Abstract
<title>Abstract</title> <p>Background: Cannabis legalization in the United States has coincided with increasing prenatal cannabis use, despite evidence linking prenatal exposure to adverse maternal and fetal outcomes. This study examined the associations between psychosocial stressors and prenatal cannabis use and assessed differences across state cannabis policy contexts. Methods: We conducted a cross-sectional multilevel analysis using nationally representative data from the Pregnancy Risk Assessment Monitoring System (PRAMS) from 2016 to 2022 (N = 35,587). The outcome was self-reported prenatal cannabis use. Individual-level predictors included psychosocial stressors (trauma-related, financial, partner-related, and emotional), sociodemographic characteristics, and concurrent substance use. State-level exposure was cannabis legalization status (recreational vs. medical-only). Multilevel logistic regression models were used to estimate adjusted odds ratios (ORs) and 95% confidence intervals (CIs). Results: Trauma-related stressors were strongly associated with prenatal cannabis use (OR = 2.16, 95% CI = 1.97–2.38), followed by financial (OR = 1.41, 95% CI = [1.29, 1.56]), partner-related (OR = 1.21, 95% CI = [1.10, 1.32), and emotional stressors (OR = 1.17, 95% CI = [1.08,1.28]). Smoking during pregnancy (OR = 3.28, 95% CI = [2.96, 3.64]) and alcohol use (OR = 2.46, 95% CI = [2.21, 2.74]) were also associated with higher odds. Higher socioeconomic status indicators, including college education (OR = 0.76, 95% CI = [0.69, 0.83]), private insurance (OR = 0.66, 95% CI = [0.59, 0.74]), and higher income (OR = 0.72, 95% CI = [0.69, 0.76]), were associated with lower odds. Compared with White individuals, Asian individuals had lower odds (OR = 0.51, 95% CI = [0.35, 0.76]), while Hispanic individuals had higher odds (OR = 1.87, 95% CI = [1.61, 2.16]). Residing in states with recreational cannabis legalization was associated with higher odds of prenatal cannabis use compared with medical-only legalization (OR = 2.43, 95% CI = [1.96, 3.01]). Conclusions: Psychosocial stressors and concurrent substance use are significant correlates of prenatal cannabis use, and residence in states with recreational legalization is associated with increased risk. These findings highlight the need for targeted interventions addressing psychosocial vulnerability and policy-informed prevention strategies.</p>