Abstract
Objective:
To estimate the prevalence of perinatal cannabis use (i.e., before and/or during pregnancy); document the frequency, modes, and motivations for use; and identify predictors of perinatal cannabis use.
Methods:
Six states in the Pregnancy Risk Assessment Monitoring System, a state-specific, population-based surveillance system, administered a supplemental questionnaire on perinatal cannabis use in 2016–18. Women with live births were surveyed 2–6 months postpartum about behaviors ≤3 months preconception and during pregnancy. Demographic, psychosocial, and behavioral characteristics were examined in relation to perinatal cannabis use using multinomial regression models. Those who: 1) never used cannabis, 2) only used in preconception period, and 3) used in both preconception and prenatal periods were compared.
Results:
Among 6428 respondents, 379 (5.8%) used cannabis preconceptionally only and 466 (4.4%) used in both the preconception and prenatal periods. Among those using prenatally, most reported smoking as their single mode (87.1%), with the two most common reasons being stress (83.8%) and nausea/vomiting (79.2%). Marital status, race/ethnicity, socioeconomic status, parity, and cigarette and alcohol use were significantly associated with perinatal cannabis use. Single (vs. partnered) women were more likely to use cannabis prenatally (odds ratio (OR)=2.4, 95% Confidence Interval (CI): 1.5, 3.9) and non-Hispanic Black (vs. White) women were less likely to use prenatally (OR=0.4, 95% CI: 0.2, 0.8).
Conclusions:
Using a population-based sample of US births in six states, several demographic, psychosocial, and behavioral characteristics were identified in relation to perinatal cannabis use. These data are valuable for counseling in prenatal care and investigations of health effects.
Keywords: Cannabis, marijuana, pregnancy, preconception, perinatal, substance use
Introduction
The American College of Obstetricians and Gynecologists states that cannabis use should be discouraged during the perinatal and lactation periods due to potential adverse health outcomes.1 Several studies have demonstrated that prenatal cannabis use is associated with preterm birth, low birth weight, neurocognitive problems in neonates, and adverse neurodevelopmental outcomes in children.2–9 However, with increasing legalization and social acceptance of cannabis, the prevalence of use among pregnant women is increasing,10–12 as is reflected by the legalization of medical cannabis in 36 states and medical and recreational cannabis in 17 states as of April 2021.13,14 Two recent studies found that women residing in states with legalized recreational cannabis were more likely to use in the perinatal period.13,15 Given the increasing prevalence, it is important to better understand cannabis use patterns andpredictors of use in perinatal period in the U.S.
Pregnant women have been shown to use cannabis for its therapeutic effects16,17 and smoke it versus use in other modes.18 Dickson et al. demonstrated that cannabis use is marketed by over 70% of dispensaries in Colorado to alleviate pregnancy symptoms of nausea and vomiting.19 Other studies have demonstrated that women self-report using cannabis in the perinatal period to manage stress, mood, as well as symptoms of nausea and vomiting.16,20–22 However, one of these studies demonstrated that although women with nausea and vomiting were more likely to use cannabis during pregnancy, prenatal use increased from 2009–2016 among both women with nausea/vomiting and those without, suggesting that other factors also contribute to the increased prevalence of use during pregnancy.20
Using data from the 2008 Dutch Generation R Study, El Marroun et al. demonstrated that perinatal cannabis use was more likely in women who were non-married, had partner who used cannabis, childhood trauma, and current or past delinquency.23 Others in the U.S. have shown that cannabis use is more likely in women who are younger, have lower education and household income, reported stressful life events before pregnancy, and use other substances, including tobacco and alcohol.17,24,25 However, the vast majority of studies have compared prenatal use with never-use; whereas a more relevant comparison may be those who use before they become pregnant and continue to use in pregnancy versus those who use before they become pregnant but stop in pregnancy. Following this rubric, a recent study by Ko et al. used 2017 Pregnancy Risk Assessment Monitoring System (PRAMS) data to compare prenatal use with preconception only use, but only examined a limited set of potential predictors.26 For example, Ko et al. did not investigate co-use with alcohol or any psychosocial characteristics including depression, physical, sexual and/or emotional abuse, or pregnancy intention. Overall, a more comprehensive characterization of women who use cannabis before and during pregnancy is needed, including an explicit comparison of women who continue to use in pregnancy with women who stop.
PRAMS is a nationally-coordinated state-level population-based surveillance system of maternal behaviors and fetal outcomes.27 Between 2016 and 2018, six participating states in PRAMS administered a unified cannabis-specific questionnaire, the PRAMS Marijuana Supplement, which asked about cannabis use in the perinatal period (i.e., defined here as the preconception and prenatal periods). The main objectives of this study were to leverage this data to estimate the prevalence of cannabis use during different intervals in the perinatal period; document the frequency, modes of, and motivations for use; and identify sociodemographic, behavioral, and psychosocial predictors of maternal cannabis use. In this study, we compared three groups of women: 1) those who never used cannabis in the perinatal period, 2) those who used cannabis before pregnancy only (i.e., preconception), and 3) those who used cannabis both before and during pregnancy (i.e., prenatal).
Methods
Study Population
This study utilized data from PRAMS, a recurring, state-specific, population-based surveillance system conducted by state health departments collaborating with the Centers for Disease Control (CDC).27 Briefly, birth certificates are used to identify women who delivered live births. A stratified sample is selected and women are contacted by mail or phone 2–6 months after delivery. PRAMS combines state-specific birth certificate data with additional survey data on maternal and neonatal health indicators. Detailed information about sampling and survey methodology can be found at www.cdc.gov/PRAMS. The CDC Institutional Review Board approved this secondary data analysis.
PRAMS Marijuana Supplement
Six participating PRAMS states administered a voluntary supplement on cannabis use in 2016–18: Alaska, Maine, New Mexico, New York, Pennsylvania, and West Virginia. All selection and weighting protocols were identical to those used in the larger PRAMS system.
Measures
Across all states participating in the supplemental questionnaire, cannabis use was determined by the question, “At any time during the 3 months before you got pregnant OR during your most recent pregnancy did you use ‘marijuana’ or hash in any form?” Cannabis use was further categorized by responses to questions about frequency of use. This allowed for the derivation of three groups: 1) those who never used cannabis within the three months before pregnancy, 2) those who used cannabis within the three months before pregnancy only (i.e., preconception), and 3) those who used cannabis both before and during pregnancy (i.e., prenatal). Initiation of use in pregnancy was extremely rare and therefore excluded (n=5). The Marijuana Supplement questionnaires administered in all states had the same questions and responses.
Information on mode of and reasons for use in the prenatal period were asked as check all that apply and yes/no questions, respectively. For example, the question in the survey was “During your most recent pregnancy, how did you use marijuana?” with responses, “Smoked it,” “Ate it,” “Drank it,” “Vaporized it,” “Dabbed it,” or “Other”. The possible responses for reasons for use were to relieve: nausea, vomiting, stress or anxiety, chronic condition symptoms, or pain, for fun or to relax, and other. Mode of and reasons for use were only asked among women reporting prenatal use and not with regard to the preconception period.
Demographic information such as maternal and paternal race/ethnicity, maternal age, education, insurance status, household income, marital status, and state of residence were collected by PRAMS and considered in this analysis based on previous cannabis and substance use literature.17,23,24,26 Substance use information such as cigarette use, e-cigarette use and alcohol use were categorized into those who never used, those who used in preconception only period, and those who used in both preconception and prenatally. Other variables of interest that were asked in PRAMS surveys included pregnancy intention (now or sooner, later, did not want, and not sure), reported current or past physical, sexual and/or emotional abuse (categorized as never, before, or during pregnancy), and depression (categorized the same way). Parity was collected from the birth certificate.
Statistical Analysis
We calculated the weighted prevalence of reported maternal cannabis use at any point within the three months before pregnancy (i.e., preconception) and during pregnancy (i.e., prenatal) and weighted distributions of demographic, psychosocial, and behavioral characteristics within strata of perinatal cannabis use. Multinomial logistic models were fit that simultaneously compared prenatal and preconception use with never use, which was the reference. First, crude models were fit that included each predictor individually. Second, multivariable models were fit and variable selection was conducted by including predictors that were significant in crude models at p≤0.10. Backward selection was conducted and variables were sequentially removed if p>0.10. Upon removing covariates, if estimates for other covariates changed by ≥10%, those variables were kept in the model,28 which only applied to maternal age. A second set of models were fit comparing prenatal cannabis use with preconception only use, which was treated as the reference, using the same set of variables identified in first set of models. All analyses were conducted using complete case analysis. Multicollinearity was tested in all models and was evaluated against a variance inflation factor (VIF)<5.29
All analyses were conducted in STATA Version 16 and accounted for the sampling survey design of PRAMS.27 Data are weighted for sample design, non-response, non-coverage and represent the total population of residents delivering live births in the respective states.
Results
Description of study population
A total of 6457 women were administered the Marijuana Supplement and 6428 provided valid responses to questions about perinatal cannabis use, which comprised the final analytic sample for this study. Among them, 379 (5.8%) used cannabis in preconception only and 466 (4.4%) used prenatally (Table 1). The prevalence of preconception only cannabis use ranged from 4.3% in New Mexico to 10.4% in Maine while the prevalence of prenatal use ranged from 2.6% in New York to 11.7% in Maine.
Table 1.
Demographic, psychosocial, and behavioral characteristics of study population by perinatal cannabis use, PRAMS Marijuana Supplement, 2016–18
| Total Study Population (N=6428, 100%) | Never use (N=5583, 89.8%) | Preconception only cannabis usea (N=379, 5.8%) | Prenatal cannabis useb (N=466, 4.4%) | |
|---|---|---|---|---|
| State of Residence c | ||||
| Alaska | 519 (1.8%) | 431 (1.6%) | 31 (2.0%) | 57 (3.9%) |
| Maine | 1029 (4.8%) | 792 (4.2%) | 94 (8.6%) | 143 (12.9%) |
| New Mexico | 2274 (13.8%) | 2067 (13.9%) | 88(10.1%) | 119 (17.5%) |
| New York | 704 (30.0%) | 632 (30.4%) | 42(32.4%) | 30 (17.9%) |
| Pennsylvania | 1199 (44.1%) | 1059 (44.4%) | 84 (42.5%) | 56 (38.6%) |
| West Virginia | 703(5.5%) | 602 (5.4%) | 40 (4.4%) | 61 (9.1%) |
| Missing | 0 | 0 | 0 | 0 |
| Marital Status c | ||||
| Married | 3630 (57.9%) | 3376 (60.8%) | 154 (43.9%) | 100 (18.4%) |
| Single | 2780 (42.1%) | 2196 (39.2%) | 224 (56.1%) | 360 (81.6%) |
| Missing | 18 | 11 | 1 | 6 |
| Maternal Race/Ethnicity c | ||||
| Hispanic | 1529 (17.9%) | 1380 (18.1%) | 68 (14.6%) | 81 (17.6%) |
| White | 3728 (65.2%) | 3195 (65.0%) | 246 (67.2%) | 287 (66.1%) |
| Black | 376 (8.1%) | 314 (7.8%) | 37 (13.8%) | 25 (6.1%) |
| Asian | 188 (3.9%) | 186 (4.3%) | 2 (0.0%) | 0 (0.0%) |
| AK Native/Native American | 390 (2.0%) | 330 (1.9%) | 11 (1.7%) | 49 (3.8%) |
| Pacific Islander/Other | 191 (3.0%) | 155 (2.8%) | 14 (2.7%) | 22 (6.6%) |
| Missing | 26 | 23 | 1 | 2 |
| Paternal Race/Ethnicity c | ||||
| Hispanic | 639 (12.5%) | 599 (13.2%) | 12 (5.6%) | 28 (5.9%) |
| White | 3985 (71.0%) | 3511 (70.7%) | 243 (75.3%) | 230 (73.1%) |
| Black | 336 (8.5%) | 282 (8.0%) | 30 (15.2%) | 24 11.7%) |
| Asian | 160 (3.8%) | 157 (4.2%) | 2 (0.4%) | 1 (0.0%) |
| AK Native/Native American | 279 (1.6%) | 239 (1.6%) | 8 (0.8%) | 32 (3.6%) |
| Pacific Islander/Other | 175 (2.6%) | 138 (2.4%) | 10 (2.7%) | 27 (5.5%) |
| Missing | 855 | 657 | 74 | 124 |
| Maternal Age (years) c | ||||
| 17–24 | 1563 (21.7%) | 1257 (20.4%) | 119 (28.0%) | 187 (40.6%) |
| 25–29 | 1962 (29.7%) | 1686 (29.5%) | 116 (28.1%) | 160 (35.8%) |
| 30–34 | 1815 (30.1%) | 1634 (30.8%) | 99 (30.2%) | 82 (15.4%) |
| ≥35 | 1088 (18.5%) | 1006 (19.3%) | 45 (13.7%) | 37 (8.2%) |
| Missing | 0 | 0 | 0 | 0 |
| Maternal Education c | ||||
| High school | 2519 (37.0%) | 2072 (36.1%) | 148 (27.8%) | 299 (67.3%) |
| College | 1800 (27.1%) | 1550 (26.6%) | 128 (38.3%) | 122(23.6%) |
| Graduate | 2078 (35.9%) | 1935 (37.3%) | 102 (33.9%) | 41 (9.8%) |
| Missing | 31 | 26 | 1 | 4 |
| Insurance d,e | ||||
| None | 671 (9.2%) | 557 (9.2%) | 39 (8.1%) | 75 (11.3%) |
| Private | 3109 (58.2%) | 2842 (59.7%) | 176 (57.9%) | 91 (27.5%) |
| Public | 2392 (32.6%) | 1956 (31.1%) | 152 (33.9%) | 284 (61.2%) |
| Missing | 256 | 228 | 12 | 16 |
| Household Income d,f | ||||
| 0–$48,000 | 3536 (53.3%) | 2913 (51.1%) | 241 (63.4%) | 382 (87.2%) |
| $48,001–$85,000 | 1167 (20.4%) | 1074 (21.1%) | 60 (17.7%) | 33 (10.0%) |
| ≥$85,001 | 1238 (26.2%) | 1179 (27.8%) | 52 (19.0%) | 7 (2.8%) |
| Missing | 487 | 417 | 26 | 44 |
| Pregnancy Intention d,g | ||||
| Now/Sooner | 3718 (59.2%) | 3364 (60.9%) | 180 (49.2%) | 133 (38.7%) |
| Other | 2614 (40.8%) | 2137 (39.1%) | 194 (50.8%) | 223 (61.3%) |
| Missing | 96 | 82 | 5 | 9 |
| Parity c | ||||
| Nulliparous | 2492 (37.5%) | 2074 (36.3%) | 211 (52.3%) | 207 (41.4%) |
| Parous | 3919 (62.6%) | 3493 (63.7%) | 167 (47.7%) | 259 (58.6%) |
| Missing | 17 | 16 | 1 | 0 |
| Physical, sexual and/or emotional abuse d | ||||
| Never | 5539 (94.4%) | 4893 (95.5%) | 310 (88.2%) | 336 (81.0%) |
| Preconception only | 145 (2.2%) | 95 (1.7%) | 15 (5.1%) | 35 (6.7%) |
| Prenatal | 215 (3.4%) | 148 (2.8%) | 25 (6.8%) | 42 (12.4%) |
| Missing | 529 | 447 | 29 | 53 |
| Depression d | ||||
| Never | 3282 (55.0%) | 2971 (56.5%) | 151 (46.4%) | 160 (34.8%) |
| Preconception only | 2022 (32.0%) | 1790 (32.2%) | 127 (29.8%) | 105 (30.2%) |
| Prenatal | 938 (13.0%) | 676 (11.3%) | 93 (23.7%) | 169 (35.0%) |
| Missing | 186 | 146 | 8 | 32 |
| Cigarette Use d | ||||
| Never | 4888 (77.8%) | 4526 (81.1%) | 217 (62.0%) | 145 (31.3%) |
| Preconception only | 584 (9.6%) | 439 (9.0%) | 74 (17.3%) | 71 (23.8%) |
| Prenatal | 956 (12.6%) | 618 (9.9%) | 88 (20.7%) | 250 (55.8%) |
| Missing | 0 | 0 | 0 | 0 |
| E-cigarette Use d | ||||
| Never | 6046 (94.9%) | 5311 (95.8%) | 338 (89.7%) | 397 (84.7%) |
| Preconception only | 203 (3.6%) | 140 (3.1%) | 27 (8.7%) | 36 (8.3%) |
| Prenatal | 104 (1.4%) | 66 (1.1%) | 10 (1.6%) | 28 (7.1%) |
| Missing | 75 | 66 | 4 | 4 |
| Alcohol Use d | ||||
| Never | 2774 (40.1%) | 2545 (41.9%) | 82 (12.7%) | 147 (22.8%) |
| Preconception only | 3313 (53.2%) | 2753 (58.2%) | 271 (77.7%) | 289 (73.1%) |
| Prenatal | 269 (6.7%) | 222 (6.6%) | 21 (9.5%) | 26 (4.1%) |
| Missing | 72 | 63 | 0 | 4 |
Preconception only use defined as use during any time within the three months before pregnancy
Prenatal use defined as use during any time in pregnancy
Extracted from birth certificate data
Self-reported on PRAMS questionnaire
Private insurance included those specifying insurance sources as healthcare exchange, insurance from a job, parent or military status. Public insurance included women with SCHIP/CHIP, government or tribal insurance (Medicaid, IHS, other state plan)
Yearly total household income before taxes in the 12 months before the baby was born
Women were asked the question, “Thinking back to just before you got pregnant with your new baby, how did you feel about becoming pregnant?”
The distributions of demographic characteristics, behaviors, and psychosocial factors stratified by perinatal cannabis use are presented in Table 1. The proportion of women who were non-Hispanic Black among those with preconception use was substantially higher than those with prenatal use (13% vs 6%). Conversely, prenatal use was more likely in those identifying as Alaska Native, Native American, Pacific Islander or other race than preconception only or never use. Similar patterns were observed across paternal race. Both preconception only (56.1%) and prenatal use (81.6 %) were more likely in single (vs. married) women and those who used prenatally tended to be younger and have less income and education than women who never used. While preconception only use was more likely in women with private insurance (57.9%), prenatal use was more likely in women with public insurance (61.2%). Never use was more likely in women with an intended pregnancy (60.9%) than preconception only (49.2%) or prenatal (38.7%) use. Although exposure to physical, sexual and/or emotional abuse was rare, both prenatal and preconception use was associated with more self-reported abuse compared with never use. Prenatal cannabis use was more likely in women using cigarettes and e-cigarettes but less likely in those using alcohol prenatally.
Perinatal cannabis use patterns
Among those who used in preconception only or prenatally, use was more frequent prenatally compared with preconception only (Table 2). Among those using marijuana prenatally, 33.2% used it every day compared with 18.4% of those using only in the preconception period. The proportions of weekly use were similar across groups and those using only in the preconception period were more likely to use only monthly (49.0%) compared with prenatal use (39.2%).
Table 2.
Maternal self-report of perinatal cannabis use frequency, mode, and reason for use, PRAMS Marijuana Supplement, 2016–18
| Preconception only cannabis usea (N=379, 5.8%) | Prenatal cannabis useb (N=466, 4.4%) | |
|---|---|---|
| Frequency of Use | ||
| Daily | 88 (18.4%) | 146 (33.2%) |
| Weekly | 122 (32.6%) | 166 (27.6%) |
| Monthly | 169 (49.0%) | 154 (39.2%) |
| Mode of Use c,d | ||
| Smoked | -- | 408 (87.1%) |
| Eaten | -- | 70 (13.5%) |
| Drank | -- | 5 (0.9%) |
| Vaporized | -- | 35 (6.4%) |
| Dabbed | -- | 28 (4.9%) |
| Other | -- | 5 (0.7%) |
| Reason for Use c,d | ||
| Nausea/Vomiting | -- | 373 (79.2%) |
| Stress | -- | 356 (83.8%) |
| Chronic Condition | -- | 111 (26.4%) |
| Pain | -- | 232 (57.8%) |
| Fun | -- | 195 (44.7%) |
| Other | -- | 104 (25.5%) |
Preconception only use defined as use during any time within the three months before pregnancy
Prenatal use defined as use during any time in pregnancy
Categories are not mutually exclusive so percents sum to >100%
Mode of and reasons for cannabis use were only asked with regard to prenatal use and not preconception use.
Most women with prenatal marijuana use (87.1%) reported smoking as mode of use, with lower prevalence for other methods, such as ingestion (13.5%). The majority of women cited a single mode, with 79.3% reporting smoking only and the rest reporting others.
Women cited many reasons for use. The most common were nausea/vomiting (79.2%) and stress (83.8%). Most women (80.4%) provided more than one reason for using cannabis prenatally, with only 19.6% citing a single reason for use.
Predictors of perinatal cannabis use
Table 3 shows the results of the crude models comparing 1) those who never used cannabis in the perinatal period, 2) those who used cannabis in preconception only, and 3) those who used cannabis prenatally. Overall, crude bivariate analyses demonstrated that marital status, state of residence, age, education, income, pregnancy intention, parity, current or past reported physical, sexual and/or emotional abuse, depression, cigarette use, e-cigarette use, and alcohol use were all significantly associated with prenatal cannabis use. Results comparing prenatal and preconception only use with never use were largely similar to those comparing prenatal use with preconception only use. The only differences were with regard to cigarette and alcohol use. Preconception only cigarette and e-cigarette smokers (vs. non-smokers) were more likely to use cannabis both before (OR=3.3, 95% CI: 2.1, 5.2) and during (OR=4.0, 95% CI: 2.3, 7.0) pregnancy when compared with never cannabis use. However, smoking cigarettes and/or e-cigarettes in the preconception only period was not associated with continued cannabis use in pregnancy (odds ratio (OR)=1.2, 95% Confidence Interval (CI): 0.6, 2.4). In addition, while preconception and prenatal alcohol use were associated with greater odds of preconception and prenatal cannabis use (vs. never use), they were associated with significantly reduced odds of continuing cannabis use in pregnancy (vs. preconception only use).
Table 3.
Crude associations between sociodemographic, psychosocial, and behavioral characteristics and perinatal cannabis use from multinomial logistic models, PRAMS Marijuana Supplement, 2016–18
| Preconception only cannabis usea (N=379) | Prenatal cannabis useb (N=466) | Prenatal cannabis useb (N=466) | |
|---|---|---|---|
| Reference category: never cannabis use | Reference category: preconception only use | ||
| Odds ratio (95% CI) | Odds ratio (95% CI) | Odds ratio (95% CI) | |
| Marital Status c | |||
| Married | Reference | Reference | Reference |
| Single | 2.0 (1.4, 2.9) ** | 6.9 (4.5, 10.3) ** | 3.5 (2.0, 5.9) ** |
| State of Residence c | |||
| Alaska | 1.1 (0.6, 2.1) | 4.0 (1.9, 8.3) ** | 3.5 (1.4, 8.9) ** |
| Maine | 1.9 (1.2, 3.1) ** | 5.2 (2.6, 10.4) ** | 2.7 (1.2, 6.1) ** |
| New Mexico | 0.7 (0.4, 1.1) | 2.1 (1.1, 4.2) ** | 3.1 (1.4, 7.1) |
| New York | Reference | Reference | Reference |
| Pennsylvania | 0.9 (0.5, 1.5) | 1.5 (0.7, 3.1) | 1.6 (0.7, 4.0) |
| West Virginia | 0.8 (0.4, 1.4) | 2.8 (1.4, 5.9) ** | 3.7 (1.5, 9.3) ** |
| Maternal Race/Ethnicity c | |||
| Hispanic | 0.8 (0.4–1.4) | 1.0 (0.6, 1.6) | 1.2 (0.6, 2.6) |
| White | Reference | Reference | Reference |
| Black | 1.7 (0.9, 3.2) | 0.8 (0.4, 1.6) | 0.5 (0.2, 1.2) |
| Other | 0.5 (0.2–1.0) | 1.1 (0.6, 2.1) | 2.4 (0.9, 6.3) |
| Maternal Age (years) c | |||
| 17–24 | 1.9 (1.1, 3.4) ** | 4.7 (1.9, 11.8) ** | 2.4 (0.8, 7.0) |
| 25–29 | 1.3 (0.8, 2.4) | 2.9 (1.1, 7.3) ** | 2.1 (0.7, 6.3) |
| 30–34 | 1.4 (0.8, 2.4) | 1.2 (0.5, 3.0) | 0.9 (0.3, 2.5) |
| ≥35 | Reference | Reference | Reference |
| Maternal Education c | |||
| High school | 0.8 (0.5, 1.3) | 7.6 (4.0, 14.7) ** | 9.0 (4.2, 19.6) ** |
| College | 1.6 (1.0, 2.5) ** | 3.6 (1.8, 7.2)** | 2.3 (1.0, 5.2)** |
| Graduate | Reference | Reference | Reference |
| Insurance d,e | |||
| Private | Reference | Reference | Reference |
| Public/none | 1.1 (0.7, 1.6) | 3.9 (2.5, 6.1) ** | 3.6 (2.1, 6.4) ** |
| Income d,f | |||
| 0–$48,000 | 1.9 (1.1, 3.1) ** | 20.6 (4.9, 85.5) ** | 9.3 (2.7, 31.7) ** |
| $48,001–$85,000 | 1.2 (0.6, 2.4) | 5.8 (1.2, 27.2) ** | 3.8 (0.9, 15.5) |
| ≥$85,001 | Reference | Reference | Reference |
| Pregnancy Intention d,g | |||
| Now/Sooner | Reference | Reference | Reference |
| Other | 1.6 (1.1, 2.3) ** | 2.5 (1.7, 3.7) ** | 1.5 (0.9, 2.6) |
| Parity c | |||
| Nulliparous | Reference | Reference | Reference |
| Parous | 0.5 (0.4, 0.8) ** | 0.8 (0.6, 1.2) | 1.6 (09, 2.6) |
| Physical, sexual and/or emotional Abuse | |||
| Never | Reference | Reference | Reference |
| Ever | 2.8 (1.4, 5.6) ** | 5.0 (3.0, 8.4) ** | 1.8 (0.8, 3.8) |
| Depression d | |||
| Never | Reference | Reference | Reference |
| Ever | 1.5 (1.0, 2.2) | 2.4 (1.6, 3.6) ** | 1.6 (1.0, 2.8) |
| Cigarette Use d | |||
| Never | Reference | Reference | Reference |
| Preconception Only | 2.5 (1.6, 4.1) ** | 3.7 (2.2, 6.4) ** | 1.5 (0.7, 2.9) |
| Prenatal | 2.7 (1.7, 4.5) ** | 14.6 (9.5, 22.4) ** | 5.3 (2.9, 9.9) ** |
| E-cigarette Use d | |||
| Never | Reference | Reference | Reference |
| Preconception Only | 3.0 (1.5, 6.0) ** | 3.1 (1.4, 6.5) ** | 1.0 (0.4, 2.6) |
| Prenatal | 1.6 (0.5, 5.0) | 7.2 (3.3, 16.0) ** | 4.7 (1.3, 17.0) ** |
| Any Smoking (cigarette and/or e-cigarette) d | |||
| Never | Reference | Reference | Reference |
| Preconception Only | 3.3 (2.1, 5.2) ** | 4.0 (2.3, 7.0) ** | 1.2 (0.6, 2.4) |
| Prenatal | 2.9 (1.7, 4.7) ** | 14.9 (9.7, 22.9) ** | 5.2 (2.8, 9.7) ** |
| Alcohol Use d | |||
| Never | Reference | Reference | Reference |
| Preconception Only | 5.1 (3.3, 8.1) ** | 2.7 (1.8, 4.1) ** | 0.5 (0.3, 1.0) ** |
| During Pregnancy | 4.8 (2.1, 10.9)** | 1.2 (0.5, 2.8) | 0.2 (0.1, 0.8)** |
p-value<0.05
Preconception only use defined as use during any time within the three months before pregnancy
Prenatal use defined as use during any time in pregnancy
Extracted from birth certificate data
Self-reported on PRAMS questionnaire
Private insurance included those specifying insurance sources as healthcare exchange, insurance from a job, parent or military status. Public insurance included women with SCHIP/CHIP, government or tribal insurance (Medicaid, IHS, other state plan)
Yearly total household income before taxes in the 12 months before the baby was born
Women were asked the question, “Thinking back to just before you got pregnant with your new baby, how did you feel about becoming pregnant?”
Variable selection yielded sociodemographic and substance use characteristics as significant determinants of cannabis use prenatally (Table 4). Specifically, significant predictors of prenatal cannabis (vs. never) use included marital status, race/ethnicity, income, and cigarette/e-cigarette and alcohol use; and significant predictors of preconception cannabis use (vs. never) were income, parity, and cigarette/e-cigarette and alcohol use. For example, single women were 2.4 times (95% CI: 1.5, 3.9) more likely to use (vs. not use) prenatally compared with married women. Similarly, women in the lowest income stratum (≤$48,000) followed the same pattern of increased odds of use compared with higher income women. Non-Hispanic Black (vs. White) women were less likely to use prenatally (OR=0.4, 95 % CI: 0.2, 0.8). Parous women were less likely to use (vs. not use) in the preconception period. Finally, any type of substance use (i.e., cigarette, alcohol) was significantly associated with increased odds of preconception only and prenatal cannabis use (vs. never use).
Table 4.
Multivariable adjusted associations between sociodemographic, psychosocial, and behavioral characteristics and perinatal cannabis use from multinomial logistic models, PRAMS Marijuana Supplement, 2016–18
| Preconception only cannabis usea (N=379) | Prenatal cannabis useb (N=466) | Prenatal cannabis useb (N=466) | |
|---|---|---|---|
| Reference category: never cannabis use | Reference category: preconception only use | ||
| Odds ratio (95% CI) | Odds ratio (95% CI) | Odds ratio (95% CI) | |
| Marital Status c | |||
| Married | Reference | Reference | Reference |
| Single | 1.2 (0.8, 2.0) | 2.4 (1.5, 3.9) ** | 1.9 (1.0, 3.6) ** |
| Maternal Race/Ethnicity c | |||
| Hispanic | 0.9 (0.5, 1.7) | 1.1 (0.6, 2.0) | 1.2 (0.5, 2.9) |
| White | Reference | Reference | Reference |
| Black | 1.9 (0.9, 3.9) | 0.4 (0.2, 0.8) ** | 0.2 (0.1, 0.5) ** |
| Other | 0.5 (0.2, 1.1) | 1.1 (0.5, 2.5) | 2.4 (0.8, 7.2) |
| Maternal Age (years) c | |||
| 17–24 | 1.1 (0.6, 2.1) | 1.6 (0.6, 4.6) | 1.5 (0.5, 4.6) |
| 25–29 | 0.8 (0.4, 1.4) | 1.0 (0.4, 2.8) | 1.3 (0.4, 4.0) |
| 30–34 | 1.1 (0.6, 2.1) | 1.2 (0.5, 3.1) | 1.1 (0.4, 3.3) |
| ≥35 | Reference | Reference | Reference |
| Income d,e | |||
| 0–$48,000 | 2.0 (1.2, 3.5) ** | 5.4 (1.7, 17.4) ** | 2.7 (0.8, 9.4) |
| $48,001–$85,000 | 1.2 (0.6, 2.2) | 2.2 (0.6, 8.1) | 2.0 (0.5, 7.9) |
| ≥$85,001 | Reference | Reference | Reference |
| Parity c | |||
| Nulliparous | Reference | Reference | Reference |
| Parous | 0.6 (0.4, 0.8) ** | 0.8 (0.5, 1.3) | 1.4 (0.8, 2.5) |
| Any Smoking (cigarette and/or e-cigarette) d | |||
| Never | Reference | Reference | Reference |
| Preconception Only | 2.1 (1.3, 3.6) ** | 2.1 (1.1, 3.8) ** | 1.0 (0.5, 2.0) |
| Prenatal | 2.3 (1.3, 4.0) ** | 9.7 (5.7, 16.4) ** | 4.3 (2.1, 8.8) ** |
| Alcohol Use d | |||
| Never | Reference | Reference | Reference |
| Preconception Only | 6.0 (3.6, 10.0) ** | 3.6 (2.3, 5.7) ** | 0.6 (0.3, 1.2) |
| Prenatal | 6.1 (2.4, 15.4) ** | 1.8 (0.7, 4.7) | 0.3 (0.1, 1.2) |
p-value<0.05
Preconception only use defined as use during any time within the three months before pregnancy
Prenatal use defined as use during any time in pregnancy
Extracted from birth certificate data
Self-reported on PRAMS questionnaire
Yearly total household income before taxes in the 12 months before the baby was born
Finally, the comparison of prenatal with preconception only use in multivariable models yielded only marital status, race, and smoking (cigarettes and/or e-cigarettes) as significantly associated with continued cannabis use prenatally. Measures of socioeconomic status such as household income and insurance were not associated with continued cannabis use prenatally. Single women were still more likely to use cannabis prenatally compared with married women and non-Hispanic Black women (vs. White women) were still significantly less likely to continue using cannabis prenatally. Women reporting any type of cigarette or e-cigarette smoking during pregnancy were 4.3 times (95% CI: 2.1, 8.8) more likely to continue using cannabis prenatally compared with women who only used cannabis in the preconception period. However, those who smoked cigarettes and/or e-cigarettes only in preconception were not more likely to continue using cannabis in pregnancy (OR=1.0, 95% CI: 0.5, 2.0). The inverse association of preconception and prenatal alcohol use with continuing cannabis use in pregnancy persisted but was not statistically significant. Results of multicollinearity tests showed VIFs for all models below appropriate thresholds (<2).
Discussion
In a population-based sample of US live births from six states from 2016–18, self-reported cannabis use was more common in the preconception period than prenatally. However, prenatal use was associated with more frequent reported use than in preconception only. Most women used cannabis prenatally by smoking and the most common reasons for use were nausea/vomiting and managing stress. Race/ethnicity, marital status, socioeconomic status, parity, and cigarette/e-cigarette and alcohol use were significantly associated with perinatal use. Associations comparing preconception only and prenatal use with never use were similar to those comparing prenatal to preconception only use except for those with other substances (i.e., cigarette and alcohol use).
Cannabis was used more frequently among pregnant women than those who used only in preconception. This may indicate that those who continue to use once they become pregnant use more heavily than those who cease use. Paired with the emerging evidence showing adverse health effects of cannabis on both the mother and fetus during this period, this poses a significant public health concern.30
At the time the data were collected, all states in the sample had legalized at least medical cannabis. Alaska and Maine had also legalized recreational cannabis. In accordance with previous observations,13,26 we found that women living in these states had the highest prevalence of use. In addition to residing in states with legalized cannabis, women using cannabis in the preconception or prenatal periods were more likely to be single, nulliparous, <24 years of age, of lower socioeconomic status, with an unintended or mistimed pregnancy, and with reported current or past physical, sexual and/or emotional abuse, depression, cigarette/e-cigarette use, or alcohol use compared with those who never used. Although not all predictors, such as age, pregnancy intention, and physical, sexual and/or emotional abuse and past and/or current depression, remained significant in mutually adjusted models, these correlates may be useful for targeting clinical intervention in prenatal care.
Race was a significant predictor of perinatal cannabis use. We consistently found that non-Hispanic Black (vs. White) women were less likely to self-report use in the prenatal period, similar to previous findings using PRAMS data.26 This finding emerged after controlling for various demographic and behavioral factors. In contrast, previous work has reported that those who used cannabis during pregnancy were more likely to be Black.31 Similar to this, two recent studies associated cannabis use both before and during pregnancy with African-American race.32,33 Further investigation into cannabis use by race and ethnic group is vital to better understand the potentially varying determinants of maternal and child health.
This study had many strengths. The data is from a population-based sample of live births in several states across the United States. We explicitly compared prenatal use with preconception use as opposed to no use, which few other studies have done15,26. This is arguably the more relevant comparison than prenatal versus never use because it reflects maternal behavior changes in pregnancy. In addition, this study benefited from the PRAMS sample that included some states with legalized recreational cannabis and some without, thus we were able to examine determinants of use across varied settings.
However, our study also had limitations. First, the sample relied on retrospective self-reporting of cannabis and other substance use information, which is likely not an accurate reflection given associated stigmas. We would generally expect an underreporting of all substance use (i.e., cannabis, tobacco, alcohol),34 which could influence our results, especially if certain groups were more or less likely to mis-report. Second, this was a cross-sectional study and the reported results reflect concurrent associations. For example, while we report that cigarette smoking in the prenatal period was a predictor of perinatal cannabis use, it is also true that perinatal cannabis use was a predictor of cigarette smoking. Third, perinatal cannabis use was defined by use in the three months before or during pregnancy as per PRAMS questionnaire design. Therefore, it is possible that those reporting “never use” of cannabis in this study may have used before the three-month preconception window. Thus, although categorizing these individuals as those who had “never use[d]” may not be accurate, the outcome of interest in this study was preconception and prenatal use specifically. While the definition is variable, the preconception period is often considered to be the three months before conception, as this is a critical time for gamete and early placental development35 and behaviors during this window have been associated with later maternal and child health outcomes.36 Still, the results of this study should be considered in context with this limitation. Furthermore, since the data stemmed from established questionnaires, we were unable to investigate specific variables of interest. For example, past studies have demonstrated that women are more likely to use cannabis in the first trimester compared to the second and third trimesters; however, we were unable to explore this as the PRAMS questionnaire did not explicitly characterize use throughout gestation.12,17,37 Additionally, mode of and reasons for use were only asked among women reporting use during pregnancy; thus, we were unable to compare with use in the preconception period. Finally, as the marijuana supplement was only given in six states, there may be lack of generalizability of results.
Conclusions
Overall, our study included a large population-based sample from several areas in the United States and demonstrated important patterns and sociodemographic, behavioral, and psychosocial predictors of cannabis use in the preconception and prenatal periods. We found significant associations with particular sociodemographic factors such as age, race, and cigarette use with continued cannabis use in pregnancy. As researchers continue investigating cannabis use among women in this sensitive developmental period, it is important to consider characteristics such as demographics, psychosocial characteristics, and substance co-use in study design and interpretation of outcomes. Furthermore, this study offers targets for clinical interventions in prenatal care, especially those factors found to be associated with continued use from the preconception to prenatal period.
Funding:
This work was supported by the National Institutes of Environmental Health Sciences (grant P30ES000260 to LT)
Footnotes
Conflicts of interest: none.
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