Cannabis use, cannabis use disorder and mental health disorders among pregnant and postpartum women in the US: A nationally representative study

Cannabis use is contraindicated during pregnancy and postpartum due to potential risks to maternal and child health (ACOG, 2017; Badowski and Smith, 2020; 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; Brown et al., 2017) and 47% among non-pregnant reproductive-age women (increasing from 6.29% to 9.27% from 2002 to 2014) (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, 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 issues 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 matter 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 and 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 issues 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.

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