis administration and product types may be more harmful or associated with greater risk of cannabis use disorder.

Beyond state cannabis policies, local governments in many states can further regulate retail cannabis sales, for example, by limiting retailer density, banning retailers altogether, requiring prominent pictorial warnings on prenatal use in stores or on advertising, or by limiting product types allowed to be sold. Of note, both states that legalized recreational cannabis in the Skelton et al study¹ (Alaska and Maine) have package warnings about prenatal use (but no minimum font) and allow local governments to opt out of permitting commercial cannabis sales, so the true reach of legalized commercial sale may vary. Where recreational use is legal, better understanding of this geographic patchwork of laws will help determine whether more cautious state and local cannabis regulatory policies protect against prenatal cannabis use, and also identify which policies effectively reduce exposure and harms to the offspring of pregnant women (e.g., by requiring on-site warnings, more prominent or graphic package warnings, or staff trained to not recommend use during pregnancy).

While cannabis legalization may reduce serious inequities in criminal justice, it can also potentially worsen existing health and social inequities in maternal and child health outcomes. Rates of low birth weight have long been a major area of inequitable outcomes between Black infants and other newborns. Prenatal cannabis use can potentially exacerbate the inequity, especially among women already at increased risk for low birth weight deliveries. If, like tobacco and alcohol retailers, cannabis retailers open disproportionately in lower-income communities, the risk is further exacerbated. In addition, child welfare laws have not kept up with cannabis legalization. Punitive policies criminalizing prenatal substance use and discrimination in their implementation may also increase cannabis-related social disparities. Black women are more likely to be reported to Child Protective Services (CPS) for prenatal substance use than White women, even when their substance use does not differ.⁷ Immigrants can still be deported for cannabis use or possession, since immigration is governed by federal law. While for a decade the American College of Obstetricians and Gynecologists has recommended that physicians work with policymakers to repeal punitive policies related to prenatal substance use,⁸ many states still consider prenatal use grounds for termination of parental rights. Women in general, and Black women in particular, may underreport prenatal use or avoid seeking prenatal care due to fear of punitive action, leading to worse pregnancy outcomes and missed opportunities for education and linkage to substance use treatment. This is especially likely in states where prenatal substance use is considered child abuse and punishable by law. Even when women choose to disclose cannabis use – and with legalization they may feel more comfortable sharing use with their health care providers during preconception, pregnancy and lactation – inequities in repercussions for honest disclosure may remain. With cannabis legalization extending across the US, research on the best policies to protect health and social equity and to minimize harm is critical.

As cannabis legalization unfolds and use increases among women of reproductive age, now is the time to reform antiquated policies that criminalize prenatal substance use in favor of focusing on protecting the health of mothers and their children. Improvements in primary prevention and education are vital, but also necessary are legal and regulatory policies that protect infants and children, inform women of risks, prohibit health and therapeutic claims for cannabis outside scientific approval processes, and assure equitable access to supportive and non-punitive substance use treatment.