Predictors of planned caesarean section births in a sample of Romanian women.

OBJECTIVES: Romania has one of the highest incidences of births by caesarean section (CS) in the European Union (EU). The present study aims to identify the possible predictors of planned caesarean section (PCS) in a convenience sample of Romanian women. METHODS: This is a secondary analysis of the cross-sectional data collected as part of the EU-level Babies Born Better online survey from 1908 Romanian women who gave birth between 2013 and 2018. Univariable and multivariable logistic regression models were performed to identify the potential individual and health system-level predictors of PCS. RESULTS: PCS was reported by 36.7% (n = 657) of the women. In the multivariable regression model, older maternal age (aOR: 1.10, 95% CI: 1.07-1.14) and presence of medical or non-medical problems during pregnancy (adjusted odds ratio [aOR]: 1.67, 95% CI: 1.31-2.12) were significantly associated with PCS. Conversely, birth at a very high level of competence hospital was inversely associated with PCS (aOR: 0.48, 95% CI: 0.30-0.76). CONCLUSIONS: Our findings indicate that PCS may be associated with both individual and health system-level variables. Our results are significant because they could be used to inform decision-making processes aimed at lowering PCS incidence.

Perceived safety of smoking a few cigarettes during pregnancy and provider advice in a sample of pregnant smokers from Romania.

AIMS: To assess the prevalence of the perceived safety of smoking a few (generally fewer than five per day) cigarettes during pregnancy and identify associated factors in a sample of pregnant smokers in Romania, a middle-income country. DESIGN AND SETTING: Cross-sectional design with a convenience sample using a polled data set collected between 2016 and 2019 in the formative and baseline phases of the Quit Together randomized control trial (RCT) in Romania. Data were collected using a structured questionnaire administered by research assistants in clinics in the formative phase and self-administered through the study website at the RCT baseline. PARTICIPANTS: A total of 217 pregnant smokers (mean age = 28.5 ± 5.8) enrolled in the formative and RCT phases of the research project. MEASUREMENTS: The main outcome was the perceived safety of smoking a few cigarettes during pregnancy (generally fewer than five per day). Covariates included the health-care providers' advice towards smoking tobacco cigarettes during pregnancy, socio-demographics, the presence of depression and anxiety symptoms and level of nicotine dependence. FINDINGS: More than 35% of participants agreed that smoking a few cigarettes during pregnancy was safe for them and their baby. The perceived safety of smoking a few cigarettes during pregnancy was significantly associated with being told by health-care providers that it is acceptable to continue to smoke cigarettes in small amounts [odds ratio (OR) = 3.08; 95% CI = 1.35-6.99; P < 0.01], perceived harm reduction of smoking light cigarettes (OR = 2.67; 95% CI = 1.19-5.97; P = 0.02) and moderate to severe depression and anxiety score (OR = 0.34; 95% CI = 0.13-0.84; P = 0.02). CONCLUSIONS: More than one-third of pregnant Romanian women appear to believe that smoking 'a few' cigarettes during pregnancy is safe for them and their fetuses. Those who are told by their health-care providers that it is acceptable to smoke in small amounts during pregnancy have higher odds of perceiving smoking 'a few' cigarettes during pregnancy as safe compared with other pregnant Romanian women.

Using Behavioral Nudges to Engage Pregnant Women in a Smoking Cessation Trial: An Online Field Quasi-Experiment.

Evidence shows that behavioral nudges could be used to enhance enrollment rates in randomized controlled trials (RCTs) by addressing enrollment barriers, but research on this topic is limited. We conducted an online field quasi-experiment with separate pretest (October 2017-January 2018) and posttest (February-May 2018) samples designed to examine the use of behavioral nudges to engage pregnant smokers in a couple-focused smoking cessation RCT relying on online enrollment through paid Facebook ads and a dedicated website, by reporting aggregate Facebook ads and Google Analytics data. The Facebook ads pretest conversion rate of 1.6% doubled and reached 3.41% in the posttest period. The pretest eligibility assessment rate decreased from 10.3% to 6.46%, but registered a relative increase of approximately 50% in the posttest period, as opposed to the pretest. The number of women who signed the informed consent in the posttest period has increased with 63%, from a proportion of 8.54% in the pretest to 11.73% in the posttest period. These findings might lend support to integrating behavioral nudges in the recruitment and enrollment materials of RCTs to boost enrollment.

Smoking and quitting smoking during pregnancy: A qualitative exploration of the socio-cultural context for the development of a couple-based smoking cessation intervention in Romania.

INTRODUCTION: Smoking during pregnancy has negative effects on the mother and the unborn infant. Barriers to and facilitators of smoking cessation during pregnancy are context-dependent and multifaceted. This qualitative research explored pregnant women's experiences with smoking and cessation in Romania, and informed the development of a couple-focused smoking cessation intervention. METHODS: Semi-structured, in-depth interviews were conducted via telephone, with 15 pregnant women who smoked during pregnancy or had quit smoking upon learning about the pregnancy or shortly before. A hybrid inductive-deductive approach to thematic analysis was used, to identify patterns in the data and explore women's narratives, in relation to smoking and smoking cessation. RESULTS: Three main themes emerged from the data, which shaped the socio-cultural adaptation of the intervention to the local context: 1) Access to and mixed messages from the healthcare system that describe an inconsistent discourse from the healthcare system regarding smoking during pregnancy with some physicians not emphasizing the need for cessation, 2) Cessation as individual or team effort with variations in partner dynamics and difficulty in quitting that have important roles in perceptions about team efforts, and 3) Transition to motherhood and motivation to quit for the health of the pregnancy and infant, although in isolated cases women felt less connected with the pregnancy and such motivators. CONCLUSIONS: Pregnant women in Romania face systemic, interpersonal, and individual-level barriers that can be responsively integrated in smoking cessation interventions, by culturally adapting them to the local context.

A couples-focused intervention for smoking cessation during pregnancy: The study protocol of the Quit Together pilot randomized controlled trial.

Tobacco smoking remains the leading global cause of preventable disease and death. Preconception and pregnancy smoking are high in Central and Eastern Europe. Quit Together is a partnership between a US university and a Romanian university, obstetrics and gynecology clinics in Romania, and other community partners in Romania. The objective of the Quit Together pilot study is to adapt, enhance and test the implementation feasibility and initial efficacy of an evidence-based pregnancy and postnatal couple intervention for smoking cessation in Romania. Quit Together builds on the Motivation and Problem Solving (MAPS) approach, enhanced by targeting the couples' smoking behavior and focusing on dyadic efficacy for smoking cessation. The study is an ongoing randomized controlled trial of 120 Romanian pregnant smokers and their partners. Participants are randomized to: 1) an intervention arm consisting, typically, of up to 8 prenatal and postnatal telephone counseling calls for the women and 4 for their partners, combining motivational strategies and problem-solving/coping skills to encourage the woman to quit smoking and the partner to support her decision; and 2) a control arm (usual care). The primary outcome is maternal biochemically verified smoking abstinence at 3 months postpartum. Quit Together has the potential to identify effective strategies to increase maternal smoking cessation during pregnancy and smoking abstinence after birth. If effective, Quit Together is expected to have a sustainable positive impact on the health of the child, mother and partner, and potentially reduced health system costs.

Use and effectiveness of behavioural economics in interventions for lifestyle risk factors of non-communicable diseases: a systematic review with policy implications.

AIM: There is limited evidence on what behavioural economics strategies are effective and can be used to inform non-communicable diseases (NCDs) public health policies designed to reduce overeating, excessive drinking, smoking, and physical inactivity. The aim of the review is to examine the evidence on the use and effectiveness of behavioural economics insights on reducing NCDs lifestyle risk factors. METHODS: Medline, Embase, PsycINFO, and EconLit were searched for studies published between January 2002 and July 2016 and reporting empirical, non-pharmacological, interventional research focusing on reducing at least one NCDs lifestyle risk factor by employing a behavioural economics perspective. RESULTS: We included 117 studies in the review; 67 studies had a low risk of bias and were classified as strong or very strong, 37 were moderate, and 13 were weak. We grouped studies by NCDs risk factors and conducted a narrative synthesis. The most frequent behavioural economics precepts used were incentives, framing, and choice architecture. We found inconclusive evidence regarding the success of behavioural economics strategies to reduce alcohol consumption, but we identified several strategies with policy-level implications which could be used to reduce smoking, improve nutrition, and increase physical activity. CONCLUSION: Most studies targeting tobacco consumption, physical activity levels, and eating behaviours from a behavioural economics perspective had promising results with potential impact on NCDs health policies. We recommend future studies to be implemented in real-life settings and on large samples from diverse populations.

Smoking and Smoking Cessation During Pregnancy. An Analysis of a Hospital Based Cohort of Women in Romania.

Perinatal smoking is associated with a wide range of negative reproductive and pregnancy outcomes. The aim of the current study was to examine the prevalence and characteristics of women who report smoking prenatally and quit during pregnancy in a large sample of Romanian women. Understanding which women are more likely to quit will contribute to public health knowledge that will help more women stop smoking prior to or during pregnancy and prevent relapse postpartum. This cross-sectional analysis was conducted based on cross-sectional data collected between May 2012 and April 2015 as part of a cohort study of pregnancy implemented in six clinical settings in central Romania (N = 2370). Approximately 28 % of the sample reported smoking in the 6 months prior to learning they were pregnant. Half of the women who reported smoking 6 months before learning of their pregnancy, also reported that they stopped smoking by the time of the interview. Overall, tobacco consumption decreased from a sample mode of 10 cigarettes/day (range: 1-30) before pregnancy, to a sample mode of 5 cigarettes/day (range: 1-25) at the time of the interview. Women who quit had a higher socioeconomic position, were more likely to live in urban areas, partnered, primigravid, nulliparous, and reported lower anxiety and more social support. The combination of a socioeconomic gradient, less anxiety, and more social support suggests that efforts should be increased to target lower income, less educated, multigravid, and multiparous women and to develop programs that heighten social support and alleviate anxiety.