Social Determinants of Prenatal Marijuana Use Among American Indian Women: Findings from the North Dakota PRAMS, 2017-2021

Background and Purpose: Research highlights the roles of economic instability, limited healthcare access, adverse childhood experiences (ACEs), and interpersonal violence (IPV) in prenatal substance use. Among American Indian (AI) populations, these social determinants of health (SDOH) are shaped by unique historical and structural forces—including historical trauma, boarding school legacies, poverty, and restricted access to traditional food and health systems—that have produced intergenerational harm to population health. However, research has yet to comprehensively examine these interrelated SDOH in relation to prenatal marijuana use specifically among AI women. Applying the Healthy People 2030 SDOH framework, this study operationalized a multidimensional set of SDOH indicators and examined their independent associations with prenatal marijuana use among AI women in a Northern Plains state.

Methods: Participants were 739 self-identified AI women from the North Dakota Pregnancy Risk Assessment Monitoring System (ND PRAMS) Phase 8 (2017–2021). PRAMS is a population-based surveillance system conducted in collaboration with the Centers for Disease Control and Prevention (CDC) and state health departments; ND PRAMS oversamples AI women. The outcome was self-reported marijuana use during pregnancy (yes=1). SDOH predictors included income relative to the federal poverty line (FPL), Women, Infants, and Children (WIC) Program receipt, high school completion, first-trimester prenatal care initiation, ACE subtypes (household dysfunction, abuse, neglect), IPV during pregnancy, urban/rural residence, and paternal acknowledgment, controlling for maternal age. Hierarchical binary logistic regression was conducted using sequential block entry to identify independent SDOH associations with prenatal marijuana use.

Results: The full model was statistically significant (χ²=89.28, df=11, p<.001; Nagelkerke R²=.17). Three protective factors significantly reduced the odds of prenatal marijuana use: income at or above the FPL (OR=0.43, 95% CI [0.24, 0.77], p=.005), first-trimester prenatal care (OR=0.59, 95% CI [0.40, 0.86], p=.006), and older maternal age (OR=0.94, 95% CI [0.90, 0.97], p<.001). Three risk factors significantly increased the odds: IPV during pregnancy (OR=2.28, 95% CI [1.38, 3.77], p=.001), childhood abuse (OR=1.82, 95% CI [1.19, 2.79], p=.006), and childhood neglect (OR=1.70, 95% CI [1.11, 2.59], p=.014). Maternal education, WIC receipt, ACE household dysfunction, urban/rural residence, and paternal acknowledgment were not statistically significant.

Conclusions and Implications: Findings identify both modifiable protective factors and trauma-related risks independently associated with prenatal marijuana use among AI women. The differential associations among ACE subtypes—where interpersonal forms of childhood adversity, but not household dysfunction, uniquely contributed to risk—underscore the centrality of relational harm in shaping prenatal health behaviors. Notably, neither urban/rural residence nor paternal acknowledgment was associated with prenatal marijuana use, suggesting that trauma exposure and economic conditions may operate as more proximal determinants than geographic context or paternal involvement for this outcome. Consistent with Indigenous resilience scholarship, the protective role of economic stability and healthcare access points to structural enablers that may support the collective and relational processes through which AI communities sustain wellbeing. These findings align with the 2024 National Indian Health Board’s Tribal Prenatal-to-Three Policy Agenda, which positions equitable investment, culturally grounded healing from trauma, and Tribally led prenatal systems as essential to promoting health equity in AI communities.