Cannabis use during pregnancy is increasing and, in some states, even outpacing use of other high-risk substances like tobacco or alcohol.
Prenatal cannabis use is associated with increased risk of lower birth weight, preterm delivery, neonatal intensive care unit admissions, neurodevelopmental changes, and childhood mental health issues. For that reason, national recommendations advise against the use of cannabis during pregnancy.
Access to counseling and treatment for cannabis use among this population is challenging, however, partly because admitting to prenatal cannabis use carries added risk of intense stigma and even legal consequences like loss of parental rights. However, a program at Kaiser Permanente Northern California (KPNC) called “Early Start,” which offers substance use screening, assessment, and counseling as part of standard prenatal care, has been found to reduce adverse outcomes for babies.
Encouraging increased uptake of programs like Early Start requires a better understanding of who participates and what their outcomes are. This study used electronic health record (EHR) data from the Early Start program to better understand patient characteristics (sociodemographics and psychiatric or substance use disorders) that predict completion of the program and engagement in substance use counseling or treatment.
The Early Start program has been offered at all KPNC prenatal clinics since 2003. For this study, part of CTN-0140 (Cannabis Use Among Pregnant Women with Polysubstance Use and Psychiatric Problems) in the NIDA Clinical Trials Network, investigators used EHR data from individuals with one or more pregnancies who had KPNC membership two years prior to pregnancy and screened positive for cannabis use at their first prenatal visit via either response to a questionnaire item or a positive urine test.
Researchers then analyzed EHR data related to whether a participant completed an Early Start substance use assessment and, if so, whether they received an intervention. They then looked for patient demographics and clinical characteristics (psychiatric disorders or SUD) that seemed to predict specific outcomes.
Among 299,496 pregnancies, 20,398 (6.8%) from 17,782 individuals were positive for prenatal cannabis use and included in the study, with 43.7% positive based on self-report on the questionnaire and 56.3% positive based on a urine test.
Participants were:
Their most prevalent psychiatric and substance use disorders were:
In this analysis, an impressive 80%-plus of individuals who were in the Early Start program stayed engaged in it at every step, from the assessment phase through counseling or treatment. Among those identified as needing counseling or treatment, 88% had at least one follow-up visit, primarily to Early Start counseling but also to Kaiser’s more intensive Addiction Medicine & Recovery Services (AMRS) program.
Patients with comorbid psychiatric or substance use disorders were more likely to attend AMRS appointments, underscoring the importance of specialized treatment programs, including detox, residential or rehabilitative facilities, and intensive outpatient care.
Older individuals, those identified later in pregnancy, and those with children were least likely to be assessed, and, importantly, individuals identified through urine testing, from Asian/Pacific Islander or Black racial/ethnic backgrounds, assessed later in pregnancy, or who had children were the least likely to attend counseling or treatment. These differences can be explained through a range of factors that all need consideration, including racial/ethnic inequities in prenatal care, stigma or other concerns related to reporting cannabis use, lack of childcare for existing children, and more. Efforts to address some of these barriers could improve uptake of programming and care.
This study found that, among pregnant patients with prenatal cannabis use, a comprehensive prenatal care substance use program that offered universal screening, assessment, and counseling kept them successfully engaged in care.
However, opportunities to improve gaps remain. To the extent that workforce members can, considering ways to address ongoing stigma in care settings, child care and transportation barriers, financial or insurance barriers, and continued racial/ethnic disparities have the ability to make a significant difference for pregnant patients who use cannabis, improving their wellness while also reducing the risk of harm to their unborn children.