Health outcomes of smoking during pregnancy and the postpartum period: an umbrella review

BACKGROUND: Smoking during pregnancy (SDP) and the postpartum period has serious health outcomes for the mother and infant. Although some systematic reviews have shown the impact of maternal SDP on particular conditions, a systematic review examining the overall health outcomes has not been published. Hence, this paper aimed to conduct an umbrella review on this issue. METHODS: A systematic review of systematic reviews (umbrella review) was conducted according to a protocol submitted to PROSPERO ( CRD42018086350 ). CINAHL, EMBASE, MEDLINE, PsycINFO, Web of Science, CRD Database and HMIC databases were searched to include all studies published in English by 31 December 2017, except those focusing exclusively on low-income countries. Two researchers conducted the study selection and quality assessment independently. RESULTS: The review included 64 studies analysing the relationship between maternal SDP and 46 health conditions. The highest increase in risks was found for sudden infant death syndrome, asthma, stillbirth, low birth weight and obesity amongst infants. The impact of SDP was associated with the number of cigarettes consumed. According to the causal link analysis, five mother-related and ten infant-related conditions had a causal link with SDP. In addition, some studies reported protective impacts of SDP on pre-eclampsia, hyperemesis gravidarum and skin defects on infants. The review identified important gaps in the literature regarding the dose-response association, exposure window, postnatal smoking. CONCLUSIONS: The review shows that maternal SDP is not only associated with short-term health conditions (e.g. preterm birth, oral clefts) but also some which can have life-long detrimental impacts (e.g. obesity, intellectual impairment). IMPLICATIONS: This umbrella review provides a comprehensive analysis of the overall health impacts of SDP. The study findings indicate that while estimating health and cost outcomes of SDP, long-term health impacts should be considered as well as short-term effects since studies not including the long-term outcomes would underestimate the magnitude of the issue. Also, interventions for pregnant women who smoke should consider the impact of reducing smoking due to health benefits on mothers and infants, and not solely cessation

Potential for health economics to influence policies on tobacco use during pregnancy in low-income and middle-income countries:a qualitative case study

INTRODUCTION: Tobacco control during pregnancy is a policy priority in high-income countries (HICs) because of the significant health and inequality consequences. However, little evidence exists on interventions to reduce tobacco use in low-income and middle-income countries (LMICs), especially for pregnant women. This study aimed to assess how health economics evidence, which is mainly produced in HICs, could be adopted for tobacco cessation policies for pregnant women in LMICs. METHODS: A qualitative case study was conducted in an international public health organisation. The organisation was chosen due to its capacity to influence health policies around the world. Tobacco control experts working in the organisation were identified through purposeful sampling and snowballing. Semistructured interviews were conducted with 18 informants with relevant experience of countries from all of the regions covered by the organisation. Data were analysed using the framework method. RESULTS: In practice, tobacco cessation during pregnancy was not viewed as a priority in LMICs despite international recognition of the issue. In LMICs, factors including the recorded country-specific prevalence of tobacco use during pregnancy, availability of healthcare resources and the characteristics of potential interventions all affected the use of health economics evidence for policy making. CONCLUSION: The scale of tobacco use among pregnant women might be greater than reported in LMICs. Health economics evidence produced in HICs has the potential to inform health policies in LMICs around tobacco cessation interventions if the country-specific circumstances are addressed. Economic evaluations of cessation interventions integrated into antenatal care with a household perspective would be especially relevant in LMICs

Towards optimum smoking cessation interventions during pregnancy: a household model to explore cost‐effectiveness

BACKGROUND AND AIMS: Previous economic evaluations of smoking cessation interventions for pregnant women are limited to single components, which do not in isolation offer sufficient potential impact to address smoking cessation targets. To inform the development of more appropriate complex interventions, we (1) describe the development of the Economics of Smoking in Pregnancy: Household (ESIP.H) model for estimating the life‐time cost‐effectiveness of smoking cessation interventions aimed at pregnant women and (2) use a hypothetical case study to demonstrate how ESIP.H can be used to identify the characteristics of optimum smoking cessation interventions. METHODS: The hypothetical intervention was based on current evidence relating to component elements, including financial incentives, partner smoking, intensive behaviour change support, cigarettes consumption and duration of support to 12 months post‐partum. ESIP.H was developed to assess the life‐time health and cost impacts of multi‐component interventions compared with standard National Health Service (NHS) care in England. ESIP.H considers cigarette consumption, partner smoking and some health conditions (e.g. obesity) that were not included in previous models. The Markov model's parameters were estimated based on published literature, expert judgement and evidence‐based assumptions. The hypothetical intervention was evaluated from an NHS perspective. RESULTS: The hypothetical intervention was associated with an incremental gain in quitters (mother and partner) at 12 months postpartum of 249 [95% confidence interval (CI) = 195–304] per 1000 pregnant smokers. Over the long‐term, it had an incremental negative cost of £193 (CI = –£779 to 344) and it improved health, with a 0.50 (CI = 0.36–0.69) increase in quality‐adjusted life years (QALYs) for mothers, partners and offspring, with a 100% probability of being cost‐effective. CONCLUSIONS: The Economics of Smoking in Pregnancy: Household model for estimating cost‐effectiveness of smoking cessation interventions aimed at pregnant women found that a hypothetical smoking cessation intervention would greatly extend reach, reduce smoking and be cost‐effective

Towards achieving interorganisational collaboration between health-care providers:a realist evidence synthesis

Background Interorganisational collaboration is currently being promoted to improve the performance of NHS providers. However, up to now, there has, to the best of our knowledge, been no systematic attempt to assess the effect of different approaches to collaboration or to understand the mechanisms through which interorganisational collaborations can work in particular contexts. Objectives Our objectives were to (1) explore the main strands of the literature about interorganisational collaboration and to identify the main theoretical and conceptual frameworks, (2) assess the empirical evidence with regard to how different interorganisational collaborations may (or may not) lead to improved performance and outcomes, (3) understand and learn from NHS evidence users and other stakeholders about how and where interorganisational collaborations can best be used to support turnaround processes, (4) develop a typology of interorganisational collaboration that considers different types and scales of collaboration appropriate to NHS provider contexts and (5) generate evidence-informed practical guidance for NHS providers, policy-makers and others with responsibility for implementing and assessing interorganisational collaboration arrangements. Design A realist synthesis was carried out to develop, test and refine theories about how interorganisational collaborations work, for whom and in what circumstances. Data sources Data sources were gathered from peer-reviewed and grey literature, realist interviews with 34 stakeholders and a focus group with patient and public representatives. Review methods Initial theories and ideas were gathered from scoping reviews that were gleaned and refined through a realist review of the literature. A range of stakeholder interviews and a focus group sought to further refine understandings of what works, for whom and in what circumstances with regard to high-performing interorganisational collaborations. Results A realist review and synthesis identified key mechanisms, such as trust, faith, confidence and risk tolerance, within the functioning of effective interorganisational collaborations. A stakeholder analysis refined this understanding and, in addition, developed a new programme theory of collaborative performance, with mechanisms related to cultural efficacy, organisational efficiency and technological effectiveness. A series of translatable tools, including a diagnostic survey and a collaboration maturity index, were also developed. Limitations The breadth of interorganisational collaboration arrangements included made it difficult to make specific recommendations for individual interorganisational collaboration types. The stakeholder analysis focused exclusively on England, UK, where the COVID-19 pandemic posed challenges for fieldwork. Conclusions Implementing successful interorganisational collaborations is a difficult, complex task that requires significant time, resource and energy to achieve the collaborative functioning that generates performance improvements. A delicate balance of building trust, instilling faith and maintaining confidence is required for high-performing interorganisational collaborations to flourish. Future work Future research should further refine our theory by incorporating other workforce and user perspectives. Research into digital platforms for interorganisational collaborations and outcome measurement are advocated, along with place-based and cross-sectoral partnerships, as well as regulatory models for overseeing interorganisational collaborations. Study registration The study is registered as PROSPERO CRD42019149009. Funding This project was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme and will be published in full in Health and Social Care Delivery Research; Vol. 11, No. 6. See the NIHR Journals Library website for further project information