Baby BEEP: A randomized controlled trial of nurses' individualized social support for poor rural pregnant smokers

Effectiveness of smoking cessation interventions among pregnant women: An updated systematic review and meta-analysis

OBJECTIVE

To carry out a systematic review of systematic reviews with an update of the existing evidence relating to a broad range of smoking cessation interventions, including psycho-social, digital and pharmacologic interventions, for pregnant women.

DATA-SOURCES

Search was conducted in March 2022 in PubMed, EMBASE, and Cochrane in two stages: 1) a search of systematic reviews and meta-analyses, published from January 2012 through January 2022; 2) an update of those that fulfilled eligibility criteria reproducing the primary search strategy.

STUDY ELIGIBILITY CRITERIA

We selected randomized clinical trials (RCTs) that evaluated the effectiveness of pharmacological, digital, and psychosocial interventions in aged 18 years and over who were daily smokers, and compared these with routine care, less intense interventions or placebo.

STUDY APPRAISAL AND SYNTHESIS METHODS

Data from eligible studies were manually extracted by two authors and reviewed by a third. The quality of the reviews was evaluated using the AMSTAR scale, and risk of bias was measured with the Rob-2 tool and GRADE level of evidence.

RESULTS

The meta-analysis included 63 RCTs (n = 19849 women). The interventions found to be effective were: financial incentives (RR:1.77; 95%CI:1.21-2.58), counseling (RR:1.27; 95%CI:1.13-1.43) and long-term nicotine replacement therapy (NRT) (RR:1.53; 95%CI:1.16-2.01). Short-term NRT, bupropion, digital interventions, feedback, social support, and exercise showed no effectiveness. The GRADE level of evidence was moderate-to-high for all interventions, with the exception of long-term NRT.

CONCLUSIONS

Non-pharmacological interventions for smoking cessation are the most effective for pregnant women. The moderator analysis suggests that pregnant women of low socioeconomic status might benefit less from smoking cessation interventions than women of a high socioeconomic status. These women are usually heavier smokers that live in pro-smoking environments and could require more intensive and targeted interventions.

Strategies to improve interpersonal communication along the continuum of maternal and newborn care: A scoping review and narrative synthesis

Effective interpersonal communication is essential to provide respectful and quality maternal and newborn care (MNC). This scoping review mapped, categorized, and analysed strategies implemented to improve interpersonal communication within MNC up to 42 days after birth. Twelve bibliographic databases were searched for quantitative and qualitative studies that evaluated interventions to improve interpersonal communication between health workers and women, their partners or newborns' families. Eligible studies were published in English between January 1st 2000 and July 1st 2020. In addition, communication studies in reproduction related domains in sexual and reproductive health and rights were included. Data extracted included study design, study population, and details of the communication intervention. Communication strategies were analysed and categorized based on existing conceptualizations of communication goals and interpersonal communication processes. A total of 138 articles were included. These reported on 128 strategies to improve interpersonal communication and were conducted in Europe and North America (n = 85), Sub-Saharan Africa (n = 12), Australia and New Zealand (n = 10), Central and Southern Asia (n = 9), Latin America and the Caribbean (n = 6), Northern Africa and Western Asia (n = 4) and Eastern and South-Eastern Asia (n = 2). Strategies addressed three communication goals: facilitating exchange of information (n = 97), creating a good interpersonal relationship (n = 57), and/or enabling the inclusion of women and partners in the decision making (n = 41). Two main approaches to strengthen interpersonal communication were identified: training health workers (n = 74) and using tools (n = 63). Narrative analysis of these interventions led to an update of an existing communication framework. The categorization of different forms of interpersonal communication strategy can inform the design, implementation and evaluation of communication improvement strategies. While most interventions focused on information provision, incorporating other communication goals (building a relationship, inclusion of women and partners in decision making) could further improve the experience of care for women, their partners and the families of newborns.

Smoking Cessation Interventions and Abstinence Outcomes for People Living in Rural, Regional, and Remote Areas of Three High-Income Countries: A Systematic Review

INTRODUCTION

Tobacco smoking rates in high-income countries are greater in rural, regional, and remote (RRR) areas compared to cities. Yet, there is limited knowledge about interventions targeted to RRR smokers. This review describes the effectiveness of smoking cessation interventions for RRR smokers in supporting smoking abstinence.

AIMS AND METHODS

Seven academic databases were searched (inception-June 2022) for smoking cessation intervention studies to include if they reported on RRR residents of Australia, Canada, or the United States, and short- (<6 months) or long-term (≥6 months) smoking abstinence outcomes. Two researchers assessed study quality, and narratively summarized findings.

RESULTS

Included studies (n = 26) were primarily randomized control (12) or pre-post (7) designs, from the United States (16) or Australia (8). Five systems change interventions were included. Interventions included cessation education or brief advice, and few included nicotine monotherapies, cessation counseling, motivational interviewing, or cognitive behavioral therapy. Interventions had limited short-term effects on RRR smoking abstinence, decreasing markedly beyond 6 months. Short-term abstinence was best supported by contingency, incentive, and online cessation interventions, and long-term abstinence by pharmacotherapy.

CONCLUSIONS

Cessation interventions for RRR smokers should include pharmacotherapy and psychological cessation counseling to establish short-term abstinence, and identify effective means of maintaining abstinence beyond 6 months. Contingency designs are a suitable vehicle for psychological and pharmacotherapy support for RRR people who smoke, and intervention tailoring should be explicitly considered.

IMPLICATIONS

Smoking disproportionately harms RRR residents, who can encounter access barriers to smoking cessation support. High-quality intervention evidence and outcome standardization are still required to support long-term RRR smoking abstinence.

Effect of digital health, biomarker feedback and nurse or midwife-led counselling interventions to assist pregnant smokers quit: a systematic review and meta-analysis

OBJECTIVE

To assess the effect of digital health (DH), biomarker feedback (BF) and nurse or midwife-led counselling (NoMC) interventions on abstinence in pregnant smokers during pregnancy and postpartum.

SETTINGS

Any healthcare setting servicing pregnant women, including any country globally.

PARTICIPANTS

Pregnant women of any social, ethnic or geographical background who smoke.

METHODS

We searched Embase, Medline, Web Of Science, Google Scholar, PsychINFO, CINAHL and PubMed between 2007 and November 2021. We included published original intervention studies in English with comparators (usual care or placebo). Two independent assessors screened and abstracted data. We performed a random-effects meta-analysis, assessed risk of bias with the Cochrane Tool and used Grading of Recommendations Assessment, Development and Evaluation to assess the quality of evidence.

RESULTS

We identified 57 studies and included 54 in the meta-analysis. Sixteen studies assessed DH (n=3961), 6 BF (n=1643), 32 NoMC (n=60 251), 1 assessed NoMC with BF (n=1120) and 2 NoMC with DH interventions (n=2107). DH interventions had moderate certainty evidence to achieve continuous abstinence (CA) at late pregnancy (4 studies; 2049 women; RR=1.98, 95% CI 1.08 to 3.64, p=0.03) and low certainty evidence to achieve point prevalence abstinence (PPA) postpartum (5 studies; 2238 women; RR=1.46, 95% CI 1.05 to 2.02, p=0.02). NoMC interventions had moderate certainty evidence to achieve PPA in late pregnancy (15 studies; 16 234 women; RR=1.54, 95% CI 1.16 to 2.06, p<0.01) and low certainty evidence to achieve PPA postpartum (13 studies; 5466 women; RR=1.79, 95% CI 1.14 to 2.83, p=0.01). Both DH and BF interventions did not achieve PPA at late pregnancy, nor NoMC interventions achieve CA postpartum. The certainty was reduced due to risk of bias, heterogeneity, inconsistency and/or imprecision.

CONCLUSION

NoMC interventions can assist pregnant smokers achieve PPA and DH interventions achieve CA in late pregnancy. These interventions may achieve other outcomes.

Telemedicine in the treatment of addictions

PURPOSE OF REVIEW

The purpose of this update is to provide an overview of recent research publications (January 2020-January 2022) on real-time telemedicine solutions for the management of addictions (alcohol, tobacco, opioids, and other drugs).

RECENT FINDINGS

Motivational interviewing by real-time telemedicine showed effectiveness in youth and adults for risky alcohol use and alcohol use disorders, even when a concurrent mental health disorder exists. Live telemedicine is well accepted for managing tobacco use disorders. The range of interventions for treating opioid use disorder by real-time telemedicine is large and has been increased due to the coronavirus disease 2019 (COVID-19) pandemic (prescription of opioid agonists, peer-to-peer support, counseling, and group therapy).

SUMMARY

The COVID-19 pandemic has accelerated the implementation of real-time telemedicine and, in parallel, research has been conducted to test its effectiveness. Videoconferencing and telephone interventions are supported by solid evidence for risky alcohol use and alcohol use disorder, tobacco use disorder and opioid use disorder. The Integration of other types of telemedicine (asynchronous telemedicine and remote monitoring) and with the entire health system is lacking. Many areas and vulnerable populations (e.g., homeless, elderly, and cannabis use disorders) need more attention.

The effectiveness of smoking cessation interventions in rural and remote populations: Systematic review and meta-analyses

BACKGROUND

Rural and remote residents are more likely to smoke tobacco than those in major cities. However, they may experience unique systemic, provider, and individual barriers to accessing smoking cessation treatments, including distance and limited resources. Understanding the effectiveness of smoking cessation interventions in this population is important due to higher smoking-related disease burden and death compared to those in major cities.

METHODS

Medline, EMBASE, Scopus, PsychINFO, and Cochrane Library were searched until 19-02/2021. Inclusion criteria were randomised controlled trials (RCTs), cluster RCTs, randomised trials, or cluster randomised trials investigating behavioural interventions and pharmacotherapies for smoking cessation in rural and remote populations compared with a control or another smoking cessation treatment; and published in English. Given there is no internationally-standardised rurality index, definitions of 'rural' and 'remote' used by authors of studies were applied to reflect their country. Exclusion criteria were studies of non-combustible smoking cessation; and studies with urban participants in the sample. Two reviewers independently screened records for eligibility, extracted data from studies utilising a modified Cochrane Effective Practice and Organisation of Care Group form, and rated methodological quality using the Quality Assessment Tool for Quantitative Studies.

RESULTS

Sixteen studies were included. Meta-analysis revealed a statistically significant treatment effect of individual face-to-face counselling on smoking cessation (RR 2.35, 95% CI 1.16-4.76, I²=0%) in rural and remote populations. There was no statistically significant treatment effect for nicotine replacement therapy (RR 2.97, 95% CI 0.84-10.53, I²=47%), telephone-counselling (RR 1.69, 95% CI 0.56-5.06, I²=62%), and community-based multiple-interventions (RR:1.57, 95% CI 0.89-2.78, I²=85%). Certainty of evidence was rated very low for each meta-analysis.

CONCLUSION

Despite limited resources in rural and remote settings, individual face-to-face counselling for smoking cessation appears promising. Given the limited number of studies, further research about the effectiveness of smoking cessation interventions in rural and remote populations is warranted.

Personalised multicomponent interventions for tobacco dependence management in low socioeconomic populations: a systematic review and meta-analysis

BACKGROUND

There remains a disproportionally high tobacco smoking rate in low-income populations. Multicomponent tobacco dependence interventions in theory are effective. However, which intervention components are necessary to include for low socioeconomic status (SES) populations is still unknown.

OBJECTIVE

To assess the effectiveness of multicomponent tobacco dependence interventions for low SES and create a checklist tool examining multicomponent interventions.

METHODS

EMBASE and MEDLINE databases were searched to identify randomised controlled trials (RCTs) published with the primary outcome of tobacco smoking cessation measured at 6 months or post intervention. RCTs that evaluated tobacco dependence management interventions (for reduction or cessation) in low SES (experience of housing insecurity, poverty, low income, unemployment, mental health challenges, illicit substance use and/or food insecurity) were included. Two authors independently abstracted data. Random effects meta-analysis and post hoc sensitivity analysis were performed.

RESULTS

Of the 33 included studies, the number of intervention components ranged from 1 to 6, with smoking quit rates varying between 1% and 36.6%. Meta-analysis revealed that both the 6-month and 12-month outcome timepoints, multicomponent interventions were successful in achieving higher smoking quit rates than the control (OR 1.64, 95% Cl 1.41 to 1.91; OR 1.74, 95% Cl 1.30 to 2.33). Evidence of low heterogeneity in the effect size was observed at 6-month (I2=26%) and moderate heterogeneity at 12-month (I2=56%) outcomes.

CONCLUSION

Multicomponent tobacco dependence interventions should focus on inclusion of social support, frequency and duration of components. Employing community-based participatory-action research approach is essential to addressing underlying psychosocioeconomic-structural factors, in addition to the proven combination pharmacotherapies.

PROSPERO REGISTRATION NUMBER

CRD42017076650.

"They're very passionate about making sure that women stay healthy": a qualitative examination of women's experiences participating in a community paramedicine program

BACKGROUND

Community paramedicine programs (i.e., physician-directed preventive care by emergency medical services personnel embedded in communities) offer a novel approach to community-based health care. Project Swaddle, a community paramedicine program for mothers and their infants, seeks to address (directly or through referrals) the physical, mental, social, and economic needs of its participants. The objective of this process evaluation was to describe women's experiences in Project Swaddle. By understanding their experiences, our work begins to build the foundation for similar programs and future examinations of the efficacy and effectiveness of these approaches.

METHODS

We completed 21 interviews with women living in Indiana (July 2019-February 2020) who were currently participating in or had graduated from Project Swaddle. Interviews were audio-recorded, transcribed, and analyzed using a six-phase approach to thematic analysis.

RESULTS

Program enrollment was influenced by the community paramedics' experience and connections, as well as information received in the community from related clinics or organizations. Participants viewed the community paramedic as a trusted provider who supplied necessary health information and support and served as their advocate. In their role as physician extenders, the community paramedics enhanced patient care through monitoring critical situations, facilitating communication with other providers, and supporting routine healthcare. Women noted how community paramedics connected them to outside resources (i.e., other experts, tangible goods), which aimed to support their holistic health and wellbeing.

CONCLUSIONS

Results demonstrate Project Swaddle helped women connect with other healthcare providers, including increased access to mental health services. The community paramedics were able to help women establish care with primary care providers and pediatricians, then facilitate communication with these providers. Women were supported through their early motherhood experience, received education on parenting and taking control of their health, and gained access to resources that met their diverse needs.

eHealth Interventions to Treat Substance Use in Pregnancy: A Systematic Review and Meta-Analysis

Substance use during pregnancy is associated with adverse pregnancy and neonatal outcomes; eHealth interventions offer a potential accessible treatment option. The objective of this systematic review and meta-analysis was to evaluate the effectiveness of eHealth interventions for the treatment of substance use during pregnancy. A comprehensive search of PsycINFO, Medline, CINAHL, Cochrane and Embase databases was conducted from May 2020 to April 2021. The protocol for this study was registered with Prospero (CRD42020205186) through the University of York Centre for Reviews and Dissemination. Two independent reviewers completed screening, data extraction, and quality assessment. RCTs were included if they reported: (a) administration of an eHealth intervention for (b) substance use outcomes, among (c) pregnant individuals. Comprehensive Meta-Analysis Software (CMA) was used to calculate pooled effect sizes (Odds Ratio) to determine the effect of eHealth interventions on substance use outcomes. Six studies were identified with substance use outcomes that included: smoking (n = 3), alcohol (n = 2), and other (n = 1). eHealth interventions were delivered through the internet (n = 1), computer (n = 3), telephone (n = 1), and text (n = 1). Results suggested that eHealth interventions significantly reduced substance use in pregnant individuals compared to controls (OR = 1.33, 95% CI = 1.06 to 1.65, p = 0.013). eHealth interventions offer a promising and accessible treatment option to reduce substance use during pregnancy. This work was supported by the generous donors of the Alberta Children's Hospital Foundation, the Canadian Child Health Clinician Scientist Program (CCHCSP), the Canadian Institute of Health Research and the Fonds de Recherche du Québec-Santé.

Cotinine Fluctuation in Maternal Saliva During and After Pregnancy: Implications for Perinatal Outcomes

PURPOSE

The purpose of this study was to determine maternal cotinine levels in saliva at the first (T-1) and third trimesters of pregnancy (T-2), and postpartum (T-3) among women who reported smoking a consistent number of cigarettes. The goal was to generate data to provide suggestions about how nurses can improve patient outcomes for women who smoke.

METHODS

Saliva cotinine values obtained from the randomized controlled trial (BabyBEEP) were used for this secondary analysis. We examined variations in saliva cotinine between the first and third trimesters of pregnancy and postpartum among light and heavy smokers. Cotinine values for pregnant smokers who were in the control group (not randomized to any intervention) and reported smoking the same range of cigarettes during and after pregnancy were used for the analyses (n = 43). Descriptive statistics and repeated-measures ANOVA were used for analyses.

RESULTS

There were differences in maternal saliva cotinine levels across the different time points and between the groups. There was a significant interaction effect between time and group. Cotinine decreased from T-1 to T-2 in heavy smokers and increased from T-2 to T-3 among both light and heavy smokers. Cotinine at T-3 was higher than T-1 among light smokers.

CLINICAL IMPLICATIONS

Findings support accelerated nicotine metabolism during pregnancy and need for smoking cessation efforts throughout pregnancy to help women stay smoke free during postpartum.

A pre-evaluation of psychological factors may positively affect the outcomes of smoking cessation treatments: A comparison in terms of smoking behavior

INTRODUCTION

The aim of this study was to compare smoking behavior in out-patients in terms of psychological factors with a view to supporting cessation treatment.

METHODS

We conducted a cross-sectional and analytical study through face-to-face interviews by the primary care physician with 765 volunteer participants who applied to our hospital for any reason between March and July 2019. The questionnaire administered had two parts: questions about sociodemographic characteristics and usage of tobacco and tobacco products, and questions of the UCLA Loneliness Scale, Multidimensional Scale of Perceived Social Support (MSPSS), Warwick-Edinburgh Mental Wellbeing Scale (WEMBS), and Fagerström Test for Nicotine Dependence (FTND).

RESULTS

The study was completed with 765 participants of which 53.1% (n=406) were female and 46.9% (n=359) male. Multidimensional perceived social support scale mean score of the participants was 69.9±15.2 (min=12, max=84). There was a significant relation between mean MPSS and mean WEMBS (p<0.05). As nicotine scores increased, the mean scores both in MPSS and WEMBS decreased (p<0.05).

CONCLUSIONS

We suggest that the results of the psychometric preliminary evaluations should be customized for individuals applying to smoking cessation clinics and that including the individual's close social connections in the process can facilitate the decision to quit, thus increase smoking cessation rates.

Interventions for Tobacco Smoking Cessation in Adults, Including Pregnant Persons: US Preventive Services Task Force Recommendation Statement

IMPORTANCE

Tobacco use is the leading preventable cause of disease, disability, and death in the US. In 2014, it was estimated that 480 000 deaths annually are attributed to cigarette smoking, including second hand smoke exposure. Smoking during pregnancy can increase the risk of numerous adverse pregnancy outcomes (eg, miscarriage and congenital anomalies) and complications in the offspring (including sudden infant death syndrome and impaired lung function in childhood). In 2019, an estimated 50.6 million US adults (20.8% of the adult population) used tobacco; 14.0% of the US adult population currently smoked cigarettes and 4.5% of the adult population used electronic cigarettes (e-cigarettes). Among pregnant US women who gave birth in 2016, 7.2% reported smoking cigarettes while pregnant.

OBJECTIVE

To update its 2015 recommendation, the USPSTF commissioned a review to evaluate the benefits and harms of primary care interventions on tobacco use cessation in adults, including pregnant persons.

POPULATION

This recommendation statement applies to adults 18 years or older, including pregnant persons.

EVIDENCE ASSESSMENT

The USPSTF concludes with high certainty that the net benefit of behavioral interventions and US Food and Drug Associated (FDA)-approved pharmacotherapy for tobacco smoking cessation, alone or combined, in nonpregnant adults who smoke is substantial. The USPSTF concludes with high certainty that the net benefit of behavioral interventions for tobacco smoking cessation on perinatal outcomes and smoking cessation in pregnant persons is substantial. The USPSTF concludes that the evidence on pharmacotherapy interventions for tobacco smoking cessation in pregnant persons is insufficient because few studies are available, and the balance of benefits and harms cannot be determined. The USPSTF concludes that the evidence on the use of e-cigarettes for tobacco smoking cessation in adults, including pregnant persons, is insufficient, and the balance of benefits and harms cannot be determined. The USPSTF has identified the lack of well-designed, randomized clinical trials on e-cigarettes that report smoking abstinence or adverse events as a critical gap in the evidence.

RECOMMENDATIONS

The USPSTF recommends that clinicians ask all adults about tobacco use, advise them to stop using tobacco, and provide behavioral interventions and FDA-approved pharmacotherapy for cessation to nonpregnant adults who use tobacco. (A recommendation) The USPSTF recommends that clinicians ask all pregnant persons about tobacco use, advise them to stop using tobacco, and provide behavioral interventions for cessation to pregnant persons who use tobacco. (A recommendation) The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of pharmacotherapy interventions for tobacco cessation in pregnant persons. (I statement) The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of e-cigarettes for tobacco cessation in adults, including pregnant persons. The USPSTF recommends that clinicians direct patients who use tobacco to other tobacco cessation interventions with proven effectiveness and established safety. (I statement).

Factors related to prenatal smoking among socioeconomically disadvantaged women

Socioeconomically disadvantaged pregnant women are especially at risk for smoking. To understand better this health behavior disparity, this systematic, integrative, comprehensive review aimed to identify factors related to prenatal smoking among socioeconomically disadvantaged women in the United States. A comprehensive literature search yielded 67 articles published between 2008 and 2016. Associated factors included any study variable related to persistent prenatal smoking. The Social Ecological Model (SEM), a multidimensional ecological framework, was used to organize the findings. Thirty-eight factors were explored in the reviewed studies and categorized according to SEM dimensions: individual, interpersonal, organizational, community, public policies and laws. At the individual level, most studies identified the socioeconomically disadvantaged prenatal smoker as older, US-born, White, unmarried, and multiparous. Other individual-level factors included alcohol abuse, nicotine dependence, and psychosocial factors such as stress and depressive symptoms. For broader levels of the SEM, associated factors included abuse/trauma, secondhand smoke exposure, lack of prenatal care, smoking cessation interventions, neighborhood risk, and state level initiatives such as cigarette taxes. The results of this review suggested multiple directions for future research to move science toward effective, scalable, and sustainable approaches that effectively address prenatal smoking among socioeconomically disadvantaged women.

Contingency Management Versus Psychotherapy for Prenatal Smoking Cessation: A Meta-Analysis of Randomized Controlled Trials

OBJECTIVES

Prenatal smoking is the leading preventable cause of poor obstetric outcomes, yet treatment options are limited. Past reviews of prenatal smoking cessation have often grouped all counseling into a single category, which ignores the fact that psychotherapy is distinct from brief counseling. The objective of this study was to compare the effect sizes of two intensive interventions for prenatal smoking cessation: contingency management (i.e., financial incentives for abstinence) and psychotherapy.

METHODS

A systematic search for randomized controlled trials testing the efficacy of contingency management or psychotherapy was completed using PubMed, PsycINFO, Web of Science, the Cochrane Library, and EMBASE. Independent raters extracted data and assessed trials for risk of bias. Treatment effects were analyzed for three times points: late pregnancy, early postpartum, and late postpartum.

RESULTS

The search yielded 22 studies, and meta-analytic results indicated that interventions (compared with control groups) generally increased the odds of abstinence. Moderator analyses indicated that intervention type (contingency management vs. psychotherapy) accounted for variability in effect sizes. When comparing treatment type, effects of contingency management interventions were significantly greater than those of psychotherapeutic interventions. Although psychotherapy did not affect smoking abstinence, contingency management interventions had significant treatment effects at all three time points.

CONCLUSIONS

Contingency management seems to be a safe and efficacious prenatal smoking cessation treatment. Although psychotherapy alone did not show an effect on prenatal smoking abstinence, future research may seek to combine this approach with contingency management to promote prenatal smoking cessation.

Supporting Rural Women During Pregnancy: Baby BEEP Nurses

PURPOSE

The aim of this study was to characterize nursing care provided by the research nurses from the Baby Behavioral Educational Enhancement of Pregnancy (Baby BEEP) study as they delivered a telephone social support intervention to low-income, pregnant women in the Midwestern United States.

STUDY DESIGN AND METHODS

This was a descriptive qualitative study that used Peplau's Theory of Interpersonal Relations to frame and interpret the analysis.

RESULTS

Research nurses from the Baby BEEP study found a novel way to reach a vulnerable population through weekly telephone interactions. Acting in several of Peplau's nursing roles, the care they provided led to a remarkable retention rate and therapeutic nurse-patient relationships. The Baby BEEP study demonstrated the provision of a well-received psychosocial support intervention that can be used to help underserved women throughout pregnancy.

CLINICAL IMPLICATIONS

Telenursing care provided to low-income, rural women was well received and reflected the principles in Peplau's Theory of Interpersonal Relations. Nurses may use this type of nursing care to support women who are difficult to reach and typically experience low levels of support. This article describes the nursing care provided by the Baby BEEP nurses and provides a model for future, novel approaches to social support in a vulnerable and difficult-to-reach population.

Pathways From Socioeconomic Status to Prenatal Smoking: A Test of the Reserve Capacity Model

BACKGROUND

Low-income, unemployed women with low levels of education are more likely to smoke during pregnancy compared to their higher-income, employed, and well-educated counterparts. The reserve capacity model (RCM) offers a theoretical framework to explain how psychosocial factors may serve as pathways connecting socioeconomic status (SES) to health behaviors. Research supports the link between prenatal smoking and several psychosocial variables such as chronic stressors, depressive symptoms, and social support. How these variables interrelate to explain the predominance of prenatal smoking in lower socioeconomic groups of pregnant women has not been fully elucidated.

OBJECTIVE

The aim of this study was to test the RCM to evaluate the roles of early pregnancy levels of chronic stress, quality of the primary intimate relationship, and depressive symptoms in explaining the relationship between SES and persistent prenatal smoking.

METHODS

A secondary analysis of data from 370 pregnant nonsmokers, spontaneous quitters, and persistent prenatal smokers was conducted. On the basis of the RCM, chronic stressors, depressive symptoms, and the quality of the primary intimate relationship were evaluated as potential mediating variables linking SES with persistent prenatal smoking using path analysis.

RESULTS

Path analyses indicated that a simple model with all three psychosocial variables as mediators of the relationship between SES and persistent prenatal smoking provided the best fit.

DISCUSSION

Findings indicated that chronic stressors, depressive symptoms, and the quality of the primary intimate relationship play important roles in the pathway from SES to prenatal smoking status. This knowledge can assist in the development of prevention and intervention strategies to target these variables and ultimately reduce prenatal smoking.

Psychosocial interventions for supporting women to stop smoking in pregnancy

BACKGROUND

Tobacco smoking remains one of the few preventable factors associated with complications in pregnancy, and has serious long-term implications for women and babies. Smoking in pregnancy is decreasing in high-income countries, but is strongly associated with poverty and is increasing in low- to middle-income countries.

OBJECTIVES

To assess the effects of smoking cessation interventions during pregnancy on smoking behaviour and perinatal health outcomes.

SEARCH METHODS

In this sixth update, we searched the Cochrane Pregnancy and Childbirth Group's Trials Register (13 November 2015), checked reference lists of retrieved studies and contacted trial authors.

SELECTION CRITERIA

Randomised controlled trials, cluster-randomised trials, and quasi-randomised controlled trials of psychosocial smoking cessation interventions during pregnancy.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion and trial quality, and extracted data. Direct comparisons were conducted in RevMan, with meta-regression conducted in STATA 14.

MAIN RESULTS

The overall quality of evidence was moderate to high, with reductions in confidence due to imprecision and heterogeneity for some outcomes. One hundred and two trials with 120 intervention arms (studies) were included, with 88 trials (involving over 28,000 women) providing data on smoking abstinence in late pregnancy. Interventions were categorised as counselling, health education, feedback, incentives, social support, exercise and dissemination.In separate comparisons, there is high-quality evidence that counselling increased smoking cessation in late pregnancy compared with usual care (30 studies; average risk ratio (RR) 1.44, 95% confidence interval (CI) 1.19 to 1.73) and less intensive interventions (18 studies; average RR 1.25, 95% CI 1.07 to 1.47). There was uncertainty whether counselling increased the chance of smoking cessation when provided as one component of a broader maternal health intervention or comparing one type of counselling with another. In studies comparing counselling and usual care (largest comparison), it was unclear whether interventions prevented smoking relapse among women who had stopped smoking spontaneously in early pregnancy. However, a clear effect was seen in smoking abstinence at zero to five months postpartum (11 studies; average RR 1.59, 95% CI 1.26 to 2.01) and 12 to 17 months (two studies, average RR 2.20, 95% CI 1.23 to 3.96), with a borderline effect at six to 11 months (six studies; average RR 1.33, 95% CI 1.00 to 1.77). In other comparisons, the effect was unclear for most secondary outcomes, but sample sizes were small.Evidence suggests a borderline effect of health education compared with usual care (five studies; average RR 1.59, 95% CI 0.99 to 2.55), but the quality was downgraded to moderate as the effect was unclear when compared with less intensive interventions (four studies; average RR 1.20, 95% CI 0.85 to 1.70), alternative interventions (one study; RR 1.88, 95% CI 0.19 to 18.60), or when smoking cessation health education was provided as one component of a broader maternal health intervention.There was evidence feedback increased smoking cessation when compared with usual care and provided in conjunction with other strategies, such as counselling (average RR 4.39, 95% CI 1.89 to 10.21), but the confidence in the quality of evidence was downgraded to moderate as this was based on only two studies and the effect was uncertain when feedback was compared to less intensive interventions (three studies; average RR 1.29, 95% CI 0.75 to 2.20).High-quality evidence suggests incentive-based interventions are effective when compared with an alternative (non-contingent incentive) intervention (four studies; RR 2.36, 95% CI 1.36 to 4.09). However pooled effects were not calculable for comparisons with usual care or less intensive interventions (substantial heterogeneity, I2 = 93%).High-quality evidence suggests the effect is unclear in social support interventions provided by peers (six studies; average RR 1.42, 95% CI 0.98 to 2.07), in a single trial of support provided by partners, or when social support for smoking cessation was provided as part of a broader intervention to improve maternal health.The effect was unclear in single interventions of exercise compared to usual care (RR 1.20, 95% CI 0.72 to 2.01) and dissemination of counselling (RR 1.63, 95% CI 0.62 to 4.32).Importantly, high-quality evidence from pooled results demonstrated that women who received psychosocial interventions had a 17% reduction in infants born with low birthweight, a significantly higher mean birthweight (mean difference (MD) 55.60 g, 95% CI 29.82 to 81.38 g higher) and a 22% reduction in neonatal intensive care admissions. However the difference in preterm births and stillbirths was unclear. There did not appear to be adverse psychological effects from the interventions.The intensity of support women received in both the intervention and comparison groups has increased over time, with higher-intensity interventions more likely to have higher-intensity comparisons, potentially explaining why no clear differences were seen with increasing intervention intensity in meta-regression analyses. Among meta-regression analyses: studies classified as having 'unclear' implementation and unequal baseline characteristics were less effective than other studies. There was no clear difference between trials implemented by researchers (efficacy studies), and those implemented by routine pregnancy staff (effectiveness studies), however there was uncertainty in the effectiveness of counselling in four dissemination trials where the focus on the intervention was at an organisational level. The pooled effects were similar in interventions provided for women classified as having predominantly low socio-economic status, compared to other women. The effect was significant in interventions among women from ethnic minority groups; however not among indigenous women. There were similar effect sizes in trials with biochemically validated smoking abstinence and those with self-reported abstinence. It was unclear whether incorporating use of self-help manuals or telephone support increased the effectiveness of interventions.

AUTHORS' CONCLUSIONS

Psychosocial interventions to support women to stop smoking in pregnancy can increase the proportion of women who stop smoking in late pregnancy and the proportion of infants born low birthweight. Counselling, feedback and incentives appear to be effective, however the characteristics and context of the interventions should be carefully considered. The effect of health education and social support is less clear. New trials have been published during the preparation of this review and will be included in the next update.

Nurse-Patient Interaction as a Treatment for Antepartum Depression: A Mixed-Methods Analysis [Formula: see text]

BACKGROUND

The U.S. Preventative Services Task Force guidelines recommend pregnant women be screened for depression and adequate systems be in place to treat this condition.

OBJECTIVE

This study examines a nurse-delivered telephone support intervention provided to low-income, pregnant women living in rural settings.

DESIGN

This study had a complementary mixed-methods design, using secondary data. Peplau's theory of interpersonal relations was used as a framework to guide the study.

RESULTS

The phases of Peplau's theory of interpersonal relations were evident in the interactions. Underserved women at high risk for depression appreciated this type of support, with the women at highest risk for depression utilizing more of the nursing support provided. On average, Mental Health Index-5 scores improved from 45 to 66.

CONCLUSION

A nurse-delivered telephone support intervention, modeled around Peplau's theory of interpersonal relations, may be an effective way of providing support to underserved women and has the potential to treat or offset antepartum depression.

Re-starting smoking in the postpartum period after receiving a smoking cessation intervention: a systematic review

AIMS

In pregnant smoking cessation trial participants, to estimate (1) among women abstinent at the end of pregnancy, the proportion who re-start smoking at time-points afterwards (primary analysis) and (2) among all trial participants, the proportion smoking at the end of pregnancy and at selected time-points during the postpartum period (secondary analysis).

METHODS

Trials identified from two Cochrane reviews plus searches of Medline and EMBASE. Twenty-seven trials were included. The included trials were randomized or quasi-randomized trials of within-pregnancy cessation interventions given to smokers who reported abstinence both at end of pregnancy and at one or more defined time-points after birth. Outcomes were validated biochemically and self-reported continuous abstinence from smoking and 7-day point prevalence abstinence. The primary random-effects meta-analysis used longitudinal data to estimate mean pooled proportions of re-starting smoking; a secondary analysis used cross-sectional data to estimate the mean proportions smoking at different postpartum time-points. Subgroup analyses were performed on biochemically validated abstinence.

RESULTS

The pooled mean proportion re-starting at 6 months postpartum was 43% [95% confidence interval (CI) = 16-72%, I(2)  = 96.7%] (11 trials, 571 abstinent women). The pooled mean proportion smoking at the end of pregnancy was 87% (95% CI = 84-90%, I(2)  = 93.2%) and 94% (95% CI = 92-96%, I(2)  = 88%) at 6 months postpartum (23 trials, 9262 trial participants). Findings were similar when using biochemically validated abstinence.

CONCLUSIONS

In clinical trials of smoking cessation interventions during pregnancy only 13% are abstinent at term. Of these, 43% re-start by 6 months postpartum.

Handling Missing Data With Multilevel Structural Equation Modeling and Full Information Maximum Likelihood Techniques

With increasing access to population-based data and electronic health records for secondary analysis, missing data are common. In the social and behavioral sciences, missing data frequently are handled with multiple imputation methods or full information maximum likelihood (FIML) techniques, but healthcare researchers have not embraced these methodologies to the same extent and more often use either traditional imputation techniques or complete case analysis, which can compromise power and introduce unintended bias. This article is a review of options for handling missing data, concluding with a case study demonstrating the utility of multilevel structural equation modeling using full information maximum likelihood (MSEM with FIML) to handle large amounts of missing data. MSEM with FIML is a parsimonious and hypothesis-driven strategy to cope with large amounts of missing data without compromising power or introducing bias. This technique is relevant for nurse researchers faced with ever-increasing amounts of electronic data and decreasing research budgets. © 2016 Wiley Periodicals, Inc.

Assessing the Effect of mHealth Interventions in Improving Maternal and Neonatal Care in Low- and Middle-Income Countries: A Systematic Review

Introduction

Maternal and neonatal mortality remains high in many low- and middle-income countries (LMIC). Availability and use of mobile phones is increasing rapidly with 90% of persons in developing countries having a mobile-cellular subscription. Mobile health (mHealth) interventions have been proposed as effective solutions to improve maternal and neonatal health. This systematic review assessed the effect of mHealth interventions that support pregnant women during the antenatal, birth and postnatal period in LMIC.

Methods

The review was registered with Prospero (CRD42014010292). Six databases were searched from June 2014–April 2015, accompanied by grey literature search using pre-defined search terms linked to pregnant women in LMIC and mHealth. Quality of articles was assessed with an adapted Cochrane Risk of Bias Tool. Because of heterogeneity in outcomes, settings and study designs a narrative synthesis of quantitative results of intervention studies on maternal outcomes, neonatal outcomes, service utilization, and healthy pregnancy education was conducted. Qualitative and quantitative results were synthesized with a strengths, weaknesses, opportunities, and threats analysis.

Results

In total, 3777 articles were found, of which 27 studies were included: twelve intervention studies and fifteen descriptive studies. mHealth interventions targeted at pregnant women increased maternal and neonatal service utilization shown through increased antenatal care attendance, facility-service utilization, skilled attendance at birth, and vaccination rates. Few articles assessed the effect on maternal or neonatal health outcomes, with inconsistent results.

Conclusion

mHealth interventions may be effective solutions to improve maternal and neonatal service utilization. Further studies assessing mHealth’s impact on maternal and neonatal outcomes are recommended. The emerging trend of strong experimental research designs with randomized controlled trials, combined with feasibility research, government involvement and integration of mHealth interventions into the healthcare system is encouraging and can pave the way to improved decision making on best practice implementation of mHealth interventions.

Nicotine Dependence Measures for Perinatal Women

This integrative review provides an overview of nicotine dependence measures used with perinatal women and an evaluation of their psychometric properties. Fifty-five articles that met inclusion and exclusion criteria were identified from five different databases. Most of the studies used the Fagerström Test for Nicotine Dependence (FTND). Other approaches included diagnostic tests, the Wisconsin Inventory of Smoking Dependence Motives (WISDM), the Tobacco Dependence Screener, and single-item measures. This review indicated that the FTND may not be the best option for measuring nicotine dependence in this population. The WISDM is a newer instrument that has excellent psychometric properties and captures nonnicotinic dimensions of nicotine dependence relevant to women. Future research is needed to assess its reliability in the perinatal population. Other recommendations from this review include the use of biomarker validation, thorough psychometric reporting on nicotine dependence instruments, and the use of multiple instruments to maximize comparability between nicotine dependence instruments.

Preventing excessive weight gain during pregnancy and promoting postpartum weight loss: a pilot lifestyle intervention for overweight and obese African American women

To test the feasibility and acceptability of a theory-based lifestyle intervention designed to prevent excessive weight gain during pregnancy and promote weight loss in the early postpartum period in overweight and obese African American women. Sixteen pregnant women (≤18 weeks gestation) were recruited from prenatal clinics in Columbia, South Carolina in 2011 and assigned to a lifestyle intervention program. The intervention, guided by formative research, consisted of an individual counseling session followed by eight group sessions alternated with telephone counseling contacts that continued through 36 weeks of gestation. At 6-8 weeks postpartum, participants received a home visit and up to three counseling calls through week 12. Medical charts were reviewed for 38 contemporary controls who met the same inclusion criteria and attended the same prenatal clinics. Compared to controls, study participants gained less total weight, had a smaller weekly rate of weight gain across the 2nd and 3rd trimesters (0.89 vs. 0.96 lbs), and were less likely to exceed weight gain recommendations (56.3 vs. 65.8 %). At 12 weeks postpartum, study participants retained 2.6 lbs from their prepregnancy weight, half of study participants were at their prepregnancy weight or lower, and only 35 % retained ≥5 lbs. The intervention also demonstrated success in promoting physical activity and reducing caloric intake, and was well-received by participants. The initial results were promising. The lessons learned can help inform future studies. The efficacy of our intervention will be tested in a large randomized controlled trial.

Smoking cessation in pregnancy: psychosocial interventions and patient-focused perspectives

BACKGROUND

Smoking during pregnancy causes obstetric and fetal complications, and smoking cessation may have great benefits for the mother and the child. However, some pregnant women continue smoking even in pregnancy.

OBJECTIVE

To review the literature addressing the prevalence of smoking during pregnancy, explore psychosocial factors associated with smoking, and review the evidence of psychosocial interventions for smoking cessation during pregnancy in recent years.

LITERATURE REVIEW

Computerized Internet search results in PubMed for the years spanning from 2004 to 2014, as well as references cited in articles, were reviewed. A search for the keywords "smoking cessation pregnancy" and "intervention" and "clinical trials" yielded 52 citations. Thirty-five citations were identified as useful to this review for the evidence of psychosocial interventions for smoking cessation during pregnancy.

RESULTS

The prevalence of smoking during pregnancy differs by country, reflecting the countries' social, cultural, and ethnic backgrounds. Women who had socioeconomic disadvantages, problems in their interpersonal relationships, higher stress, depression, less social support, and who engaged in health-risk behaviors were more prone to smoking during pregnancy. Psychosocial interventions, such as counseling, are effective methods for increasing smoking cessation.

CONCLUSION

Smokers may have various psychosocial problems in addition to health problems. It is important to understand each individual's social situation or psychosocial characteristics, and a psychosocial intervention focused on the characteristics of the individual is required.

A pilot study of home-based smoking cessation programs for rural, appalachian, pregnant smokers

OBJECTIVE

To evaluate a web-based contingency management program (CM) and a phone-delivered cessation counseling program (Smoking Cessation for Healthy Births [SCHB]) with pregnant smokers in rural Appalachia who were ≤12 weeks gestation at enrollment.

DESIGN

Two group randomized design.

SETTING

Home-based cessation programs in rural Appalachia Ohio and Kentucky.

PARTICIPANTS

A community sample of pregnant smokers (N = 17).

METHODS

Participants completed demographic and smoking-related questionnaires and were assigned to CM (n = 7) or SCHB (n = 10) conditions. Smoking status was assessed monthly using breath carbon monoxide and urinary cotinine.

RESULTS

For CM, two of seven (28.57%) of the participants achieved abstinence, and three of 10 (30%) of those enrolled in SCHB were abstinent by late in pregnancy. Participants in CM attained abstinence more rapidly than those in SCHB. However, those in SCHB experienced less relapse to smoking, and a greater percentage of these participants reduced their smoking by at least 50%.

CONCLUSION

Based on this initial evaluation, the web-based CM and SCHB programs appeared to be feasible for use with rural pregnant smokers with acceptable program adherence for both approaches. Future researchers could explore combining these programs to capitalize on the strengths of each, for example, rapid smoking cessation based on CM incentives and better sustained cessation or reductions in smoking facilitated by the counseling support of SCHB.

A content analysis of self-reported barriers and facilitators to preventing postpartum smoking relapse among a sample of current and former smokers in an underserved population

To characterize the barriers and facilitators thatprevent postpartum relapse and maintain smoking abstinence among a socioeconomically underserved population, recruited through Philadelphia-area women, infants, and children clinics, in-person interviews were conducted with 30 women who had quit smoking for one or more pregnancies in the past 3 years to retrospectively describe their attempts to remain abstinent during the postpartum period. Responses were analysed using the constructs from the Cognitive-Social Health Information Processing model, which identifies the cognitive, affective and behavioral factors involved in goal-oriented self-regulatory actions, in the context of a vulnerable population of women. Motherhood demands were a significant source of relapse stress. Stresses associated with partner and family relationships also contributed to relapse. The presence of other smokers in the environment was mentioned by many women in our sample as affecting their ability to remain smoke-free postpartum. Participants reported four main strategies that helped them to successfully cope with postpartum cravings and relapses, including being informed of smoking risks, maintaining goal-oriented thoughts, focusing on their concerns about the baby's health and receiving positive social support from families and friends. Results provide guidance for the design of smoking relapse interventions that may address the unique stressors reported by underserved postpartum women.

Maintenance of smoking cessation in the postpartum period: which interventions work best in the long-term?

Smoking during pregnancy has been linked to a variety of adverse outcomes for both maternal and child health. Decades of studies have sought to increase cessation antepartum and reduce relapse postpartum. A number of effective interventions exist to significantly reduce smoking rates during pregnancy; however, less is known about how to prevent relapse in the postpartum period. This review investigates interventions to prevent relapse in the long-term postpartum period. We focus specifically on nonspontaneous quitters (individuals who quit smoking as a result of an external intervention) to reveal differences in long-term response to interventions for this population compared to spontaneous quitters. A systematic literature search yielded 32 relevant studies of pharmacological, behavioral, and incentives-based interventions. Results were compiled, analyzed, and compared in order to evaluate success factors in maintaining cessation postpartum. Though intervention groups showed consistently higher quit rates during pregnancy than control groups, none of the intervention types were effective at preventing relapse in the longer-term postpartum period. One study maintained significantly higher abstinence in the longer-term period postpartum using a mix of behavioral and incentives strategies. Additional research in this area is needed to identify optimal intervention strategies to reduce long-term postpartum relapse, particularly for nonspontaneous quitters.

Examination of the Wisconsin Inventory of Smoking Dependence Motives (WISDM-68) Factor Structure in a Sample of Pregnant Smokers

INTRODUCTION

Smoking during pregnancy poses known risks to fetal and infant development. Women who continue to smoke during pregnancy exhibit higher levels of nicotine dependence than women who quit. Increased understanding of the construct of nicotine dependence in pregnant smokers may aid in the development of effective treatments. Research has suggested that nicotine dependence is a multifaceted construct, driven not only by withdrawal and tolerance processes, but also by reinforcement, sensory, and contextual processes. The Wisconsin inventory of smoking dependence motives (WISDM-68) assesses 13 varied smoking motives in order to assess processes that may lead to nicotine dependence.

METHODS

The factor structure of the WISDM-68 was explored using an ethnically diverse sample of 294 pregnant women who had been screened and/or enrolled in a smoking cessation treatment study. Confirmatory analyses were conducted with previously published models. An exploratory factor analysis and exploratory structural equation modeling (ESEM) were conducted to develop and validate a measurement model for the WISDM-68 in this sample.

RESULTS

Previously established models were not a good fit for the present data. Using ESEM, a 9-factor model exhibiting both predictive and concurrent validity emerged. Two factors predicted abstinence 6 months posttreatment. Several factors were associated with smoking heaviness, the Fagerström test for cigarette dependence and time to first cigarette.

CONCLUSIONS

In contrast to previously published studies, a 9-factor model best characterizes the WISDM in the present sample. These findings may reflect smoking motivations unique to young, pregnant women who continue to smoke during pregnancy.

Are interventions for low-income groups effective in changing healthy eating, physical activity and smoking behaviours? A systematic review and meta-analysis

OBJECTIVE

To conduct a systematic review and meta-analysis examining the effectiveness of behavioural interventions targeting diet, physical activity or smoking in low-income adults.

DESIGN

Systematic review with random effects meta-analyses. Studies before 2006 were identified from a previously published systematic review (searching 1995-2006) with similar but broader inclusion criteria (including non-randomised controlled trials (RCTs)). Studies from 2006 to 2014 were identified from eight electronic databases using a similar search strategy.

DATA SOURCES

MEDLINE, EMBASE, PsycINFO, ASSIA, CINAHL, Cochrane Controlled Trials, Cochrane Systematic Review and DARE.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

RCTs and cluster RCTs published from 1995 to 2014; interventions targeting dietary, physical activity and smoking; low-income adults; reporting of behavioural outcomes.

MAIN OUTCOME MEASURES

Dietary, physical activity and smoking cessation behaviours.

RESULTS

35 studies containing 45 interventions with 17,000 participants met inclusion criteria. At postintervention, effects were positive but small for diet (standardised mean difference (SMD) 0.22, 95% CI 0.14 to 0.29), physical activity (SMD 0.21, 95% CI 0.06 to 0.36) and smoking (relative risk (RR) of 1.59, 95% CI 1.34 to 1.89). Studies reporting follow-up results suggested that effects were maintained over time for diet (SMD 0.16, 95% CI 0.08 to 0.25) but not physical activity (SMD 0.17, 95% CI -0.02 to 0.37) or smoking (RR 1.11, 95% CI 0.93 to 1.34).

CONCLUSIONS

Behaviour change interventions for low-income groups had small positive effects on healthy eating, physical activity and smoking. Further work is needed to improve the effectiveness of behaviour change interventions for deprived populations.

Interventions for preventing or reducing domestic violence against pregnant women

BACKGROUND

Domestic violence during pregnancy is a major public health concern. This preventable risk factor threatens both the mother and baby. Routine perinatal care visits offer opportunities for healthcare professionals to screen and refer abused women for effective interventions. It is, however, not clear which interventions best serve mothers during pregnancy and postpartum to ensure their safety.

OBJECTIVES

To examine the effectiveness and safety of interventions in preventing or reducing domestic violence against pregnant women.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 July 2014), scanned bibliographies of published studies and corresponded with investigators.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) including cluster-randomised trials, and quasi-randomised controlled trials (e.g. where there was alternate allocation) investigating the effect of interventions in preventing or reducing domestic violence during pregnancy.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy.

MAIN RESULTS

We included 10 trials with a total of 3417 women randomised. Seven of these trials, recruiting 2629 women, contributed data to the review. However, results for all outcomes were based on single studies. There was limited evidence for the primary outcomes of reduction of episodes of violence (physical, sexual, and/or psychological) and prevention of violence during and up to one year after pregnancy (as defined by the authors of trials). In one study, women who received the intervention reported fewer episodes of partner violence during pregnancy and in the postpartum period (risk ratio (RR) 0.62, 95% confidence interval (CI) 0.43 to 0.88, 306 women, moderate quality). Groups did not differ for Conflict Tactics Score - the mean partner abuse scores in the first three months postpartum (mean difference (MD) 4.20 higher, 95% CI -10.74 to 19.14, one study, 46 women, very low quality). The Current Abuse Score for partner abuse in the first three months was also similar between groups (MD -0.12 lower, 95% CI -0.31 lower to 0.07 higher, one study, 191 women, very low quality). Evidence for the outcomes episodes of partner abuse during pregnancy or episodes during the first three months postpartum was not significant (respectively, RR 0.50, 95% CI 0.25 to 1.02, one study with 220 women, very low quality; and RR 0.60, 95% CI 0.35 to 1.04, one study, 271 women, very low quality). Finally, the risk for low birthweight (< 2500 g) did not differ between groups (RR 0.74, 95 % CI 0.41 to 1.32, 306 infants, low quality).There were few statistically significant differences between intervention and control groups for depression during pregnancy and the postnatal period. Only one study reported findings for neonatal outcomes such as preterm delivery and birthweight, and there were no clinically significant differences between groups. None of the studies reported results for other secondary outcomes: Apgar score less than seven at one minute and five minutes, stillbirth, neonatal death, miscarriage, maternal mortality, antepartum haemorrhage, and placental abruption.

AUTHORS' CONCLUSIONS

There is insufficient evidence to assess the effectiveness of interventions for domestic violence on pregnancy outcomes. There is a need for high-quality, RCTs with adequate statistical power to determine whether intervention programs prevent or reduce domestic violence episodes during pregnancy, or have any effect on maternal and neonatal mortality and morbidity outcomes.

Exploring promising gender-sensitive tobacco and alcohol use interventions: results of a scoping review

This review examined the breadth of gender-sensitive tobacco and alcohol interventions that target girls and women. A comprehensive review of databases and websites was conducted in 2011/2012 for interventions that focused on girls and women health, incorporated an understanding of sex and/or gender, engaged with the determinants of women's health, and sought to reduce gender-related social and health inequities. Results of the review suggest that interventions designed with an understanding of the effect of gender roles, norms, and behaviors on women's health are limited and that much work remains to encourage practitioners to use a gender-sensitive approach when designing interventions.

A systematic review of the quality of reporting in published smoking cessation trials for pregnant women: an explanation for the evidence-practice gap?

Background

To facilitate translation of evidence into clinical practice, it is critical that clear, specific, and detailed information about interventions is provided in publications to promote replication, appropriate aggregation in meta-analysis, and implementation. This study examined whether twenty elements of interventions deemed essential for such translational application were reported in sufficient detail in smoking cessation trials with pregnant women.

Methods

Searches of electronic databases using MeSH terms and keywords identified peer-reviewed English language studies published between 2001 and 2012. Eligible studies reported a smoking cessation intervention targeted at pregnant women and met Cochrane’s Effective Practice and Organization of Care group study design criteria. Each intervention arm of eligible studies was assessed against the developed twenty criteria.

Results

Thirty relevant studies reported the findings of 45 intervention arms. The mode of delivery of the intervention was reported in 100% of intervention arms. Other well-reported criteria included reporting of the provider who delivered the intervention (96%), sample characteristics (80%), and the intervention setting (80%). Criteria not reported adequately included care provided to women who relapse (96% not reported), details about training given to providers (77% not reported), and the method of quit advice advised (76% not reported). No studies reported 100% of relevant criteria.

Conclusions

Current standards of reporting of intervention content and implementation are suboptimal. The use of smoking cessation specific checklists for reporting of trials, standard reporting using behaviour change taxonomies, and the publication of protocols as supplements should be considered as ways of improving the specificity of reporting.

Electronic supplementary material

The online version of this article (doi:10.1186/s13012-014-0094-z) contains supplementary material, which is available to authorized users.

Preventing postpartum smoking relapse among inner city women: development of a theory-based and evidence-guided text messaging intervention

Background

Underserved women are at high risk for smoking relapse after childbirth due to their unique socioeconomic and postpartum stressors and barriers. Mobile text messaging technology allows delivery of relapse prevention programs targeted to their personal needs over time.

Objective

To describe the development of a social-cognitive theory-based and evidence-guided text messaging intervention for preventing postpartum smoking relapse among inner city women.

Methods

Guided by the cognitive-social health information processing framework, user-centered design, and health communication best practices, the intervention was developed through a systematic process that included needs assessment, followed by an iterative cycling through message drafting, health literacy evaluation and rewriting, review by target community members and a scientific advisory panel, and message revision, concluding with usability testing.

Results

All message content was theory-grounded, derived by needs assessment analysis and evidence-based materials, reviewed and revised by the target population, health literacy experts, and scientific advisors. The final program, “Txt2Commit,” was developed as a fully automated system, designed to deliver 3 proactive messages per day for a 1-month postpartum smoking relapse intervention, with crave and lapse user-initiated message functions available when needed.

Conclusions

The developmental process suggests that the application of theory and best practices in the design of text messaging smoking cessation interventions is not only feasible but necessary for ensuring that the interventions are evidence based and user-centered.

Psychosocial interventions for supporting women to stop smoking in pregnancy

BACKGROUND

Tobacco smoking in pregnancy remains one of the few preventable factors associated with complications in pregnancy, stillbirth, low birthweight and preterm birth and has serious long-term implications for women and babies. Smoking in pregnancy is decreasing in high-income countries, but is strongly associated with poverty and increasing in low- to middle-income countries.

OBJECTIVES

To assess the effects of smoking cessation interventions during pregnancy on smoking behaviour and perinatal health outcomes.

SEARCH METHODS

In this fifth update, we searched the Cochrane Pregnancy and Childbirth Group's Trials Register (1 March 2013), checked reference lists of retrieved studies and contacted trial authors to locate additional unpublished data.

SELECTION CRITERIA

Randomised controlled trials, cluster-randomised trials, randomised cross-over trials, and quasi-randomised controlled trials (with allocation by maternal birth date or hospital record number) of psychosocial smoking cessation interventions during pregnancy.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion and trial quality, and extracted data. Direct comparisons were conducted in RevMan, and subgroup analyses and sensitivity analysis were conducted in SPSS.

MAIN RESULTS

Eighty-six trials were included in this updated review, with 77 trials (involving over 29,000 women) providing data on smoking abstinence in late pregnancy.In separate comparisons, counselling interventions demonstrated a significant effect compared with usual care (27 studies; average risk ratio (RR) 1.44, 95% confidence interval (CI) 1.19 to 1.75), and a borderline effect compared with less intensive interventions (16 studies; average RR 1.35, 95% CI 1.00 to 1.82). However, a significant effect was only seen in subsets where counselling was provided in conjunction with other strategies. It was unclear whether any type of counselling strategy is more effective than others (one study; RR 1.15, 95% CI 0.86 to 1.53). In studies comparing counselling and usual care (the largest comparison), it was unclear whether interventions prevented smoking relapse among women who had stopped smoking spontaneously in early pregnancy (eight studies; average RR 1.06, 95% CI 0.93 to 1.21). However, a clear effect was seen in smoking abstinence at zero to five months postpartum (10 studies; average RR 1.76, 95% CI 1.05 to 2.95), a borderline effect at six to 11 months (six studies; average RR 1.33, 95% CI 1.00 to 1.77), and a significant effect at 12 to 17 months (two studies, average RR 2.20, 95% CI 1.23 to 3.96), but not in the longer term. In other comparisons, the effect was not significantly different from the null effect for most secondary outcomes, but sample sizes were small.Incentive-based interventions had the largest effect size compared with a less intensive intervention (one study; RR 3.64, 95% CI 1.84 to 7.23) and an alternative intervention (one study; RR 4.05, 95% CI 1.48 to 11.11).Feedback interventions demonstrated a significant effect only when compared with usual care and provided in conjunction with other strategies, such as counselling (two studies; average RR 4.39, 95% CI 1.89 to 10.21), but the effect was unclear when compared with a less intensive intervention (two studies; average RR 1.19, 95% CI 0.45 to 3.12).The effect of health education was unclear when compared with usual care (three studies; average RR 1.51, 95% CI 0.64 to 3.59) or less intensive interventions (two studies; average RR 1.50, 95% CI 0.97 to 2.31).Social support interventions appeared effective when provided by peers (five studies; average RR 1.49, 95% CI 1.01 to 2.19), but the effect was unclear in a single trial of support provided by partners.The effects were mixed where the smoking interventions were provided as part of broader interventions to improve maternal health, rather than targeted smoking cessation interventions.Subgroup analyses on primary outcome for all studies showed the intensity of interventions and comparisons has increased over time, with higher intensity interventions more likely to have higher intensity comparisons. While there was no significant difference, trials where the comparison group received usual care had the largest pooled effect size (37 studies; average RR 1.34, 95% CI 1.25 to 1.44), with lower effect sizes when the comparison group received less intensive interventions (30 studies; average RR 1.20, 95% CI 1.08 to 1.31), or alternative interventions (two studies; average RR 1.26, 95% CI 0.98 to 1.53). More recent studies included in this update had a lower effect size (20 studies; average RR 1.26, 95% CI 1.00 to 1.59), I(2)= 3%, compared to those in the previous version of the review (50 studies; average RR 1.50, 95% CI 1.30 to 1.73). There were similar effect sizes in trials with biochemically validated smoking abstinence (49 studies; average RR 1.43, 95% CI 1.22 to 1.67) and those with self-reported abstinence (20 studies; average RR 1.48, 95% CI 1.17 to 1.87). There was no significant difference between trials implemented by researchers (efficacy studies), and those implemented by routine pregnancy staff (effectiveness studies), however the effect was unclear in three dissemination trials of counselling interventions where the focus on the intervention was at an organisational level (average RR 0.96, 95% CI 0.37 to 2.50). The pooled effects were similar in interventions provided for women with predominantly low socio-economic status (44 studies; average RR 1.41, 95% CI 1.19 to 1.66), compared to other women (26 studies; average RR 1.47, 95% CI 1.21 to 1.79); though the effect was unclear in interventions among women from ethnic minority groups (five studies; average RR 1.08, 95% CI 0.83 to 1.40) and aboriginal women (two studies; average RR 0.40, 95% CI 0.06 to 2.67). Importantly, pooled results demonstrated that women who received psychosocial interventions had an 18% reduction in preterm births (14 studies; average RR 0.82, 95% CI 0.70 to 0.96), and infants born with low birthweight (14 studies; average RR 0.82, 95% CI 0.71 to 0.94). There did not appear to be any adverse effects from the psychosocial interventions, and three studies measured an improvement in women's psychological wellbeing.

AUTHORS' CONCLUSIONS

Psychosocial interventions to support women to stop smoking in pregnancy can increase the proportion of women who stop smoking in late pregnancy, and reduce low birthweight and preterm births.

Telephone support for women during pregnancy and the first six weeks postpartum

BACKGROUND

Telephone communication is increasingly being accepted as a useful form of support within health care. There is some evidence that telephone support may be of benefit in specific areas of maternity care such as to support breastfeeding and for women at risk of depression. There is a plethora of telephone-based interventions currently being used in maternity care. It is therefore timely to examine which interventions may be of benefit, which are ineffective, and which may be harmful.

OBJECTIVES

To assess the effects of telephone support during pregnancy and the first six weeks post birth, compared with routine care, on maternal and infant outcomes.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (23 January 2013) and reference lists of all retrieved studies.

SELECTION CRITERIA

We included randomised controlled trials, comparing telephone support with routine care or with another supportive intervention aimed at pregnant women and women in the first six weeks post birth.

DATA COLLECTION AND ANALYSIS

Three review authors independently assessed studies identified by the search strategy, carried out data extraction and assessed risk of bias. Data were entered by one review author and checked by a second. Where necessary, we contacted trial authors for further information on methods or results.

MAIN RESULTS

We have included data from 27 randomised trials involving 12,256 women. All of the trials examined telephone support versus usual care (no additional telephone support). We did not identify any trials comparing different modes of telephone support (for example, text messaging versus one-to-one calls). All but one of the trials were carried out in high-resource settings. The majority of studies examined support provided via telephone conversations between women and health professionals although a small number of trials included telephone support from peers. In two trials women received automated text messages. Many of the interventions aimed to address specific health problems and collected data on behavioural outcomes such as smoking cessation and relapse (seven trials) or breastfeeding continuation (seven trials). Other studies examined support interventions aimed at women at high risk of postnatal depression (two trials) or preterm birth (two trials); the rest of the interventions were designed to offer women more general support and advice.For most of our pre-specified outcomes few studies contributed data, and many of the results described in the review are based on findings from only one or two studies. Overall, results were inconsistent and inconclusive although there was some evidence that telephone support may be a promising intervention. Results suggest that telephone support may increase women's overall satisfaction with their care during pregnancy and the postnatal period, although results for both periods were derived from only two studies. There was no consistent evidence confirming that telephone support reduces maternal anxiety during pregnancy or after the birth of the baby, although results on anxiety outcomes were not easy to interpret as data were collected at different time points using a variety of measurement tools. There was evidence from two trials that women at high risk of depression who received support had lower mean depression scores in the postnatal period, although there was no clear evidence that women who received support were less likely to have a diagnosis of depression. Results from trials offering breastfeeding telephone support were also inconsistent, although the evidence suggests that telephone support may increase the duration of breastfeeding. There was no strong evidence that women receiving telephone support were less likely to be smoking at the end of pregnancy or during the postnatal period.For infant outcomes, such as preterm birth and infant birthweight, overall, there was little evidence. Where evidence was available, there were no clear differences between groups. Results from two trials suggest that babies whose mothers received support may have been less likely to have been admitted to a neonatal intensive care unit (NICU), although it is not easy to understand the mechanisms underpinning this finding.

AUTHORS' CONCLUSIONS

Despite some encouraging findings, there is insufficient evidence to recommend routine telephone support for women accessing maternity services, as the evidence from included trials is neither strong nor consistent. Although benefits were found in terms of reduced depression scores, breastfeeding duration and increased overall satisfaction, the current trials do not provide strong enough evidence to warrant investment in resources.

Interventions for preventing or reducing domestic violence against pregnant women

BACKGROUND

Domestic violence during pregnancy is a major public health concern. This preventable risk factor threatens both the mother and baby. Routine perinatal care visits offer opportunities for healthcare professionals to screen and refer abused women for effective interventions. It is, however, not clear which interventions best serve mothers during pregnancy and postpartum to ensure their safety.

OBJECTIVES

To examine the effectiveness and safety of interventions in preventing or reducing domestic violence against pregnant women.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (19 June 2012), scanned bibliographies of published studies and corresponded with investigators.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) including cluster-randomised trials, and quasi-randomised controlled trials (e.g. where there was alternate allocation) investigating the effect of interventions in preventing or reducing domestic violence during pregnancy.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality and extracted data.

MAIN RESULTS

We included nine trials with a total of 2391 women; however, for most outcomes very few studies contributed data and results were predominantly based on findings from single studies. There was evidence from one study that the total number of women reporting episodes of partner violence during pregnancy, and in the postpartum period was reduced for women receiving a psychological therapy intervention (risk ratio (RR) 0.62, 95% confidence interval (CI) 0.48 to 0.88). There were few statistically significant differences between intervention and control groups for depression during pregnancy and the postnatal period. Only one study reported findings for neonatal outcomes such as preterm delivery and birthweight, and there were no clinically significant differences between groups. None of the studies reported results for other secondary outcomes: Apgar score less than seven at one minute and five minutes, stillbirth, neonatal death, miscarriage, maternal mortality, antepartum haemorrhage, and placental abruption.

AUTHORS' CONCLUSIONS

There is insufficient evidence to assess the effectiveness of interventions for domestic violence on pregnancy outcomes. There is a need for high-quality, RCTs with adequate statistical power to determine whether intervention programs prevent or reduce domestic violence episodes during pregnancy, or have any effect on maternal and neonatal mortality and morbidity outcomes.

Promoting heart health in rural women

PURPOSE

To compare 2 strategies, stage-matched nursing and community intervention (SMN+CI) and community intervention (CI) alone in changing cardiovascular risk factors in up to 3 behavioral areas: diet, physical activity, and/or smoking among rural women.

METHODS

A 14-month, multisite randomized controlled trial of 117 rural women was conducted. Transtheoretical model was used in identification of stage of change and development of the SMN+CI nursing interventions. A social-ecological model was used to address issues of rurality in the development of interventions.

FINDINGS

The SMN + CI group was superior on 4 outcomes. There were significant increases in 2 measures of dietary intake; improvement in dietary stage of change for fruits and vegetables; and reduced diastolic blood pressure (DBP) in the SMN + CI group. After log transformation DBP significance was lost. The CI group had a significant reduction in change in total cholesterol; however, significance was lost after control for the initiation of lipid lowering medications. There was a significant reduction in Framingham risk scores pre- to postintervention, regardless of group.

CONCLUSIONS

There continues to be a need to improve cardiovascular risk factors in rural women. There should be an exploration of whether intensified dose and fidelity of the intervention strategies of diet and physical activity are effective in improving anthropometric and laboratory values. Further investigation is warranted into factors influencing the pre- to postreduction in Framingham risk scores.

Factors associated with antenatal smoking among Aboriginal and Torres Strait Islander women in two jurisdictions

INTRODUCTION AND AIMS

Smoking rates are three times as high for pregnant Indigenous women relative to non-Indigenous women, in Australia. This paper describes Indigenous women's self-reported antenatal smoking behaviour and compares knowledge and attitudes of those who: (i) smoke and don't smoke during pregnancy; and (ii) quit or continued to smoke since the beginning of pregnancy.

DESIGN AND METHODS

Cross-sectional surveys with 264 pregnant Indigenous women in two states collected data on smoking status, antenatal changes, risk knowledge, attitudes to smoking and sociodemographic characteristics. Multivariable logistic regression analyses assessed associations between knowledge and attitude variables and smoking status and antenatal changes in smoking status.

RESULTS

Forty-six per cent of the women (n = 121) reported currently smoking. The majority (68%) who smoked at the beginning of pregnancy reported quitting (21%) or reducing (47%). Relative to smokers, non-smokers had more schooling (P = 0.002), more post-secondary education (P = 0.023), lower parity (P = 0.003), better understanding of smoking-related risks (miscarriage P = 0.01; low birth weight P = 0.003; infant illness P < 0.001; childhood behavioural problems P = 0.007), and less frequently expressed attitudes indicating that quitting was very difficult given other problems they faced. Similar patterns were found for women who quit during pregnancy compared to those who continued smoking.

DISCUSSION AND CONCLUSIONS

Increasing awareness of antenatal smoking risks and the benefits of quitting may motivate women to attempt to quit. However, knowledge alone is unlikely to be sufficient considering the life circumstances of many Indigenous women. Addressing the social environment and daily stressors, particularly those exacerbated by pregnancy, may be critical to supporting quit attempts.

Perinatal mortality and adverse pregnancy outcomes in a low-income rural population of women who smoke

We describe adverse pregnancy outcomes, including congenital anomalies, fetal, neonatal, and infant mortality among a Missouri population of low-income, rural mothers who participated in two randomized smoking cessation trials. In the Baby BEEP (BB) trial, 695 rural women were recruited from 21 WIC clinics with 650 women's pregnancy outcomes known (93.5% retention rate). Following the BB trial, 298 women who had a live infant after November 2004 were recruited again into and completed the Baby Beep for Kids (BBK) trial. Simple statistics describing the population and perinatal and postneonatal mortality rates were calculated. Of the adverse pregnancy outcomes (n = 79), 29% were spontaneous abortions of less than 20 weeks' gestation, 23% were premature births, and 49% were identified birth defects. The perinatal mortality rate was 15.9 per 1000 births (BB study) compared with 8.6 per 1000 births (state of Missouri) and 8.5 per 1000 births (United States). The postneonatal infant mortality rate was 13.4 per 1000 live births (BBK) compared with 2.1 per 1000 live births (United States). The health disparity in this population of impoverished, rural, pregnant women who smoke, particularly in regard to perinatal and infant deaths, warrants attention.

A systematic review and meta-analysis of the effectiveness of behavioural smoking cessation interventions in selected disadvantaged groups

AIMS

A systematic review and meta-analysis was conducted to assess the methodological quality and effectiveness of behavioural smoking cessation interventions targeted at six disadvantaged groups; the homeless, prisoners, indigenous populations, at-risk youth, individuals with low socio-economic status and individuals with a mental illness.

METHODS

Medline, EMBASE, the Cochrane Library and PsycInfo databases were searched using MeSH and keywords for studies conducted in developed countries prior to October 2010. Included studies were assessed for methodological quality. A DerSimonian and Laird random effects meta-analysis was conducted where possible to explore the effectiveness of interventions for the different subgroups. A narrative review was conducted for studies unable to be included in the meta-analysis. Outcomes examined were abstinence rates at short-term (up to 3 months) and long-term (6 months or the longest) follow-up.

RESULTS

Thirty-two relevant studies were identified. The majority (n = 20) were rated low in methodological quality. Results of the meta-analysis showed a significant increase in cessation for behavioural support interventions targeted at low-income female smokers at short-term follow-up [relative risk (RR) 1.68, confidence interval (CI) 1.21-2.33], and behavioural support interventions targeted at individuals with a mental illness at long-term follow-up (RR 1.35, CI 1.01-1.81). Results of the narrative review showed several promising interventions that increased cessation rates at 6-month or longer follow-up.

CONCLUSIONS

Few well-controlled trials have examined the most effective smoking cessation strategies for highly disadvantaged groups, especially among the homeless, indigenous smokers and prisoners. The use of behavioural smoking cessation interventions for some socially disadvantaged groups appears promising; however, overall findings are inconsistent. Further research is needed to establish the most effective interventions for vulnerable high-risk groups. Special attention should be given to increasing sample size and power, and to sound evaluation methodology to overcome methodological limitations of conducting research with these high-risk groups.

The effect of smoking cessation counselling in pregnant women: a meta-analysis of randomised controlled trials

BACKGROUND

Pregnant smokers are often prescribed counselling as part of multicomponent cessation interventions. However, the isolated effect of counselling in this population remains unclear, and individual randomised controlled trials (RCTs) are inconclusive.

OBJECTIVE

To conduct a meta-analysis of RCTs examining counselling in pregnant smokers.

SEARCH STRATEGY

We searched the CDC Tobacco Information and Prevention, Cochrane Library, EMBASE, Medline and PsycINFO databases for RCTs evaluating smoking cessation counselling.

SELECTION CRITERIA

We included RCTs conducted in pregnant women in which the effect of counselling could be isolated and those that reported biochemically validated abstinence at 6 or 12 months after the target quit date.

DATA COLLECTION AND ANALYSIS

Overall estimates were derived using random effects meta-analysis models.

MAIN RESULTS

Our search identified eight RCTs (n = 3290 women), all of which examined abstinence at 6 months. The proportion of women that remained abstinent at the end of follow up was modest, ranging from 4 to 24% among those randomised to counselling and from 2 to 21% among control women. The absolute difference in abstinence reached a maximum of only 4%. Summary estimates are inconclusive because of wide confidence intervals, albeit with little evidence to suggest that counselling is efficacious at promoting abstinence (odds ratio 1.08, 95% confidence interval 0.84-1.40). There was no evidence to suggest that efficacy differed by counselling type.

CONCLUSIONS

Available data from RCTs examining the isolated effect of smoking cessation counselling in pregnant women are limited but sufficient to rule out large treatment effects. Future RCTs should examine pharmacological therapies in this population.

Subjective social status affects smoking abstinence during acute withdrawal through affective mediators

OBJECTIVES

Direct and mediated associations between subjective social status (SSS), a subjective measure of socio-economic status, and smoking abstinence were examined during the period of acute withdrawal among a diverse sample of 421 smokers (33% Caucasian, 34% African American, 33% Latino) undergoing a quit attempt.

METHODS

Logistic regressions examined relations between SSS and abstinence, controlling for socio-demographic variables. Depression, stress, positive affect and negative affect on the quit day were examined as potential affective mediators of the SSS-abstinence association, with and without adjusting for pre-quit mediator scores.

RESULTS

SSS predicted abstinence to 2 weeks post-quit. Abstinence rates were 2.6 (postquit week 1) and 2.4 (postquit week 2) times higher in the highest versus the lowest SSS quartile. Depression and positive affect mediated the SSS-abstinence relationships, but only depression maintained significance when adjusting for the baseline mediator score.

CONCLUSIONS

Among a diverse sample of quitting smokers, low SSS predicted relapse during acute withdrawal after controlling for numerous covariates, an effect accounted for partially by quit day affective symptomatology. Smokers endorsing lower SSS face significant hurdles in achieving cessation, highlighting the need for targeted interventions encompassing attention to quit day mood reactivity.

Preventing postpartum smoking relapse among diverse low-income women: a randomized clinical trial

INTRODUCTION

Postpartum relapse rates are high among women who spontaneously quit smoking during pregnancy. This randomized clinical trial tested a Motivation and Problem-Solving (MAPS) treatment for reducing postpartum relapse among diverse low-income women who quit smoking during pregnancy (N = 251; 32% Black, 30% Latino, and 36% White; 55% <$30,000/year household income).

METHODS

Pregnant women were randomly assigned to MAPS/MAPS+ or Usual Care (UC). Continuation ratio logit models were used to examine differences in biochemically confirmed continuous abstinence at Weeks 8 and 26 postpartum by treatment group and moderators of the treatment effect. Analyses controlled for age, race/ethnicity, partner status, education, smoking rate, and the number of smokers in the participant's environment.

RESULTS

MAPS/MAPS+ was more efficacious than UC in the prevention of postpartum relapse (p = .05). An interaction between treatment and the number of cigarettes smoked per day before quitting approached significance (p = .09), suggesting that the MAPS/MAPS+ treatment effect was stronger among women who smoked more cigarettes per day.

DISCUSSION

MAPS, a holistic and dynamic approach to changing behavior using a combined motivational enhancement and social cognitive approach, is a promising intervention for postpartum smoking relapse prevention among low-income women, which may have particular relevance for women with higher prequit smoking rates.

Postpartum smoking relapse and secondhand smoke

OBJECTIVE

There has been an abundance of research evaluating prenatal and postnatal smoking abstinence programs. However, few researchers have tested postpartum relapse interventions that address secondhand smoke (SHS) exposure. Pregnant women exposed to SHS are more likely to relapse. This article explores the similarities and differences among postpartum interventions that incorporate SHS education. Generating knowledge about the components of postpartum relapse prevention interventions that do and do not achieve prolongation of abstinence is integral to the development of effective SHS interventions that help women achieve lifelong abstinence.

METHODS

We used a methodological review of 11 randomized, controlled trials testing the efficacy of relapse prevention interventions that address SHS exposure. We compared intervention strength, biomarker validation of home smoking and SHS, as well as abstinence and relapse rates. We examined three predictors of postpartum relapse: (1) partner smoking in the home, (2) adoption of home smoking restrictions, and (3) motivation/confidence to remain abstinent.

RESULTS

Findings revealed a need for more comprehensive SHS interventions and a clear delineation of abstinence/relapse terminology. Biomarker validation of home smoking and SHS was primarily measured by self-report, passive nicotine monitors, and hair nicotine levels. Furthermore, studies using nurse- and pediatrician-led interventions resulted in the lowest relapse rates.

CONCLUSION

A comprehensive intervention that specifically prioritizes parental education on the health effects of SHS on the family, empowerment of the mother and family members to remain abstinent and adopt a smoke-free home smoking policy, and partner influence on smoking could result in a significant reduction in postpartum relapse rates.