Objectives
With legislative changes to cannabis legalization and increasing prevalence of use, cannabis is the most commonly used federally illicit drug in pregnancy. Our study aims to assess the perinatal outcomes associated with prenatal cannabis use disorder.

Methods
We conducted a retrospective cohort study using California linked hospital discharge-vital statistics data and included singleton, nonanomalous births occurring between 23 and 42 weeks of gestational age. χ2 Test and multivariable logistic regression were used for statistical analyses.

Results
A total of 2,380,446 patients were included, and 9144 (0.38%) were identified as using cannabis during pregnancy. There was a significantly increased risk for adverse birthing person outcomes, including gestational hypertension (adjusted odds ratio [AOR], 1.19; 95% confidence interval [CI], 1.06–1.34; P = 0.004), preeclampsia (AOR, 1.16; 95% CI, 1.0–1.28; P = 0.006), preterm delivery (AOR, 1.45; 95% CI, 1.35–1.55; P < 0.001), and severe maternal morbidity (AOR, 1.22; 95% CI, 1.02–1.47; P = 0.033). Prenatal cannabis use disorder was also associated with an increased risk of neonatal outcomes including respiratory distress syndrome (AOR, 1.16; 95% CI, 1.07–1.27; P < 0.001), small for gestational age (AOR, 1.47; 95% CI, 1.38–1.56; P < 0.001), neonatal intensive care unit admission (AOR, 1.24; 95% CI, 1.16–1.33; P < 0.001), and infant death (AOR, 1.86; 95% CI, 1.44–2.41; P < 0.001). There was no statistically significant difference in stillbirth (AOR, 0.96; 95% CI, 0.69–1.34; P = 0.80) and hypoglycemia (AOR, 1.22; 95% CI, 1.00–1.49; P = 0.045)

Conclusions
Our study suggests that prenatal cannabis use disorder is associated with increased maternal and neonatal morbidity and mortality. As cannabis use disorder in pregnancy is becoming more prevalent, our findings can help guide preconception and prenatal counseling.