What components of smoking cessation care during pregnancy are implemented by health providers? A systematic review and meta-analysis

Background: Pregnancy is an opportunity for health providers to support women to stop smoking. Objectives: Identify the pooled prevalence for health providers in providing components of smoking cessation care to women who smoke during pregnancy. Design: A systematic review synthesising original articles that reported on (1) prevalence of health providers' performing the 5As ('Ask', ' Advise', ' Assess', ' Assist', ' Arrange'), prescribing nicotine replacement therapy (NRT) and (2) factors associated with smoking cessation care. Data sources: MEDLINE, EMBASE, CINAHL and PsycINFO databases searched using ' smoking', ' pregnancy' and ' health provider practices'. Eligibility criteria for selecting studies: Studies included any design except interventions (self-report, audit, observed consultations and women's reports), in English, with no date restriction, up to June 2017. Participants: Health providers of any profession. Data extraction, appraisal and analysis: Data were extracted, then appraised with the Hawker tool. Meta-analyses pooled percentages for performing each of the 5As and prescribing NRT, using, for example, ' often/always' and ' always/all'. Meta-regressions were performed of 5As for ' often/always'. Results: Of 3933 papers, 54 were included (n=29 225 participants): 33 for meta-analysis. Health providers included general practitioners, obstetricians, midwives and others from 10 countries. Pooled percentages of studies reporting practices ' often/always' were: ' Ask' (n=9) 91.6% (95% CI 88.2% to 95%); 'Advise' (n=7) 90% (95% CI 72.5% to 99.3%), ' Assess' (n=3) 79.2% (95% CI 76.5% to 81.8%), ' Assist (cessation support)' (n=5) 59.1% (95% CI 56% to 62.2%), ' Arrange (referral)' (n=6) 33.3% (95% CI 20.4% to 46.2%) and ' prescribing NRT' (n=6) 25.4% (95% CI 12.8% to 38%). Heterogeneity (I 2) was 95.9%-99.1%. Meta-regressions for ' Arrange' were significant for year (p=0.013) and country (p=0.037). Conclusions: Health providers ' Ask', ' Advise' and ' Assess' most pregnant women about smoking. 'Assist', ' Arrange' and ' prescribing NRT' are reported at lower rates: Strategies to improve these should be considered.