Few Ob/Gyns Counsel Pregnant Patients About Marijuana Use

Diana Phillips

March 16, 2016

Obstetrical care providers are not consistently counseling pregnant women who use marijuana about the associated perinatal risks, a study has shown. In fact, nearly half of pregnant women who disclosed marijuana use in first obstetric care encounters did not receive counseling or information specific to its use, researchers report in a study published online March 7 in Obstetrics & Gynecology.

When counseling did occur, "discussions focused on potential legal or child protective services implications rather than potential medical or pregnancy consequences," write Cynthia L. Holland, MPH, from the Magee-Women's Research Institute of the University of Pittsburgh, Pennsylvania, and colleagues.

The findings point to a communication gap that parallels a dearth of literature focusing on obstetric care providers' counseling of pregnant patients about marijuana use, according to the authors, who note that the issue is taking on increasing importance as public acceptance of marijuana use is growing.

A subanalysis of a larger study focusing on provider–patient communication regarding substance use during pregnancy, the current investigation was derived from audio recordings of first obstetric visit conversations between pregnant patients and their obstetric healthcare providers from five urban prenatal, outpatient clinic sites in Pittsburgh between 2011 and 2014.

Complete recordings were available for 468 patient visits. Of these, 90 (19%) included patient disclosure of marijuana use. "Forty-eight (53%) patients disclosed current marijuana use within the previous 30 days to their health care provider. Twenty-six patients (29%) described their last use of marijuana as more than 30 days before the recorded visit. Sixteen patients (18%) disclosed marijuana use to their health care provider, but the timing of their last marijuana use was undetermined," the authors report.

Of the patients who disclosed any marijuana use, 64% had a positive urine drug screen in the second phase of the study, according to the authors.

The majority (90%) of marijuana use disclosures were in response to a provider screening question about illicit drug or marijuana use. "[T]he remaining 10% of patients either had a positive urine drug screen documented in their medical record before the new obstetric visit or self-disclosed marijuana use when discussing nausea or asked about smoking," the authors write.

In response to marijuana use disclosure, clinicians offered counseling or marijuana-specific information to 47 (52%) of the 90 patients. Of the 43 visits (48%) in which no counseling or information was offered, providers did not acknowledge the disclosure in any manner in 21 of the visits.

In the remaining 22 visits, "the obstetric health care providers assessed patients' last use of marijuana or inquired whether the patient had quit since confirming the pregnancy yet offered no other counseling, information, or guidance on marijuana use in pregnancy," the authors write. They contrast that with tobacco counseling, which was delivered to 36 (86%) of 42 patients who disclosed both marijuana use and smoking.

To assess the nature of the counseling about marijuana use in those visits that included it, the investigators categorized it across four domains: punitive, medical, helpful and supportive, and unclear. "Punitive (n=33) and helpful and supportive (n=34) were the two most commonly used counseling domains," the authors write.

Punitive counseling included informing patients that they would undergo toxicology testing and warning them about the possibility of child protective services notification, whereas helpful and supportive counseling validated "the health care provider's belief in the patient's ability and motivation to quit marijuana," the authors report.

Most providers who provided counseling or information used multiple domains in their communication. Of note, the authors write, "In more than half (n=20 [61%]) of visits during which health care providers' counseling contained punitive responses, health care providers would also use supportive or validating statements encouraging patients' efforts to quit."

In multivariate analyses with patient race, healthcare provider type, and timing of marijuana use, patient timing of marijuana use was significantly associated with receipt of counseling. "Those who disclosed past use had six times the odds of receiving no counseling ([odds ratio] OR 5.9, [confidence interval] CI 1.7–20.5); those whose timing of use was undetermined had 12 times the odds (OR 12.0, CI 2.4–60.9)."

The lack of marijuana use counseling in this population may reflect increasingly favorable attitudes about marijuana compared with other illicit substances, or it could be related to a lack of knowledge about the risks associated with perinatal marijuana. In PubMed and Google searches on the topic, "we could find no studies examining either health care providers' views or knowledge regarding marijuana use in pregnancy," the authors state.

There is, however, a body of literature linking negative outcomes with marijuana use during pregnancy. These include small gestational weight, preterm delivery, respiratory complications, cognitive deficits, and higher rates of anxiety and depression. Counseling should address these risks and provide strategies to support patients in quitting, the authors write.

"Furthermore," the authors conclude, "studies are needed to better understand the beliefs, perspectives, knowledge, and concerns of both pregnant patients and obstetric health care providers to develop and tailor effective communication resources and training interventions on perinatal marijuana that address the specific needs and concerns of health care providers and patients in the varying regions across the nation."

The authors have disclosed no relevant financial relationships.

Obstet Gynecol. Published online March 7, 2016. Abstract

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