Long-term maintenance of smoking cessation in pregnancy: an analysis of the birth cohort generation XXI

The Fish Oil to Reduce Tobacco Use iN Expectant mothers (FORTUNE) feasibility trial

BACKGROUND

Three small clinical trials have suggested that supplementation with n-3 long-chain polyunsaturated fatty acids (eicosapentaenoic acid and docosahexaenoic acid) found in fish oils may reduce nicotine cravings and at higher doses reduce cigarette consumption. Pregnant women who smoke have fewer pharmacologic options to aid them with smoking cessation. Although n-3 long-chain polyunsaturated fatty acid supplementation has been studied in pregnancy, few studies have evaluated doses of ≥4 g per day, and no previous studies have selectively enrolled pregnant women who smoke. High-dose n-3 long-chain polyunsaturated fatty acids may aid cessation but could be poorly tolerated in pregnant women who smoke because of gastrointestinal side effects.

OBJECTIVE

We conducted a feasibility trial to determine the tolerability of high-dose n-3 long-chain polyunsaturated fatty acid supplementation in pregnant women who smoked. We hypothesized that n-3 long-chain polyunsaturated fatty acid doses of 4.2 g a day would be well-tolerated relative to an olive oil placebo. We assessed red blood cell phospholipid membrane concentrations at baseline and end of therapy (4 weeks) and piloted outcomes for a future efficacy trial of n-3 long-chain polyunsaturated fatty acid supplementation for smoking cessation in pregnancy.

STUDY DESIGN

We recruited 28 pregnant women between the gestational ages of 6 and 36 weeks who reported daily cigarette smoking and were motivated to quit to participate in a double-blind placebo-controlled randomized feasibility trial of 4.2 g per day of n-3 long-chain polyunsaturated fatty acid supplementation. Participants reported cigarettes per day, completed the Fagerström Test for Cigarette Dependence, and provided blood, urine, and exhaled CO samples. We used repeated-measures analysis of variance to pilot analyses of changes in cigarettes per day and Fagerström Test for Cigarette Dependence scores.

RESULTS

At baseline, red blood cell membrane eicosapentaenoic acid concentrations were negatively correlated with cigarettes per day (r=-0.44; P=.04). By 4 weeks, circulating n-3 long-chain polyunsaturated fatty acid levels increased by 18% in the n-3 long-chain polyunsaturated fatty acid supplementation arm vs a decrease of 3% in the placebo arm. Occurrence of gastrointestinal side effects such as burping, heartburn, diarrhea, abdominal pain, or nausea did not differ statistically between study arms. At 4 weeks, participants allocated to the n-3 long-chain polyunsaturated fatty acids arm reported a median of 3 cigarettes per day (interquartile range, 1-8) vs 7 cigarettes per day (interquartile range, 1-14) in the placebo arm, which was not statistically significant (P=.99). Participants allocated to the n-3 long-chain polyunsaturated fatty acids arm had a decrease of 1 (interquartile range, 0-1) on the Fagerström Test for Cigarette Dependence score vs 0 (interquartile range, 0-0) for placebo (P=.46).

CONCLUSION

High-dose n-3 long-chain polyunsaturated fatty acids may be tolerated in pregnant women who smoke; however, there was a high level of participant dropout, with more participants allocated to the fish oil arm becoming lost to follow-up. These results will inform the design of a future large-scale randomized controlled trial to test the impact of fish oil supplements on smoking cessation in pregnancy.

Does Maternal Obesity Affect Preterm Birth? Documentary Cohort Study of Preterm in Firstborns—Silesia (Poland)

In addition to low birth weight and intrauterine growth restriction, prematurity is a major problem in modern neonatology. The etiology of premature delivery is multifactorial, but maternal obesity has been indicated as an important risk factor for preterm birth. This study aimed to assess the relationship between early pregnancy body mass index (BMI) and the risk of preterm delivery according to gestational age. In the cohort of 2794 firstborns, preterm deliveries accounted for 9.1%. Of all deliveries, 16, 48, and 189 were classified as extremely preterm, very preterm, and moderately preterm deliveries, respectively. The risk of extremely, very, and moderately preterm deliveries increased with the increasing BMI, with the highest overweight and obesity-related risk for extremely and very preterm delivery. The rate of extremely and very preterm delivery among normal-weight women (BMI 18.5 ≤ 25) was 1.8%, while that among overweight and obese women (BMI ≥ 25) was 2.36%. The rate of all preterm deliveries (22 ≤ 37 weeks) was 8% for normal-weight women and 10.3% for overweight and obese women. Compared with normal-weight women, the adjusted odds ratio (95% CI) for preterm delivery in overweight and obese women was 1.33 (0.98–1.79). In Poland, being overweight and obese during pregnancy was associated with an increased risk of preterm delivery, especially extremely and very preterm delivery. This relationship should be assessed in other populations.

Tobacco Smoking during Pregnancy: Women's Perception about the Usefulness of Smoking Cessation Interventions

Tobacco consumption during pregnancy is a serious public health problem due to its negative effects on fetal development and on pregnant women's health and well-being. Thus, it is of utmost importance to plan and implement smoking cessation interventions, to prevent the negative impact of this risk factor, namely on children's health and development. This cross-sectional study aimed at exploring the perceptions and beliefs about the usefulness of smoking cessation interventions during pregnancy, in a sample of pregnant Portuguese women. The smoking use by pregnant women, as well as the risk factors associated with tobacco smoking during pregnancy, were also analyzed. The sample included 247 pregnant Portuguese women aged between 18-43-years-old (M = 30.30, SD = 5.02): 42.5% never smoked, 18.3% quit smoking before pregnancy, 19.0% quit smoking after getting pregnant and 20.2% were current smokers. The pregnant Portuguese women who smoked during pregnancy (current smokers or who quit smoking after getting pregnant) were mostly single or divorced, with lower education levels, showed a higher prevalence of clinically significant anxiety symptoms, and perceived smoking cessation interventions during pregnancy as less useful when compared to women who never smoked or quit smoking prior pregnancy. Daily or weekly smoking cessation interventions, implemented by health professionals such as doctors, nurses, or psychologists are the ones perceived as the most useful for pregnant women. These findings provide important clues for the planning of smoking cessation interventions during pregnancy, highlighting the domains that should be carefully monitored by health professionals. Specific strategies should also be used by health professionals to promote smoking cessation considering the demands of pregnancy and postpartum.

Fast-track referral for health interventions during pregnancy: study protocol of a randomised pragmatic experimental study to reduce low birth weight in Portugal (STOP LBW)

INTRODUCTION

Low birth weight (LBW) is associated with a wide range of short-term and long-term consequences and is related to maternal psychosocial and behavioural determinants. The objective of this study is to estimate the effect of implementing fast-track referral for early intervention on psychosocial and behavioural risk factors-smoking, alcohol consumption, depression and physical violence-in reducing the incidence of LBW.

METHODS AND ANALYSIS

Parallel superiority pragmatic clinical trial randomised by clusters. Primary healthcare units (PHCU) located in Portugal will be randomised (1:1) to intervention or control groups. Pregnant women over 18 years of age attending these PHCU will be eligible to the study. Risk factors will be assessed through face-to-face interviews. In the intervention group, women who report at least one risk factor will have immediate access to referral services. The comparison group will be the local standard of care for these risk factors. We will use intention-to-treat analyses to compare intervention and control groups. We estimated a sample size of 2832 pregnant women to detect a 30% reduction in the incidence rate of LBW between the control and intervention groups. Secondary outcomes are the reduction of preterm births, reduction of the four risk factors and acceptance of the intervention.

ETHICS AND DISSEMINATION

The study was approved by the Ethics Committee of the Public Health Institute of the University of Porto (no CE20140). The findings will be disseminated to the public, the funders, health professionals, health managers and other researchers.

TRIAL REGISTRATION NUMBER

NCT04866277.

Urinary cotinine assessment of maternal smoking and environmental tobacco smoke exposure status and its associations with perinatal outcomes: a cross-sectional birth study

Tobacco consumption and environmental tobacco smoke (ETS) exposure remains an important public health concern. Pregnant women require particular attention as active and passive smoking during pregnancy are associated with multiple adverse perinatal outcomes. This study aimed to biochemically validate self-reported smoking and ETS exposure status among pregnant women, to more precisely ascertain its association with adverse perinatal outcomes. Data refers to 595 pregnant women who sought prenatal care in a public hospital in Porto, Portugal. A standard questionnaire on smoking and ETS-related variables was completed. Urinary cotinine (UC) concentrations were assessed by solid-phase competitive ELISA, in maternal urine samples collected on the day of delivery. The results showed that the optimal UC cut-off value to distinguish smokers from non-smokers and within non-smokers those who were exposed to ETS from those non-exposed in the third trimester of pregnancy was 74.1 ng/mL (sensitivity and specificity of 96.7% and 98.0%, respectively) and 1.6 ng/mL (sensitivity of 66.2% and specificity of 75.7%, respectively). The agreement between maternal self-reported and UC-based smoking status was very good (κ=0.919, p<0.001), but much lower for ETS exposure (κ=0.386, p<0.001). Maternal active smoking in the third trimester of pregnancy was associated with a significant decrease in birth weight, length and head circumference of 157.66 g (95% CI: -245.81, -69.52; p<0.001), 0.78 cm (95% CI: -1.22, -0.34; p=0.001) and 0.39 cm (95% CI: -0.70, -0.07; p=0.016), respectively. Maternal ETS exposure in the third trimester of pregnancy was associated with a non-significant increase in birth weight of 38.37 g (95% CI: -28.91, 105.64; p=0.263). Furthermore, maternal smoking cessation was associated with the increase of approximately 172 g in birth weight (95% CI: 50.00, 293.19). As such, there is an urgent need for increased public health awareness campaigns to encourage smoking cessation during pregnancy, in order to improve perinatal outcomes.

Investigating N-3 Fatty Acids to prevent Neonatal Tobacco-related outcomeS (INFANTS): study protocol for a double-blind, randomized, placebo-controlled parallel clinical trial of n-3 polyunsaturated fatty acids in pregnant smokers

BACKGROUND

Tobacco use during pregnancy is the most important modifiable risk factor associated with adverse pregnancy outcomes, increasing the risk of preterm birth, intrauterine growth restriction and sudden infant death syndrome. Fewer than half of pregnant smokers can quit on their own. Identifying safe and effective therapies to prevent tobacco-related adverse pregnancy outcomes and/or increase smoking cessation in pregnant women would have a substantial public health impact. Cigarette smoking is associated with a relative deficiency in circulating n-3 long-chain polyunsaturated fatty acid (n-3 LCPUFA) levels. A recent analysis found that smokers taking n-3 LCPUFAs during pregnancy had a reduction in preterm labor risk when compared to non-smokers. Studies have shown that supplemental n-3 LCPUFAs may also reduce nicotine cravings and daily cigarette use. Thus, smokers may benefit from supplemental n-3 LCPUFAs by lowering the risk of preterm labor and/or increased smoking cessation. To address important remaining knowledge gaps, we propose the Investigating N-3 Fatty Acids to prevent Neonatal Tobacco related outcomeS (INFANTS).

METHODS

The INFANTS study is a multicenter, randomized, double-blind, placebo-controlled study that will randomize 400 pregnant smokers to either supplemental n-3 LCPUFAs or placebo. Participants will be enrolled between 12 and 24 weeks' gestation and followed until 6 weeks after delivery. We will recruit from clinical centers throughout Middle Tennessee. We will assess smoking behavior after 12 weeks of supplementation using self-report and validated biomarkers of tobacco exposure. We will measure response to supplementation using biological markers of n-3 LCPUFA status. Our primary endpoint will be preterm labor as reflected by gestational age at delivery. Our secondary endpoint will be change from baseline in cigarettes per day at 12 weeks.

DISCUSSION

This study tests the hypothesis that smoking-induced n-3 LCPUFA deficiencies contribute to tobacco-related adverse pregnancy outcomes and that supplementation of n-3 LCPUFAs in pregnant smokers may prevent these complications. If our study demonstrates that supplemental n-3 LCPUFAs are effective at reducing the risk of tobacco-related adverse neonatal outcomes and/or reducing tobacco use during pregnancy, our results could have an immediate and major impact on pregnancy care and neonatal outcomes.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04417595. Registered on April 21, 2020.

Effects of active and/or passive smoking during pregnancy and the postpartum period

INTRODUCTION

Tobacco smoking may cause adverse effects during pregnancy and postpartum. The aim of this study was to evaluate several repercussions of active and/or passive smoking by the mother at home, during pregnancy, at delivery, as well as for the newborn baby and breastfeeding, including the effect of quitting smoking in the first trimester of pregnancy.

METHODS

A prospective longitudinal study was carried out with a sample of 800 pregnant women. Four evaluations were made: first and third trimester of pregnancy, and 2 and 6/8 months postpartum. Sociodemographic, obstetric, health and tobacco consumption details were collected, with biochemical tests being performed to confirm the self-reported abstinence.

RESULTS

Being an active and passive smoker predicted suffering complications in pregnancy (OR 2.50; 95% CI; 1.42-4.35) and delivery (OR 3.10; 95% CI; 1.75-5.51), and also tended not to breastfeed (OR 2.44; 95% CI; 1.35-4.42). Being an active smoker predicted complications at childbirth (OR 5.58; 95% CI; 2.64-7.77), for the baby (OR 3.77; 95% CI; 1.53-9.36) and not breastfeeding at 2 (OR 25.73; 95% CI; 11.95-55.40), and 6/8 months postpartum (OR 6.61; 95% CI; 3.21-13.58). Being a passive smoker reduces the intend to breastfeed (OR 1.81; 95% CI; 1.11-2.95), and the practice of breastfeeding at 2 months postpartum (OR 1.94; 95% CI; 1.11-3.37). Women who quit smoking are less likely to suffer complications in pregnancy and childbirth, and are more likely to attend antenatal and breastfeeding classes, and to have babies with higher birth weight.

CONCLUSIONS

Active and passive tobacco consumption has significant implications during pregnancy and postpartum period. Smoking cessation at the beginning of pregnancy reverses much of these effects.

Asthma in pregnancy: An update

AIM

To update obstetric care providers about asthma management.

SUMMARY

Asthma is the most frequent comorbid chronic illness in pregnancy. Convincing evidence shows that uncontrolled asthma magnifies the risk of maternal, fetal and neonate complications. Unfortunately, one in four women take no inhaler during pregnancy, and it is likely that decreased adherence, rather than changes in pathology, explains uncontrolled maternal asthma. Patient surveys reveal a need for information and reassurance. Although some molecules are preferred in pregnancy, there is currently no basis to withhold any asthma medication - old or new. Biomarkers such as blood eosinophils and fractional exhaled nitric oxide are an effective way to assess the risk of asthma attacks and the likelihood of responding to inhaled steroids. Furthermore, practice-changing trials in mild asthma show that switching reliever-only regimens to as-needed 'controller-and-reliever' therapy is effective. We suggest that applying these changes can alleviate women's concerns and improve outcomes.

[Effects of active and/or passive smoking during pregnancy and the postpartum period]

INTRODUCTION

Tobacco smoking may cause adverse effects during pregnancy and postpartum. The aim of this study was to evaluate several repercussions of active and/or passive smoking by the mother at home, during pregnancy, at delivery, as well as for the new born baby and breastfeeding, including the effect of quitting smoking in the first trimester of pregnancy.

METHODS

A prospective longitudinal study was carried out with a sample of 800 pregnant women. Four evaluations were made: first and third trimester of pregnancy, and 2 and 6/8 months postpartum. Sociodemographic, obstetric, health and tobacco consumption information was collected, with biochemical tests being performed to confirm the self-reported abstinence.

RESULTS

Being an active and passive smoker predicted suffering complications in pregnancy (OR 2.50; 95% CI; 1.42-4.35) and delivery (OR 3.10; 95% CI; 1.75-5.51), and also intend not to breastfeed (OR 2.44; 95% CI; 1.35-4.42). Being an active smoker predicted complications at childbirth (OR 5.58; 95% CI; 2.64-7.77), for the baby (OR 3.77; 95% CI; 1.53-9.36) and not breastfeeding at 2 (OR 25.73; 95% CI; 11.95-55.40), and 6/8 months postpartum (OR 6.61; 95% CI; 3.21-13.58). Being a passive smoker reduces the intention to breastfeed (OR 1.81; 95% CI; 1.11-2.95), and the practice of breastfeeding at 2 months postpartum (OR 1.94; 95% CI; 1.11-3.37). Women who quit smoking are less likely to suffer complications in pregnancy and childbirth, and are more likely to attend antenatal and breastfeeding classes, and to have babies with higher birth weight.

CONCLUSIONS

Active and passive tobacco consumption has significant implications during pregnancy and postpartum period. Smoking cessation at the beginning of pregnancy reverses much of these effects.

The importance of socioeconomic position in smoking, cessation and environmental tobacco smoke exposure during pregnancy

Tobacco is still a leading cause of premature death and morbidity. Particular attention has been given to pregnant women due to the scientific evidence on the importance of early life exposures for disease onset later in life. The purpose of this study was to assess smoking prevalence, smoking cessation rate and environmental tobacco smoke (ETS) exposure, and the role of socioeconomic position (SEP) on these behaviors among pregnant women. Cross-sectional data of 619 pregnant women, aged between 18 and 46 years, from Porto Metropolitan Area, Portugal, on current smoking, ETS exposure and SEP indicators was collected, face-to-face, using a questionnaire filled in during a personal interview at the postpartum hospital stay. The smoking prevalence, and ETS exposure among non-smokers before pregnancy was 27.6% and 57.4%, respectively. 4.1% of the participants reported to have stopped smoking before pregnancy, whereas about 41% quitted along pregnancy, resulting in a smoking prevalence at birth of 14.6%. Exposure to ETS also decreased throughout pregnancy to 49.8% at birth. Lower educational level was significantly associated with both higher smoking prevalence and exposure to ETS and lower smoking cessation. This study demonstrates that smoking and ETS exposure during pregnancy remains high, and that there are still significant socioeconomic inequalities in smoking; thus tobacco-focused preventive interventions need to be reinforced.

Description of Maternal Smoking Status Before and After Pregnancy: A Longitudinal, Community-Based Cohort Study

Background

Maternal smoking during pregnancy is a major risk for adverse perinatal outcomes, as well as children’s health status. Thus, it is important to describe maternal smoking status during pregnancy and child-rearing to devise better intervention strategies. However, there have been no longitudinal studies to describe the status. Thus, in this study, we aimed to describe maternal smoking status during pregnancy and child-rearing based on population-based maternal and child health information. Moreover, we explored the factors associated with maternal smoking relapse after delivery.

Methods

We performed a survey of 1,220 mothers in a Japanese rural area who responded to a questionnaire upon registration of their pregnancies. When their children received health checkups at 4, 18, and 36 months of age, maternal smoking status was also surveyed. We then performed multiple logistic regression analysis to explore factors associated with maternal smoking relapse after delivery.

Results

Ultimately, the total number of mothers with data available for longitudinal analysis was 727 (59.6%). At the time of pregnancy registration, there were 74 current smokers (10.2%) and 176 former smokers (24.2%). Among them, 59 (33.5%) relapsed after delivery. Under 28 years of maternal age at pregnancy registration (OR 2.6; 95% CI, 1.2–5.4) was associated with maternal smoking relapse after delivery.

Conclusions

Longitudinal analyses showed that about 60% of mothers who smoked before and after delivery failed smoking cessation. In addition, younger mothers were significantly likely to relapse smoking after delivery.

Prevalence of pre-gestational and gestational smoking and factors associated with smoking cessation during pregnancy, Brazil, 2011-2012

Gestational smoking is associated with various adverse maternal and fetal outcomes. Over the last three decades, despite considerable advances in tobacco control policy in Brazil, gestational smoking has caused a considerable number of fetal deaths and disabilities. The aim of this study is to estimate the prevalence of pre-gestational and gestational smoking and to identify the factors associated with smoking cessation up to the 20th gestational week.

METHODS

"Birth in Brazil" was a nationwide hospital-based study conducted from February 2011 to October 2012. Smoking prevalence and smoking cessation during pregnancy was estimated through face-to-face interviews with postpartum women during hospitalization for birth care. We performed multivariate logistic regression to verify the factors associated with smoking cessation up to the 5th month of pregnancy.

RESULTS

prevalence of pre-gestational smoking of 16.1% (CI 95% 15.3%-16.9%); prevalence of smoking any time during pregnancy of 9.6% (CI 95% 9.0%-10.3%); and prevalence of smoking cessation up to the 5th month of pregnancy of 56.7% (CI 95% 54.0%-59.4%). The factors associated with smoking cessation were residence in the North, Northeast, and Central-West of Brazil, having received at least one prenatal consultation (OR 3.51 CI 95% 1.85-6.67), more years of schooling (15 or more vs less than 7 years of schooling OR 5.54 CI 95% 2.97-10.34), living with a partner (OR 1.35 CI 95% 1.01-1.79), no children prior to the index pregnancy (OR 2.77 CI 95% 2.13-3.61), and absence of alcohol use (1.74 CI 95% 1.39-2.18) or of suspected alcohol abuse (OR 1.62 CI 95% 1.07-2.45).

CONCLUSION

The estimated smoking rate during pregnancy in Brazil is still high and is associated with factors of increased maternal social vulnerability, which may contribute to the increased occurrence of unfavorable perinatal outcomes.

Smoking cessation strategies in pregnancy: Current concepts and controversies

Smoking during pregnancy is a risk factor associated with adverse pregnancy outcomes. Despite the fact that these outcomes are well known, a considerable proportion of pregnant women continue to smoke during this critical period. This paper evaluates critically smoking cessation interventions targeting pregnant women. We describe the findings of key published studies, review papers and expert statements to report the efficacy and safety of strategies for smoking cessation in pregnancy, including counselling and pharmacotherapy. Counselling appears to improve quit rates but mainly when used in combination with pharmacological therapy. Pharmacotherapy is recommended for women who are heavy smokers and are unable to quit smoking on their own. Nicotine replacement therapy is a reasonable first-line drug option. It is recommended that women who are pregnant, or planning to become pregnant, should be informed of potential risks for the foetus before considering smoking cessation therapy with bupropion or varenicline. Pregnant women view electronic nicotine delivery systems as being safer than combustible cigarettes, and this indeed may be the case; however, further evidence is required to assess their effectiveness as a smoking cessation aid and their safety for the mother and the child. Postpartum relapse is a significant problem, with approximately one out of two quitters relapsing in the first 2 months after delivery. These women should be considered 'at risk' and provided with ongoing support.

Smoking-related behaviours of pregnant women depending on their place of residence

OBJECTIVES

Smoking is a commonly recognized risk factor of civilization diseases. Despite many educational programmes concerning harmful effects of tobacco smoking, this habit is still very popular. Particularly alarming is a high percentage of pregnant women who smoke.

METHODS

The aim of the study was to analyse the prevalence of smoking among pregnant women depending on their place of residence. The research was conducted in randomly selected 30 outpatient clinics for women in Łodź and 16 outpatient clinics in rural communes of the Łodź province. The epidemiological analysis included 400 women. Collected data were processed statistically using the descriptive methods and statistical inference.

RESULTS

It has been demonstrated that smoking in the past was more popular among city residents than countryside residents (58.2% and 47.9%, respectively). Women living in the city smoked almost three times more frequently during the whole pregnancy than the respondents from the countryside (13.4% and 4.3%, respectively). Furthermore, every fifth respondent living in the urban area (f=0.21) smoked over 10 cigarettes a day, and every fourth respondent from rural communes (f=0.24) smoked from 5 to 10 cigarettes a day. However, in the month preceding the research, pregnant women from rural areas smoked slightly more frequently as compared to the subjects from the city. In the group of pregnant women who smoked in the past or who smoke at present, regardless from their place of residence, every other woman did not breastfeed her baby. 6.1% of city residents and 4.3% of countryside residents declared that they smoked during the breastfeeding period.

CONCLUSIONS

Within the analysed population the influence of place of residence on the prevalence of active smoking, number of smoked cigarettes and giving up smoking during pregnancy and breastfeeding period has been evidenced.

Effect of maternal smoking on stress physiology in healthy neonates

OBJECTIVE

To assess the impact of maternal smoking during pregnancy (MSDP) on the neonatal hypothalamic-pituitary-adrenal axis.

STUDY DESIGN

In a prospective observational study, salivary cortisol and cortisone levels were measured at the fourth day of life during resting conditions and in response to a pain-induced stress event in healthy neonates whose mothers smoked cigarettes during each stage of pregnancy and compared with controls.

RESULTS

Neonates in the control group (n=70) exhibited a physiologic stress response with a significant increase in cortisol (1.3 to 2.1 ng ml^-1; P<0.05) and cortisone (11.8 to 17.8 ng ml^-1; P<0.05) from baseline levels, whereas in neonates from mothers who smoked (n=33), cortisol (0.9 to 0.8 ng ml^-1; P=0.77) and cortisone (11.5 to 13.0; P=0.19) stress response was not significantly different from baseline levels. A two-way analysis of variance confirmed these findings in both groups.

CONCLUSIONS

Healthy neonates whose mothers smoked during pregnancy show a blunted stress response on the fourth day of life. Thus, MSDP leads to a dysregulation of the HPA axis with continued effects in neonatal life. This might explain long-term consequences of MSDP such as overweight, diabetes mellitus and modification of blood pressure control mechanisms in adult life.

Surgical site infection after cesarean delivery: incidence and risk factors at a US academic institution

PURPOSE

To identify the rate of surgical site infection (SSI) after Cesarean delivery (CD) and determine risk factors predictive for infection at a large academic institution.

METHODS

This was a retrospective cohort study in women undergoing CD during 2013. SSIs were defined by Centers for Disease Control (CDC) criteria. Chi square and t-tests were used for bivariate analysis and multivariate logistic regression was used to identify SSI risk factors.

RESULTS

In 2419 patients, the rate of SSI was 5.5% (n = 133) with cellulitis in 4.9% (n = 118), deep incisional infection in 0.6% (n = 15) and intra-abdominal infection in 0.3% (n = 7). On multivariate analysis, SSI was higher among CD for labor arrest (OR 2.4; 95%CI 1.6-3.5; p <.001). Preterm labor (OR 2.8; 95%CI 1.3-6.0; p = .01) and general anesthesia (OR 4.4; 95%CI 2.0-9.8; p = .003) were predictive for SSI. Increasing BMI (OR 1.1; 95%CI 1.05-1.09; p = .02), asthma (OR 1.9; 95%CI 1.1-3.2; p = .02) and smoking (OR 1.9; 95%CI 1.1-3.2; p = .02) were associated with increased SSI.

CONCLUSIONS

Several patient and surgical variables are associated with increased rate of SSI after CD. Identification of risk factors for SSI after CD is important for targeted implementation of quality improvement measures and infection control interventions.

Assessing the effect on outcomes of public or private provision of prenatal care in Portugal

To evaluate whether public and private prenatal care users experience similar outcomes, taking into consideration maternal pre-pregnancy social and clinical risk. We studied 7,325 women who delivered single newborns at five public maternity units in Porto, Portugal. Health behaviors and prenatal care were self-reported; pregnancy complications and delivery data were retrieved from medical files. The odds of inadequate weight gain, continuing to smoke, gestational hypertension, gestational diabetes, caesarean section, preterm birth, low birthweight, and small- and large-for-gestational-age were estimated for public and private providers using logistic regression, stratified by pre-pregnancy risk profile, adjusted for maternal characteristics. 38 % of women used private prenatal care. Among low-risk women, public care users were more likely to gain excessive weight (OR 1.26; 95 % CI 1.06-1.57) and be diagnosed with gestational diabetes (OR 1.37; 95 % CI 1.01-1.86). They were less likely to have a caesarean (OR 0.63; 95 % CI 0.51-0.78) and more likely to deliver small-for-gestational-age babies (OR 1.48; 95 % CI 1.19-1.83). Outcomes were similar in high-risk women although preterm and pre-labor caesarean were less frequent in public care users (OR 0.64 95 % CI 0.45-0.91; OR 0.69 95 % CI 0.49-0.97). The amount of care was not significantly related to risk profile in either case. Public care users experienced similar outcomes to those using private care, despite higher pre-pregnancy disadvantage. Low-risk women need further attention if narrowing inequalities in birth outcomes remains a priority.

A biopsychosocial approach to the interrelation between motherhood and women's excessive weight

Portugal is characterized by a high prevalence of overweight and obesity among women, whose weight increases most rapidly in early adulthood. Individual genetic features and behaviours, along with social, cultural and environmental factors interact in complex relationships with body weight and with its variation throughout time. Motherhood may trigger an increase in weight, potentially influencing the associations between excessive weight and several other health determinants. Taking into account the quality of prenatal care within Portugal's health care system, regarding coverage and success in improved outcomes, we theoretically demonstrate why pregnancy and motherhood should be seen as opportunities for prevention and why a deeper knowledge about the interplay of biological, social and psychological determinants of weight at this stage of life can be useful to design more effective weight control interventions towards this population.

Real-time fatigue reduction in emergency care clinicians: The SleepTrackTXT randomized trial

BACKGROUND

We assessed performance characteristics and impact of a mobile phone text-message intervention for reducing intra-shift fatigue among emergency clinician shift workers.

METHODS

We used a randomized controlled trial of 100 participants. All participants received text-message assessments at the start, every 4 hr during, and at end of scheduled shifts over a 90-day period. Text-message queries measured self-rated sleepiness, fatigue, and difficulty with concentration. Additional text-messages were sent to intervention participants to promote alertness. A performance measure of interest was compliance with answering text-messages.

RESULTS

Ninety-nine participants documented 2,621 shifts and responded to 36,073 of 40,947 text-messages (88% compliance rate). Intervention participants reported lower mean fatigue and sleepiness at 4 hr, 8 hr, and at the end of 12 hr shifts compared to controls (P < 0.05). Intervention participants reported better sleep quality at 90-days compared to baseline (P = 0.01).

CONCLUSIONS

We showed feasibility and short-term efficacy of a text-message based assessment and intervention tool.

Mobile phone text messaging intervention to improve alertness and reduce sleepiness and fatigue during shiftwork among emergency medicine clinicians: study protocol for the SleepTrackTXT pilot randomized controlled trial

Background

Mental and physical fatigue while at work is common among emergency medical services (EMS) shift workers. Extended shifts (for example 24 hours) and excessive amounts of overtime work increase the likelihood of negative safety outcomes and pose a challenge for EMS fatigue-risk management. Text message-based interventions are a potentially high-impact, low-cost platform for sleep and fatigue assessment and distributing information to workers at risk of negative safety outcomes related to sleep behaviors and fatigue.

Methods/Design

We will conduct a pilot randomized trial with a convenience sample of adult EMS workers recruited from across the United States using a single study website. Participants will be allocated to one of two possible arms for a 90-day study period. The intervention arm will involve text message assessments of sleepiness, fatigue, and difficulty with concentration at the beginning, during, and end of scheduled shifts. Intervention subjects reporting high levels of sleepiness or fatigue will receive one of four randomly selected intervention messages promoting behavior change during shiftwork. Control subjects will receive assessment only text messages. We aim to determine the performance characteristics of a text messaging tool for the delivery of a sleep and fatigue intervention. We seek to determine if a text messaging program with tailored intervention messages is effective at reducing perceived sleepiness and/or fatigue among emergency medicine clinician shift workers. Additional aims include testing whether a theory-based behavioral intervention, delivered by text message, changes ‘alertness behaviors’.

Discussion

The SleepTrackTXT pilot trial could provide evidence of compliance and effectiveness that would support rapid widespread expansion in one of two forms: 1) a stand-alone program in the form of a tailored/individualized sleep monitoring and fatigue reduction support service for EMS workers; or 2) an add-on to a multi-component fatigue risk management program led and maintained by employers or by safety and risk management services.

Trial Registration

Clinicaltrials.gov NCT02063737, Registered on 10 January 2014