Health providers' performance of the 5As for smoking cessation care during pregnancy: A systematic review and meta-analysis

Significance Pregnancy is an opportunity for health providers (HPs) to support women to stop smoking. Aim To identify the pooled prevalence for HP in providing various components of smoking cessation care (SCC) to women who smoke during pregnancy.
Methods A systematic review synthesising original articles that reported on 1) prevalence of HPs performing the 5As (‘Ask’, ‘Advise’, ‘Assess’, ‘Assist’, ‘Arrange’), prescribing nicotine replacement therapy (NRT), and other SCC, and 2) factors associated with SCC practices. MEDLINE, EMBASE, CINAHL and PsycINFO databases searched using “smoking”, “pregnancy” and “HP practices”. Studies included any design except interventions (self-report, audit, observed consultations, women’s reports), in English, with no date restriction, up to June 2017. Health providers included could be of any profession. Data were extracted, then appraised with the Hawker tool. Meta-analyses pooled percentages for performing each of the 5As and prescribing NRT, using e.g., ‘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. HPs 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:88.2,95); ‘Advise’ (n=7) 90% (CI:72.5,99.3), ‘Assess’ (n=3) 79.2% (CI:76.5,81.8), ‘Assist (cessation support)’ (n=5) 59.1% (CI:56, 62.2), ‘Arrange (referral)’ (n=6) 33.3% (CI:20.4,46.2), and ‘prescribing NRT’ (n=6) 25.4% (CI:12.8,38). Heterogeneity (I2) was 95.9%-99.1%. Meta-regressions for ‘Arrange’ were significant for year (p=0.013) and country (p=0.037).
Conclusions HPs ‘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. Strength of this review is the inclusion of papers from 10 countries, and the detailed analysis of study measures from HP and women’s viewpoints, limited by few studies in each category, and high heterogeneity.