Leslie Siu had never experienced a migraine in her life until she became pregnant.

As she prepared for the birth of her first child, she found herself battling daily headaches and migraines every few days. The migraine pain was so intense she couldn’t get off the floor.

“It was really tough, and you can’t take traditional painkillers [when you’re pregnant],” Siu, 41, told INSIDER. “I was in so much pain that I was willing to try anything.”

Throughout 2014 and into 2015, Siu and her husband had been traveling regularly to Colorado, where they now live, to help care for a sick family member. The state had legalized marijuana for recreational use in 2012, and during a visit to a dispensary, someone suggested she try a cannabis tincture for her migraines. (Cannabis tinctures are infused liquids that can be absorbed under the tongue or added to foods and drinks.)

Cannabis didn’t completely resolve her migraines, Siu said, but it made the pain more tolerable.

“It helped make me functioning,” she added. “So instead of me being on the floor in the dark of my office, at work, I was able to maybe sit up at my desk and continue working.”

Siu researched the topic, reading studies that included participants who said they smoked marijuana heavily while pregnant.

“I made a judgment call that, ‘Hey, I’m taking a scant amount,'” she said. “And it didn’t feel wrong or unhealthy to me.”

Marijuana use during pregnancy is on the rise

Siu’s story may not be unique. A research letter published in 2018, drawing on data from a nationwide drug use survey, found that marijuana use during pregnancy in the US climbed over a 14-year period, from 2.9% in 2002 to 5% in 2016.

That increase has occurred against a backdrop of sweeping of marijuana legalization and acceptance in the US. To date, 33 states and Washington, DC, have legalized medical marijuana and 10 states and Washington, DC, have legalized the drug for recreational use, with New York and New Jersey possibly following suit.

But many experts maintain that we don’t have enough research to say whether marijuana is safe for mothers-to-be or their fetuses, and there’s surprisingly little research on the effects of cannabis use while breastfeeding. And in some states, patient-doctor conversations regarding the drug use may be further complicated by laws that require medical professionals to report prenatal marijuana use.

Marijuana use has increased among pregnant women, according to some recent research.

It seems plenty of mothers and moms-to-be who turn to the drug aren’t doing so for recreational purposes. Some report using cannabis as a way to address severe nausea and vomiting and the symptoms of perinatal depression, a common and serious pregnancy complication.

INSIDER spoke with doctors and women who used cannabis while pregnant and in the postpartum period to learn more about their experiences, and the critical questions still unanswered.

Some moms-to-be turn to the drug to help with nausea

Even though marijuana use during pregnancy is on the rise, scientists still aren’t sure why more moms-to-be are consuming the drug. But one hypothesis is that pregnant people may turn to marijuana to help with nausea and vomiting, according to a 2018 research letter published in JAMA Internal Medicine. Those side effects occur in about 70% of pregnancies, according to the Cleveland Clinic.

There’s research to back up this suggestion. The 2018 research letter looked at more than 200,000 pregnant women and found that those who had both mild and severe nausea were more likely to use marijuana compared with those who didn’t have nausea. Another large analysis from 2014 studied more than 4,700 women in Hawaii and also found the odds of prenatal marijuana use were higher in those who reported severe nausea while pregnant.

The idea isn’t far-fetched: There’s evidence that marijuana effectively treats nausea and vomiting caused by chemotherapy. Some of the women INSIDER interviewed said they found the drug helpful for treating nausea and vomiting caused by pregnancy.

Nausea and vomiting are common pregnancy side effects. Hollis Johnson/INSIDER

“I used marijuana during pregnancy to ease my nausea as well as to help me sleep,” Laiken, 26, who asked to be identified by her first name only to protect her identity, told INSIDER in an email. “It seemed I was constantly up at night and part of that was [because of] nausea.”

Laiken, a mother of two, said the nausea persisted through the entirety of both her pregnancies. Once, while expecting her first child and driving with a coworker, she had to open the car door to vomit outside.

For about a month during that pregnancy, she tried standard anti-nausea treatments, but found they didn’t really help.

That’s when she turned to marijuana. Laiken told INSIDER she had consumed the drug before her pregnancies, too, but reduced her usage during those nine-month stretches. While pregnant, she said, she typically used marijuana once in the morning, once at night, and sometimes during the day when she still felt nauseated. She either took an oil product orally or smoked, taking a few hits from a pipe.

“Marijuana relieved it almost immediately and helped with my appetite,” she said. “It made it to where I could keep what I was eating down.”

Apie Binkley, 33, has a similar story.

“Extreme nausea was a big part of why I continued to consume [during pregnancy],” Brinkley told INSIDER. She used marijuana in its flower form, consuming half a gram or more depending on her nausea, and while it didn’t give complete relief, Brinkley said, it helped make the nausea tolerable enough so that she could function.

Others say it helped fight pain and improve mental health

Siu used a low-dose cannabis tincture as needed to address migraine pain during her pregnancy. It was through this experience that she discovered sublingual cannabis products, she said. In these applications, the drug is absorbed into the bloodstream through the tissue beneath the tongue, rather than ingested like an edible.

“I was like, huh, this is a very different feeling than smoking or eating. It feels really manageable, like an attitude adjustment,” she said.

In 2017, prompted in part by this discovery, Siu cofounded the company Mother & Clone, which sells low-dose sublingual cannabis sprays. The products are available in Colorado, but there are plans to expand to Canada.

Recently, Siu said, prospective customers have written to the company expressing curiosity about cannabis use during and after pregnancy.

“We’re not the medical community so we don’t like to speak on it,” she added. “It seems like the women within our community, all they want to know is that they’re not the only one wanting to explore this.”

Some moms say cannabis helped with postpartum mental-health struggles. Hollis Johnson/INSIDER

Siu also found that low-dose sublingual cannabis products relieved attacks of postpartum depression, or PPD, and anxiety symptoms.

“Post-pregnancy, it was, like, paralyzing anxiety. I could not get up, could not function,” she said. “I tried everything. I had tried Zoloft. I tried exercise. I ran a marathon. I went to therapy. I feel like did almost everything that the medical community would suggest.”

Siu said she couldn’t say whether cannabis alone helped her depression and anxiety, because she didn’t use it on its own. She added that the passage of time might have helped, too. She has felt better each year after giving birth.

“But I do know that cannabis helped stop it in its tracks,” she said. “If I was having an anxiety attack or depression, it gave just instant relief.”

Celia Behar, 45, a life coach in California who helps run the blog Lil’ Mamas, said she used cannabis to combat postpartum depression and anxiety that came on after the birth of her second daughter.

“I had crazy insomnia and I just had panic about everything,” she told INSIDER. “I was positive one or both of my kids was going to die. I would go from being completely fine to really ragey and screaming at both of the kids and one of them was not even a year old.”

Behar said she didn’t use cannabis while pregnant or while breastfeeding her daughters. She tried it after she stopped nursing her second daughter, when a friend suggested it as a way to cope with her panic.

“I thought he was a total jerk for telling me that,” Behar recalled. “I was, like, ‘I’m a mom, I can’t.’ But I was so desperate.”

That night she slept for a full eight hours, something she hadn’t done since the birth of her first child. She also felt that cannabis helped stabilize her mood.

“I just started to feel normal. I remember just being able to sit down on my couch for the first time in so long and actually watch a show,” she said. “For me, it became about self-care and emotional regulation. I just wasn’t so sad.”

Pregnant people who use marijuana may have ‘complicated feelings’ about it

In a new, small study published in January, a team of researchers conducted detailed interviews with 25 pregnant women who said they’d either used marijuana or tested positive for the drug at the time.

One of the study’s findings was that pregnant women using marijuana, at least in this limited sampling, had “complicated feelings” about the drug, the authors wrote.

In general they perceived marijuana as natural and safer than prescriptions, but they also attempted to reduce their marijuana use once they found out they were pregnant, and they expressed some concern about the drug’s potential risks during pregnancy.

The women in the study said they used marijuana to manage stress and address nausea while pregnant, though some people in the study experienced conflict in this decision, too.

A recent small study examined women’s attitudes toward marijuana use in pregnancy. Hollis Johnson/INSIDER

One said she didn’t want to use the drug but that it helped keep her from vomiting. Another said she was more concerned about keeping food down and getting enough nutrients for her fetus than about marijuana exposure.

“All of our participants were wanting to be really good mothers and were wanting what was best for their babies. That was not surprising to me as an OB-GYN,” the study author Judy Chang, an associate professor of obstetrics, gynecology, and reproductive sciences at the University of Pittsburgh, told INSIDER. “What was interesting was how they struggled with their marijuana use in the context of this desire to do good by their baby.”

Experts say there’s still not enough research on the safety of marijuana use during pregnancy

When it comes to the possible effects of marijuana use in pregnancy and breastfeeding, there’s still a lot to be learned.

“What we know today is pretty sparse,” Kjersti Aagard, a maternal-fetal medicine specialist and professor at Baylor College of Medicine and Texas Children’s Hospital, previously told INSIDER. “We don’t have the long-term studies to really examine that carefully from a public health perspective.”

Even in light of limited data, there’s evidence to suggest that marijuana use in pregnancy can be harmful, Torri Metz, an associate professor of obstetrics and gynecology, a maternal-fetal medicine specialist, and the director of perinatal research at the University of Utah Health, told INSIDER.

There’s still a lack of research in this area, experts say. Hollis Johnson/INSIDER

Metz, who’s authored several papers on this topic, explained that doctors have some concerns based on existing research. First, that marijuana use in pregnancy might affect fetal growth. Second, it might affect the rate of babies admitted to the neonatal intensive-care unit (NICU) after birth. Third, the drug could affect fetal brain development, possibly leading to worse cognitive performance.

The available evidence is hampered by some limitations. Some studies have failed to control for social or economic factors besides cannabis use that might have influenced mothers’ and babies’ health, Metz said. Others haven’t accounted for participants’ use of substances like tobacco or alcohol, which could have affected results.

“These studies are controversial,” Sheryl Ryan, a pediatrician at Penn State Health Milton S. Hershey Medical Center, and coauthor of a 2018 American Academy of Pediatrics report on marijuana use in pregnancy and lactation, told INSIDER. “The difficulty has been to tease out the independent effect of marijuana.”

There’s also some science to suggest that marijuana has become more potent over time, possibly rendering the conclusions of older studies less relevant.

What’s considered ‘marijuana use’ can vary dramatically

Further complicating things is that marijuana “use” can mean a lot of different things. Some people smoke the plant, others use vape pens, and others take edibles or tinctures, all in varying doses and at different frequencies.

In Chang’s recent study, for example, women reported prepregnancy marijuana usage ranging from two hits from a blunt or joint daily up to seven blunts a day.

“As we move forward in terms of doing the research, we really should be asking more details,” Chang said. “Not just ‘Do you use?’ but ‘Tell me a little bit more about your use.'”

And not every published research paper suggests marijuana use during pregnancy is risky. A small study from 1991 following children of Jamaican women found no significant developmental differences between young kids whose mothers used the drug while pregnant and the kids whose moms abstained.

Marijuana can include a variety of products, including edibles. Hollis Johnson/INSIDER

“Marijuana in pregnancy is one of those topics where if you go out in search of literature to support your viewpoint, you can certainly find it,” Metz said. “When we take all the information that’s available and put it together, there’s a risk of harm in pregnancy.”

In 2017, the National Academies of Sciences, Medicine, and Engineering published a massive report reviewing previous research on the health effects of cannabis use. They concluded there was substantial evidence linking maternal cannabis smoking to lower birth weight in babies, but only limited evidence that the drug is linked to pregnancy complications and NICU stays. Finally, there was “insufficient evidence to support or refute” an association between moms’ cannabis use and later outcomes for their children.

Major medical groups say pregnant people should avoid the drug until there’s more research

Siu and Laiken told INSIDER they had no pregnancy complications and that their children were healthy. Binkley, now a mother to stepchildren and an adopted child, had two pregnancies that ended in miscarriages, but said she “never thought that my marijuana use attributed” to the loss of those pregnancies.

For now, many major medical organizations advise steering clear. Given the scant evidence, the American College of Obstetricians and Gynecologists (ACOG) and the Centers for Disease Control and Prevention (CDC) recommend that expecting mothers not use the drug. The American Academy of Pediatrics (AAP) also recommends they avoid it.

Additionally, doctors can inform patients about better-researched treatments available for the conditions and symptoms that may spur marijuana use in pregnant people.

Groups like the CDC advise avoiding marijuana while pregnant. Hollis Johnson/INSIDER

“Sometimes we don’t do a good job as healthcare providers at trying to understand why women are using marijuana and then actually providing alternatives, rather than just saying, ‘Well, you shouldn’t use it,'” Metz said.

To treat nausea and vomiting in pregnancy, the ACOG recommends a combination of vitamin B6 and the sleep aid doxylamine. If this doesn’t work, pregnant people may use a class of drugs known as antiemetics. While there is conflicting safety data for some of these drugs during pregnancy, others are safe to use, according to the ACOG.

“If a woman has tried everything for nausea and can’t control it and a little marijuana helps, that may be the only alternative,” Ryan said. “But I still think a woman has to be counseled about the fact that we’re still not sure about how safe it is.”

When it comes to perinatal depression, an umbrella term that includes PPD, Metz again recommended established treatments, including antidepressants and talk therapy.

Even less is known about the effects of marijuana while breastfeeding

The science on cannabis use and breastfeeding is even scanter.

Some studies suggest that tetrahydrocannabinol, or THC, the main psychoactive component of marijuana, crosses into breast milk, but for a while the evidence was limited to a few case reports, Ryan wrote in a 2018 commentary published in the journal Pediatrics.

But in 2018, Christina Chambers, a professor at the University of California San Diego School of Medicine and codirector of the Center for Better Beginnings, coauthored a larger study that looked at breast milk samples from 50 moms who reported using the drug. Most said they consumed by inhaling, and about 90% said they used cannabis at least once a day.

THC was found in 34 of the 54 breast-milk samples provided. The concentration of THC varied widely from sample to sample and was “low compared with adult doses.” But as Chambers later said in a statement about the research, experts still don’t know enough to say whether there’s a safe dose of THC for infants.

There’s little research on cannabis use and breastfeeding. Hollis Johnson/INSIDER

There’s also little evidence on how marijuana in breast milk could affect a baby’s health, though two small studies published 1985 and 1990 attempted to find answers. One found a link between nursing mothers’ marijuana use and decreased motor development in their 1-year-old babies. The other found no link between maternal marijuana use and impaired motor or mental development in 1-year-olds.

But those studies couldn’t entirely account for prenatal exposure, which is an important consideration for future studies, Chambers previously told INSIDER. Additional research may find that marijuana compounds end up in breast milk at concentrations so low there’s no cause for concern, she added.

But for now the ACOG and AAP advise avoiding marijuana use while breastfeeding, and the CDC says breastfeeding moms who use pot should be encouraged to “abstain from or significantly reduce” their use.

“The little bit of data that we do have suggests that at least some of the active ingredients in the drug do cross into breast milk,” Chambers previously told INSIDER. “So clearly the better-safe-than-sorry approach would be to avoid it altogether.”

Pregnant people may not ask their doctors about marijuana use, fearing legal risks
Several US states have mandatory reporting laws, in which healthcare providers are required to report prenatal substance use to child protective agencies, though in some states this is required only when substance use is associated with maltreatment of a child, according to a 2017 analysis published in Women’s Health Issues.

“A big fear among women is obviously these things being reported,” Siu said.

Binkley said she had apprehensions about discussing prenatal marijuana use with her doctor.

“I did have some concerns about a whole lot of backlash, legal and otherwise, if he was against it,” she said. “Would he continue to treat me? Would he classify me as a hopeless cause? Would he call the police to go to my house like I was El Chapo smuggling dirt weed across county lines?”

Eventually, she said, she started a conversation about medical marijuana with her doctor before she got pregnant and found that her physician “believed in the benefits” of cannabis.

Marijuana edible gummy
Some US states’ laws require doctors to report prenatal substance use. Hollis Johnson/INSIDER
Still, the threat of legal consequences may keep patients from asking doctors questions about marijuana use in pregnancy, potentially shutting down the opportunity for a conversation about possible health effects and alternative treatments.

In Chang’s study, the 25 participants perceived that prenatal marijuana use risked the potential involvement of child-protective services. They listed this risk as one reason they didn’t tell their OB-GYNs about their use, Chang told INSIDER.

She added that the way mandatory reporting laws are implemented may be inadvertently limiting open communication between patients and doctors about prenatal marijuana use.

“As an OB provider, that breaks my heart,” Chang said. “Because I would want to be able to be there for my patients and give them as much information as they need. And so to have that silence exist as a result of their fear around this — that is disturbing to me.”

In its latest committee opinion on prenatal marijuana use, the ACOG addressed mandatory reporting.

“Seeking obstetric-gynecologic care should not expose a woman to criminal or civil penalties for marijuana use, such as incarceration, involuntary commitment, loss of custody of her children, or loss of housing,” the opinion said. “Drug enforcement policies that deter women from seeking prenatal care are contrary to the welfare of the mother and fetus.”

Doctors may also be reluctant to have conversations about substance use. A small 2016 study, also coauthored by Chang, analyzed audio recordings of doctors’ visits in which 90 pregnant patients disclosed marijuana use to 47 healthcare providers. In nearly half these visits, healthcare providers didn’t respond to that disclosure or offer any counseling, the study found.

Marijuana use in pregnancy and breastfeeding presents major public-health questions that need answers

Lingering questions on marijuana’s safety during pregnancy and breastfeeding can be answered only by more research. But conducting that research is difficult.

The US Drug Enforcement Agency (DEA) still classifies marijuana as a Schedule I drug, defined as “drugs with no currently accepted medical use and a high potential for abuse,” meaning there are restrictions on scientists’ ability to study it. Any researcher who wants to study a Schedule I drug (a category that includes heroin and LSD) has to register with the DEA and provide details about their qualifications and research protocols.

Experts say there’s an urgent need for more research. Hollis Johnson/INSIDER

The National Academies of Sciences, Medicine, and Engineering’s 2017 report said this classification imposes “numerous” barriers on marijuana research. “Unless these barriers are directly addressed … a comprehensive national cannabis research agenda will remain an elusive goal,” the report said.

In the absence of needed research, and with many states weighing recreational legalization, more moms-to-be may turn to the drug if it’s recommended on social media or elsewhere online.

“I understand how a woman can go online say: ‘This has really helped all these women. I think I’m going to try this because nothing’s helping me,'” Ryan said. “There’s not a whole lot of science to refute what’s being spread across the internet.”

The internet isn’t the only place these recommendations can spread.

In 2018, Metz and a team of researchers conducted a study in which a “mystery caller” contacted 400 marijuana dispensaries in Colorado — some medical, some recreational, some both. The caller said she was eight weeks pregnant and experiencing morning sickness. They found nearly 70% of the dispensaries recommended cannabis as a way to treat morning sickness, and only about 32% encouraged a discussion with a doctor without prompting.

“An urgent need exists to understand the effects of prenatal marijuana exposure because it may continue to rise in conjunction with the growing acceptance, accessibility, and spread of legalization in the United States,” Kelly Young-Wolff, a research scientist at the Kaiser Permanente Northern California, wrote in a paper published in the Annals of Internal Medicine in 2018.

In other words, we need answers about marijuana in pregnancy and breastfeeding, and if the rate of marijuana use keeps rising, we need those answers soon.

Ryan said she’s hopeful that increasing legalization could open the door to more research.

“There are a lot of scientists looking at the different molecules in cannabis and studying the potential benefits, and as more of this research moves forward, I think there’ll be more of a demand for increasing the availability of the substances,” she said. “We’re going to have more and more of a push, if not for a drug schedule change, at least to make it easier to study — fewer hoops to jump through to do the research that’s really needed.”