Less than 24 hours after being discharged from the hospital, a new mother was resting at home with her newborn baby when she got an unexpected knock on the door. The Child Protective Services (CPS) agent on the other side came as a complete surprise, as she had not been notified she was drug tested while hospitalized, nor had she been told that she tested positive for cannabis use. Like any new mother, she was terrified.
“I felt for this woman and how she must have felt so much anxiety and fear from having CPS at her door and not understanding why,” said Dr. Kara Skelton, a researcher at Johns Hopkins Bloomberg School of Public Health who spoke to the woman for a qualitative study on pregnant people’s experience with drug screening published in September.
“Unfortunately, this is something that's happening in multiple places,” she told Salon in a phone interview.
One 2021 study in JAMA found as many as 7% of pregnant women in the U.S. use cannabis in pregnancy, although estimates vary and are likely underestimated because many women fear disclosing this information will get the police involved. Yet as more and more states vote to decriminalize cannabis while medical access has expanded to 38 states, other data suggests pregnant people are increasingly being prosecuted for using the drug in pregnancy. In Skelton’s study, this stigma often prevented mothers from seeking prenatal care or communicating with their provider, which is known to have negative impacts on outcomes like birthweight.
“If you criminalize them, they're less likely to come to the medical establishment,” said Dr. Carl Hart, a researcher at Columbia University who studies the neuropharmacological effects of psychoactive drugs. “That's the major harm that's happening.”
Evidence suggests allegations of using substances like cannabis in pregnancy are present in the vast majority of criminal charges taken against pregnant women. In a September report from Pregnancy Justice, a reproductive rights advocacy group, nearly all cases in which women were prosecuted in pregnancy involved some form of substance use, and cannabis was the second most common drug used, following methamphetamine.
Although 24 states have legalized cannabis, it remains illegal at the federal level, carrying the same criminal penalties as heroin and MDMA. As of this writing, 24 states included substance use in pregnancy in their definitions of “childhood abuse or neglect,” and some states in which cannabis was legal have even charged women with child abuse.
Yet the vast majority of these prosecutions do not require proof of harm. Even if they did the research linking cannabis use in pregnancy to child outcomes is observational in nature — meaning it’s not possible to determine a direct casual relationship.
“As time has gone on, we see more of an association with cannabis use in pregnancy and certain birth outcomes in particular, like admission to the neonatal care intensive care unit,” said Dr. Mishka Terplan, an OB-GYN and addiction medicine doctor at the Friends Research Institute. “What that means and whether they are attributable to a cannabis exposure is a far more complicated question.”
To be clear, it is not recommended to use cannabis in pregnancy because the data is too limited to determine if it is harmful. The Centers for Disease Control and Prevention (CDC), the American Academy of Pediatrics (AAP), and the American College of Obstetricians and Gynecologists (ACOG) all recommend against it, either citing studies that link it to developmental issues or behavioral problems later in life, or saying there isn’t enough evidence showing it is safe.
"That's the typical recommendation that we have for any medication or substance if we don't know what the cause and effects of it are on maternal and infant health," said Dr. Kathleen Chaput, a researcher at the University of Calgary who studies substance use and pregnancy. "It's not just a lack of evidence for safety, but there isn't a huge amount of evidence saying that it is really harmful either — so we're kind of in this gray zone."
In mouse studies, the chemical found in cannabis delta-9-tetrahydrocannabinol (THC) has been shown to pass through the bloodstream from mother to child, where it activates endocannabinoid receptors in the fetus and can impact cell growth and the growth of blood vessels.
“There’s biological plausibility that it could be having an impact for sure,” Chaput told Salon in a phone interview. “Animal models are useful, but not definitive evidence for what happens in humans.”
Research in humans following cohorts of women during and after pregnancy reported associations between cannabis use and lower birth weight, a higher chance of preterm birth, and a higher chance of admission to the neonatal intensive care unit (NICU). However, in many of these studies, researchers were not able to fully separate out whether women were smoking both cannabis and tobacco, which was a limitation. (Tobacco, along with alcohol, has relatively clear evidence linking its use to birth defects.)
Other associations have been made between cannabis use in pregnancy and childhood cognitive development, with studies finding children whose mothers used cannabis in pregnancy had poorer academic achievement and attention. The limitation of these studies is that the further researchers get from an exposure in research, like cannabis use in pregnancy, the harder it becomes to determine whether behavioral changes are related to that factor or some of the other highly variable changes made in a developing child’s environment.
In a 2020 study Hart coauthored in Frontiers of Psychology reviewing the evidence behind the latter point, the authors reported that the changes in cognition that were observed among children whose mothers smoked cannabis in pregnancy still fell in a normal clinical range and concluded that “the current evidence does not suggest that prenatal cannabis exposure alone is associated with clinically significant cognitive functioning impairments.”
“The children who are born to the women who use cannabis … you see that their cognitive function falls dead smack in the normal range on all of these tasks,” Hart told Salon in a phone interview.
What’s often left out of the equation of risks are those associated with the punitive policies used to criminalize cannabis use in pregnancy, said Dr. Sarah Roberts, an epidemiologist at the University of California San Francisco who studies substance use policies and pregnancy. CPS involvement has been shown to negatively impact prenatal care at birth, which can have lasting impacts, and has also been associated with mental health problems and substance use in children later on.
Black mothers are particularly subject to this intersection of drug policy and maternal and infant health. Studies show that, compared to white mothers, Black mothers are more likely to be drug tested and more likely to be reported to CPS, with each step of involvement in the child welfare system deepening racial inequities. Black mothers also shoulder a far greater burden of the maternal and infant mortality crisis.
“A lot of the research, as well as the media coverage, focuses on the harms of the use of the substance itself, and not on the adverse effects of the policies that are adopted in response,” Roberts told Salon in a phone interview. “Research has shown … policies that stigmatize and punish pregnant people for their substance use actually seem to make things worse rather than better, so we really need to focus on the harms of the policies that are adopted in response and not just what the effective thing that substance is.”
The vast majority of pregnant women who report using cannabis say they do so to manage pregnancy symptoms like pain or nausea. They often view it as medicine, Chaput said.
“The key thing that's missing right now in this whole discussion is that cannabis isn't being viewed [as a medicine],” Chaput said. “It’s still being seen as this stigmatized street drug, which is a real mismatch with how patients are actually consuming it.”
When it comes down to it, the decision to use any medicine is a personal one in which mothers weigh the risks with the symptom relief provided. For example, studies have linked the use of selective serotonin reuptake inhibitors (SSRIs) in pregnancy to neonatal adaptation syndrome, in which infants experience respiratory distress or increased jitteriness. Yet millions of women have decided to continue taking antidepressants in pregnancy because untreated mental illness also poses risks.
But for cannabis use, along with many decisions made in pregnancy, that choice is under higher scrutiny due to its criminalization.
“There's a lot of history of women not having bodily autonomy during pregnancy,” Chaput said. “Women are viewed in society as carriers of pregnancies and somehow that responsibility is larger than any other: Once you are carrying a child, a lot of health concerns and other issues are dismissed as not as important.”
