Table 1 Characteristics of included studies (N = 11)

Canada

 Bartlett 2020

478 pregnant women; Obstetrical, midwifery, and family practice clinics, greater Hamilton, Ontario area

Estimate prenatal cannabis use prevalence; evaluate pregnant women’s beliefs about transmission of cannabis during pregnancy and breastfeeding; and examine association between information from a health care provider and decision to discontinue cannabis use

Majority believed cannabis could be passed to the baby during pregnancy (94.3%) and while breastfeed (91.2%). About 23% received information about cannabis from a health care provider, while the most reported source of cannabis related information was the internet (75.1%). Receiving information from a health care provider was significantly related to continuation of prenatal cannabis use. Women continuing cannabis use during pregnancy were more likely to report receiving cannabis information from a health care provider (52%) than those who discontinued use (35%) (p = 0.035).

Education regarding prenatal cannabis use must take a nonjudgmental approach to ensure that all women are making informed decisions and adequate support is given to those with difficulty discontinuing use.

 Bayrampour 2019

6 studies (5 quantitative; 1 qualitative); Integrative review

Identify and synthesize current evidence to answer the question: What are women’s perspectives on the health aspects of cannabis use, and how do these perceptions influence decision-making about cannabis use during the perinatal period?

All studies examined women’s perceptions during pregnancy, with half using a nationally representative sample. 3 articles asked: “How much do people risk harming themselves physically and in other ways when they smoke marijuana once or twice a week?” Decreasing risk perceptions of cannabis use and increasing social acceptability were seen; 70% of past-year cannabis users perceived no or slight risk of harm from using cannabis. Health care provider communications about cannabis often focused on child welfare agencies’ potential involvement and legal consequences.

Perceived safety of cannabis use, both generally and during pregnancy is increasing. Women’s perceptions of health risks due to cannabis use during the perinatal period are an important factor when making decisions about cannabis cessation, particularly as legal concerns diminish.

 Jordan 2020

270 infertility patients; Mount Sinai Fertility Clinic, Toronto

Report prevalence of cannabis use among infertility patients and perception of effects of cannabis on pregnancy and fertility, cessation of use due to infertility and personal history of disclosing use to health care providers.

49% of respondents had never used cannabis and 13% reporting past-year use. Of past year users, 72% said they had or would disclose use to their healthcare provider, but only 9.4% reported their health care providers had instructed them to discontinue use. Across four measures of fertility and pregnancy health, past-year cannabis users perceived less of a negative effect compared to > 1-year users, and never users.

Cannabis use is common among infertility patients (13%). Most patients were willing to disclose cannabis use to a health care provider, but only 9.4% were counselled to discontinue use. Perceptions of negative effects of cannabis on fertility and pregnancy are correlated.

 Postonogova 2020

132 postpartum women; Royal Victoria Hospital, a tertiary care obstetric center, Montreal, Quebec

Survey women who had recently given birth about their attitudes and experiences regarding the use of marijuana for the medical treatment of pain during labor

34% reported possible consideration of marijuana use for labor pain, with 25% reporting previous use during labor. Most women (52%) reported being highly or extremely worried about the effect of marijuana on the baby. Yet, most women (60%) indicated a lack of knowledge of the side effects of marijuana in labor. Nearly 60% of women reported they would be comfortable talking with their obstetrician about marijuana, with 14% reporting they would not feel comfortable discussing use with anyone. Women who would consider marijuana for labor pain were less likely to be worried about any side effect, more likely to have used marijuana for pain in the past, to agree that marijuana was an effective pain reliever.

One-third of women would consider the use of marijuana for labor pain, although there are many who are unsure of its effects. Most women would feel comfortable discussing this with their obstetrician.

United States

 Beatty 2012

50 postpartum women; large urban hospital, Michigan

Measure perceived risks and costs of marijuana and tobacco use during pregnancy

Only 1 participant selected marijuana as the substance most likely to harm the baby if used during pregnancy. When asked to rate the level of danger of marijuana to a fetus, marijuana was rated as highly dangerous with a mean rating of 9.46 (SD = 2.04). Most women indicated there is no safe amount of prenatal marijuana use (86%). 76% of women reported knowing people who felt marijuana use during pregnancy was not very dangerous for the baby. 44% of women felt that marijuana costs less to use during pregnancy than cigarettes. When asked how much women who use marijuana per day spend, participants median response was $6.00 to $10.00.

Marijuana use may be as or more prevalent than tobacco use among low-income, African American pregnant women. A broader public health response to prenatal marijuana use, is needed.

 Coy 2021

4604 women with a recent live birth; PRAMS; Alaska, Illinois, Maine, New Mexico, New York, Pennsylvania, West Virginia

Describe characteristics of postpartum marijuana users; evaluate the relationship between postpartum marijuana use and breastfeeding behaviors; and assess, among postpartum marijuana users, how safety perceptions are associated with breastfeeding behaviors

Among women who used marijuana postpartum, 46.5% of reported currently breastfeeding. 91.8% believed it was unsafe to breastfeed while using marijuana; 63.0% were asked by a health care provider about marijuana use. No significant difference in breastfeeding initiation or duration between participants who used and did not use marijuana postpartum. Postpartum marijuana users who believed it was unsafe for breastfeeding women to use marijuana were significantly less likely to have initiated breastfeeding (29.9% vs.12.2%) or to have breastfed > 12 weeks (19.3% vs. 54.2%). Information delivered by health care providers to postpartum marijuana users varied; 2 in 5 were advised against breastfeeding while using marijuana, 1 in 2 were advised against marijuana use, and 1 in 15 received a recommendation to use marijuana.

Safety perceptions of marijuana use while breastfeeding may influence breastfeeding behaviors among postpartum users. Provider education about current clinical guidance of postpartum marijuana use should be considered.

 Hayaki 2010

332 women; Local primary care clinics, college campuses, community health centers, and community businesses

Examine associations between endorsement of marijuana use expectancies and marijuana use frequency and severity in young females

On average participants had used marijuana “regularly” for 3.9 (± 2.6) years. Participants met an average of 2.9 (± 2.6) current marijuana abuse/dependence criteria; 70 (21.1%) met no criteria. 175 (52.7%) met current DSM IV criteria for marijuana abuse and 131 (39.6%) for marijuana dependence; 125 (37.8%) participants did not meet diagnostic criteria for either abuse or dependence. Marijuana use frequency was moderately correlated with marijuana use severity (r = 0.50, p < 0.05). Marijuana use severity was positively associated with all six expectancy subscales; the strongest were with Relaxation/ Tension Reduction (r = 0.28) and Global Negative Effects (r = 0.29).

Marijuana use expectancies may represent a clinical target that could be incorporated into future interventions.

 Lynn 2019

373 women; single, academic, obstetrics and gynecology practice

Determine how women perceive the sexual experience (sexual satisfaction, sex drive, orgasm, dyspareunia, and lubrication) when using marijuana before sex and examine the effect of frequency of marijuana use on satisfaction across different sexual function domains.

Of the 176 marijuana users, 34.1% used marijuana before sex. Among users, 68.5% reported a more pleasurable overall sexual experience, 60.6% noted an increase in sex drive, and 52.8% reported an increase in satisfying orgasms. Most women reported their sexual experiences as “always to sometimes” positive, with a decrease in pain but no change in lubrication. Women who used marijuana before sexual activity were more likely to report satisfactory orgasms (aOR = 2.13; 95% CI = 1.05, 4.35) than those who reported not using marijuana. Women with frequent marijuana use, regardless of use before sex or not, were more likely to report satisfactory orgasms than those with infrequent use (aOR= 2.10; 95% CI = 1.01, 4.44).

Timing appears to be important with those who use before sex reporting a positive effect on orgasm. Among any users, the most perceived improvement was in overall experience, sex drive, orgasm, and pain. A better understanding of the role of the endocannabinoid system in women is needed, as it could help lead to development of treatments for female sexual dysfunction.

 Mark 2017

306 pregnant women; Outpatient Obstetrics and Gynecology Clinics at the University of Maryland Medical Center, Baltimore MD

Investigate the relationship between current cannabis use among pregnant women and intended patterns of use and their views of cannabis legalization, knowledge of potential harms, and motivations for cessation during and after pregnancy

35% of women reported current cannabis use at the time of diagnosis of pregnancy; 34% continued use. A majority of women believed that cannabis use during pregnancy can be harmful and that it should be legalized in some form (70% and 59%, respectively. 10% reported they would use cannabis more during pregnancy if it were legalized. Those that continued use during pregnancy were less likely than those who quit to believe that cannabis use could be harmful during pregnancy (26% vs. 75%, p < 0.001). The most common motivation for cannabis cessation while pregnant was to avoid being a bad example (74%). Only 27% of women listed a doctor’s recommendation as a motivation to quit.

A significant minority of women continue to use cannabis during pregnancy, and some even increase use. Motivations to quit use during pregnancy are varied but many are related to legality.

 Ng 2020

843 pregnant women; Regional perinatal center, Central New Jersey

Evaluate pregnant women’s knowledge and opinions about marijuana use, potential risks, and legalization

Most women (71%) supported or were neutral about marijuana legalization, with rates of “neutral” answers being substantially higher for prior tobacco smokers compared to nonsmokers (14.7% vs. 8.4%). Over 90% of pregnant subjects noted that they would be more likely to use marijuana in pregnancy if it were legalized. Compared to patients with prior tobacco use, nonsmokers had higher likelihood of agreeing that marijuana use during pregnancy may result in greater risks. Participants who attended high school or less were less knowledgeable about the possible risks of marijuana in pregnancy.

Pregnant women’s attitudes about marijuana use may be impacted by cannabis legalization. Pregnant women demonstrated poor knowledge about the potential risks associated with marijuana use in pregnancy.

 Odom 2020

2247 pregnant women; NSDUH

Identify correlates of low risk perceptions of weekly cannabis use, past 30-day cannabis use, and frequency of cannabis use in the past 30 days among a pregnant women aged 14–44

21.6% of pregnant women did not perceive any risk with weekly cannabis use, 5.3% used cannabis in the past 30 days, and among past-month users, the average number of days of use was 15.6. Younger maternal age, early trimester of pregnancy, living below the poverty line, and co-use of tobacco and/or alcohol were all associated with not perceiving any risk associated with weekly or past 30-day cannabis use, and cannabis use in the past 30 days.

This study confirms reductions in risk perceptions of weekly cannabis use over time, increases in past 30-day cannabis use, and increases in days used, as well as identifying specific population subgroups more at risk for increases in past 30-day cannabis use.