Counselling about cannabis use during pregnancy and lactation: A qualitative study of pregnant and lactating people and their clinicians

Problem

Cannabis use has increased since its legalization in 2018, including during pregnancy and lactation. Clinical counselling is an important factor in reducing the potential harm of perinatal cannabis use, but clinician comfort is challenged by limited clinical evidence and the lack of evidence-based harm reduction strategies. The objective of this study was to better understand how prenatal and postpartum counselling about cannabis use occurs, what patients desire, and what challenges clinicians experience.

Approach

We used a qualitative descriptive approach to conduct semi-structured interviews with two groups: 1) people who are currently pregnant or lactating who used cannabis before becoming pregnant and had to make a decision about cessation or continuation during the perinatal period; 2) clinicians who counsel pregnant or lactating people. Participants were purposively-sampled. Patients were living in Canada and in the past year had made a decision about whether or not to use cannabis while pregnant or lactating. Clinician participants were independent health or social care practitioners in Canada, including physicians, nurses, midwives, physician assistants, lactation consultants, social workers, and doulas. Data were collected until theoretical saturation was reached.

Findings

We interviewed 52 pregnant and lactating people and 23 clinicians. Clinicians reported asking all patients about cannabis in order to complete an element of the standardized antenatal record. Only about half of patients recalled being asked about cannabis use, sometimes in the context of a broader question on drug or substance use. Many patients did not initiate this discussion, as they did not desire clinician input on their cannabis use and in some cases were wary of how the clinician might respond. Many clinicians recognized the potential for discomfort around this question. Where conversations about cannabis did happen, they were not always recorded. Counselling sometimes included referral to other services. Patients were concerned that if they disclosed cannabis use the clinician would report this use to child welfare agencies. Clinicians stated they would infrequently report cannabis use to these agencies, and only in cases where they suspected cannabis use would result in neglect or abuse of children. Patients desired evidence-based harm reduction strategies but clinicians had little advice to offer beyond counselling cessation, due to a lack of clinical evidence.

Consequences

This comparative study identified several barriers to counselling about cannabis, including the stigmatized nature of substance use which may prevent disclosure, a lack of evidence-based harm reduction strategies, and insufficient research about clinical outcomes. Clinicians prioritized maintaining trusting relationships to enable high quality care and harm reduction where possible.