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Maternal Use of Cannabis and Pregnancy Outcome

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Maternal Use of Cannabis and Pregnancy Outcome BJOG: an International Journal of Obstetrics and Gynaecology January 2002, Vol. 109, pp. 21–27 Maternal use of cannabis and pregnancy outcome David M. Fergussona, L. John Horwooda, Kate Northstoneb,*, ALSPAC Study Teamb Objective To document the prevalence of cannabis use in a large sample of British women studied during pregnancy, to determine the association between cannabis use and social and lifestyle factors and assess any independent effects on pregnancy outcome. Design Self-completed questionnaire on use of cannabis before and during pregnancy. Sample Over 12,000 women expecting singletons at 18 to 20 weeks of gestation who were enrolled in the Avon Longitudinal Study of Pregnancy and Childhood. Methods Any association with the use of cannabis before and during pregnancy with pregnancy outcome was examined, taking into account potentially confounding factors including maternal social background and other substance use during pregnancy. Main outcome measures Late fetal and perinatal death, special care admission of the newborn infant, birthweight, birth length and head circumference. Results Five percent of mothers reported smoking cannabis before and/or during pregnancy; they were younger, of lower parity, better educated and more likely to use alcohol, cigarettes, coffee, tea and hard drugs. Cannabis use during pregnancy was unrelated to risk of perinatal death or need for special care, but, the babies of women who used cannabis at least once per week before and throughout pregnancy were 216g lighter than those of non-users, had significantly shorter birth lengths and smaller head circumferences. After adjustment for confounding factors, the association between cannabis use and birthweight failed to be statistically significant ( P ¼ 0.056 ) and was clearly non-linear: the adjusted mean birthweights for babies of women using cannabis at least once per week before and throughout pregnancy were 90g lighter than the offspring of other women. No significant adjusted effects were seen for birth length and head circumference. Conclusions The results of this study suggest that the use of cannabis during pregnancy was not associated with increased risk of perinatal mortality or morbidity in this sample. However, frequent and regular use of cannabis throughout pregnancy may be associated with small but statistically detectable decrements in birthweight. INTRODUCTION findings of this literature have been somewhat inconsistent. There is some evidence that the offspring of cannabis users Over the last 30 years there has been a marked increase in may have slightly lower birthweight and/or increased risk cannabis use in developed countries including Europe, Great of preterm birth, but studies are conflicting. For example, Britain, the USA and Australasia1. The increase in cannabis Gibson et al.3, in a study of 7301 Australian births found use has, in turn, raised questions about the extent to which that the offspring of relatively heavy cannabis users had a cannabis may have harmful physical or psychological ef- higher incidence of low birthweight and were also more fects2. One aspect of this concern has focused on the extent to prone to preterm delivery. They showed that the low which cannabis use during pregnancy may lead to adverse birthweight relationship was entirely due to excess preterm outcomes including miscarriage, perinatal death, congenital delivery; nevertheless, they found no relationship between abnormality, preterm delivery, intrauterine growth retarda- lower consumption of cannabis (1/wk) and adverse out- tion, reduced gestational age or other neonatal problems3–9. come, and the numbers in the heavy user group were small There is a growing literature on the fetal and neonatal (n ¼ 36). In contrast, in a study of 1226 mothers from an consequences of maternal cannabis use in pregnancy. The American prenatal clinic, Zuckerman et al.4 found that the offspring of relatively heavy cannabis users (i.e. positive urine screen) had lower mean birthweight (79g), and were shorter at birth (0.52cm) than the offspring of non-users a Christchurch Health and Development Study, Christchurch when allowance was made for a number of confounding School of Medicine, Christchurch Hospital, New Zealand factors including cigarette smoking and gestation, thus b Unit of Paediatric and Perinatal Epidemiology, University implying some growth retardation. A large study compris- of Bristol, UK ing 12,424 singleton deliveries in Boston identified 880 mothers who occasionally smoked cannabis in pregnancy, * Correspondence: Mrs K. Northstone, Unit of Paediatric and Perinatal 5 Epidemiology, Division of Child Health, 24 Tyndall Avenue, Bristol, BS8 229 who did so at least weekly and 137 who smoked daily . 1TQ, UK. Unadjusted data indicated increased rates of low birth- D RCOG 2002 BJOG: an International Journal of Obstetrics and Gynaecology PII: S 1470-0328(02)01020-0 www.bjog-elsevier.com 22 D.M FERGUSSON ET AL. weight (<2500g) and preterm delivery (<37 weeks), but of environmental exposure prenatally and postnatally that adjusted analyses gave odds ratios (95% confidence inter- affect the development, health and wellbeing of children14. val) for any cannabis use of 1.07 (0.87, 1.31) and 1.02 All pregnant mothers resident in the three Bristol-based (0.82, 1.27) for low birthweight and preterm delivery, health districts of Avon with expected dates of delivery respectively. No analysis was carried out to see if there between 1 April 1991 and 31 December 1992 were eligible was any reduction in mean birthweight among cannabis for enrolment. It is estimated that 85%–90% of the eligible users. A study of 3857 pregnancies in Connecticut found population took part, comprising 15,541 pregnancies. Of the adjusted risk of giving birth to a low birthweight baby these 13,921 were still pregnant at 18–20 weeks of gesta- (<2500g) to be 2.6 (1.1, 6.2) among white women who tion; 13,710 had singleton pregnancies resulting in live were regular users of cannabis. They also reported an births and were eligible for this study. There were 130 almost twofold risk of preterm delivery in the same pregnancies that resulted in perinatal death, defined as fetal women6. In a group of adolescent mothers marijuana use death of 20 weeks or more and early neonatal death during the first trimester resulted in a seven day reduction (i.e. death of a live birth within seven days) of which 113 in gestation after adjusting for various confounders (includ- were singleton pregnancies. ing smoking) and use in the second trimester gave an odds Data on cannabis use were collected by self-completion ratio of 3.8 (1.2–14.0) of having a baby that was small for questionnaires posted to the mothers at 18–20 weeks of gestational age7. Fried et al.8 also reported a reduction in gestation and returned by them in reply-paid envelopes. gestation of 0.8 weeks in the offspring of mothers who used The questions were: ‘‘How often did you smoke mari- cannabis at least six times a week during pregnancy. juana/grass/cannabis/ganja: (a) in the six months before Despite the negative associations noted above, various you conceived, (b) in the first three months of pregnancy, studies have reported no significant effects of cannabis use (c) between three months and now’’. For each of (a), (b), on preterm labour10,11, birthweight12 or adverse intrauterine and (c), the options given were: ‘‘Every day, two to four growth10,12. A meta-analysis of 10 studies of cannabis use times a week, once a week, less than once a week, not concluded that the evidence of cannabis use affecting at all’’. birthweight was inadequate13. Associations with cannabis use and a variety of factors Although the literature on the effects of maternal can- were investigated, and these factors were considered as nabis use during pregnancy has been steadily growing, it possible confounders in multivariate analyses. These has a number of limitations which include: the use of were: relatively small samples; the failure to provide estimates of the extent of maternal cannabis use; lack of prospec- Age of mother at 18–20 weeks of gestation (<20, 20–24, tively collected measures of cannabis use; and failure to 25–29, 30–34, 35þ). control for factors that may potentially confound the Parity (number of previous pregnancies resulting in a live association between cannabis use and pregnancy outcomes. or stillbirth). Against this general background, this paper reports on Cigarette smoking just before pregnancy (0, 1–4, 5–9, the relationship between cannabis use during pregnancy 10–14, 15–19, 20–24, 25–29, 30þ). and neonatal outcomes in a large sample of British single- Cigarette smoking in the first three months of pregnancy ton pregnancies studied prospectively during pregnancy. (grouped as above). The aims of this study were: 1. to estimate the proportion of Cigarette smoking at 18–20 weeks of pregnancy women who reported cannabis use before and during (grouped as above). pregnancy; 2. to document the social, individual and related Alcohol consumption before pregnancy (none, <1 drink/ factors that distinguish women who used cannabis during week, 1þ drinks/week, 1–2 drinks/day, 3þ drinks/day). pregnancy from those who did not use cannabis; and 3. to Alcohol consumption during first three months of examine the extent to which use of cannabis during pregnancy (grouped as above). pregnancy was associated with increased risks of late fetal Alcohol consumption at the time the mother first felt the death and perinatal mortality, reduced birthweight, birth baby move (grouped as above). length and head circumference. Number of cups of tea/week at 18–20 weeks. Number of cups of coffee/week at 18–20 weeks. Use of hard drugs during pregnancy (yes/no). METHODS Maternal ethnic origins (white, non-white). Maternal education level achieved (five groups). The Avon Longitudinal Study of Pregnancy and Child- Maternal height and maternal weight before pregnancy.
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