Rates of Prenatal Cannabis Use Among Pregnant Women Before and During the COVID-19 Pandemic | Adolescent Medicine | JAMA | JAMA Network
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Figure.  Monthly Trends in Cannabis Use During Pregnancy Before and During the COVID-19 Pandemic (N = 100 005)
Monthly Trends in Cannabis Use During Pregnancy Before and During the COVID-19 Pandemic (N = 100 005)

Prenatal cannabis use was based on a positive toxicology screening result conducted as part of standard prenatal care (≈8 weeks’ gestation) and includes 1 screening per pregnancy. All positive toxicology test results were confirmed by a laboratory test (see Laboratory Methods in the Supplement). The median monthly sample size in the months before COVID-19 was 4085 (range, 3655-5040), with a mean of 4189. The median monthly sample size in the months during COVID-19 was 4124 (range, 3932-4356), with a mean of 4130. Error bars indicate 95% CIs of the standardized rates.

Table.  Change in Percentage of Cannabis Use During Pregnancy After the Start of the Pandemica
Change in Percentage of Cannabis Use During Pregnancy After the Start of the Pandemica
1.
Volkow  ND, Han  B, Compton  WM, McCance-Katz  EF.  Self-reported medical and nonmedical cannabis use among pregnant women in the United States.   JAMA. 2019;322(2):167-169. doi:10.1001/jama.2019.7982PubMedGoogle ScholarCrossref
2.
Ko  JY, Coy  KC, Haight  SC,  et al.  Characteristics of marijuana use during pregnancy—eight states, Pregnancy Risk Assessment Monitoring System, 2017.   MMWR Morb Mortal Wkly Rep. 2020;69(32):1058-1063. doi:10.15585/mmwr.mm6932a2PubMedGoogle ScholarCrossref
3.
Davenport  MH, Meyer  S, Meah  VL, Strynadka  MC, Khurana  R.  Moms are not OK: COVID-19 and maternal mental health.   Front Glob Womens Health. 2020;1:1. doi:10.3389/fgwh.2020.00001Google ScholarCrossref
4.
Basu  A, Kim  HH, Basaldua  R,  et al.  A cross-national study of factors associated with women’s perinatal mental health and wellbeing during the COVID-19 pandemic.   PLoS One. 2021;16(4):e0249780. doi:10.1371/journal.pone.0249780PubMedGoogle Scholar
5.
California Department of Tax and Fee Administration. Cannabis tax revenues. Accessed July 29, 2021. https://www.cdtfa.ca.gov/dataportal/dataset.htm?url=CannabisTaxRevenues
6.
Committee on Obstetric Practice.  Committee opinion No. 722: marijuana use during pregnancy and lactation.   Obstet Gynecol. 2017;130(4):e205-e209. doi:10.1097/AOG.0000000000002354PubMedGoogle ScholarCrossref
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    What Do We Expect?
    Kurtis Elward, Clinical Professor | Private Practice Family Medicine
    So we learn that as an "essential business" marijuana sales (like alcohol) were continued during COVID, and more pregnant women used marijuana. As legalization is championed by many in the medical and political arenas, women were deluded with an increased opportunity to use what has been claimed to be a "harmless" drug. Serious health effects are associated with marijuana use but the opportunity for tax income has helped propel state legislatures to legalize marijuana and has allowed increased risks for pregnancy and in utero children who cannot yet make their own decision re: drug use. So we run after another problem that we as a society have allowed to develop. To say that this would happen anyway is disproved by the increase associated with legalization. Advocates for legalization have said that it would help reduce disparities - and yet it has simply created potentially far worse disparities for future generations.

    Young, Silver and Brown, while laudably vocalizing advocacy for women and infants, unfortunately repeat the mantra that we must "reform . .. policies that criminalize prenatal substance use" - when it was legalization that seems to be creating the problem. There were no criminal penalties for the women in this study. Despite the calls for "education", their proposed efforts at primary prevention are often ineffectual, and their recommendation for "legal and regulatory policies that protect infants and children" is not supported by any example or realistic recommendation.

    As a physician community, so many of us are speaking out of both sides of our mouth - advocating for legalization of drug use and then clamoring for more support for the very problems it has caused. In many ways, we will have ourselves to blame for not only the problem but the lack of practical solutions that do anything more than make us feel better - while allowing marginalized communities to suffer another contribution to another generation's deprivation and disadvantage.
    CONFLICT OF INTEREST: None Reported
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    Research Letter
    September 27, 2021

    Rates of Prenatal Cannabis Use Among Pregnant Women Before and During the COVID-19 Pandemic

    Author Affiliations
    • 1Division of Research, Kaiser Permanente Northern California, Oakland
    • 2Regional Offices, Kaiser Permanente Northern California, Oakland
    JAMA. 2021;326(17):1745-1747. doi:10.1001/jama.2021.16328

    Cannabis use among pregnant women is common and has increased in recent years in the US, from an estimated 3.4% in 2002 to 7.0% in 2017.1 Pregnant women report using cannabis to relieve stress and anxiety,2 and prenatal cannabis use may have risen during the COVID-19 pandemic as pregnant women faced general and pregnancy-specific COVID-related stressors (eg, social isolation, financial and psychosocial distress, increased burden of childcare, changes in prenatal care, and concerns about heightened risks of COVID-19).3,4

    Considered an essential business in California, cannabis retailers remained open during the pandemic with record sales in 2020.5 We used data from Kaiser Permanente Northern California (KPNC), a large integrated health care delivery system with universal screening for prenatal cannabis use to test the hypothesis that rates of prenatal cannabis use increased during the COVID-19 pandemic.

    Methods

    The sample comprised all KPNC pregnant women screened for prenatal cannabis use via a universal urine toxicology test from January 1, 2019, through December 31, 2020, during standard prenatal care (at ≈8 weeks’ gestation). The institutional review board of KPNC approved this study and waived the need for informed consent.

    We computed monthly rates of prenatal cannabis use standardized to the year 2020 age and race and ethnicity distribution. We fit interrupted time-series (ITS) models to monthly rate data using negative binomial regression, adjusted for age (<25, 25 to <35, ≥35 years) and self-reported race and ethnicity (Asian/Pacific Islander, Black, Hispanic, non-Hispanic White, or other or unknown), which were included because of the known age and race and ethnicity differences in the prevalence of prenatal cannabis use. The prepandemic period was defined as urine toxicology tests conducted from January 2019 to March 2020 and the pandemic period from April through December 2020 (see Laboratory Methods in the Supplement).

    The rate ratio and corresponding 95% CIs are reported herein. We conducted the analyses using SAS version 9.4 (SAS Institute Inc). A 2-sided P < .05 was considered statistically significant.

    Results

    Of 100 005 pregnancies (95 412 women), 26% were Asian or Pacific Islander; 7%, Black; 28%, Hispanic; 34%, non-Hispanic White; and 5%, other, unknown, or multiracial. The patients were a mean age of 31 years (median, 31 years). There were negligible differences in age or race and ethnicity in the 2 periods. During the pandemic, patients completed toxicology testing slightly earlier in their pregnancies (before pandemic mean, 8.51 weeks’ gestation; during pandemic mean, 8.04 weeks’ gestation).

    Before the pandemic, the standardized rate of prenatal cannabis use was 6.75% of pregnancies (95% CI, 6.55%-6.95%); that rate increased to 8.14% of pregnancies (95% CI, 7.85%-8.43%) during the pandemic (Figure). In the ITS analysis, we found that prenatal cannabis use increased by 25% (95% CI, 12%-40%; Table) during the pandemic over prenatal cannabis use during the 15 months before the pandemic. The ITS analysis confirmed that these rates before and during the pandemic were stable, with no statistically significant month-to-month trends (Table).

    Discussion

    Rates of biochemically verified prenatal cannabis use increased significantly during the COVID-19 pandemic among pregnant women in Northern California. Results are consistent with the rise in cannabis sales seen in California during the same period.5 When the toll of the COVID-19 pandemic begins to fade and restrictions are lifted, it is unknown whether pandemic-related increases in rates of cannabis use during pregnancy will reverse or remain elevated. Continued monitoring of trends is critical as the pandemic continues to evolve.

    This study is limited to pregnant women universally screened in the KPNC system for prenatal cannabis use via urine toxicology testing early in pregnancy (≈8 weeks’ gestation) as part of standard prenatal care, and data do not reflect continued use throughout pregnancy. In some cases, positive toxicology test results may detect prenatal cannabis use that occurred prior to pregnancy recognition. Additional studies that capture pandemic-related changes in frequency of and reasons for cannabis use during pregnancy and among nonpregnant women are also needed.

    Prenatal cannabis use is associated with health risks, including low infant birth weight and potential effects on offspring neurodevelopment.6 Clinicians should educate pregnant women about the harms of prenatal cannabis use, support women to quit, and provide resources for stress reduction.

    Section Editors: Jody W. Zylke, MD, Deputy Editor; Kristin Walter, MD, Associate Editor.
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    Article Information

    Accepted for Publication: September 9, 2021.

    Published Online: September 27, 2021. doi:10.1001/jama.2021.16328

    Corresponding Author: Kelly C. Young-Wolff, PhD, MPH, Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA 94612 (kelly.c.young-wolff@kp.org).

    Author Contributions: Dr Young-Wolff had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

    Concept and design: Young-Wolff, Alexeeff, Adams, Does, Ansley, Avalos.

    Acquisition, analysis, or interpretation of data: Young-Wolff, Ray, Alexeeff, Adams, Ansley, Avalos.

    Drafting of the manuscript: Young-Wolff, Ray.

    Critical revision of the manuscript for important intellectual content: All authors.

    Statistical analysis: Ray, Alexeeff, Avalos.

    Obtained funding: Young-Wolff, Avalos.

    Administrative, technical, or material support: Young-Wolff, Adams, Does, Ansley, Avalos.

    Supervision: Young-Wolff, Avalos.

    Conflict of Interest Disclosures: None reported.

    Funding/Support: This study was supported by grants DA047405, DA043604, and DA048033 from the National Institute on Drug Abuse.

    Role of the Funder/Sponsor: The National Institute on Drug Abuse 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.

    References
    1.
    Volkow  ND, Han  B, Compton  WM, McCance-Katz  EF.  Self-reported medical and nonmedical cannabis use among pregnant women in the United States.   JAMA. 2019;322(2):167-169. doi:10.1001/jama.2019.7982PubMedGoogle ScholarCrossref
    2.
    Ko  JY, Coy  KC, Haight  SC,  et al.  Characteristics of marijuana use during pregnancy—eight states, Pregnancy Risk Assessment Monitoring System, 2017.   MMWR Morb Mortal Wkly Rep. 2020;69(32):1058-1063. doi:10.15585/mmwr.mm6932a2PubMedGoogle ScholarCrossref
    3.
    Davenport  MH, Meyer  S, Meah  VL, Strynadka  MC, Khurana  R.  Moms are not OK: COVID-19 and maternal mental health.   Front Glob Womens Health. 2020;1:1. doi:10.3389/fgwh.2020.00001Google ScholarCrossref
    4.
    Basu  A, Kim  HH, Basaldua  R,  et al.  A cross-national study of factors associated with women’s perinatal mental health and wellbeing during the COVID-19 pandemic.   PLoS One. 2021;16(4):e0249780. doi:10.1371/journal.pone.0249780PubMedGoogle Scholar
    5.
    California Department of Tax and Fee Administration. Cannabis tax revenues. Accessed July 29, 2021. https://www.cdtfa.ca.gov/dataportal/dataset.htm?url=CannabisTaxRevenues
    6.
    Committee on Obstetric Practice.  Committee opinion No. 722: marijuana use during pregnancy and lactation.   Obstet Gynecol. 2017;130(4):e205-e209. doi:10.1097/AOG.0000000000002354PubMedGoogle ScholarCrossref
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