Smoking during pregnancy: where next for stage-based interventions?

mHealth interventions for postpartum family planning in LMICs: A realist review

The unmet need for family planning is a pervasive public health concern in many low- and middle-income countries (LMICs). Mobile health (mHealth) interventions have been designed and implemented in LMIC settings to address this issue through health information dissemination via voice calls, apps, and short message services (SMS). Although the impact of mHealth programmes on postpartum family planning outcomes have been systematically reviewed, the contexts, conditions, and mechanisms underpinning programme engagement and their impact on outcomes remain unclear. This study aims to formulate hypotheses in the form of context-mechanism-outcome configurations (CMOCs) of whether, how, why, for whom, and in what contexts mHealth interventions implemented in LMICs influence postpartum family planning (PPFP) outcomes. We conducted a realist review of peer-reviewed and grey literature. Peer-reviewed literature was identified through MEDLINE, Embase, Global Health, Web of Science, and Google Scholar. Grey Literature was identified through The National Grey Literature Conference, FHI 360, Guttmacher Institute, Population Council, and MSI Reproductive Choices. Inclusion criteria were updated as the review progressed. Narrative data were analysed using dimensional analysis to build CMOCs. Two overarching concepts (underpinned by 12 CMOCs) emerged from the 37 included records: mobile phone access, use, and ownership as well as women's motivation. Women's confidence to independently own, access, and operate a mobile phone was a central mechanism leading to mHealth programme engagement and subsequent change in PPFP knowledge, awareness, and outcomes. Receiving family and social support positively interacted with this while low digital literacy and harmful gender norms pertaining to prescribed domestic duties and women's household influence were barriers to programme engagement. Intrinsic motivation for health improvement functioned at times both as a context and potential mechanism influencing mHealth programme engagement and PPFP outcomes. However, these contexts rarely occur in isolation and need to be evaluated as co-occurring phenomena. (Review registration: PROSPERO CRD42023386841).

Informing a healthy eating and physical activity program to decrease postnatal weight retention: What are women experiencing and what type of program do they want?

ISSUE ADDRESSED

Retention of weight gained during pregnancy contributes to overweight and obesity and consequent chronic disease risk. Early programs have been successful in improving diet quality, physical activity levels and reducing postnatal weight retention. However, barriers to program engagement remain. This study aimed to investigate women's healthy eating, physical activity and weight experiences and explore their views regarding digital health interventions to assist meeting their lifestyle goals.

METHODS

This qualitative descriptive study utilised semi-structured interviews with women who had recently become mothers who had gestational diabetes or a body mass index above 25 kg/m2 . Themes were then identified through thematic analysis of interview transcripts.

RESULTS

Nine women were interviewed (average age 33.4 ± 4.2 years). The two distinct areas of questioning resulted in two overarching topics: (i) Enablers and barriers to maintaining regular physical activity and a healthy dietary pattern; and (ii) characteristics of a postpartum program to enable meeting of diet, physical activity and weight loss goals. These topics each had their own descriptive themes and sub-themes.

CONCLUSIONS

Understanding women's needs and viewpoints for a postnatal diet, physical activity and weight program allows researchers to design a program to maximise engagement and outcomes. SO WHAT?: Any further postnatal program must leverage off existing infrastructure, integrate learnings from published formative work and harnesses the impact of digital delivery. This will improve program accessibility and provide ongoing contact for sustained behaviour change through text messaging and providing digital resources in a dynamic format women can engage with in their own time.

Understanding pregnant women's readiness to engage in risk-reducing measures to prevent infections during pregnancy

The aim of this study was to develop a conceptual understanding of women's readiness to engage in behaviours to reduce the risk of acquiring infections during pregnancy, using cytomegalovirus, the most common congenital infection as a case. Thirty-three pregnant women participated in semi-structured interviews. The findings illustrate that for behavioural change to become viable, it is necessary for individuals to consider barriers or facilitators at the individual, inter-personal and system levels. By widening the theoretical lens beyond individual cognitive determinants, the model places sufficient emphasis on factors, such as collective identity, support networks, interaction with the healthcare system and wider community, relevant to pregnant women.

What helped and hindered implementation of an intervention package to reduce smoking in pregnancy: process evaluation guided by normalization process theory

BACKGROUND

Smoking in pregnancy causes harm to mother and baby. Despite evidence from trials of what helps women quit, implementation in the real world has been hard to achieve. An evidence-based intervention, babyClear©, involving staff training, universal carbon monoxide monitoring, opt-out referral to smoking cessation services, enhanced follow-up protocols and a risk perception tool was introduced across North East England. This paper presents the results of the qualitative analyses, reporting acceptability of the system changes to staff, as well as aids and hindrances to implementation and normalization of this complex intervention.

METHODS

Process evaluation was used to complement an effectiveness study. Interviews with maternity and smoking cessation services staff and observations of training were undertaken. Normalization Process Theory (NPT) was used to frame the interview guides and analysis. NPT is an empirically-derived theory, developed by sociologists, that uses four concepts to understand the process of routinising new practices.

RESULTS

Staff interviews took place across eight National Health Service trusts at a time of widespread restructuring in smoking cessation services. Principally interviewees worked in maternity (n = 63) and smoking cessation services (n = 35). Five main themes, identified inductively, influenced the implementation: 1) initial preparedness of the organisations; 2) staff training; 3) managing partnership working; 4) resources; 5) review and planning for sustainability.

CONCLUSIONS

NPT was used to show that the babyClear© package was acceptable to staff in a range of organisations. Illustrated in Themes 1, 2 & 3, staff welcomed ways to approach pregnant women about their smoking, without damaging their professional relationship with them. Predicated on producing individual behaviour change in women, the intervention does this largely through reorganising and standardising healthcare systems that are required to implement best practice guidelines. Changing organisational systems requires belief and commitment from staff, so that they set up and maintain practical adjustments to their practice and are reflective about adapting themselves and the work context as new challenges are encountered. The ongoing challenge is to identify and maintain the elements of the intervention package which are essential for its effectiveness and how to tailor them to local circumstances and resources without compromising its core ingredients.

Exposure to active and passive smoking among Greek pregnant women

Background

Active smoking and exposure to passive smoke are responsible for numerous adverse pregnancy outcomes for women and their infants. The aim of this study was to explore the perceptions, attitudes, patterns of personal tobacco use and exposure to environmental smoke among a sample of pregnant women in Greece.

Method

A cross sectional survey was undertaken of 300 women identified from the perinatal care records of the Maternity Departments of two hospitals in Athens between February 2013 and May 2013. Data on active and passive maternal smoking status in the first, second, and third trimesters of pregnancy, fetal and neonatal tobacco related complications, exposure to environmental tobacco smoke during pregnancy, quit attempts, behaviors towards avoiding passive smoking and beliefs towards smoking cessation during pregnancy were collected using self-administered questionnaires on the 3rd postnatal day. Women also completed the Edinburgh Postnatal Depression Scale (EPDS).

Results

Of 300 women recruited to the study 48 % reported tobacco use during the first trimester of pregnancy. Amongst participants who were tobacco users, 83.3 % reported making an attempt to quit but less than half (45.1 %) were successful. Among women who continued to smoke during pregnancy the majority (55.8 %) reported that they felt unable to quit, and 9.3 % reported that they considered smoking cessation was not an important health issue for them. Participants who continued to smoke during pregnancy were more likely to report fetal (χ2 = 11.41; df = 5; p < 0.05) and newborn complications (χ2 = 6.41; df = 2; p < 0.05), including preterm birth and low birth weight. Participants who reported that their partners were smokers were more likely to smoke throughout their pregnancy (χ2 = 14.62; df = 1; p < 0.001). High rates of second-hand smoke exposure were reported among both smoking and non-smoking women. Pregnant smokers had significantly higher levels of postnatal depressive and anxiety symptomatology, as measured using the EPDS, than non-smokers.

Conclusion

Our data supports the importance of ensuring that pregnant women, their partners and close relatives are educated on the health risks of active and passive smoking and how these could have an adverse effect to their fetus and infants, as well as the pregnant women themselves.

Knowledge and attitudes of adults towards smoking in pregnancy: results from the HealthStyles© 2008 survey

Smoking during pregnancy is causally associated with many adverse health outcomes. Quitting smoking, even late in pregnancy, improves some outcomes. Among adults in general and reproductive-aged women, we sought to understand knowledge and attitudes towards prenatal smoking and its effects on pregnancy outcomes. Using data from the 2008 HealthStyles© survey, we assessed knowledge and attitudes about prenatal smoking and smoking cessation. We classified respondents as having high knowledge if they gave ≥ 5 correct responses to six knowledge questions regarding the health effects of prenatal smoking. We calculated frequencies of correct responses to assess knowledge about prenatal smoking and estimated relative risk to examine knowledge by demographic and lifestyle factors. Only 15 % of all respondents and 23 % of reproductive-aged women had high knowledge of the adverse effects of prenatal smoking on pregnancy outcomes. Preterm birth and low birth weight were most often recognized as adverse outcomes associated with prenatal smoking. Nearly 70 % of reproductive-aged women smokers reported they would quit smoking if they became pregnant without any specific reasons from their doctor. Few respondents recognized the benefits of quitting smoking after the first trimester of pregnancy. Our results suggest that many women lack knowledge regarding the increased risks for adverse outcomes associated with prenatal smoking. Healthcare providers should follow the recommendations provided by the American Congress of Obstetricians and Gynecologists, which include educating women about the health risks of prenatal smoking and the benefits of quitting. Healthcare providers should emphasize quitting smoking even after the first trimester of pregnancy.

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.

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

INTRODUCTION

To identify and juxtapose midwives' perceptions of providing stop-smoking advice and pregnant smokers' perceptions of stop-smoking services.

METHODS

A qualitative design was used in an attempt to expose and compare in-depth perceptions of midwives and pregnant smokers. Three focus groups lasting approximately 1 hour and involving 15 midwives were carried out, and 10 pregnant smokers participated in semistructured interviews. The qualitative data were analyzed by using the full version of grounded theory.

RESULTS

The perceptions of midwives regarding provision of advice were related to outcome of advice, the relationship with patients, personal experiences, attributes, perception of role, the impact of external factors, and aspects related to pregnant smokers and pregnancy. Pregnant smokers' perceived barriers and facilitators to approaching stop-smoking services were categorized into areas of smoking behavior, advice from health professionals, stop-smoking services, and negative perceptions of pregnant women who smoke.

DISCUSSION

In theory, many of the perceived barriers to providing advice could be overcome by implementing effective mandatory training for midwives. However, real issues, such as lack of time, have a major impact on the provision of advice. Pregnant smokers expect and appreciate receiving stop-smoking advice from midwives. Yet, they tend to have negative expectations of stop-smoking services, although the experiences of those who have attended these services are positive. Raising awareness of stop-smoking support for pregnant women is crucial in empowering women to make informed choices about their health and the health of their children.

Naturalistic changes in the readiness of postpartum women to quit smoking

BACKGROUND

This study involves a long-term examination of the natural behavioral changes in postpartum women undergoing smoking cessation. The analysis was based on the readiness to quit smoking as assessed using the Transtheoretical Model of intentional behavioral change. This is a secondary data analysis of a randomized controlled trial.

METHODS

Between May 2002 and March 2003, all women in the maternity wards of six hospitals in the German state of Mecklenburg-West Pomerania were screened for smoking before or during pregnancy. Of the women who answered in the affirmative, 871 (77%) participated in the study.We utilized a questionnaire to classify 345 women into stages of progress regarding their motivation to change their smoking behavior 4–6 weeks postpartum (T0). Participants were followed-up after 6 (T1), 12 (T2), and 18 months(T3). In addition to the descriptive analysis, latent transition analysis was applied as a statistical method to test models of patterns of change and to evaluate transitions in the stages of change over time.

RESULTS

During the time interval between consecutive follow-up surveys, 59.1% (T0/T1), 72.3% (T1/T2), and 67.9% (T2/T3) of women remained at the same stage of motivation to change. Most relapses into earlier stages occurred 6 months postpartum (T1) (31.5% of the stage transition). The patterns of change across the first three time points were best described by a model that includes stability, one-stage progressions,and one-to-four-stage regressions.

CONCLUSIONS

Readiness to quit smoking in study participants did not substantially change over the span of 18 months postpartum.