An Exploratory Qualitative Study of Screening, Testing, and Reporting Prenatal Cannabis Use by Recreational Legalization Status

BACKGROUND: In recent years, state-level recreational cannabis legalization has bourgeoned throughout the United States, which may explain increasing rates of cannabis use among pregnant women. OBJECTIVE: Our objectives were to: (1) comprehensively explore policies and practices related to screening, testing, and reporting prenatal cannabis use across a multi-state sample, and (2) describe variations in policies and practices by state-level recreational cannabis legalization. METHODS: We conducted an exploratory, multiple-case qualitative case study of perinatal nurses using a combination of convenience and snowball sampling. Interviews were analyzed using content analysis. RESULTS: Of the 22 registered nurses from 15 states of mixed recreational cannabis legalization statuses (legal: n = 6, illegal: n = 9), universal verbal screening was reported in all but one state, which had recreational cannabis legalization. Nurses from nearly one-quarter of states described universal maternal toxicology testing, which is inconsistent with current clinical recommendations. Although discouraged as a standard practice, nurses from most states described policies in which positive toxicology results were reported to social work and/or child protective services. In response to positive toxicology results, changes in clinical practice reported by nurses included discouragement of breastfeeding, which may have concerning health equity implications. CONCLUSION: In contrast to clinical guidelines, nurses in one-third of states reported universal maternal toxicology testing. Nurses reported ethical concerns about testing practices, including biased rationales for testing, failure to conduct informed consent, and threatening with punitive consequences to accomplish testing.