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Cannabis legalization may have made use easier in pregnancy

Kaiser Permanente researchers conduct focus groups with pregnant patients, who say California law reduced cannabis stigma

California’s legalization of cannabis for adult use may have reduced the stigma of using cannabis products during pregnancy and made them easier to obtain, according to new research from Kaiser Permanente investigators.

Kelly Young-Wolff, PhD, MPH

Their study, published December 14 in JAMA Network Open, reported insights from 18 virtual, 90-minute focus groups with 53 Black and white pregnant patients who said they used cannabis during early pregnancy.

Many of the women said the reduced stigma made it more likely they would use cannabis during pregnancy, but also made them more comfortable talking with their doctors about it. Current medical advice recommends against prenatal cannabis use because of the possible harms to the baby after birth, including low birthweight and potential neurodevelopmental problems.

“This focus group study is so important because it allowed us to hear directly from patients who use cannabis during pregnancy, providing rich, valuable, and actionable qualitative data,” said lead author Kelly Young-Wolff, PhD, MPH, a research scientist at the Kaiser Permanente Division of Research. “These findings can be used to improve patient-doctor communication, inform health-promoting cannabis regulation, and educate cannabis retailers.”

Understanding increased use

Young-Wolff and her research team have published studies documenting increased rates of prenatal cannabis use over the past decade, and found that it is more likely among pregnant patients who experienced nausea, depression, anxiety, and trauma. Their research uses unique data from routine prenatal substance use screening of a large, diverse population in Kaiser Permanente Northern California (KPNC).

For this qualitative study, the research team recruited women with prenatal cannabis use to hear directly how and why they use cannabis, with a focus on the effects of California’s legalization. Recreational cannabis use was authorized by voters in 2016 and legal sales began in 2018. The researchers included pregnant patients who self-reported daily or weekly cannabis use during pregnancy to reach those for whom cannabis may play a significant role in their lives.

It was clear that patients were eager for more concrete information about how cannabis might influence their health and that of their babies.
—Esti Iturralde, PhD

Participants consistently said that since legalization, there has been an increase in cannabis use among pregnant individuals they know and greater acceptance of cannabis use both in general and during pregnancy. Legalization also led some of the women to be more willing to discuss cannabis use with their women’s health providers; one participant said a conversation with her obstetrician resulted in her quitting use during her pregnancy.

Andrea Green, PsyD

Findings suggest that legalization has reduced barriers to prenatal cannabis use, but also created opportunities to better support pregnant patients who use cannabis.

“For some people cannabis is very entrenched in their lives, and we need to be able to talk about it,” said Kaiser Permanente psychologist Andrea Green, PsyD, who led the focus group of Black women. Green works with the KPNC Early Start program, which provides support for pregnant patients. “They want to feel like they can have these conversations with their doctors without being judged,” Green said. “They go into labor and delivery and their chart may mention cannabis use, and they just don’t want to be treated differently. That’s especially important for Black women, who find it hard to tease apart whether they are being treated differently because they are Black or for some other reason. They want to be treated with respect.”

Participants also expressed how legalization has contributed to greater access to cannabis through ubiquitous cannabis retailers, delivery options, and marketing and advertising. In general, participants trusted cannabis retailers to provide them with safe products and expert advice about which types of cannabis products to use for pregnancy-related symptoms. They described their relationships with budtenders as nonjudgmental and providing a sense of community.

Tara Foti, PhD

Tara Foti, PhD, MPH, a research fellow with the Division of Research who led the focus groups of white women, said many of them reported appreciation that researchers were interested in their thoughts about their use of a legal product they see as beneficial. “For some women, there is a sense of being a trailblazer and lighting the way for better acceptance of cannabis use,” she said.

“These focus groups have provided us with key insights into the ways rapidly shifting cannabis policy affects people’s lives during pregnancy,” said senior author Esti Iturralde, PhD. “It was clear that patients were eager for more concrete information about how cannabis might influence their health and that of their babies.”

Regulation, education could follow

With the focus group insights in hand, the authors developed a list of potential interventions and research opportunities to reduce cannabis-related harms for pregnant individuals. These include limiting the neighborhood concentration of cannabis retailers, restricting billboard advertising, and prohibiting health claims related to pregnancy or breastfeeding. They also highlighted the need for further research to learn the risks of different products and modes of use in pregnancy.

Esti Iturralde, PhD

The researchers also suggested research and education focused on individuals who work at cannabis retailers, known as budtenders, to learn about their attitudes about prenatal cannabis use and to provide them with the latest research findings on the health effects. “It will be important to leverage budtender relationships with customers to support future public health interventions,” Young-Wolff said.

The research team expects to publish further qualitative research on pregnant women’s perceptions of potential harms and desired information about risks, how they balance pros and cons of different modes of administration, and the impact of the COVID-19 pandemic.

The research was funded by the National Institute on Drug Abuse and a Division of Research Health Equity Research Supplement, supported by Kaiser Permanente Northern California Community Health.

Additional co-authors were Andrea Altschuler, PhD, Monique B. Does, MPH, Melanie Jackson-Morris, MS, Sara R. Adams, MPH, and Maha N. Mian, PhD, of the Division of Research; and Deborah Ansley, MD, Amy Conway, MPH, and Nancy Goler, MD, of The Permanente Medical Group.

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About the Kaiser Permanente Division of Research

The Kaiser Permanente Division of Research conducts, publishes and disseminates epidemiologic and health services research to improve the health and medical care of Kaiser Permanente members and society at large. It seeks to understand the determinants of illness and well-being, and to improve the quality and cost-effectiveness of health care. Currently, DOR’s 600-plus staff is working on more than 450 epidemiological and health services research projects. For more information, visit or follow us @KPDOR.

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