Introduction
Cannabis use is contraindicated during pregnancy and postpartum due to potential risks to maternal and child health (American College of Obstetricians and Gynecologists [ACOG], 2017; Badowski and Smith, 2020; S. J. Brown et al., 2016; Calvigioni et al., 2014; Dong et al., 2018; El Marroun et al., 2018; Gabrhelik et al., 2021; Gunn et al., 2016; Haight et al., 2021; Kharbanda et al., 2020; Luke et al., 2019; Marchand et al., 2022; Mark et al., 2021; Meinhofer et al., 2022; Nguyen and Harley, 2022; Ordean and Kim, 2020; Paul et al., 2020; Ryan et al., 2018; U.S. Department of Health and Human Services, 2019; Volkow et al., 2017; Young-Wolff et al., 2020). Despite public health messaging and recommendations from the ACOG and the American Academy of Pediatrics (AAP) that women abstain from cannabis use during pregnancy and postpartum (ACOG, 2017, Ryan et al., 2018), the prevalence of cannabis use in the US has increased more than 110% among pregnant women (increasing from 2.37% to 4.98% from 2002 to 2016 (Agrawal et al., 2019; Q. L. Brown et al., 2017) and 47% among non-pregnant reproductive-age women (increasing from 6.29% to 9.27% from 2002 to 2014) (Q. L. Brown et al., 2017).Additionally, rates of prenatal cannabis use disorder (CUD) have increased more than 5-fold in the US from 1993 to 2014, rising from 18.53 to 93.64 cases per 10,000 pregnancy-related delivery hospitalizations (Shi and Zhong, 2018). Moreover, in one US nationally representative study, the prevalence of CUD was significantly higher among pregnant women (18.1%) than non-pregnant reproductive-age women (11.4%) (Ko et al., 2015), indicating that pregnant women may be particularly vulnerable to CUD. Prior research illustrates that cannabis use and CUD are problematic during and around the time of pregnancy. However, it is unclear why women in the US are using cannabis during pregnancy and postpartum despite public health messaging to abstain. Nationally representative studies are needed to examine this.
Pregnant and postpartum women use cannabis to relieve stress, anxiety and cope with mental health symptoms (Barbosa-Leiker et al., 2020, Ko et al., 2020, Vanstone et al., 2021), which may indicate that they are self-medicating mental health conditions. However, little is known about the mental health correlates of cannabis use and CUD in nationally representative samples of pregnant and postpartum women. Prior research shows associations between prenatal cannabis use, CUD and mental health problems, but studies used patient-based data, were limited by geographic location, and/or had relatively small sample sizes (Chang et al., 2019, Emery et al., 2015, Latuskie et al., 2019, Mark et al., 2021, Meinhofer et al., 2022, Nagel et al., 2021, Young-Wolff et al., 2020), which may not be representative of the broader population making it impossible to determine whether the issues (i.e., positive associations between prenatal cannabis use, CUD and mental health) observed in smaller studies are problems at the national level. Extant nationally representative studies are limited in that they focused on prenatal cannabis use, not CUD, used older Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) criteria or self-reported measures of mental health and focused on only anxiety and depression (Goodwin et al., 2020, Oh et al., 2017). The few studies examining cannabis use and mental health during postpartum have small sample sizes (Barbosa-Leiker et al., 2020, Vanstone et al., 2021). Extant research is dated, lacks generalizability and/or is limited in scope.
It is unknown what general classes (e.g., any mood disorder) or specific types of DSM-5 mental health disorders (e.g., major depressive disorder, persistent depressive disorder) are associated with cannabis use and CUD among pregnant and postpartum women in the US. Studies examining mental health correlates of cannabis use and CUD among the same population are needed to determine whether mental health correlates of cannabis use differ from those associated with CUD among pregnant and postpartum women. Moreover, examining both general classes and specific types of mental health disorders can provide a more complete understanding by elucidating potential differences in cannabis use or CUD by specific types of mental health disorders that would be missed in aggregate data. Comprehensive, generalizable research using up-to-date diagnostic criteria is needed to examine the relationship between cannabis use, CUD and mental health during pregnancy and postpartum to estimate the scope of this problem in the US, especially given the current sociopolitical landscape where the majority of states have legalized cannabis for medical or non-medical use (National Conference of State Legislatures NCSL, 2023). Given the rapid legalization of cannabis use followed by an increase in access and availability of cannabis and the potential for misinformation regarding the safety of cannabis use during and around the time of pregnancy (Brown, Hasin, 2019), it understandable why some women may be using cannabis for various reason including to self-medicate mental health symptoms during pregnancy and postpartum. Prevention interventions aimed at reducing cannabis use, CUD and mental health problems among pregnant and postpartum women in the US should be based on nationally representative data. We therefore conducted the first nationally representative study of the relationship between mental health disorders, cannabis use and CUD among women pregnant in the past year (i.e., currently pregnant and recently postpartum women). We used data from the 2012 to 2013 National Epidemiologic Survey on Alcohol and Related Conditions-III (NESARC-III) to examine associations between general classes and specific types of mental health disorders, cannabis use and CUD using DSM-5 criteria while controlling for covariates. Mood, anxiety, personality and post-traumatic stress disorders were examined as correlates of cannabis use and CUD.
Section snippets
Sample and procedures
The NESARC-III is a nationally representative, cross-sectional, face-to-face survey of 36,309 US adult civilians,18 years and older living in households and select noninstitutionalized group quarters (Grant et al., 2014, Grant et al., 2015a, Hasin et al., 2015a). Respondents were randomly selected through multistage probability sampling. Hispanic, Black and Asian respondents were oversampled (Grant et al., 2014, Grant et al., 2015a, Hasin et al., 2015a). The overall response rate was 60.1%,
Results
Descriptive characteristics are reported in Table 1. Twenty-three percent of women who used cannabis in the past year, but did not have CUD used cannabis daily or near daily compared to 66% of women with CUD (Table 2). Of the pregnant and postpartum women, 12 (0.7%, standard error [SE] =0.21) reported using cannabis medically, 9 of whom also used non-medically (0.6%, SE=0.23) and 3 who used medically-only (0.2%, SE=0.09). The odds of past-year cannabis use were significantly higher among those
Discussion
Most states have legalized cannabis use for medical or recreational purposes (NCSL, 2023). However, there is little evidenced-based health policy guidance regarding how information on the safety of prenatal and postpartum cannabis use should be conveyed to the public including how this information is displayed at cannabis dispensaries (e.g., via posted warning signs similar to alcohol policies adopted by some states), communicated by budtenders to pregnant and postpartum customers and reflected
Conclusions
From pregnancy up to one year postpartum is a critical period where women may be particularly vulnerable to mental health disorders, cannabis use and CUD. Screening, treatment and clinic- and population-level prevention efforts are essential during this time, especially given that of the pregnant and postpartum women who used cannabis non-medically in the past year, more than 1 of 3 used daily or near daily (Table 2). While screening may be common practice among some healthcare providers, other
Role of Funding Source
This work was supported by National Institute on Drug Abuse grants R25DA035163 (Brown) and K01DA043604 (Young-Wolff). The funding organization had no role in the design and conduct of the study; collection, management, analysis and interpretation of the data; preparation, review or approval of the manuscript; and decision to submit the manuscript for publication.
CRediT authorship contribution statement
Dr. Brown conceptualized and designed the study, developed the analysis plan and wrote the initial draft of the manuscript. Drs. Shmulewitz, Sarvet and Hasin provided consultation on design and analysis plan. Dr. Shmulewitz conducted the data analysis and had full access to all the data in the study. All authors made significant contributions to the writing and development of subsequent drafts of the manuscript, interpretation of the results and approved the final version of the manuscript.
Declaration of Competing Interest
No conflict declared.
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