HEALTHCARE PROFESSIONALS’ AND BUDTENDERS’ PERCEPTIONS OF PERINATAL CANNABIS USE

Abstract

Background

While national guidelines state that cannabis should not be consumed during pregnancy, cannabis use during pregnancy continues to increase. Pregnant individuals have reported using healthcare professionals and budtenders (i.e., cannabis store retailers) as resources for information on cannabis use during pregnancy and postpartum.

Objectives

To determine healthcare professionals’ and budtenders’ perceptions of risks and benefits of perinatal cannabis use.

Method

A qualitative study, using semi-structured, open-ended questions, was conducted with ten healthcare professionals (predominantly nurses; 100% women) and ten budtenders (70% women) in a state where cannabis use is legal for adults 21 years of age and older. Data were interpreted using a qualitative description methodology to identify themes. Themes were generated from participant responses (implicit and explicit). We analyzed data separately and sequentially and present linked themes across samples. Data saturation, rigor, and trustworthiness were discussed and agreed upon by the analytic team.

Results

Six themes arose from the healthcare professional and budtender data: 1) Perinatal customers and patients perceive cannabis to be medicinal, 2) Supporting perinatal people who use cannabis, 3) Spectrum of perceived impacts of perinatal cannabis use, 4) Comparison to use of other substances during pregnancy, 5) Perceived limited knowledge and training about cannabis regulation and product safety, and 6) Current trends of purchase and use.

Conclusion

Participants reported that perinatal patients/customers perceived cannabis to be medicinal, and highlighted non-judgmental/harm reduction strategies for engaging patients/customers. Training is needed for healthcare professionals and budtenders to assist with patient/customer discussions about perinatal cannabis use.

INTRODUCTION

National guidelines state that women should refrain from using cannabis while pregnant and while breastfeeding (1), yet cannabis use during pregnancy has continued to rise (2–4), with past-month cannabis use doubling from 3.4% to 7.0% and daily/near daily use tripling from 0.9% to 3.4% in pregnant individuals from 2002–2017(3). Δ9-Tetrahydrocannabinol (THC) crosses the placenta during gestation (5) and has been linked to lower birth weight, still birth, and neurodevelopmental issues in offspring (e.g., attention deficits, impulsivity/hyperactivity, verbal and visual reasoning difficulties) (6,7). While confounding factors such as tobacco use and sociodemographics make it difficult to note causal evidence of perinatal outcomes, longitudinal cohort studies and meta analyses offer moderate support for such outcomes (7). In addition, as THC passes through breastmilk, it is recommended to eliminate cannabis use while breastfeeding to avoid infant exposure (8).

While the American College of Obstetrics and Gynecologists advises healthcare professionals to ask their patients about cannabis use and offer counseling on adverse health consequences of cannabis (9), many report limited education, training, and support to care for patients who use substances (10). In a state where cannabis is legal, healthcare providers who were surveyed had not received education regarding medical cannabis or clinical best practices, reporting needs for additional training within medical curricula (11). Providers also reported deficits in knowledge and comfort levels in counseling patients about perinatal cannabis use, noting mixed opinions on risks and benefits of perinatal cannabis use (12).

As states continue to legalize adult-use of cannabis, perinatal women are consulting budtenders (i.e., cannabis retailers) for advice on therapeutic effects of cannabis (13). Despite widespread access to cannabis stores/dispensaries, there is limited knowledge about the nature of budtender-customer interactions (14), and even less about budtender interactions with perinatal customers. A previous study found that budtenders with more extensive training prioritized patient-centered decisions and perceived medically-based decision-making as less important with customers (14). Budtenders also recommended THC-dominant products more frequently than cannabidiol (CBD) products with little to no THC to customers seeking appetite stimulation (15), with possible implications for perinatal cannabis use. Another study found that 69% of budtenders recommended using cannabis products to pregnant customers to treat nausea, basing their recommendations on personal opinion that prenatal cannabis use was safe (16). In addition, only 30% of budtenders recommended that pregnant customers discuss cannabis use with their healthcare provider (16). As women report using healthcare professionals and budtenders as a resources for information on cannabis use during pregnancy (13), we conducted a qualitative study to describe healthcare professionals’ and budtenders’ perceived risks and benefits of perinatal cannabis use.

MATERIALS AND METHODS

This study was conducted in Washington, a state that legalized the sale of cannabis for adults (21 years of age or older) in 2012 (17). Medical Marijuana Certified Consultants can assist customers with selecting products that may help with their qualifying medical condition by describing risks and benefits of methods for using products, but they cannot provide medical advice, diagnose conditions, or recommend treatment changes (18). In Washington, it is not against the law for a pregnant individual to have a positive toxicology result for THC. Reports may be made to Child Protective Services once the baby is born and based on suspicion of child abuse and neglect, which may or may not accompany perinatal cannabis use.

A qualitative description methodology was used as the framework for the interviews, the goal being to provide a rich description of participant experiences (19–21). As such, 10 healthcare professionals and 10 budtenders were recruited into the study, enrolling participants until saturation occurred for each of the two participant groups. Data was collected between February 2018 and August 2019. Participants were each given a $50 gift card to recognize their time. The university’s Institutional Review Board approved these studies as exempt from review.

Participants

We first recruited healthcare professionals who self-reported providing healthcare services to women who used cannabis while pregnant or postpartum. Healthcare professionals were recruited to participate through professional contacts (e-mails, announcements at clinic meetings, regional conferences). Budtenders were recruited via advertisement on the Craigslist^™ platform. Budtenders aged 21 or older were eligible to participate based on self-report of employment at a cannabis retail store within the last year.

Procedures

Interviews were conducted by two researchers on the university campus in a clinical lab or over the phone, depending on participant preference. Interview guides are presented in Table 1. Interview questions were centered around opinions about perinatal cannabis use and perceptions of reasons for perinatal cannabis use. Interviews averaged approximately 45 minutes and were recorded and transcribed verbatim with identifying information removed by the transcriptionist. Transcribed data were then made available to the research team.

Table 1.

Interview guides for healthcare professional and budtender participants

Healthcare Professional Interview Guide
Over the last few years, what have you noticed in terms of cannabis use during pregnancy?
Please describe your views (as a healthcare professional) on cannabis use during pregnancy.
Please also share with us your opinions (as a healthcare professional) about cannabis use after delivery/postpartum.
What are your opinions (as a healthcare professional) about using cannabis while breastfeeding?
How do you provide education to pregnant and postpartum women regarding marijuana/cannabis use by women that are pregnant, caring for infants, and while breastfeeding?
What other information (as a healthcare professional) do you think is important for us to know about cannabis use during pregnancy, breastfeeding, and/or parenting an infant?
Budtender Interview Guide
Tell us about your role at the cannabis retailer where you work.
What have you noticed about cannabis purchases in recent years (e.g., demographic of customer/type purchased/increase or decrease in sales)?
Can you describe what would typically happen when a woman that is pregnant comes in seeking to buy product and what advice would you give, if any? Would you advise pregnant women differently than your other customers (e.g., dose/mode of delivery/products/concerns for secondhand smoke)?
What are the main reasons pregnant women report they need cannabis? 5) Would you recommend types or brands of cannabis for the following reasons: Sleep, anxiety, nausea, pain, breastfeeding; What kind of feedback are you getting from pregnant women about the products?
Do you have any cannabis training specific to pregnant women? 9) Do you have any cannabis training specific to breastfeeding women?
What are your personal beliefs about pregnant women using cannabis?
Do you think there is judgment against pregnant women using cannabis in your store? In the cannabis industry in general? If yes, give me an example.
What are your thoughts about any positive effects of using cannabis while pregnant? How about negative effects or using cannabis during pregnancy?
Anything else at all that you would like us to know about pregnant women that use cannabis?

Qualitative analysis

This study was informed by social constructivism (22) as participants’ subjective experiences toward perinatal cannabis use and perceptions of the roles of pregnant women and mothers are informed socially and historically. Healthcare professional and budtender data (interview responses) were collected and interpreted using a qualitative description approach and qualitative content analysis methods (20,21), based on the recommendations of Schreier (19). We analyzed data separately and sequentially across samples, first analyzing healthcare professional transcripts and then budtender transcripts. Four researchers engaged in building a coding frame, dividing the material into coding units, applying and testing the coding frame against the material, evaluating and modifying the coding frame, analyzing the data, and interpreting and presenting the findings (19). Each researcher took marginal notes while analyzing the data and at analytic meetings, an iterative process combining concept- and data-driven analysis was used to distill the data into themes. Next, themes were generated for participant responses within each separate sample (implicit and explicit), and based on congruence of themes across the data, the themes were then connected across the two samples (healthcare professionals and budtenders). Any discrepancies in theme development were discussed among the analysts and the final themes were reached via consensus. Steps were taken to provide rigor and trustworthiness to the study, to improve credibility, confirmability, dependability, and transferability (23,24), including purposeful sampling, rich description of responses, providing direct quotes from participants in the manuscript, and keeping an audit trail to track theme development, meetings, and process, to provide trustworthiness and rigor to the data analysis. Data was collected as a set of 10 budtenders and 10 healthcare professionals and analyzed with the intention that lack of saturation would suggest the need for additional interviews. Analysts agreed that while a wide spectrum of responses was provided by participants, themes were readily identifiable, and saturation was reached based on frequency of consistent data supporting each theme, with no new data offering additional unique information.

RESULTS

Participant characteristics

Healthcare professionals consisted of 10 women who worked in Washington. Nine participants were nurses (two public health nurses, five nurses working in the neonatal intensive care unit, one nurse midwife, and one labor and delivery nurse) and one participant was a pediatric occupational therapist. Budtenders were seven women and three men who worked in cannabis retail stores in Washington in which six participants worked in a store with a Medical Marijuana Certified Consultant and two participants self-reported being a Medical Marijuana Certified Consultant. No other demographic information was collected from participants to ensure data were non-identifiable.

Qualitative descriptive themes

Six themes arose from the healthcare professional and budtender data: 1) Perinatal customers and patients perceive cannabis to be medicinal, 2) Supporting perinatal people who use cannabis, 3) Spectrum of perceived impacts of perinatal cannabis use, 4) Comparison to use of other substances during pregnancy, 5) Perceived limited knowledge and training about cannabis regulation and product safety, and 6) Current trends of purchase and use. We detail the themes and provide exemplary quotes below.

Theme 1: Perinatal customers and patients perceive cannabis to be medicinal

Healthcare professionals and budtenders both noted that perinatal women report using cannabis for medical, and not recreational, reasons. Relief from nausea, anxiety, pain, and stress are noted to be the most common reasons perinatal women are using cannabis.

I do think that women have less anxiety [when using cannabis]. And I do think it helps them with nausea in early pregnancy. And that’s primarily the two reasons my women use it. They’re not using it to get high.

-#7, healthcare professional

So I would say the most common from pregnant women would be nausea and pain that they’re looking for relief from.

-#1 budtender

Some budtenders assumed the pregnant customer was consulting with their healthcare professional to determine safe use of cannabis during pregnancy.

You know, obviously, they’re talking with their doctors, they’re being safe about it. That’s the biggest thing is everybody’s being healthy.

-#3 budtender

Comparisons with prescription medications also arose from healthcare professionals and budtenders.

[…] people who don’t want to take drugs for depression or for anxiety issues. They don’t want to take other drugs, but they will utilize marijuana for that purpose.

-#7, healthcare professional

I’d much rather she – everybody indulging in cannabis for pain and medical issues than I would Big Pharma making money and making us all into a bunch of pill junkies.

-#14, budtender

Healthcare professionals and budtenders reported that perinatal patients/customers are using cannabis for health-related reasons, often related to pregnancy, but some perinatal individuals use cannabis for chronic health issues. Comparisons to medications and “Big Pharma” were made by participants as they reported that patients/customers are looking for alternatives to pharmaceuticals.

Theme 2: Supporting perinatal people who use cannabis

Healthcare professionals and budtenders described supporting perinatal people with varying levels of nonjudgmental interactions and harm reduction approaches. Healthcare professionals noted that their goal was to provide nonjudgmental care to their patient.

So I always try to be nonjudgmental and tell them I know it’s a legal substance, but I just need to educate them on the risks and what we don’t know about it.

-#5, healthcare professional

However, they also stated that this was not always the case with colleagues. Not discussing cannabis use with pregnant patients due to personal attitudes and not being prepared to address perinatal cannabis use were noted by healthcare professionals.

So a lot of nurses just won’t even talk about it with the mamas. They won’t breach it ‘cause they’re so angry that mama would do that to the baby. It’s very split.

-#6, healthcare professional

I don’t know if many are bringing up the subject because they don’t have a lot of information to say one way or another. And if you bring it up, then you have to deal with it.

-#7, healthcare professional

Budtenders also described nonjudgmental service to the customer and treating pregnant customers like they would treat any other customer were important in their roles.

I mean, I’m not going to make judgment on a gal if she wants to be able to eat.

-#14, budtender

Harm reduction approaches were common with budtenders; nearly all budtenders stated that they guide pregnant women toward low-THC products or products containing CBD. Some noted recommending edible THC over smoked products because they perceived this to be safer.

There’s not a law against it, so we can’t stop them, but we try to persuade them if you’re gonna do this – do cannabis – go more for the edibles than the smoking. We’re trying to prevent people from doing the smoking if they’re pregnant.

-#18, budtender

If she was worried about having any THC in her, then I would definitely tell her not to buy anything at the store […] I immediately refer them to a CBD store that has no THC in it because that’s what they’re looking for.

-#20, budtender

Harm reduction approaches were discussed less frequently by healthcare professionals. However, they did note education with perinatal patients was about decreasing use in order to decrease harm. Emphasis on infant safety was the focus of harm reduction approaches for healthcare professionals.

How do we move forward and again give these kids the best success rate? Their parents are going to smoke marijuana. Okay, so how do you make it safe for a kid?

-#6, healthcare professional

Healthcare professionals and budtenders discussed ways to serve perinatal patients/customers in ways that would help decrease stigma. While different approaches were used by the groups of participants, healthcare professionals noted the need for colleagues to also engage with patients to share the risks of perinatal cannabis use.

Theme 3: Spectrum of perceived impacts of perinatal cannabis use

Healthcare professionals described negative impacts of perinatal cannabis use related to the infant, mother, and breastfeeding. Premature birth, infant feeding issues, meconium staining, meconium aspiration, slow development, and infant cannabis withdrawal were noted as impacts of perinatal cannabis use.

They can’t coordinate, suck, swallow, breathe […] And then after that spell of being lazy, then they’re irritable with lack of soothing with the mom that wants to formula feed. [….] So they try to tell me that there’s no withdrawal. Oh, my gosh. There’s withdrawal.

-#6, healthcare professional

And her baby was getting breastmilk, and it was just a very, very sleepy baby. And we could not get it to eat, it wouldn’t do anything. It would just basically lay there.”

-#1, healthcare professional

Budtenders had a wide spectrum of beliefs about impacts of perinatal cannabis use: some described positive impacts related to the mother while others noted adverse infant and breastfeeding effects. Some budtenders believed that there are no impacts, or a lack of evidence for negative impacts, of perinatal cannabis use.

I honestly don’t think that there is any [negative effects]. I know that obviously as far as like research-wise and stuff there isn’t.

-#19, budtender

I mean, postpartum, I feel like go ahead, do whatever you’re gonna do. It’s not even an issue. I’m going to sell it to you.

-#20, budtender

I know that sometimes it can cause developmental delays or like children whose mothers used marijuana have difficulty regulating emotions better … we haven’t seen this kind of marijuana use in humans ever before. And I think it’s something that unfortunately we’re just going to have to see play out in this generation.

-#15, budtender

Healthcare professionals and budtenders offered conflicting statements about cannabis use and breastfeeding. Particularly for healthcare professionals, there exists a tension between advocating for breastfeeding versus counseling a patient to avoid breastfeeding if using cannabis.

But at this point, it’s still recommended that we recommend breastfeeding.

-#7, healthcare professional

They either have to quit [cannabis] or they have to quit breastfeeding.

-#3, healthcare professional

[….] so nurse first if you plan on having active THC. When you’re done, then that’s fine. Obviously, it’s still in your system, but it’s not active.”

-#13, budtender

Healthcare professionals and budtenders were aware of the increase of THC in current cannabis products and linked that increase to uncertainty of the impacts of perinatal cannabis use.

Theme 4: Comparison to use of other substances during pregnancy

Comparing perinatal cannabis use to perinatal alcohol and cigarette use was common for healthcare professionals and budtenders, but with divergent views. Healthcare professionals likened cannabis to alcohol and cigarettes in terms of legal status and harm to the fetus and baby.

And that’s the one thing healthcare providers need to really say is, “Yes, alcohol is legal in the state. Marijuana is legal in the state. But neither one of them are healthy for you during your pregnancy or your fetus or to have in your breastmilk.” We need to get the scripts out for healthcare providers

-#10, healthcare professional

They see it as, “oh, it’s legal. It’s okay.” You’ll ask ‘em about tobacco use, and they have a much worse image of tobacco use than marijuana use. They think it’s more benign than tobacco use.

-#7, healthcare professional

Conversely, most budtenders said that cannabis was much safer to use than cigarettes or alcohol during pregnancy.

You know, cannabis seems to be so normal and adaptable with the human body that it just – it doesn’t seem as damaging as something like alcohol or cigarettes in my view.

-#16, budtender

I believe that if a woman wants to do that [use cannabis], there’s no harm in it. I mean, smoking tobacco – that’s different.

-#18, budtender

Budtenders also discussed fetal alcohol spectrum disorders (FASD), and negative physical impacts of alcohol use during pregnancy on the baby compared to cannabis use during pregnancy.

But it’s rough when you don’t have babies – you don’t have weed babies. Like you have fetal alcohol babies where you can really see the negative impact. So I think that it’s a really difficult thing. People don’t associate the really bad effects with that.

-#15, budtender

Budtenders noted stark differences in perceptions of harm between perinatal cannabis use versus perinatal alcohol or tobacco use. Conversely, healthcare professionals perceived the comparisons of legal substances as helpful when educating perinatal patients.

Theme 5: Perceived limited knowledge and training about cannabis regulation and products safety

Healthcare professionals and budtenders alike noted the need for training for themselves, colleagues, and patients/customers. Healthcare professionals also highlighted the need for additional research to help with patient education.

I think we need more education on either it is safe or it’s not safe. Let us know what we’re going to teach and I’ll put my personal opinions aside and teach that.

-#6, healthcare professional

Similarly, budtenders described a desire for more training, customer guides, etc. However, they also noted skepticism of state-sponsored training and information pamphlets.

People come to budtenders with a lot of questions, expecting them to have answers. There’s a lot of what I call ‘stoner science’, which is kind of just unverified claims about marijuana that are made by users and – and retail associates.”

-#16, budtender

I think everyone would’ve been really excited to have more information. We would’ve been over the moon to have like a central guide to what not to recommend, what were the actual effects, what were not the effects. But what the problem is is then if it comes like from a government agency or like from the LCB [Liquor Cannabis Board], there’s – like people don’t really believe them when they advise about weed and pregnancy and stuff like that.

-#15, budtender

Healthcare professionals also did not feel knowledgeable about cannabis products and a few budtenders noted the same concern. Budtenders spoke of wanting a central guide to help them best serve their customers.

[…] That healthcare providers be given information on something as simple as what’s the difference between CBD and THC.

-#10, healthcare professional

So budtenders often don’t have a lot of info about what they’re selling [….] And we kind of have to guess what it is. I can’t tell you how many times I would like literally Google a strain, and there was no information about the strain so we’d just come up with whatever just to sell it. It was – it was insane […]It’s just like this crazy – it’s like the Wild West of industries.

-#15, budtender

New cannabis products and newer modes of ingestion are causing healthcare professionals to want ongoing training and accessible information for perinatal patients. Not knowing this information is causing healthcare professionals to feel ill prepared for these discussions with patients.

Theme 6: Current trends of purchase and use

Healthcare professionals discussed the prevalence of perinatal cannabis use versus an increase in disclosure of use post-legalization. Our sample was split with respect to whether perinatal cannabis use is now more prevalent or if legalization has led to increased disclosure.

I think use has skyrocketed since it has become legal.

-#7, healthcare professional

And so I’ve actually completely changed the way I do a hospital intake with the patient in terms of the way that I talk to people about substances, because it is so prevalent

-#3, healthcare professional

I don’t know if we’re seeing more marijuana use, but it’s more disclosed.”

-#5, healthcare professional

Budtenders noticed an increase in perinatal cannabis use regardless of location. They also stated that there had been an increase in perinatal cannabis use purchases from pre-legalization, when only medical cannabis was available for purchase, to post-legalization.

… It definitely I think is starting to evolve. People are starting – especially pregnant women – are starting to feel more comfortable.”

-#13, budtender

We don’t get a lot of pregnant women, but we get a lot of women that just had a baby.

-#18, budtender

Lastly, Child Protection Services (CPS) involvement was discussed by healthcare professionals, noting a decrease in CPS involvement or legal ramifications for perinatal cannabis use.

And then it used to be that that would be us calling to CPS or some kind of red flag, but now it’s just like, “oh, it’s just marijuana.”

-#2, healthcare professional

CPS isn’t going to take the kid away. So that used to be a lot of go-to’s. “Let’s call CPS.” That’s – that’s kinda gone.

-#6, healthcare professional

Perinatal cannabis use used to be a warning for risky behavior in which CPS needed to be involved, and CPS was also as a deterrent when talking to patients about their cannabis use. Currently, perinatal cannabis use and CPS are not as interconnected.

DISCUSSION

Healthcare professionals and budtenders reported that the primary reasons perinatal people use cannabis are for relief from nausea, anxiety, pain, and stress. This corresponds with previous research establishing that perinatal people were using cannabis for health management (13,25) and sought advice regarding the therapeutic effects of cannabis (16). Comparisons to prescription medications were made by both healthcare professionals and budtenders, with contrasts between cannabis and “Big Pharma” highlighted by budtenders, in line with research with medical cannabis card holders who noted fewer side effects with cannabis compared to other prescription medications (26).

Non-judgmental strategies (asking questions, seeking additional information, etc.) were discussed by healthcare professionals and harm reduction strategies (CBD and low THC products) were noted by budtenders. CBD, having low to zero THC and different psychoactive effects than THC, is being used by pregnant individuals to help with nausea, pain, and anxiety (27), however, the US Food and Drug Administration advises against the use of CBD products while pregnant or breastfeeding (28). Previous studies with healthcare providers indirectly support our finding that there is a need for nonjudgmental harm reduction approaches; studies report that healthcare providers, including obstetric providers, do not counsel pregnant patients about cannabis use, or if they do, describe cannabis in terms of policy and legal consequences (12,29). This is unfortunate as research has established that the threat of CPS often deters women from involvement with the healthcare system (30–32). Pregnant women have also reported feeling stigmatized by healthcare professionals due to perceived lack of communication (33), gaps in healthcare professional education about cannabis use during pregnancy (13), perceived risk-taking behavior (34), race/ethnicity or class status (35), and potential legal ramifications regarding cannabis use (13). Perinatal individuals who violate gender norms and expectations of the “good mother” are often labeled as risky, resulting in additional stigmatization (34). Perinatal individuals stigmatized due to their substance use also have barriers in accessing and maintaining support to reduce harms associated with their substance use (36). This stigma is often even more pronounced for women of color, as structural racism disadvantages women of color who report or are suspected of perinatal substance use, contributing to poor reproductive health outcomes (35).

Perinatal patients report seeking additional sources of information from budtenders, internet, friends, and family (13,30), and describe interactions with healthcare professionals about perinatal cannabis use as generally unhelpful (30). Although research with budtenders is limited, they have been described by perinatal people as unbiased and having a customer-centered approach (13). Taken together, this highlights the critical need for healthcare professional education and training regarding perinatal cannabis use. (10–12,37) Indeed, healthcare professionals and budtenders in the current study stated the need for more research, education, and training related to perinatal cannabis use and cannabis products.

Healthcare professionals and budtenders reported seeing more perinatal cannabis use yet it was unclear whether the prevalence of perinatal cannabis use was higher, as noted by national trends (2–4), or if women were more likely to report cannabis use post-legalization due to more general acceptance and lack of legal consequences. Healthcare professionals noted the need to change their clinical practices to address the increase in perinatal cannabis use, while budtenders observed more postpartum customers.

Healthcare professionals focused on the possible negative impacts of perinatal cannabis use whereas budtenders presented a wide spectrum of attitudes regarding perinatal cannabis use. Previous research found that many healthcare professionals have reported not being familiar with risks of cannabis use during pregnancy (12), yet discourage perinatal substance use (29). Budtenders in this study had a wider range of responses regarding perceived impacts of perinatal cannabis use, yet our results align with those demonstrating that budtenders describe cannabis use as safe for the woman during pregnancy, with few noting concerns about fetal safety (16). Perceived impacts of cannabis use appear to be based on the personal opinion of budtenders (14,16), which was the case in the current study. In contrast, healthcare professionals stated that they would follow research and national guidelines regarding perinatal cannabis use, whether or not it aligned with their personal beliefs regarding use. Interestingly, our data do not support perceptions of a spectrum of cannabis use. Instead, our healthcare professionals discussed perceived impacts that they see in infants that were admitted to the NICU and infants that were withdrawing from cannabis, suggesting a binary perspective of no cannabis use versus heavy cannabis use.

Healthcare professionals and budtenders compared cannabis use to alcohol and tobacco use. Healthcare professionals stated that cannabis (like alcohol and tobacco) is legal yet not recommended or safe to use during pregnancy or while breastfeeding, whereas budtenders stated perinatal cannabis use should not be viewed with the same negative lens as alcohol and tobacco use (16). Healthcare professionals have described cannabis as less harmful than illicit drugs (12,29) and our study finds that they view perinatal cannabis use similar to perinatal alcohol and tobacco use, which presents a guiding framework for discussions with perinatal patients.

Limitations of this study include participants who were primarily women, nurses, and from one state. Views regarding perinatal cannabis use may differ across states depending on if/when the sales of adult-use cannabis were legalized. Given the limited number of studies from healthcare professional and budtender perspectives, we did not expect that 85% of our sample would identify as women. Nurses who are women may feel more committed to reducing perinatal cannabis use and this may have been reflected in the study results. Additionally, not all healthcare professions were represented in our study. Physicians, pharmacists, social workers, etc., may have different perspectives on risks and benefits of perinatal cannabis use. However, as many healthcare professionals engage with perinatal women regarding health behaviors, we believe that we have adequately captured themes from healthcare professionals. Additional research should focus on additional healthcare professionals, including healthcare professionals caring for perinatal people outside of the hospital setting.

Training is needed for healthcare professionals to assist with patient discussions about cannabis products and to manage changes in clinical practices due to increases in perinatal cannabis use. Budtenders also need training on cannabis products and request training on how to best serve perinatal customers. We encourage researchers and healthcare professionals to work with patients and budtenders to better serve perinatal women that use cannabis. Combined efforts are crucial for harm reduction approaches and will help decrease stigmatization perceived by perinatal women who use cannabis.