Perceptions of Cannabis Use and Its Benefits and Risks Among Breastfeeding Mothers

Medical cannabis is legal in 38 U.S. states, 3 territories, and the District of Columbia, and nonmedical cannabis is legal in 25 states, 2 territories, and the District of Columbia.¹ As more states legalize cannabis, its use has become more accepted. A study in 2020 showed women living in states with legalized recreational cannabis were 2.2 and 1.7 times more likely to use cannabis prenatally and postpartum, respectively, compared with women in states where recreational cannabis remained illegal.² Simultaneously, concentrations of Δ9-tetrahydrocannabinol (THC), the psychoactive component in cannabis, have risen from 3% in 1980 to 14% in 2019.³

THC can cross the placenta and cross into breast milk resulting in infant exposure.^4,5 Current evidence suggests an association between cannabis use during pregnancy and fetal growth restriction, preterm birth, stillbirth, and increased neonatal intensive care unit admission.⁶ Prenatal exposure may also increase the risk of long-term neurobehavioral effects such as decreased reasoning and attention.⁷ However, evidence of adverse development due to cannabis exposure is mixed and difficult to study because of confounding variables such as differences in dose and duration of exposure.⁶ Owing to limited data evaluating the effects of cannabis on infants during breastfeeding, the American College of Obstetricians and Gynecologists (ACOG) discourages cannabis use while breastfeeding, and the Academy of Breastfeeding Medicine recommends counseling mothers to reduce or eliminate use of marijuana.^8,9 There is currently no standard recommendation for cannabis use and timing breastfeeding.

An estimated 5% of pregnant and breastfeeding women report using cannabis.^10,11 In postpartum individuals and women who used cannabis during either pregnancy or breastfeeding, perinatal cannabis use has been reported to address mental health problems (anxiety and stress), conditions related to pregnancy (nausea and vomiting), and pain.^12–14 A study that analyzed anonymous data from HealthTap, an online digital platform that provides free access to online health information, and a study of Jamaican women who used cannabis while pregnant reported more general benefits including improved general health, spiritual well-being, and improved mood.^14,15 Only half (46%–54%) of women who used cannabis during pregnancy reported using it to get high.^12,13

Perceived safety of cannabis is complex and influenced by many factors including opinions of health care providers, information read online, personal experiences, and anecdotal information.¹⁶ A 2020 study reported that around 20% of women perceived no risk with weekly cannabis use; lower perceived risk has been associated with higher cannabis use during pregnancy.^17,18

Despite reports of some perceived safety during pregnancy, 92% of postpartum individuals completing the Pregnancy Risk Assessment Monitoring System (PRAMS) questionnaire across seven states believed that cannabis use while breastfeeding was unsafe.¹¹ Those same women were less likely to breastfeed and had shorter duration of breastfeeding compared with women who believed it was safe.¹¹ This study aimed to understand mothers’ perceptions of risks and benefits of cannabis use while breastfeeding.

The mothers in this study perceived perinatal cannabis use as more natural, more effective, and safer than medicines to address medical conditions. In open-ended comments, respondents described using cannabis for reasons previously reported (anxiety and depression, nausea and vomiting, pain, insomnia, and appetite)^13,20 and specified use for trauma, ADHD, and autoimmune conditions while pregnant or breastfeeding. The relief from symptoms was great enough some women in our study reported “being saved” by cannabis and described it as working when other medications failed them. The language used by our participants demonstrated strongly held beliefs about the positive health impact of cannabis on mothers and sometimes on their children. In some cases, mothers attributed carrying their pregnancy to term to cannabis, further supporting their beliefs of cannabis being “life-saving.”

Not only was cannabis perceived as more effective at treating medical conditions, it was also perceived to improve overall quality of life and help respondents be better parents. These perceived benefits are consistent with previous research on mothers who used cannabis during pregnancy for parenting-related stress.^15,16,21 In our study, mothers similarly described how it helped them to be patient and engaged rather than irritable or anxious. A reduction in anxiety and stress is beneficial to both the parent and the child. Postpartum stress, which may include depression, anxiety, and posttraumatic stress disorder, has a negative association with infant outcomes in terms of growth and development, nutrition, and bonding.²²

A majority (98%) of respondents in this survey perceived cannabis to be a natural alternative to medications. Two-thirds of respondents in our study were “not at all concerned” about cannabis affecting their infant while breastfeeding. In contrast, Odom et al.¹⁸ reported that only 20% of women perceived no risk of cannabis use while pregnant, and Coy et al.¹¹ reported 92% of breastfeeding women felt cannabis use was unsafe during breastfeeding. Differences in these findings may be attributed to our convenience sampling strategy versus the more representative PRAMS and National Survey on Drug Use and Health datasets. Mothers also noticed fewer side effects for them and their children with cannabis compared with medications. The perception that cannabis is a safer option for pregnant and breastfeeding women is consistent with previous literature, particularly for controlling nausea in pregnancy.^21,23

Few women attributed negative outcomes in their children to their use of cannabis. The lack of perceived negative effects is in contrast with evidence that suggests an association between cannabis use during pregnancy and adverse short-term outcomes (sleep and birthweight) and longer-term effects (attention, hyperactivity, and depression) for the child.^6,24 The risk of negative outcomes because of cannabis use may be downplayed by mothers who perceive benefits from its use. In addition, clinicians and patients tend to overestimate the risk of dramatic, low-probability outcomes, like large malformations, and underestimate risks of more common outcomes, like low birthweight.^25,26

Despite perceiving cannabis as a best option and reporting low concern of impacts on their infants, many respondents described behaviors to decrease their infants’ exposure to cannabis through breast milk or smoke. Use of harm-reduction strategies were evident in the open-ended question and the multiple-choice questions in this study. Strategies included washing hands, changing clothes, using cannabis when the child is not present, breastfeeding before using cannabis, and waiting a variable amount of time after cannabis use to breastfeed. The behaviors reported are similar to those recommended to mothers who smoke cigarettes or drink alcohol while breastfeeding. Previous studies have reported behaviors for reducing secondhand smoke exposure include smoking in a designated room away from a child to reduce environmental exposure.²⁷ Current recommendations on alcohol consumption during breastfeeding advise waiting 90–120 minutes after drinking a serving of alcohol to breastfeed or expressing and discarding the breast milk from that timeframe.⁸ There is currently no standard recommended time to wait after using cannabis to breastfeed.⁴

Nearly half of respondents altered breastfeeding habits to reduce cannabis exposure to the infant. Cannabis has been detected in breast milk from 4 hours up to 6 weeks after its use. Factors that affect the THC content of breast milk include frequency of use, time since most recent use, and THC concentration of the cannabis, which is currently much higher than 20 years ago.^3,28 Although there is no consensus on how to adjust breastfeeding for cannabis use, there is agreement on advising mothers who consume cannabis through smoking to take measures to reduce second-hand smoke exposure to reduce the risk of sudden infant death syndrome.^29,30

Fear of CPS involvement or other legal or social repercussions led some mothers to reduce their cannabis use or adopt strategies as mentioned earlier to reduce their child’s exposure. This fear was also a reason for withholding information about cannabis use from their health care provider. CPS involvement and social repercussions have been previously reported as motivators for reducing or discontinuing cannabis use during pregnancy.³¹ The counseling approach of clinicians may often rely on the legal aspect of use rather than the potential health effects of cannabis use during pregnancy and breastfeeding.³² Clinical guidelines from ACOG recommend discouraging pregnant and breastfeeding women from using cannabis, and counseling patients that the purpose of cannabis screening is to treat substance use not to punish or prosecute them.⁹ However, it is also recommended to inform the mother of any potential ramifications of positive test results.⁹

Interestingly, using cannabis during pregnancy or while breastfeeding was described by some as a shared decision; partners, friends, family, and even health care providers engaged in the decision to use cannabis perinatally. There is little known about the influence of health care providers, partners, and family on the decision to use cannabis in the postpartum period. A 2017 study reported that mothers who quit smoking cannabis during their pregnancy were more likely to be motivated by the belief that it could harm their pregnancy while few decreased or ceased cannabis use simply because they were advised by their doctor to do so.^16,31 Furthermore, including warning signs against use of cannabis on cannabis-containing products during pregnancy was not associated with beliefs about its safety among those who used it.³³ However, it increased support for punishment and stigma among those who did not use cannabis.³³

This study had a large sample size of women who used cannabis while breastfeeding, whereas previous studies have focused on cannabis use during pregnancy.¹⁶ Coy et al. also examined perceptions of risk associated with cannabis use in the postpartum period but was limited by closed-ended survey questions. The large number of open-text responses in this study provides insight into how or why benefits and risks of cannabis use are perceived and managed among women who use cannabis while breastfeeding. Lack of substantial differences between open-ended question respondents and nonrespondents improves our confidence that the qualitative findings may not be solely unique to this subset.

This research has several limitations. First, our sampling strategies limit the representativeness of all breastfeeding women who have used cannabis, and thus, the generalizability of our findings. The survey was distributed in one support group of mothers who used cannabis, and thus, frequent cannabis users may be overrepresented in this sample possibly skewing in favor of more positive perceptions. Second, the low representation of minorities in this study may be in part because of differences in rates of cannabis use or racial disparity in breastfeeding.^13,34 This study had a large portion of White, non-Hispanic respondents. This group also has higher rates of both cannabis use and breastfeeding initiation and continuation than black women, which may have contributed to our low sample of individuals who identified as black or people of color.³⁴ When informed of studies and given equal access, minorities in the United States have shown similar willingness to participate in health research.³⁵ However, it is possible that our sampling strategy did not provide equal access to minorities given the survey’s distribution through a specific website, social media outlets, and snowball sampling.

Another limitation of this study was the inability to further explore perceptions and behaviors described in the open-ended responses because of the nature of the data collection method. For example, the exact medical conditions for which a respondent used cannabis were not always stated, or some of the responses provided were vague or unclear.

As cannabis legalization continues, its use among breastfeeding women may also continue to rise. This study provides insights into decision-making among breastfeeding women who use cannabis and their strategies to reduce risks for their infants. Breastfeeding women who used cannabis perceived it as safer than medications; some perceived benefits to cannabis. It was perceived to reduce stress and allow them to be more attentive to their children and engaged as parents. Few mothers who used cannabis perceived negative outcomes; however, nearly half of respondents reported harm-reduction strategies. Several participants reported concern about the risk of legal repercussions. Focusing counseling on legal and social repercussions may discourage some mothers from sharing information with their providers. Practitioners should hold open nonjudgmental conversations about cannabis use in the perinatal period and counsel on risk–benefit analysis while being aware of parents’ concerns of possible CPS involvement. Future studies should examine patient counseling, the decision-making process around perinatal cannabis use, and further explore health outcomes in the parent and child with cannabis use. This would give health care providers the information necessary to be prepared participants in the shared decision-making process.

Thomas W. Hale, PhD, RPh, Professor Emeritus, and Kathleen Kendall-Tackett, PhD, IBCLC, Clinical Assistant Professor at the InfantRisk Center at Texas Tech University Health Sciences Center assisted with development of the data collection instrument. Charles DeWare, medical student, assisted with the qualitative analysis.