Midwives' perceptions of providing stop-smoking advice and pregnant smokers' perceptions of stop-smoking services within the same deprived area of London

International and national frameworks, guidelines, recommendations, and strategies for maternal tobacco prevention and cessation: A scoping review protocol

Tobacco use during and around pregnancy can significantly increase the risk of stillbirth, congenital disabilities, premature birth, and low-weight birth. To establish maternal tobacco prevention and cessation frameworks for primary care and dental providers and to facilitate cross-national learning, this scoping review aims: 1) to analyze the body of literature on maternal tobacco prevention and cessation frameworks, guidelines, recommendations, and strategies at the international and national level; 2) to identify common core elements; and 3) to identify gaps in the literature, and propose future initiatives and policy development directions. A systematic database search based on the JBI methodology and corresponding PRISMA-ScR guidelines will be conducted from January 2015 to August 2023. Searches in different databases will be combined with an expert survey among the members of the World Federation of Public Health Associations (WFPHA) - Oral Health, Tobacco Control, and the Women, Adolescent, and Children's Working Groups to evaluate the search outcomes and add maternal tobacco prevention and cessation frameworks, guidelines, recommendations, or strategies. Using a systematic review tool to support the screening, two independent reviewers will screen the titles and abstracts of all articles, in order to include the relevant ones for full-text screening, and an independent third author will resolve conflicts, if there is any discrepancy between the two independent reviewers' search. After a full-text review, data extraction will be conducted for analysis. Descriptive analyses include the publication year, country, legal quality, and target group addressed. A narrative synthesis will describe the scope and content of the frameworks, guidelines, recommendations, and strategies. The scoping review will serve as a stepping-stone to creating a WFPHA policy resolution on tobacco prevention and cessation framework for women of childbearing age led by the WFPHA Oral Health, Tobacco Control and the Women, Adolescent, and Children's Working Group members. This WFPHA policy resolution 'Maternal Tobacco Cessation and Prevention Recommendations for Primary Care Providers and Dental Providers' will be forwarded to the WFPHA General Council and the General Assembly for approval and will be disseminated to the WFPHA public health association members. Ultimately, this recommendation will be used by each national public health association to consider integrating it into their maternal health strategy.

Smoking cessation care during pregnancy: A qualitative exploration of midwives' challenging role

PROBLEM

The majority of South Australian pregnant women who smoke do not quit during pregnancy. Additionally, the prevalence of smoking is higher among pregnant women living in socially disadvantaged areas.

BACKGROUND

Understanding challenges in midwives' provision of smoking cessation care can elucidate opportunities to facilitate women's smoking cessation.

AIM

We aimed to understand midwives' perspectives on current practices, perceived barriers and facilitators to delivery of smoking cessation care, and potential improvements to models of smoking cessation care.

METHODS

An exploratory qualitative research methodology and thematic analysis was used to understand the perspectives of midwives in five focus groups.

FINDINGS

Four themes were generated from the data on how midwives perceived their ability to provide smoking cessation care: Tensions between providing smoking cessation care and maternal care; Organisational barriers in the delivery of smoking cessation care; Scepticism and doubt in the provision of smoking cessation care; and Opportunities to enable midwives' ability to provide smoking cessation care.

DISCUSSION

A combination of interpersonal, organisational and individual barriers impeded on midwives' capacities to approach, follow-up and prioritise smoking cessation care. Working with women living with disadvantage and high rates of smoking, the midwife's role was challenging as it balanced delivering smoking cessation care without jeopardising antenatal care.

CONCLUSION

Providing midwives with resources and skills may alleviate the sense of futility that surrounds smoking cessation care. Provision of routine training and education could also improve understandings of the current practice guidelines.

Pregnant and postnatal women's experiences of interacting with health care providers about their tobacco smoking: a qualitative systematic review

OBJECTIVE

The objective of this review was twofold: (i) to comprehensively identify the best available evidence about the experiences of women who smoked tobacco during pregnancy or postnatally (or both) concerning health care providers' interactions with them about their smoking, when such interactions occurred during contact for prenatal or postnatal health care in any health care setting; and (ii) to synthesize the research findings for recommendations to strengthen health care providers' interventions regarding smoking during pregnancy and smoking during the postnatal period.

INTRODUCTION

Maternal tobacco smoking during pregnancy and maternal tobacco smoking postnatally pose serious health risks for the woman, fetus, and offspring, whereas maternal smoking cessation has beneficial health effects. Given the importance of health care providers' interactions with pregnant and postnatal women for smoking cessation care, it is essential to understand women's experiences of such interactions.

INCLUSION CRITERIA

Studies considered for this review had qualitative research findings about the experiences of women who smoked tobacco during pregnancy or postnatally (or both) in relation to health care providers' interactions with them about their smoking.

METHODS

The review was conducted using the JBI approach to qualitative systematic reviews. Published studies were sought through 6 academic databases (eg, CINAHL, MEDLINE). Unpublished studies were searched in 6 gray literature sources (eg, ProQuest Dissertations and Theses, Google Scholar). Reference lists of retrieved records were also searched. The searches occurred in October and November 2020; no country, language, or date limits were applied. Study selection involved title and abstract screening, full-text examination, and critical appraisal of all studies that met the inclusion criteria for the review. Study characteristics and research findings were extracted from the included studies. Study selection and extraction of findings were conducted by two reviewers independently; differences between reviewers were resolved through consensus. The research findings were categorized, and the categories were aggregated into a set of synthesized findings. The synthesized finding were assigned confidence scores. The categories and finalized synthesized findings were agreed upon by all reviewers.

RESULTS

The 57 included studies varied in qualitative research designs and in methodological quality (from mostly low to high). There were approximately 1092 eligible participants, and 250 credible and unequivocal research findings. The research findings yielded 14 categories and 6 synthesized findings with low to very low confidence scores. Some women who smoked tobacco during pregnancy and some women who smoked tobacco postnatally lacked supportive interactions by health care providers regarding their smoking; other women experienced supportive interactions by health care providers. Women were adversely impacted when health care providers' interactions lacked supportiveness, and were beneficially impacted when interactions were supportive. Women varied in openness to health care providers' interactions regarding their smoking, from not being receptive to being accepting, and some women wanted meaningful health care provider interactions.

CONCLUSIONS

Although confidence in the synthesized findings is low to very low, the evidence indicates that supportive health care provider interactions may facilitate positive smoking behavior change in pregnancy and postnatally. It is recommended that health care providers implement accepted clinical practice guidelines with women who smoke prenatally or postnatally, using an approach that is person-centered, emotionally supportive, engaging (eg, understanding), and non-authoritarian.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42020178866.

“If the social circle is engaged, more pregnant women will successfully quit smoking”: a qualitative study of the experiences of midwives in the Netherlands with smoking cessation care

Background

If smoking is common within a pregnant woman’s social circle, she is more likely to smoke and her chances of succeeding in quitting smoking are reduced. It is therefore important to encourage smoking cessation in a pregnant woman’s social circle. Midwives are ideally positioned to help pregnant women and members of their social circle quit smoking but there is currently little knowledge about if and how midwives approach smoking cessation with pregnant women’s social circles.

Methods

In 2017 and 2018, semi-structured interviews were conducted with 14 birth care providers in the Netherlands. Interviews were inductively coded; data were analyzed thematically.

Results

In the interviews, midwives reported that they don’t commonly provide smoking cessation support to members of pregnant women’s social circles. The respondents noted that they primarily focused on mothers and weren’t always convinced that advising the partners, family, and friends of pregnant women to quit smoking was their responsibility. Data from the interviews revealed that barriers to giving advice to the social circle included a lack of a trusting relationship with the social circle, concerns about raising the topic and giving unwanted advice on cessation to members of the social circle and a lack of opportunity to discuss smoking.

Conclusions

Midwives in the Netherlands were reluctant to actively provide smoking cessation advice to the social circle of pregnant women. To overcome barriers to addressing cessation to the social circle, educational programs or new modules for existing programs could be used to improve skills related to discussing smoking. Clear guidelines and protocols on the role of midwives in providing cessation support to the social circle could help midwives overcome ambivalence that they might have.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08472-7.

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.

Isolation, marginalisation and disempowerment - understanding how interactions with health providers can influence smoking cessation in pregnancy

Background

Maternal smoking during pregnancy can lead to serious adverse health outcomes for both women and their infants. While smoking in pregnancy has declined over time, it remains consistently higher in women with lower socioeconomic circumstances. Furthermore, fewer women in this group will successfully quit during pregnancy.

Aim

This study explores the barriers to smoking cessation experienced by socially disadvantaged pregnant women and investigates how interactions with health providers can influence their smoking cessation journey.

Methods

Women (either pregnant or birthed in the previous 10 years, who smoked or quit smoking in pregnancy) were recruited from a metropolitan public hospital antenatal clinic in South Australia and community organisations in surrounding suburbs. Seventeen women participated in qualitative semi-structured small focus groups or interviews. The focus groups and interviews were recorded, transcribed and thematically analysed.

Findings

Four interconnected themes were identified: 1) smoking embedded in women’s challenging lives and pregnancies, 2) cyclic isolation and marginalisation, 3) feeling disempowered, and 4) autonomy and self-determination. Themes 3 and 4 are characterised as being two sides of a single coin in that they coexist simultaneously and are inseparable. A key finding is a strong unanimous desire for smoking cessation in pregnancy but women felt they did not have the necessary support from health providers or confidence and self-efficacy to be successful.

Conclusion

Women would like improvements to antenatal care that increase health practitioners’ understanding of the social and contextual healthcare barriers faced by women who smoke in pregnancy. They seek improved interventions from health providers to make informed choices about smoking cessation and would like women-centred care. Women feel that with greater support, more options for cessation strategies and consistency and encouragement from health providers they could be more successful at antenatal smoking cessation. If such changes were made, then South Australian practice could align more with best practice international guidelines for addressing smoking cessation in pregnancy, and potentially improve outcomes for women and their children.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-022-04720-0.

Smoking Cessation Support for Pregnant Women Provided by English Stop Smoking Services and National Health Service Trusts: A Survey

Reducing smoking rates in pregnancy continues to be a public health priority. Given a recent UK government policy change resulting in The National Health Service (NHS) making a significant new contribution to cessation support in pregnancy in England, in addition to that of Local Authorities (LA), an up-to-date assessment of national support offered to pregnant women is needed. LA Stop Smoking Service (SSS) managers and representatives from maternity services in NHS Trusts were invited to participate in an online survey in autumn 2020. Topics included service configuration, staffing, practitioner consultations and treatments offered. The survey response rate was 66% (99/151) of LAs and 68% (95/140) of Trusts. Most LAs provided smoking support for pregnant smokers (78%), whereas under half (43%) of NHS Trusts did. Combination nicotine replacement therapy, i.e., a combination of a patch and short-acting product, was offered by LAs (92%) and Trusts (95%) and most commonly for 12 weeks duration, at 53% and 50%, respectively. Similar national online training was undertaken by those supporting women, with the majority undertaking the specialist pregnancy-specific module: LAs 60% and Trusts 79%. However, clinicians were reported to deliver specialist stop smoking support in over 50% of Trusts, whereas this was reported in only 16% of LAs. In England, both LA and NHS Trusts are currently delivering similar stop smoking support to pregnant women. Having nationally recognised treatment programmes and training allows for the delivery of consistent, evidence-based smoking cessation to pregnant women in different healthcare settings.

Improving implementation of smoking cessation guidelines in pregnancy care: development of an intervention to address system, maternity service leader and clinician factors

Background

Smoking during pregnancy increases the risk of multiple serious adverse infant, child and maternal outcomes, yet nearly 10% of Australian women still smoke during pregnancy. Despite evidence-based guidelines that recommend routine and repeated smoking cessation support (SCS) for all pregnant women, the provision of recommended SCS remains poor. Guidance on developing complex interventions to improve health care recommends drawing on existing theories, reviewing evidence, undertaking primary data collection, attending to future real-world implementation and designing and refining interventions using iterative cycles with stakeholder input throughout. Here, we describe using the Behaviour Change Wheel (BCW) and the Theoretical Domains Framework to apply these principles in developing an intervention to improve the provision of SCS in Australian maternity services.

Methods

Working closely with key stakeholders in the New South Wales (NSW) health system, we applied the steps of the BCW method then undertook a small feasibility study in one service to further refine the intervention. Stakeholders were engaged in multiple ways—as a core research team member, through a project Advisory Group, targeted meetings with policymakers, a large workshop to review potential components and the feasibility study.

Results

Barriers to and enablers of providing SCS were identified in five of six components described in the BCW method (psychological capability, physical opportunity, social opportunity and reflective and automatic motivation). These were mapped to intervention types and we selected education, training, enablement, environmental restructuring, persuasion, incentivisation and modelling as suitable in our context. Through application of the APEASE criteria (Affordability, Practicability, Effectiveness, Acceptability, Side effects and Equity) in the stakeholder workshop, behaviour change techniques were selected and applied in developing the intervention which includes systems, clinician and leadership elements. The feasibility study confirmed the feasibility and acceptability of the midwifery component and the need to further strengthen the leadership component.

Conclusions

Using the BCW method combined with strong stakeholder engagement from inception resulted in transparent development of the MOHMQuit intervention, which targets identified barriers to and enablers of the provision of SCS and is developed specifically for the context in which it will be implemented. The intervention is being trialled in eight public maternity services in NSW.

Supplementary Information

The online version contains supplementary material available at 10.1186/s43058-021-00235-5.

Health providers' and pregnant women's perspectives about smoking cessation support: a COM-B analysis of a global systematic review of qualitative studies

Background

Smoking cessation in pregnancy has unique challenges. Health providers (HP) may need support to successfully implement smoking cessation care (SCC) for pregnant women (PW). We aimed to synthesize qualitative data about views of HPs and PW on SCC during pregnancy using COM-B (Capability, Opportunity, Motivation, Behaviour) framework.

Methods

A systematic search of online databases (MEDLINE, EMBASE, PsycINFO and CINAHL) using PRISMA guidelines. PW’s and HPs’ quotes, as well as the authors’ analysis, were extracted and double-coded (30%) using the COM-B framework.

Results

Thirty-two studies included research from 5 continents: twelve on HPs’ perspectives, 16 on PW’s perspectives, four papers included both. HPs’ capability and motivation were affected by role confusion and a lack of training, time, and resources to provide interventions. HPs acknowledged that advice should be delivered while taking women’s psychological state (capability) and stressors into consideration. Pregnant women’s physical capabilities to quit (e.g., increased metabolism of nicotine and dependence) was seldom addressed due to uncertainty about nicotine replacement therapy (NRT) use in pregnancy. Improving women’s motivation to quit depended on explaining the risks of smoking versus the safety of quit methods. Women considered advice from HPs during antenatal visits as effective, if accompanied by resources, peer support, feedback, and encouragement.

Conclusions

HPs found it challenging to provide effective SCC due to lack of training, time, and role confusion. The inability to address psychological stress in women and inadequate use of pharmacotherapy were additional barriers. These findings could aid in designing training programs that address HPs’ and PW’s attitudes and supportive campaigns for pregnant smokers.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-021-03773-x.

Prevalence of Alcohol and Tobacco Use and Perceptions Regarding Prenatal Care among Pregnant Brazilian Women, 2017 to 2018: A Mixed-Methods Study

OBJECTIVE

To identify the prevalence of alcohol and tobacco drug use among pregnant women and investigate their perceptions regarding advice from health professionals during prenatal care.

METHOD

We used a sequential explanatory mixed-methods design for this cross-sectional study; the study period was January 2017 to December 2018. Multistage random sampling resulted in the selection of 255 pregnant women assisted in primary care units and through the Family Health Strategy in a city in southern Brazil. Trained interviewers collected data on the use of alcohol and tobacco drugs and socioeconomic characteristics via a questionnaire. Qualitative interviews were performed with pregnant women identified as alcohol and tobacco drug users in the quantitative phase. Interviews proceeded consecutively until saturation was reached, followed by a thematic analysis of interview content based on Braun and Clarke.

RESULTS

The prevalence of smoking and alcohol use was 12.55% and 14.12%, respectively. From the 14 interviews conducted, five categories emerged from the discourses: prenatal care from the perspective of pregnant women, habits and knowledge regarding smoking during pregnancy, habits and knowledge regarding alcohol use during pregnancy, previous experiences and empirical knowledge, and pregnant women's preferences for talking about their habits.

CONCLUSION FOR PRACTICE

Study findings identified smoking and alcohol use as habits among some women during pregnancy and, consequently, the need for improving care because of their superficial knowledge regarding tobacco and alcohol use. The findings underscore the importance of strengthening measures and establishing new strategies that ensure women's understanding, empowerment, and choices-from the beginning of childbearing age-regarding habits during pregnancy.

Understanding pregnant women's adherence-related beliefs about Nicotine Replacement Therapy for smoking cessation: A qualitative study

INTRODUCTION

Reducing smoking during pregnancy is a public health priority. Nicotine replacement therapy (NRT) is offered routinely to pregnant women who smoke in the United Kingdom. However, evidence of treatment efficacy in this population is weak, most likely due to poor adherence. Guided by the Necessity-Concerns Framework, we conducted a qualitative study to better understand pregnant women's perceived needs and concerns regarding NRT use, with consideration of combination NRT.

METHODS

Semi-structured interviews were conducted by telephone with 18 pregnant or recently pregnant women in England and Wales, purposively sampled for different NRT-related experiences. Participants were recruited online via Facebook adverts and through a Stop Smoking Service. A hybrid approach of deductive and inductive thematic coding was used for analysis.

RESULTS

Findings were organized around three themes: 1) the role of motivation to stop smoking; 2) necessity beliefs about using NRT; and 3) concerns about NRT. Some women reported fluctuating motivation for stopping smoking which undermined their NRT use. Others used NRT to cut down the number of cigarettes they smoked. Reasons for low NRT necessity beliefs included a preference for quitting unassisted, low or unrealistic expectations of efficacy, and overconfidence in achieving cessation (necessity testing). Concerns included safety, particularly around increased nicotine exposure with combination NRT, addictiveness, side effects, and capability to use.

CONCLUSION

Pregnant women have multiple necessity beliefs and concerns that influence their use of NRT. Targeting these, alongside increasing and maintaining motivation to quit smoking, will likely help optimize NRT use in pregnancy and improve quit rates.

Factors influencing the uptake and use of nicotine replacement therapy and e-cigarettes in pregnant women who smoke: a qualitative evidence synthesis

BACKGROUND

Nicotine replacement therapy (NRT) delivers nicotine without the toxic chemicals present in tobacco smoke. It is an effective smoking cessation aid in non-pregnant smokers, but there is less evidence of effectiveness in pregnancy. Systematic review evidence suggests that pregnant women do not adhere to NRT as prescribed, which might undermine effectiveness. Electronic cigarettes (e-cigarettes) have grown in popularity, but effectiveness and safety in pregnancy are not yet established. The determinants of uptake and use of NRT and e-cigarettes in pregnancy are unknown.

OBJECTIVES

To explore factors affecting uptake and use of NRT and e-cigarettes in pregnancy.

SEARCH METHODS

We searched MEDLINE(R), CINAHL and PsycINFO on 1 February 2019. We manually searched OpenGrey database and screened references of included studies and relevant reviews. We also conducted forward citation searches of included studies.

SELECTION CRITERIA

We selected studies that used qualitative methods of data collection and analysis, included women who had smoked in pregnancy, and elicited participants' views about using NRT/e-cigarettes for smoking cessation or harm reduction (i.e. to smoke fewer cigarettes) during pregnancy.

DATA COLLECTION AND ANALYSIS

We identified determinants of uptake and use of NRT/e-cigarettes in pregnancy using a thematic synthesis approach. Two review authors assessed the quality of included studies with the Wallace tool. Two review authors used the CERQual approach to assess confidence in review findings. The contexts of studies from this review and the relevant Cochrane effectiveness review were not similar enough to fully integrate findings; however, we created a matrix to juxtapose findings from this review with the descriptions of behavioural support from trials in the effectiveness review.

MAIN RESULTS

We included 21 studies: 15 focused on NRT, 3 on e-cigarettes, and 3 on both. Studies took place in five high-income countries. Most studies contributed few relevant data; substantially fewer data were available on determinants of e-cigarettes. Many studies focused predominantly on issues relating to smoking cessation, and determinants of NRT/e-cigarette use was often presented as one of the themes. We identified six descriptive themes and 18 findings within those themes; from these we developed three overarching analytical themes representing key determinants of uptake and adherence to NRT and/or e-cigarettes in pregnancy. The analytical themes show that women's desire to protect their unborn babies from harm is one of the main reasons they use these products. Furthermore, women consider advice from health professionals when deciding whether to use NRT or e-cigarettes; when health professionals tell women that NRT or e-cigarettes are safer than smoking and that it is okay for them to use these in pregnancy, women report feeling more confident about using them. Conversely, women who are told that NRT or e-cigarettes are as dangerous or more dangerous than smoking and that they should not use them during pregnancy feel less confident about using them. Women's past experiences with NRT can also affect their willingness to use NRT in pregnancy; women who feel that NRT had worked for them (or someone they know) in the past were more confident about using it again. However, women who had negative experiences were more reluctant to use NRT. No trials on e-cigarette use in pregnancy were included in the Cochrane effectiveness review, so we considered only NRT findings when integrating results from this review and the effectiveness review. No qualitative studies were conducted alongside trials, making full integration of the findings challenging. Women enrolled in trials would have agreed to being allocated to NRT or control group and would have received standardised information on NRT at the start of the trial. Overall, the findings of this synthesis are less relevant to women's decisions about starting NRT in trials and more likely to help explain trial participants' adherence to NRT after starting it. We considered most findings to be of moderate certainty; we assessed findings on NRT use as being of higher certainty than those on e-cigarette use. This was mainly due to the limited data from fewer studies (only in the UK and USA) that contributed to e-cigarette findings. Overall, we judged studies to be of acceptable quality with only minor methodological issues.

AUTHORS' CONCLUSIONS

Consistent messages from health professionals, based on high-quality evidence and clearly explaining the safety of NRT and e-cigarettes compared to smoking in pregnancy, could help women use NRT and e-cigarettes more consistently/as recommended. This may improve their attitudes towards NRT or e-cigarettes, increase their willingness to use these in their attempt to quit, and subsequently encourage them to stay smoke-free.

Midwives' engagement in smoking- and alcohol-prevention in prenatal care before and after the introduction of practice guidelines in Switzerland: comparison of survey findings from 2008 and 2018

Background

Evidence suggests that cigarette smoking and alcohol consumption during pregnancy negatively impacts fetal health. Health agencies across countries have developed specific guidelines for health professionals in perinatal care to strengthen their role in smoking and alcohol use prevention. One such example is the “Guideline on Screening and Counselling for prevention of cigarette smoking and alcohol consumption before, during, and after pregnancy” introduced by the Swiss Midwives Association in 2011. The current study assesses the changes in midwives’ engagement in smoking and alcohol use prevention before (2008) and after the introduction of the Guideline (2018). Further, the current study examines differences across regions (German vs. French speaking regions), graduation years (before and after the introduction of the Guideline) and different work settings (hospital vs. self-employed).

Methods

Survey data were collected in 2008 (n = 366) and in 2018 (n = 459). Differences in how midwives engaged in smoking and alcohol use prevention between 2008 and 2018 were assessed with chi-square tests, as were differences across German and French speaking regions, graduation years (before and after the introduction of the Guideline) and across different work settings (working in hospitals or as self-employed).

Results

An increase in midwives’ awareness of the risks of consuming even small quantities of cigarettes and alcohol for the unborn child between 2008 and 2018 is evident. Explaining the risks to pregnant women who smoke or use alcohol remained the most frequently reported prevention strategy. However, engagement with more extensive smoking and alcohol use preventive strategies across the whole course of pregnancy, such as assisting women in the elaboration of a plan to stop smoking/alcohol use, remained limited.

Conclusions

Seven years after its introduction, the effectiveness of the Guideline in increasing midwives’ engagement in smoking and alcohol use prevention appears limited despite midwives’ increased awareness.

Barriers and enablers to implementation of antenatal smoking cessation guidelines in general practice

Smoking is a major preventable cause of adverse outcomes in pregnancy. Despite the existence of smoking cessation support guidelines, many pregnant smokers do not receive support in quitting. The aim of this study was to identify and understand the facilitators and barriers experienced by GPs in implementing the 5As of smoking cessation support with pregnant women. The results of this study may help in shaping interventions to support GPs in implementing the guidelines. This was a qualitative study using semi-structured interviews built around the Theoretical Domains Framework. Participants were 15 GPs, and thematic analysis was used to identify relevant themes. Perceived barriers to implementing guidelines included unfamiliarity with the 5As, uncertainty using nicotine replacement therapy, lack of time, and fears of damaging rapport. Perceived facilitators included high levels of knowledge and skills, patients' expectations and a recognition that smoking cessation was a fundamental and essential part of the GPs' role in antenatal care. Educating and training GPs regarding the 5As and NRT (nicotine replacement therapy) use in pregnancy may have a role in improving delivery of smoking cessation support. The strong overall commitment to provision of smoking cessation support among GPs may also have a role in developing interventions in the future.

Experiences and cessation needs of Indigenous women who smoke during pregnancy: a systematic review of qualitative evidence

OBJECTIVES

The aim of this review was to identify and synthesize the best available evidence to address two questions: i) what is the experience of smoking during pregnancy for Indigenous women? and ii) what are the smoking cessation needs of Indigenous women who smoke during pregnancy?

INTRODUCTION

Smoking during pregnancy not only affects pregnant women's general health but also causes such serious problems as pre-term delivery, low birth weight, and sudden infant death. Rates of smoking during pregnancy are particularly high among Indigenous women. Learning about Indigenous women's experiences of smoking during pregnancy and associated smoking cessation needs is important to providing informed health care to them.

INCLUSION CRITERIA

The participants of interest were Indigenous women who smoked during a current or past pregnancy. The phenomena of interest were the experiences of smoking during pregnancy for Indigenous women and the smoking cessation needs of Indigenous women during pregnancy. The context was any community worldwide where pregnant Indigenous women live. Studies considered for this review were those in which qualitative data were gathered and analysed on the phenomena of interest, including mixed methods research.

METHODS

A comprehensive search was conducted for published studies in academic databases (i.e. PubMed, CINAHL, PsycINFO, Embase, Sociological Abstracts, SocINDEX, and Web of Science), unpublished studies in sources of gray literature (i.e. ProQuest Dissertations and Theses, OAIster, LILACS, MedNar, Google, Google Scholar, OpenGrey and relevant websites), and any additional studies in reference lists. Language and date limiters were not applied. The searches included all studies globally and were carried out on October 31, 2016. Studies that met the inclusion criteria were assessed for methodological quality by two reviewers independently, using the criteria of the Joanna Briggs Institute (JBI) Critical Appraisal Checklist for Qualitative Research. Descriptive details of each study accepted for this review were extracted in accordance with the elements of the JBI Data Extraction Form for Qualitative Research. The research findings that were relevant to the phenomena of interest and had participant voice were extracted from each included study and synthesized using the JBI meta-aggregative approach. The synthesized findings were assigned confidence scores in accordance with the JBI ConQual approach.

RESULTS

Thirteen studies were included in this review following careful consideration of the methodological quality of each study. The studies yielded a total of 116 research findings, which were grouped into 19 categories and then aggregated to form five synthesized findings. Confidence in the findings was determined to be low to very low (see ConQual Summary of Findings).

CONCLUSION

There is a small body of research evidence on Indigenous women's experiences of smoking during pregnancy and their smoking cessation needs. Confidence in the synthesized findings is constrained due to methodological limitations in many of the primary studies included in this review, along with mixed credibility of the research findings from across primary studies.

Accessing National Health Service Stop Smoking Services in the UK: a COM-B analysis of barriers and facilitators perceived by smokers, ex-smokers and stop smoking advisors

OBJECTIVE

Smokers who access free National Health Service (NHS) Stop Smoking Services (SSS) in the UK are four times more likely to stop smoking, yet uptake of the services has been in decline in recent years. Evidence was collated to explore the beliefs of smokers, ex-smokers and Stop Smoking Advisors (SSAs) about SSS and the barriers and facilitators to access.

STUDY DESIGN

Mixed-methods design including i) a search of the literature; ii) a cross-sectional online questionnaire completed by 38 smokers and ex-smokers; and iii) semistructured interviews with 5 SSAs.

METHODS

PubMed, Web of Science, Scopus, Prospero and the NIHR Portfolio were searched in October 2017 to identify relevant studies. Smokers and ex-smokers were recruited to the online questionnaire via Public Health websites and social media in Warwickshire. SSAs identified via Public Health Warwickshire were invited to take part in an interview conducted over the telephone. Findings were collated and analysed using the COM-B ('Capability', 'Opportunity', 'Motivation' and 'Behaviour') model framework.

RESULTS

A range of practical and psychological or belief-based barriers and facilitators to accessing SSS were identified within all the components of the COM-B model, aside from physical capability, for example; 'Psychological capability', such as lack of understanding about what the service offers; 'Reflective motivation', such as lack of confidence in service efficacy; and 'Social opportunity', such as recommendations from healthcare professionals to attend. Suggestions and consideration on how future tobacco control intervention and public health messages can address these components are reported.

CONCLUSIONS

Public health interventions and campaigns may benefit from focussing on addressing the well-known perceived barriers and facilitators smokers experience, in particular focussing on the components of the COM-B that have been identified as being important to increase the uptake of SSS.

Barriers and facilitators to smoking cessation in pregnancy and in the post-partum period: The health care professionals' perspective

Objectives

Health care professionals and the health care environment play a central role in protecting pregnant and post‐partum women and their infants from smoking‐related harms. This study aimed to better understand the health professional's perspective on how interactions between women, health care professionals, and the environment influence how smoking is managed.

Design

Semi‐structured interviews and focus groups.

Methods

Data were from 48 health care staff involved in antenatal or post‐partum care at two UK sites, including midwives, obstetricians, health visitors, GPs, pharmacists, service commissioners, and Stop Smoking Service (SSS) advisors and managers. Thematic analysis was guided by a social–ecological framework (SEF).

Results

Themes were divided across three SEF levels and represented factors connected to the management of smoking in the health care context and the beliefs and behaviour of pregnant or post‐partum smokers. Organizational level: Service reconfigurations, ‘last resort’ nicotine replacement therapy prescribing policies, and non‐mandatory training were largely negative factors. There were mixed views on opt‐out referral pathways and positive views on carbon monoxide monitoring. Interpersonal level: Protection of client–professional relationships often inhibited frank discussions about smoking, and weak interservice relationships affected SSS referral motivation and quality. Individual level: Professionals felt community midwives had primary responsibility for managing smoking, although midwives felt underskilled doing this. Midwives’ perceived priority for addressing smoking was influenced by the demands from unrelated organizational initiatives.

Conclusions

Opportunities to improve clinical support for pregnant smokers exist at organizational, interservice, and health care professional levels. Interactions between levels reflect the importance of simultaneously addressing different level‐specific barriers to smoking cessation in pregnancy.

Barriers to and facilitators of smoking cessation in pregnancy and following childbirth: literature review and qualitative study

BACKGROUND

Although many women stop smoking in pregnancy, others continue, causing harm to maternal and child health. Smoking behaviour is influenced by many factors, including the role of women's significant others (SOs) and support from health-care professionals (HPs).

OBJECTIVES

To enhance understanding of the barriers to, and facilitators of, smoking cessation and the feasibility and acceptability of interventions to reach and support pregnant women to stop smoking.

DESIGN

Four parts: (1) a description of interventions in the UK for smoking cessation in pregnancy; (2) three systematic reviews (syntheses) of qualitative research of women's, SOs' and HPs' views of smoking in pregnancy using meta-ethnography (interpretative approach for combining findings); (3) semistructured interviews with pregnant women, SOs and HPs, guided by the social-ecological framework (conceptualises behaviour as an outcome of individuals' interactions with environment); and (4) identification of new/improved interventions for future testing.

SETTING

Studies in reviews conducted in high-income countries. Qualitative research was conducted from October 2013 to December 2014 in two mixed urban/rural study sites: area A (Scotland) and area B (England).

PARTICIPANTS

Thirty-eight studies (1100 pregnant women) in 42 papers, nine studies (150 partners) in 14 papers and eight studies described in nine papers (190 HPs) included in reviews. Forty-one interviews with pregnant women, 32 interviews with pregnant women's SOs and 28 individual/group interviews with 48 HPs were conducted.

MAIN OUTCOME MEASURES

The perceived barriers to, and facilitators of, smoking cessation in pregnancy and the identification of potential new/modified interventions.

RESULTS

Syntheses identified smoking-related perceptions and experiences for pregnant women and SOs that were fluid and context dependent with the capacity to help or hinder smoking cessation. Themes were analysed in accordance with the social-ecological framework levels. From the analysis of the interviews, the themes that were central to cessation in pregnancy at an individual level, and that reflected the findings from the reviews, were perception of risk to baby, self-efficacy, influence of close relationships and smoking as a way of coping with stress. Overall, pregnant smokers were faced with more barriers than facilitators. At an interpersonal level, partners' emotional and practical support, willingness to change smoking behaviour and role of smoking within relationships were important. Across the review and interviews of HPs, education to enhance knowledge and confidence in delivering information about smoking in pregnancy and the centrality of the client relationship, protection of which could be a factor in downplaying risks, were important. HPs acknowledged that they could best assist by providing support and understanding, and access to effective interventions, including an opt-out referral pathway to Stop Smoking Services, routine carbon monoxide screening, behavioural support and access to pharmacotherapy. Additional themes at community, organisational and societal levels were also identified.

LIMITATIONS

Limitations include a design grounded in qualitative studies, difficulties recruiting SOs, and local service configurations and recruitment processes that potentially skewed the sample.

CONCLUSIONS

Perceptions and experiences of barriers to and facilitators of smoking cessation in pregnancy are fluid and context dependent. Effective interventions for smoking cessation in pregnancy should take account of the interplay between the individual, interpersonal and environmental aspects of women's lives.

FUTURE WORK

Research focus: removing barriers to support, improving HPs' capacity to offer accurate advice, and exploration of weight concerns and relapse prevention. Interventions focus: financial incentives, self-help and social network interventions.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42013004170.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Improving implementation of the smoking cessation guidelines with pregnant women: How to support clinicians?

OBJECTIVE

this study aimed to explore the enablers and barriers to implementation of the Australian smoking cessation in pregnancy guidelines. These guidelines direct clinicians to follow the 5As of cessation: Ask, Advise, Assess, Assist and Arrange follow-up.

DESIGN

semi-structured interviews based on the Theoretical Domains Framework (TDF) elicited clinicians' views and experiences of implementing the guidelines.

SETTING

antenatal care in the NSW public health system.

PARTICIPANTS

27 maternity service managers, obstetricians and midwives.

FINDINGS

participants confirmed that implementation of the smoking cessation guidelines was sub-optimal. This was particularly the case with Assist and Arrange follow up at the initial visit, and with following any of the 5As at subsequent visits. Key barriers included systems which did not support implementation or monitoring, lack of knowledge, skills and training, perceived time restrictions, 'difficult conversations' and perceiving smoking as a social activity. Enablers included clinicians' knowledge of the harms of smoking in pregnancy, clinicians' skills in communicating with pregnant women, positive emotions, professional role and identity, the potential of training and of champions to influence practice, and systems that regulated behaviour.

KEY CONCLUSIONS

these findings will contribute to the development of a multifaceted intervention to support clinicians in implementing the guidelines.

IMPLICATIONS FOR PRACTICE

Building on existing strengths, antenatal care providers may be supported in implementing the guidelines by working with systems which remind and support implementation, the clear reframing of smoking as an addiction, knowledge and skills development and by realizing the potential of leadership to maximise the impact of reinforcement and social influence.

CE: Original Research: The Experiences of Pregnant Smokers and Their Providers

: Background: The U.S. Department of Health and Human Services' initiative Healthy People 2020 targets tobacco use, including smoking during pregnancy, as a continuing major health concern in this country. Yet bringing the U.S. Public Health Service's 2008 clinical practice guideline, Treating Tobacco Use and Dependence, into routine prenatal care remains challenging. Our previous nurse-managed intervention study of rural pregnant women found no significant cessation effect and significant discordance between self-reported smoker status and urinary cotinine levels.

PURPOSE

The overall purpose of this follow-up study was to increase our understanding of the experiences of pregnant smokers and their providers. No qualitative studies could be found that simultaneously explored the experiences of both groups.

DESIGN AND METHODS

This qualitative descriptive study used focus group methodology. Nine focus groups were held in two counties in upper New York State; six groups consisted of providers and three consisted of pregnant women. Four semistructured questions guided the group discussions, which were audiotaped and transcribed verbatim. Transcripts were read and coded independently by six investigators. Themes were identified using constant comparative analysis and were validated using the consensus process.

RESULTS

The total sample consisted of 66 participants: 45 providers and 21 pregnant women. Most of the providers were white (93%) and female (93%). A majority worked as RNs (71%); the sample included perinatal and neonatal nursery nurses, midwives, and physicians. The pregnant women were exclusively white (reflecting the rural demographic); the average age was 24 years. All the pregnant women had smoked at the beginning of their pregnancies. Four common themes emerged in both the provider and the pregnant women groups: barriers to quitting, mixed messages, approaches and attitudes, and program modalities. These themes corroborate previous findings that cigarette smoking is used for stress relief, especially when pregnancy itself is a stressor, and that pregnant women may feel guilty but don't want to be nagged or preached to.

CONCLUSIONS

These results have implications for how smoking cessation programs for pregnant women should be designed. Health care providers need to be cognizant of their approaches and attitudes when addressing the subject of smoking cessation. Specific educational suggestions include "putting a face" to the issue of tobacco use during pregnancy. More research is needed on how best to implement the 2008 clinical practice guideline in specific populations.

Usability testing of a smoking cessation smartphone application ('SmokeFree Baby'): A think-aloud study with pregnant smokers

BACKGROUND

Only a few digital interventions have been developed for pregnant smokers, and little is known about the acceptability and usability of smartphone apps to aid cessation in pregnancy. This study aimed to explore pregnant smokers' views on the design, content and usability of a pregnancy-specific smoking cessation app in order to inform intervention development and optimisation.

METHODS

Ten interviews were conducted and the 'think-aloud' protocol was used in order to explore participants' views about a smoking cessation smartphone app ('SmokeFree Baby'). The data were subsequently thematically analysed. Participants were 18 and over, pregnant, and daily or weekly cigarette smokers.

RESULTS

Three main themes were identified: views about the design elements, mode of delivery and content of the intervention. App design was considered as an important element that might influence potential users' engagement with the intervention. Participants felt that the intervention content was educational, motivational and non-judgemental. However, it was emphasised that the app should provide further options for personalisation and include more practical features.

CONCLUSIONS

Delivering smoking cessation support via a smartphone app can be feasible and acceptable for pregnant smokers. They appear to value content that is motivational, educational and personalised, and meeting these requirements may be important for user experience and promoting engagement with the intervention.

Are digital interventions for smoking cessation in pregnancy effective? A systematic review protocol

BACKGROUND

Behavioural support for smoking cessation in pregnancy can be effective; however, many pregnant women face barriers to seeking support to stop smoking. Some digital interventions have been found to be effective for smoking cessation in the general population and may be effective for supporting cessation in pregnancy due to their flexibility and the potential for personalisation. To date, there is limited evidence of the effectiveness of digital interventions for smoking cessation in pregnancy. This review aims to assess the following: (1) whether digital interventions are effective at promoting smoking cessation among pregnant women; (2) which behaviour change techniques (BCTs) or combinations of BCTs are associated with the effectiveness of digital interventions for smoking cessation in pregnancy; and (3) whether the number of BCTs used is associated with the effectiveness of digital interventions for smoking cessation in pregnancy.

METHODS

This review will include digital interventions delivered largely through computer (PC or laptop), video/DVD, mobile phone (including smartphones) or portable handheld device (e.g. tablet, iPad) and include websites, mobile or tablet applications and SMS text messages. Interventions must be randomised or quasi-randomised controlled trials aimed at women who smoke in pregnancy, with smoking cessation as a measured outcome (preferably the latest available point prevalence smoking status measure taken during pregnancy, biochemically verified if available). Electronic bibliographic databases will be searched to identify suitable studies indexed in the following: Academic Search Complete, ASSIA, CINAHL, The Cochrane Library, EMBASE, Medline, PsycINFO, Scopus, and Web of Science. The search strategy will include key words and database-specific subject headings relating to 'pregnancy' and 'smoking' and synonyms for the terms 'digital' and 'randomised controlled trial'. Where required and where possible, the first and second authors will independently code interventions and control groups for BCTs. If data allows, meta-analyses will be used to assess intervention effectiveness and the effectiveness of BCTs.

DISCUSSION

This systematic review will provide a detailed synthesis of the effectiveness of current research using digital interventions for smoking cessation in pregnancy, to build on the evidence base and guide the development of future research in this area.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42016036201.

Health professionals' perceptions of the barriers and facilitators to providing smoking cessation advice to women in pregnancy and during the post-partum period: a systematic review of qualitative research

BACKGROUND

Reducing smoking in pregnancy is a policy priority in many countries and as a result there has been a rise in the development of services to help pregnant women to quit. A wide range of professionals are involved in providing these services, with midwives playing a particularly pivotal role. Understanding professionals' experiences of providing smoking cessation support in pregnancy can help to inform the design of interventions as well as to improve routine care.

METHODS

A synthesis of qualitative research of health professionals' perceptions of the barriers and facilitators to providing smoking cessation advice to women in pregnancy and the post-partum period was conducted using meta-ethnography. Searches were undertaken from 1990 to January 2015 using terms for maternity health professionals and smoking cessation advisors, pregnancy, post-partum, smoking, and qualitative in seven electronic databases. The review was reported in accordance with the 'Enhancing transparency in reporting the synthesis of qualitative research' (ENTREQ) statement.

RESULTS

Eight studies reported in nine papers were included, reporting on the views of 190 health professionals/key informants, including 85 midwives and health visitors. The synthesis identified that both the professional role of participants and the organisational context in which they worked could act as either barriers or facilitators to an individual's ability to provide smoking cessation support to pregnant or post-partum women. Underpinning these factors was an acknowledgment that the association between maternal smoking and social disadvantage was a considerable barrier to addressing and supporting smoking cessation

CONCLUSIONS

The review identifies a role for professional education, both pre-qualification and in continuing professional development that will enable individuals to provide smoking cessation support to pregnant women. Key to the success of this education is recognising the centrality of the professional-client/patient relationship in any interaction. The review also highlights a widespread professional perception of the barriers associated with helping women give up smoking in pregnancy, particularly for those in disadvantaged circumstances. Improving the quality and accessibility of evidence on effective healthcare interventions, including evidence on 'what works' to support smoking cessation in disadvantaged groups, should therefore be a priority. PROSPERO 2013: CRD42013004170.

Exploring the experiences of pregnant women using an NHS stop smoking service: a qualitative study

AIM

The purpose of this article was to explore women's experiences of attempting to stop smoking while pregnant using National Health Service (NHS) support.

METHOD

A qualitative methodological approach was adopted to enable the researcher to develop an understanding of the women's experiences. Six individual semi-structured interviews were conducted with women who accessed an NHS stop smoking service while pregnant. The data were analysed using comparative analysis.

RESULTS

Five themes were identified: health risks, motivations to stop smoking, influences on smoking behaviour, feelings about smoking and experiences of using NHS stop smoking support. Motivation to stop smoking was predominantly due to concerns about their unborn baby's health, and knowledge of health risks was generally good. Limited information relating to the associated health risks of continued smoking in pregnancy from healthcare professionals appeared to be a common experience. External pressures both positively and negatively influenced the smoking status of the women. Stress was cited by all the women as a significant challenge to smoking cessation and something which they all struggled with. The women's experiences of using NHS support while pregnant was varied; some felt it adequately met their needs, while others felt that their expectations were not met.

CONCLUSION

Continued smoking in pregnancy is complex, and it appears that successful smoking cessation is related to a number of internal and external factors which present significant challenges for expectant mothers who smoke. Stress was found to be a major contributor in continued smoking; therefore, NHS stop smoking services should incorporate stress management techniques into stop smoking interventions. In addition, services should be flexible, adapting service provision to meet women's needs.

Barriers and promoters of an evidenced-based smoking cessation counseling during prenatal care in Argentina and Uruguay

In Argentina and Uruguay, 10.3 and 18.3 %, respectively, of pregnant women smoked in 2005. Brief cessation counseling, based on the 5A's model, has been effective in different settings. This qualitative study aims to improve the understanding of factors influencing the provision of smoking cessation counseling during pregnancy in Argentina and Uruguay. In 2010, we obtained prenatal care providers', clinic directors', and pregnant smokers' opinions regarding barriers and promoters to brief smoking cessation counseling in publicly-funded prenatal care clinics in Buenos Aires, Argentina and Montevideo, Uruguay. We interviewed six prenatal clinic directors, conducted focus groups with 46 health professionals and 24 pregnant smokers. Themes emerged from three issue areas: health professionals, health system, and patients. Health professional barriers to cessation counseling included inadequate knowledge and motivation, perceived low self-efficacy, and concerns about inadequate time and large workload. They expressed interest in obtaining a counseling script. Health system barriers included low prioritization of smoking cessation and a lack of clinic protocols to implement interventions. Pregnant smokers lacked information on the risks of prenatal smoking and underestimated the difficulty of smoking cessation. Having access to written materials and receiving cessation services during clinic waiting times were mentioned as promoters for the intervention. Women also were receptive to non-physician office staff delivering intervention components. Implementing smoking cessation counseling in publicly-funded prenatal care clinics in Argentina and Uruguay may require integrating counseling into routine prenatal care and educating and training providers on best-practices approaches.

Which role do midwives and gynecologists have in smoking cessation in pregnant women? - A study in Flanders, Belgium

OBJECTIVES

The objectives of our study were (1) to explore knowledge, beliefs and practice among midwives and gynecologists concerning a smoking cessation policy for pregnant women and their partners and (2) to examine if midwives and gynecologists do have a role in smoking cessation in pregnant women.

METHOD

We performed a qualitative study using semi-structured interviews with nine midwives and eight gynecologists. Data were analyzed using deductive content analysis, based on the 5 A's framework (Ask-Advise-Assess-Assist-Arrange).

RESULTS

The national smoking cessation policy seemed to be insufficiently known. "Ask" and "Advise" were part of a standard prenatal consultation, the next three steps were rarely implemented. Participants had a negative image of "the smoking pregnant woman": a low educated woman with a smoking partner and "bad examples" in their history. Reported barriers were fear of provoking resistance and lack of time and communication skills regarding smoking cessation.

CONCLUSIONS

These findings suggest that training in communication skills and dealing with resistance should be offered, i.e. by using motivational interviewing. It could be considered that a trained midwife or tobaccologist is part of an obstetrical team or that the AAR-method (Ask-Advise-Refer) is used instead of the 5 A's framework.

Qualitative systematic review: barriers and facilitators to smoking cessation experienced by women in pregnancy and following childbirth

AIM

To explore barriers and facilitators to smoking cessation experienced by women during pregnancy and postpartum by undertaking a synthesis of qualitative studies.

BACKGROUND

The majority of pregnant women are aware that smoking in pregnancy compromises maternal and infant health. Despite this knowledge, quit rates among pregnant women remain low, particularly among women in disadvantaged circumstances; disadvantage also increases the chances of living with a partner who smokes and returning to smoking after birth. A deeper understanding of what hinders and what helps pregnant smokers to quit and remain ex-smokers postpartum is needed.

DESIGN

A synthesis of qualitative research using meta-ethnography.

DATA SOURCES

Five electronic databases (January 1990-May 2013) were searched comprehensively, updating and extending the search for an earlier review to identify qualitative research related to the review's aims.

REVIEW METHODS

Following appraisal, 38 studies reported in 42 papers were included and synthesized following the principles of meta-ethnography. Over 1100 pregnant women were represented, the majority drawn from disadvantaged groups.

RESULTS

Four factors were identified that acted both as barriers and facilitators to women's ability to quit smoking in pregnancy and postpartum: psychological well-being, relationships with significant others, changing connections with her baby through and after pregnancy; appraisal of the risk of smoking.

CONCLUSION

The synthesis indicates that barriers and facilitators are not fixed and mutually exclusive categories; instead, they are factors with a latent capacity to help or hinder smoking cessation. For disadvantaged smokers, these factors are more often experienced as barriers than facilitators to quitting.

"An on-going individual adjustment": a qualitative study of midwives' experiences counselling pregnant women on physical activity in Sweden

Background

In Sweden, midwives play prominent supportive role in antenatal care by counselling and promoting healthy lifestyles. This study aimed to explore how Swedish midwives experience the counselling of pregnant women on physical activity, specifically focusing on facilitators and barriers during pregnancy. Also, addressing whether the midwives perceive that their own lifestyle and body shape may influence the content of the counselling they provide.

Methods

Eight focus group discussions (FGD) were conducted with 41 midwives working in antenatal care clinics in different parts of Sweden between September 2013 and January 2014. Purposive sampling was applied to ensure a variation in age, work experience, and geographical location. The FGD were digitally recorded, transcribed verbatim, and analyzed using manifest and latent content analysis.

Results

The main theme– “An on-going individual adjustment” was built on three categories: “Counselling as a challenge”; “Counselling as walking the thin ice” and “Counselling as an opportunity” reflecting the midwives on-going need to adjust their counselling depending on each woman’s specific situation. Furthermore, counselling pregnant women on physical activity was experienced as complex and ambiguous, presenting challenges as well as opportunities. When midwives challenged barriers to physical activity, they risked being rejected by the pregnant women. Despite risking rejection, the midwives tried to promote increased physical activity based on their assessment of individual needs of the pregnant woman. Some participants felt that their own lifestyle and body shape might negatively influence the counselling; however, the majority of participants did not agree with this perspective.

Conclusions

Counselling on physical activity during pregnancy may be a challenging task for midwives, characterized by on-going adjustments based on a pregnant woman’s individual needs. Midwives strive to find individual solutions to encourage physical activity. However, to improve their counselling, midwives may benefit from further training, also organizational and financial barriers need to be addressed. Such efforts might result in improved opportunities to further support pregnant women’s motivation for performance of physical activity.

Cutting down: insights from qualitative studies of smoking in pregnancy

The adverse effects of smoking in pregnancy are minimised if the mother quits completely in early pregnancy. Smokers are therefore advised to quit abruptly; cutting down is not recommended either as a method of, or alternative to, quitting. However, most pregnant smokers do not quit and cutting down is widely reported. Evidence comes primarily from quantitative studies; qualitative research has contributed little to understandings of cigarette consumption in pregnancy. In consequence, little is known about the place and meaning of cutting down for pregnant smokers. The paper investigates this important dimension of maternal smoking. It explores perceptions and experiences of cutting down among pregnant smokers by examining data from a systematic review of qualitative studies of smoking in pregnancy. The studies were located in high-income countries and published between 1970 and 2012. Twenty-six studies, reported in 29 papers, were included, representing over 640 women. Meta-ethnography guided the analysis and synthesis. Data (participants' accounts and authors' interpretations) were extracted and coded; codes were progressively combined to identify overarching themes ('lines of argument'). Running through the lines of argument was evidence on cutting down; the paper presents and analyses this evidence. The analysis indicates that cutting down figured centrally as both a method of quitting and, for persistent smokers, a method of harm reduction. While pregnant women were aware that official advice was to quit abruptly, cutting down was seen as a positive behaviour change in often-difficult domestic circumstances, and one that health professionals condoned. Our findings suggest that cutting down in pregnancy, as an aid and an alternative to quitting, requires greater recognition if healthcare and tobacco control policies are to be sensitive to the perspectives and circumstances of pregnant smokers.

Healthcare Providers’ Views on Digital Smoking Cessation Interventions for Pregnant Women

Introduction: Digital smoking cessation aids may benefit pregnant smokers who do not wish to receive face-to-face behavioural support. Healthcare providers (HCPs) who interact with pregnant smokers may have valuable insights into their development and use.

Aims: To explore HCPs’ views of using digital smoking cessation interventions with pregnant women in order to inform the design and delivery of digital smoking cessation interventions.

Methods: Two structured focus groups were conducted with HCPs (n = 16) who provided smoking cessation support for pregnant women in England. Discussions covered participants’ general views about digital smoking cessation interventions, the potential of such interventions for smoking cessation support for pregnant smokers, and recommendations for future intervention development. Transcripts were analysed thematically.

Results: HCPs identified a variety of ways in which digital interventions could benefit pregnant smokers, such as by providing anonymity, offering consistent quality of advice, and being available on demand. The identified limitations of digital smoking cessation interventions included lack of access among those most economically disadvantaged, the need for high levels of self-motivation, and lack of human contact. Addressing pregnant smokers’ negative perceptions of smoking cessation support, providing rewarding experiences, and tailoring the intervention to smokers’ level of confidence were among HCPs’ recommendations.

Conclusions: HCPs indicated that digital interventions offer a range of potential benefits that could make them useful for pregnant smokers. Nonetheless, important limitations and recommendations regarding their design and delivery were identified and these need to be addressed in intervention development.

Smoking and pregnancy--a review on the first major environmental risk factor of the unborn

Smoking cigarettes throughout pregnancy is one of the single most important avoidable causes of adverse pregnancy outcomes and it represents the first major environmental risk of the unborn. If compared with other risk factors in the perinatal period, exposure to tobacco smoke is considered to be amongst the most harmful and it is associated with high rates of long and short term morbidity and mortality for mother and child. A variety of adverse pregnancy outcomes are linked with cigarette consumption before and during pregnancy. Maternal prenatal cigarette smoke disturbs the equilibrium among the oxidant and antioxidant system, has negative impact on the genetic and cellular level of both mother and fetus and causes a large quantity of diseases in the unborn child. These smoking-induced damages for the unborn offspring manifest themselves at various times in life and for most only a very limited range of causal treatment exists. Education, support and assistance are of high importance to decrease maternal and fetal morbidity and mortality, as there are few other avoidable factors which influence a child's health that profoundly throughout its life. It is imperative that smoking control should be seen as a public health priority.