Substance use during pregnancy continues to be a significant public health concern, resulting in adverse health outcomes for pregnant individuals and their developing offspring. While prevalence of tobacco and alcohol use declined overall between 2002 and 2016, with about 10% of expectant parents smoking tobacco or drinking alcohol while pregnant (Agrawal et al., 2019), the prevalence of cannabis use has significantly increased (Agrawal et al., 2019; Alshaarawy and Anthony, 2019; Brown et al., 2017; Hasin et al., 2019; Ko et al., 2015; Odom et al., 2020; Volkow et al., 2019). Specifically, the percentage of pregnant women who reported using cannabis in the past 30 days increased from 3.4% in 2002–2003 to 7.0% in 2016–2017 (Alshaarawy and Anthony, 2019). Daily cannabis use, also increased over the same period (Alshaarawy and Anthony, 2019). Medicalization of cannabis products, and their increased acceptability and availability of cannabis products, might explain these trends (Odom et al., 2020; Martin et al., 2015). Prenatal exposure to substances has been associated with an increased risk of miscarriage, stillbirth, preterm birth, and low birth weight (Alpár et al., 2016; Gunn et al., 2016; Metz et al., 2017; Petrangelo et al., 2019; Vitalis et al., 2008; Lo et al., 2022). Later life adverse outcomes include neurocognitive deficits in verbal and visual reasoning skills, short-term memory and response inhibition, psychopathology, and substance use (Grant et al., 2018; Huizink, 2014; Paul et al., 2021; Sharapova et al., 2018).

Serious psychological distress (SPD) has been associated with substance use during pregnancy (Goodwin et al., 2017; Vadukapuram et al., 2022). SPD encompasses the occurrence of mental health problems severe enough to cause moderate-to-serious social or occupational impairments that require treatment (Pratt et al., 2007). Recent estimates indicate that rates of SPD among adults in the US have significantly increased from 2.7% in 1999–2000 to 4% in 2017–2018 (Daly, 2022). Health consequences associated with SPD include premature mortality, more emergency room visits, and increased rates of chronic health conditions (Alhussain et al., 2017; Hamer et al., 2009; Russ et al., 2012). Among pregnant women, between 2008 and 2012, nearly 5% experienced SPD (Glasheen et al., 2015). Studies specifically examining the association between SPD and the occurrence of substance use during pregnancy have found that SPD was associated with cigarette use (Glasheen et al., 2015; Goodwin et al., 2007; Massey and Compton, 2013) and cannabis use (Mark et al., 2021). Consistently, multiple studies have suggested that women experiencing mental health disorders and stressful life events might use substances as a coping strategy (Testa et al., 2021). Unfortunately, less than half of those who report distress during pregnancy receive mental health care (Glasheen et al., 2015), which is concerning as rates of mental health and substance use during pregnancy are increasing in the US (Odom et al., 2020; Goodwin et al., 2017; Glasheen et al., 2015; Mark et al., 2021; Latuskie et al., 2019), and the public health system is not well prepared to address these complex trends (Moore et al., 2021).

Our study expands prior studies linking substance use and SPD among pregnant women by exploring the extent to which SPD during pregnancy influences the quantity or frequency of tobacco, alcohol, and cannabis use. We hypothesize that SPD might be associated with increases in the quantity of cigarettes smoked and the frequency of binge drinking and cannabis use among pregnant women. As substance use and SPD are significantly increasing among pregnant women in the US, understanding in detail patterns of use among pregnant women might help designing and conducting preventive prenatal interventions.