“They might take my baby away”: experiences of using cannabis during pregnancy in California while engaged in perinatal care

In 1996, California became the first state to establish a medical marijuana program in the United States. Ten years later, it became the fifth state in the country to legalize cannabis in November 2016. Seven years later, Rachel Carmen Ceasar, PhD, assistant professor of clinical population and public health sciences at Keck School of Medicine of USC, is exploring the unintended maternal health consequences of legalization for people who use cannabis use during pregnancy. “While there is vast research conducted on the use, patterns, and motivations of cannabis use, less is known about the unique challenges and stigma faced by people who use cannabis during pregnancy from their health care providers,’ divulges Ceasar, who also serves as director of the USC Maternal Cannabis Lab.

Ceasar conducted a qualitative study using data from the MADRES study to capture the experiences, motivations and challenges of Black and Latina people using cannabis during pregnancy and engaged in perinatal care. Black, Indigenous, and Persons of Color (BIPOC) are disproportionately affected by laws that criminalize substance use during pregnancy.

“Despite cannabis being legal in California we found that when participants disclosed cannabis use during pregnancy, they received threats from their health care providers about family separation and taking their babies away from them. Another finding revealed actual punitive action where child services were called in. When health care providers discovered babies had tested positive for THC, they separated them from their parents—even after patient’s records reflected cannabis disclosure multiple times,” she reports.

Yet, participants expressed not intending to jeopardize their babies’ health. They had turned to cannabis as an alternative therapy to pharmaceuticals and the medical system, which they felt offered them inadequate care or support during pregnancy. “Just about every person we talked to had tapered or changed their use in some way across pregnancy to what they perceived was safer,” Ceasar maintains. Notably, a quarter of the cohort reported having hyperemesis (severe vomiting and nausea during pregnancy) and had used cannabis to alleviate their symptoms.

“I am surprised this is happening in California—a legal and open environment,” shares Ceasar. “Why do we have different rules for pregnant folks?” Ceasar has worked with Alameda and Santa Barbara County public health departments to lend her research to support education efforts across the state. “We are putting together educational materials so that people can have evidence-based research to address knowledge gaps using a harm reduction approach,” she explains. Her efforts are advancing health education across departments of public health in California.

Similarly, health care providers want more information about caring for people who use cannabis during pregnancy. In a subsequent study, Ceasar spoke to providers in safety net health settings who disclosed they did not have sufficient evidence on the effects of cannabis use during pregnancy to advise or counsel their pregnant patients. In these instances, she found providers relied on self-directed education to inform their knowledge gaps, and weighed cannabis pros and cons on a case-by-case basis. Providers also shared their awareness of the link between the medical and criminal justice systems and wanted to preserve the provider-patient relationship. As a result, they purposely avoided cannabis use inquiry for fear of stigmatizing patients and losing them to care. Without definitive evidence demonstrating the exact adverse outcomes and magnitude of risks, there is often confusion and miscommunication among pregnant people and providers about the use of cannabis during pregnancy.

Additionally, providers have varying views of cannabis legalization which may impact their standard of care. “I’m amazed that anyone discloses cannabis use,” Ceasar remarks. Some participants shared that after disclosure, providers treated them as though they had a substance use disorder and incorporated frequent urine tests at every visit to test for THC. “In future studies we want to understand the extent of changes in care as a result of disclosure,” Ceasar states. It is critical to study how social-structural contexts—such as provider bias or opinion play a role in provider decision-making surrounding patient cannabis use during pregnancy.

As states continue to legalize cannabis use, providers will play a critical role in guiding patients about cannabis use during pregnancy. It is crucial for public health campaigns to build confidence in providers on how to respond to the disclosure of cannabis use, and capitalize on the window of opportunity to bring and retain patients into the health system.