Contents lists available at ScienceDirect Preventive Medicine journal homepage: www.elsevier.com/locate/ypmed Review Article Women's perspectives about cannabis use during pregnancy and the postpartum period: An integrative review ☆ Hamideh Bayrampour a, ⁎ , Mike Zahradnik b , Sarka Lisonkova c , Patti Janssen c a Department of Family Practice, Midwifery Program, University of British Columbia, Suite 320 - 5950 University Boulevard, Vancouver, BC V6T 1Z3, Canada b University of British Columbia, Suite 320 - 5950 University Boulevard, Vancouver, BC V6T 1Z3, Canada c University of British Columbia, Vancouver, BC, Canada ARTICLEINFO Keywords: Cannabis Marijuana Pregnancy Postpartum Perspectives Risk ABSTRACT Cannabis is the most commonly used illicit drug among general and pregnant populations. Despite re- commendations to abstain from cannabis use, its use is increasing during the perinatal period. In this integrative review, we aim to understand women's perspectives about the health aspects of perinatal cannabis use. The following databases were searched: MEDLINE, PsycInfo, EMBASE, and CINAHL. We included quantitative and qualitative studies with a primary focus on perinatal cannabis use. The methodological quality of the included studies was appraised using appropriate checklists. Extracted data were integrated into a single data matrix and iteratively compared across studies to summarize and synthesize the data. Full text of 33 citations was retrieved and reviewed of which 6 studies met the inclusion criteria. Women who continued to use cannabis during pregnancy often perceived no general or pregnancy-specific risk compared to nonusers. The uncertainty re- garding adverse perinatal consequences, its perceived therapeutic effects, and lower costs of cannabis compared to that of cigarettes contributed to cannabis use. A lack of communication with health care providers regarding the health aspects of cannabis was evident. Women perceived this lack of counseling as an indication that adverse outcomes associated with cannabis use are not significant. Women's perceptions of health risks asso- ciated with cannabis use are important factors in the decision-making process regarding use or cessation, par- ticularly as legal concerns are fading away. A discussion about health concerns surrounding cannabis use may influence women's perceptions of risk and help them to make informed choices. 1. Introduction Cannabis (marijuana) is the most commonly used illicit drug among general (United Nations, 2018) and pregnant populations (Schauberger et al., 2014; Metz and Stickrath, 2015). The relationship between cannabis use and adverse perinatal outcomes is controversial. While some studies have shown increased risk of adverse outcomes, such as anemia, low birth weight (LBW) (Gunn et al., 2016), stillbirth (Varner et al., 2014), and newborn intensive care unit (NICU) admission (Gunn et al., 2016) with cannabis use, others have attributed observed asso- ciations to confounding factors, including socioeconomic character- istics, smoking, alcohol and other illicit drug use (Conner et al., 2016). More recent evidence supports independent associations between can- nabis use and adverse perinatal outcomes: A 2018 observational study showed that controlling for tobacco use and demographic profiles such as age, ethnicity, and level of education, cannabis use at any time during pregnancy was associated with a 50% increased risk of LBW (Crume et al., 2018). Another recent study reported a 3-fold increase in the risk of neonatal morbidity or death after adjustment for ethnicity, tobacco and other illicit drug use (Metz et al., 2017). Due to the potential adverse consequences, professional organiza- tions recommend discontinuing use of cannabis during preconception, pregnancy, and lactation (American College of Obstetricians and Gynecologists Committee on Obstetric Practice, 2015). However, can- nabis use is increasing among women of reproductive ages, including pregnant women. Based on the US National Survey on Drug Use and Health report, between 2002 and 2014, cannabis use among the preg- nant population increased 62%, from 2.37% to 3.85% (Brown et al., 2017). While reasons for such increases are yet to be understood, stu- dies have shown that this growing trend is concurrent with increased https://doi.org/10.1016/j.ypmed.2018.12.002 Received 14 August 2018; Received in revised form 24 October 2018; Accepted 10 December 2018 ☆ Funding: None. ⁎ Corresponding author at: Department of Family Practice, Midwifery Program, University of British Columbia, 320 - 5950 University Boulevard, Vancouver, BC V6T 1Z3, Canada. E-mail address: hamideh.bayrampour@ubc.ca (H. Bayrampour). Preventive Medicine 119 (2019) 17–23 Available online 12 December 2018 0091-7435/ © 2018 Elsevier Inc. All rights reserved. T