Screening and Brief Interventions for Alcohol and Other Drug Use Among Pregnant Women Attending Midwife Obstetric Units in Cape Town, South Africa: A Qualitative Study of the Views of Health Care Professionals.

INTRODUCTION: Despite the negative consequences of alcohol and other drug use during pregnancy, few interventions for pregnant women are implemented, and little is known about their feasibility and acceptability in primary health care settings in South Africa. As part of the formative phase of screening, brief intervention, and referral to treatment for substance use among women presenting for antenatal care, the present study explored health care workers' attitudes and perceptions about screening, brief intervention, and referral to treatment among this population. METHODS: Forty-three health care providers at 2 public sector midwife obstetric units in Cape Town, South Africa, were interviewed using an open-ended, semistructured interview schedule designed to identify factors that hinder or support the implementation of screening, brief intervention, and referral to treatment for substance use in these settings. Transcribed interviews were analyzed using the framework approach. RESULTS: Health care providers agreed that there is a substantial need for screening, brief intervention, and referral to treatment for substance use among pregnant women and believe such services potentially could be integrated into routine care. Several women-, staff-, and clinic-level barriers were identified that could hinder the successful implementation in antenatal services. These barriers included the nondisclosure of alcohol and other drug use, the intervention being considered as an add-on service or additional work, negative staff attitudes toward implementation of an intervention, poor staff communication styles such as berating women for their behavior, lack of interest from staff, time constraints, staff shortages, overburdened workloads, and language barriers. DISCUSSION: The utility of screening, brief intervention, and referral to treatment for addressing substance use among pregnant women in public health midwife obstetric units was supported, but consideration will need to be given to addressing a variety of barriers that have been identified.

Identifying with a process of change: a qualitative assessment of the components included in a smoking cessation intervention at antenatal clinics in South Africa.

INTRODUCTION: previous research has suggested that pregnant women prefer a person-centred approach for smoking cessation interventions. However few studies have illustrated the mechanism through which such an approach has an influence on quitting or reduction rates among pregnant women in resource poor settings. PURPOSE: to explore the role of different components included in a smoking cessation intervention delivered to disadvantaged pregnant women with high smoking rates attending public health antenatal clinics in South Africa. METHODS: a qualitative design consisting of focus-group discussion with women exposed to the intervention was used. Women were purposively selected from four antenatal clinics and one tertiary hospital to represent different experiences of the intervention. Focus group discussions with four groups of smokers and four groups of quitters were conducted and a total of 41 women were interviewed. Data were analysed using content analysis. MAIN FINDINGS: the main theme describing the intervention effect that emerged from the interviews was, 'Making identification with change possible'. The categories 'An impulse for change', 'An achievable recipe', 'A physical reminder' and 'A compassionate companion' further described how each intervention component was perceived by women and how it contributed to behaviour change. CONCLUSIONS: behaviour change interventions that are directly informed by the target population with regards to its design, content and delivery offer great opportunities for positive behaviour change. Women positively evaluated all the components employed in this intervention but rated the social support they received from peer-counsellors as the overriding aspect of the intervention.

The effectiveness of adapted, best practice guidelines for smoking cessation counseling with disadvantaged, pregnant smokers attending public sector antenatal clinics in Cape Town, South Africa.

AIM AND OBJECTIVES: To evaluate the effect of a smoking cessation intervention, based on best practice guidelines on the quit rates of disadvantaged, pregnant women in Cape Town, South Africa. DESIGN: Quasi-experimental using a natural history cohort as a control group, consisting of women attending antenatal care in 2006 and an intervention cohort, attending the same clinics a year later. SETTING: Four, public sector antenatal clinics in Cape Town staffed and managed by midwives. POPULATION: Pregnant women of low socio-economic status. METHODS: The natural history cohort received usual care, whilst the intervention cohort was offered self-help quit materials in the context of brief counseling by midwives and peer counselors. Smoking behavior was measured in early, mid and late pregnancy. The equivalence of the groups in terms of smoking profile, self-reported smoking and demographic variables was assessed at baseline. MAIN OUTCOME MEASURES: Quit rates measured by urinary cotinine towards the end of pregnancy (36-39 weeks gestation). RESULTS: The two cohorts were comparable at baseline. The difference in quit rates between the two cohorts in late pregnancy was 5.3% (95% CI: 3.2-7.4%, p < 0.0001) in an intention to treat analysis. There was also a significant difference in reduction of smoking of 11.8% (95% CI: 5.0-18.4%, p = 0.0006). CONCLUSION: A smoking cessation intervention based on best practice guidelines was effective among high risk, pregnant smokers in South Africa.

Possibilities for transparency and trust in the communication between midwives and pregnant women: the case of smoking.

OBJECTIVE: to explore barriers to and possibilities for interactive communication between midwives and pregnant women regarding smoking behaviour during pregnancy. DESIGN: the study was based on a qualitative research design aiming at a Grounded Theory analysis of interviews with pregnant women. SETTING: public sector antenatal clinics in Cape Town, South Africa predominantly providing care to women of mixed ancestry. INFORMANTS: in-depth interviews with 12 pregnant women purposively selected on the basis of smoking behaviour, age and marital status to reach maximum variation. FINDINGS: the findings indicated low levels of transparency and trust in antenatal visits. Lack of trust was related to categories such as conflicting personal capabilities and socio-cultural and medical expectations, combined with a didactic approach from caregivers. The unworthy woman was identified as the core category of the interviews describing how women feel in their relationship with midwives. A theoretical model illustrates possibilities for change in relation to an ideal situation where a supportive caregiver, congruent expectations and capabilities result in women feeling visible. KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: culturally appropriate smoking cessation interventions should be of high priority. Training in patient-centred counselling for midwives is necessary for creating an open dialogue with pregnant mothers about their smoking habits. The time constraint experienced by midwives also suggests that other methods apart from midwife counselling should be investigated for inclusion in the clinical setting.