When Maryland legalized recreational cannabis for those 21 and older in 2023, it opened more than just storefronts. It also unlocked a set of hard questions for people working in maternal and child health. Pregnant people and new parents were talking about cannabis more openly – and providers weren’t sure how to respond.
“It’s a new moment of risk and opportunity,” says Tina Suliman, a senior program manager at the Johns Hopkins Center for Communication Programs. “People are willing to talk, but providers don’t always have the tools to advise them.”
After legalization, more pregnant patients were disclosing cannabis use. That’s not necessarily because more people were using it. Legalization “made it acceptable to report it,” Suliman says. Suddenly, clinicians were facing honest conversations about cannabis, without clear guidance on how to have them safely, respectfully or effectively.
CCP, through the Baltimore’s B’more for Healthy Babies initiative, has created a new counseling tool to help providers through these necessary conversations. The idea is to equip OB/GYNs, pediatricians, primary care doctors, and community health workers with the tools to address questions they hadn’t felt equipped to answer.
“This is really for regular providers who aren’t necessarily steeped in substance use,” says Gena O’Keefe, a consultant on the project.
Cannabis isn’t just a recreational habit. Listening sessions in Baltimore neighborhoods like Upton/Druid Heights revealed a pattern. People often use marijuana to cope with stress, anxiety, nausea or trauma. A simple “don’t do it” message ignores that reality.
Using cannabis during pregnancy or while breastfeeding can be risky for both the parent and the baby. It may also trigger or worsen mental health problems, such as anxiety, trouble sleeping, or psychosis.
“Some people who intend to use cannabis for nausea or sleep are surprised to learn that their weed use is actually the cause of worsening stomach pain, sleep disturbance, and stress,” says Jen Kirschner, who works at the Baltimore City Health Department on perinatal substance use programming. “What’s happening is they are experiencing cannabis withdrawal symptoms, which they ‘treat’ with more cannabis, and the cycle continues.”
When it comes to fetal and infant development, no amount or form of cannabis exposure is known to be safe. Research has linked it to lower birth weight, preterm birth and potential impacts on a child’s early learning, attention and behavior. Babies exposed to THC through breast milk can become sluggish drinkers, leading to inadequate weight gain.
The counseling guide encourages providers to share this information clearly while listening first, exploring why a patient might be using cannabis, and offering safer alternatives for managing symptoms or stress.
The emphasis is on dialogue, not lectures. Motivational interviewing guides help clinicians treat the conversation like a dance, not a wrestling match, Suliman says.
Historical context matters, too. Substance use has often been treated punitively, especially in Black communities. Families face child welfare involvement, legal consequences and stigma.
“It has created rupture, distrust between Baltimore communities and health professionals,” Suliman says. The counseling tool is meant to repair that trust, offering conversations that are non-punitive, trauma-aware and equity-centered.
Pediatrician Kima Taylor, who also consulted on the project, sees it as a long-overdue course correction. “We need providers to have a full set of tools in their tool belt,” she says.
Compassion and curiosity, she says, should come first: “Why are you using? I see you, I hear you, and how can we help?”
The guide also addresses a common misperception: Legal doesn’t mean safe. Some patients see cannabis as natural and assume it’s harmless. The counseling tool helps providers place cannabis alongside alcohol and tobacco in pregnancy, explaining risks clearly while respecting patients’ autonomy and lived experiences.
By equipping everyday providers with practical tools, CCP and the Baltimore City Health Department are hoping to turn a moment of uncertainty into better care.
“Thoughtful counseling, grounded in evidence, equity and empathy, can help families make safer choices and strengthen trust between patients and the clinicians who care for them,” Suliman says.
B’more for Healthy Babies will host a webinar, “Compassionate Conversations, Informed Decisions: Practical Guidance for Counseling Pregnant Patients About Cannabis Use,” on March 26 at 9 a.m. Register here. The webinar will equip providers to support patients in making decisions that align with their health goals, without shame, fear or judgment.
