Despite the known dangers of pregnancy smoking, rates remain high, especially in the rural, Southern United States. Interventions are effective, but few have been developed and tested in regions with high rates of pregnancy smoking, a culture that normalizes smoking, and a hard-to-reach prenatal population. The goals were to describe a smoking cessation intervention, the Tennessee Intervention for Pregnant Smokers program, and examine the impact on quit rates compared to usual care. Additionally we sought to examine reduction in smoking levels and number of quit attempts related to the intervention and finally to examine the impact of the intervention on birth outcomes. Intervention and historical control group participants, all smokers at entry to prenatal care, were recruited from five medical practices providing prenatal care in rural, South-Central Appalachia. The intervention, an expanded 5A’s (Ask, Advise, Assess, Assist, Arrange) model, was delivered by trained health educators. Over 28% of intervention group women quit smoking, compared to 9.8% in the control group. Two thirds of intervention group women significantly reduced smoking by delivery, with 40%+ attempting to quit at least once. Compared to controls, intervention group women saw significantly better birth outcomes, including newborns weighing 270g more and 50% less likely to have a neonatal intensive care unit admission. Among intervention group participants, those who quit smoking had significantly better birth outcomes than those who did not quit smoking. Findings point to the potential for appropriately tailored pregnancy smoking interventions to produce substantial improvements in birth outcomes within populations with health disparities.

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Background: In 2000, the American College of Obstetricians/Gynecologists (ACOG) established the 5 A's method of brief smoking cessation counseling (ask, advise, assess, assist, arrange) as a standard component of prenatal care. The purpose of this study was to describe use of the 5 A's in prenatal care in Northeast Tennessee, where pregnancy smoking rates are three times the national average, and to evaluate provider attitudes toward addressing pregnancy smoking. Method: Surveys were distributed to all obstetric practices in a 6-county area. Results: One-quarter of respondents indicated they always asked pregnant patients about smoking, with two-thirds always giving their pregnant smokers advice to quit. Over half reported always assessing willingness to quit, while one-quarter or fewer always provided quit assistance, or arranged follow up. Over half believed addressing smoking was of significant value. Secondhand smoke was infrequently addressed. Demographics, efficacy, and outcome beliefs predicted use of the 5 A's. Conclusions: Most obstetric providers in Northeast Tennessee are not following ACOG recommendations for pregnancy smoking. Efforts to address pregnancy smoking and associated adverse pregnancy outcomes in the region should include facilitation of smoking cessation interventions in prenatal care.

Objectives: The goal of this investigation was to examine the prevalence of different types of intimate partner violence (IPV) during pregnancy, as well as the association between both physical and psychological IPV and negative health behaviors, including smoking, other substance use, inadequate prenatal care utilization, and nutrition, in a rural sample. Methods: 104 southern Appalachian women, primarily Caucasian and lower SES, completed a pregnancy interview focused on IPV (CTS2) and health behaviors. Medical records were also reviewed. Results: 81% of participants reported some type of IPV during the current pregnancy, with 28% reporting physical IPV, and 20% reporting sexual violence. More than half were current smokers. Physical IPV during pregnancy was associated with significantly increased rates of pregnancy smoking (including decreased rates of quitting and reducing), increased rates of alcohol, marijuana, and harder illicit drug use around the time of conception, and later entry into prenatal care. The experience of psychological IPV during pregnancy was associated with a significantly decreased likelihood of quitting or reducing smoking during pregnancy, an increased rate of alcohol use around the time of conception, and an increased rate of pre-pregnancy obesity. Conclusions: In this sample, pregnancy IPV and smoking occurred at rates well above national averages. Additionally, while physical IPV during pregnancy was associated with several negative pregnancy health behaviors, the experience of psychological IPV, even in the absence of physical IPV, also placed women at increased risk for negative health behaviors, all of which have been linked to poor pregnancy and newborn outcomes.

Objectives: To determine rates of pregnancy smoking concealment compared to behavioral observation and to identify factors predicting untruthful denial. Methods: Review of 843 delivery charts. Results: Based on observation during delivery hospitalization, 8% of smokers denied at hospital admission, 16% denied throughout prenatal care. Compared with those admitting smoking, false deniers had higher levels of education, incomes and adequate prenatal care utilization; and were less likely to have drug use, STDs, or hepatitis C. Observation was a valid tool for assessing smoking status. Conclusions: Typical concealers were those considered lower risk, increasing the chance they would go undetected as smokers.

Objectives: The purpose of the present study was to examine background and modifiable pregnancy health behavior factors predicting infant birthweight in an economically and educationally disadvantaged sample with low medical risk. Methods: Participants were recruited from a family practice center in rural Appalachia. Participants: Over 220, predominantly Caucasian and lower SES women with low risk pregnancies were included in the sample. Data were collected through systematic chart review. Half of the women smoked during pregnancy and over 10% gave birth to low birth weight (LBW; < 2500 g) babies. Results: Compared with those who gave birth to normal weight newborns, women with LBW babies had more miscarriages, but did not differ significantly on other background factors. Women who delivered LBW babies gained less weight during pregnancy and were more likely to smoke than remaining women. After control for background factors, modifiable pregnancy health behavior factors (weight gain, prenatal care, smoking, alcohol and substance use) accounted for over 11% of birth weight variance, with nearly 7% attributable solely to smoking. Conclusions: Pregnancy smoking was the strongest behavioral predictor of LBW in this economically and educationally disadvantaged rural sample, suggesting that efforts to reduce LBW in similar populations should include targeting pregnancy smoking.

Objective: Rates of pregnancy smoking in the rural South are twice national averages and contribute to poor birth and long term outcomes for affected women and children. Efforts to intervene during prenatal care with pregnant women have been hampered by lack of knowledge, skill, comfort, and commitment from prenatal providers and their nursing staff. Regional community providers and staff have been reluctant to participate in available trainings, and even those who do seldom exhibit attitude and practice change long term. Therefore, efforts to educate health care professionals on the dangers of pregnancy smoking, and to provide necessary skills for intervention efforts, may need to occur before they ever enter practice. Thus, the goal of the current project was to implement and evaluate a pregnancy smoking-related training session for baccalaureate nursing students in rural Southern Appalachia. Design: Nursing students attended training on pregnancy smoking dangers/intervention techniques. Sample: Third year students beginning clinical rotations in obstetrics. Methods: 1.5-hour training including pre- and post-tests. Implementation Strategies: Four months later, follow-up survey assessed gains in knowledge, skill, comfort, and willingness to address smoking. Results: Over seven semesters, 659 nursing students were trained. Substantial gains in knowledge of pregnancy smoking issues were seen from pre- to post-testing, with knowledge retained at four- month follow-up. The percentage of students who felt they lacked skills to intervene with pregnant smokers dropped from 39% at pre-test to 6% at same day post-test. In addition, the percentage who reported they would be uncomfortable talking with pregnant women about smoking dropped from 10% to 1%, while the percentage who indicated they would always make time to address smoking with pregnant women increased from 54% to 87%. While most students did address smoking with multiple pregnant patients encountered during clinicals, and over half felt the patients benefited from their actions, only 58% were confident in their intervention skills at four month follow-up. Finally, 83% felt the training had been beneficial, and over 90% committed to addressing smoking with pregnant patients once they graduated. Conclusion/Implications for nursing practice: Training can increase nursing student knowledge, skill, comfort, and willingness to address smoking with pregnant women. However, it appears ongoing education may be needed to promote skills and confidence long term. In the rural South, where smoking rates are high and provider efforts to address pregnancy smoking are inconsistent, educating future nurses could have substantial impact on pregnancy smoking rates and birth outcomes into the future.

The incidence of Low Birth Weight (LBW) babies born in the Uitenhage Provincial Hospital would seem to be a cause of concern from a public health of view. The incidence of 21% recorded during 1999 is markedly higher than the 7% recorded in the United States of America in 1998 and the average of 17% noted for developing countries. Some health concerns related to LBW babies are Sudden Infant Death Syndrome, scholastic performances later in life, and several chronic diseases in adults associated with them having been born as LBW babies.

The incidence of Low Birth Weight (LBW) babies born in the Uitenhage Provincial Hospital would seem to be a cause of concern from a public health of view. The incidence of 21% recorded during 1999 is markedly higher than the 7% recorded in the United States of America in 1998 and the average of 17% noted for developing countries. Some health concerns related to LBW babies are Sudden Infant Death Syndrome, scholastic performances later in life, and several chronic diseases in adults associated with them having been born as LBW babies.

Master of Public Health - MPH / The incidence of Low Birth Weight (LBW) babies born in the Uitenhage Provincial Hospital would seem to be a cause of concern from a public health of view. The incidence of 21% recorded during 1999 is markedly higher than the 7% recorded in the United States of America in 1998 and the average of 17% noted for developing countries. Some health concerns related to LBW babies are Sudden Infant Death Syndrome, scholastic performances later in life, and several chronic diseases in adults associated with them having been born as LBW babies. / South Africa