Tobacco exposure among antenatal women in India: Challenges in tobacco screening & cessation counselling

Challenges in the identification of pregnant tobacco users:

Low-risk perception and high social acceptability of tobacco: Mistry et al10 reported that very few participants in their study considered antenatal tobacco use as a cause for concern. The factors include poor education level and low awareness about harmful effects, easy availability at a low cost, leading to low-risk perception and increased demand614. Some women initiate tobacco use during their pregnancy due to craving, to relieve stress and anxiety related to pregnancy or to suppress vomiting during pregnancy6. Others believe that it relieves ‘labour pain’ and body pain and strengthens teeth during pregnancy5714. One study reported that women use tobacco because they believe that it relieves gastric problems and body pain, suppresses hunger, eases stress, relieves tooth ache and is customary to use in special family functions such as weddings and after eating non-vegetarian meals. Some women reported that they suffered distress due to discontinuation, so they continued tobacco use215. Women are exposed to tobacco at a very young age, mostly influenced by family members (mothers, grandmothers, fathers and husbands), peers who are tobacco users, thus making smokeless tobacco (SLT) use socially acceptable615. Since it is economical and easily available near their homes, it has become a part of their daily routine25. All these identified factors can act as barriers to self-reporting tobacco use and delay in getting cessation support.

Absence of targeted screening of pregnant tobacco users: Currently, the maternal health schemes in India focus on targeting nutritional deficiencies and promoting safe institutional deliveries16. Antenatal check-ups in India focus primarily on iron-deficiency anaemia (IDA) among pregnant women and have a systematic approach towards anaemic individuals. A study conducted in Primary Health Centres in Mumbai highlighted this issue, where antenatal clinics had a system in place for screening, treatment as well as follow up care for anaemic and iron-deficient pregnant women, but no services were provided for screening tobacco use10.

Under the NTCP, currently, no IEC or training material focusses on tobacco cessation among pregnant women17. Booklets and antenatal cards are given to pregnant women that contain registration information and lay emphasis on timely check-ups, tetanus injections, IFA supplements, nutritious diet, hygiene, danger signs during pregnancy and labour, postpartum care, newborn care, breastfeeding, complementary feeding, immunization schedule for babies, family planning advice and maternal health programme details, but there is no mention of quitting tobacco habits or advice to the users for informing doctor regarding the same11.

Verma et al6 conducted a cross-sectional survey among 3839 women admitted in the postpartum ward and found that only 3.8 per cent of tobacco users and 3.9 per cent of non-tobacco users were asked about tobacco consumption habit/history during their antenatal visits.

Inadequate sensitization of healthcare workers to identify pregnant tobacco users: The following training materials for healthcare professionals were reviewed–‘A handbook for Auxiliary Nurse Midwives (ANM), Lady Health Visitors and Staff Nurses 2010 and ‘ASHA training module’, ‘Care During Pregnancy and Childbirth Training Manual for Community Health Officer (CHO)’ and ‘Induction training module for ASHA’. No mention of tobacco harm in pregnancy, history taking for tobacco use or screening procedures were described in these modules. Since healthcare workers lack adequate training to identify tobacco users among pregnant women, thiscreates one of the biggest challenges in tobacco control. Most pregnant women do not receive any health advice regarding tobacco use and its harmful effects by ASHAs and ANMs6. Whereas, Mistry et al10 reported that clinicians and community health workers (CHW) were interested in integrating tobacco screening and cessation services but did not find themselves to be well-trained in tackling this issue. This study also reported that CHWs accepted that they did not enquire about its use from the patients because they did not perceive it to be harmful, due to lack of enough knowledge about its harmful effect on pregnancy10. Under NHM, ASHA provide pregnant women with routine antenatal care, information and support and are in constant contact with pregnant women throughout their pregnancy and even after their delivery. Therefore, they can be recognized as a vital link between tobacco users and the healthcare system and can be used after appropriate training to screen women for tobacco use111718192021.

Poor utilization of antenatal care services and loss of follow up: In India, where only 21 per cent of pregnant women utilize full antenatal care22, some women reach antenatal care clinics only in their last trimester of pregnancy, leaving very little time for tobacco counsellors to provide tobacco cessation advice and services to them. In a study based in an antenatal care setting, an interview with a tobacco cessation counsellor revealed that the women who attended counselling sessions provided either the wrong contact number or that of their spouses’, which made it difficult to establish effective contacts for further follow ups and telephonic counselling. Some even hid their tobacco habits from other family members and did not want to be contacted at home, thereby leading to high attrition rates from counselling sessions7.

Challenges in counselling pregnant tobacco user:

Lack of tobacco cessation counselling material for health workers: The Indian Public Health Standard guidelines for Primary Health Centres recommend that brief tobacco cessation advice should be provided to pregnant tobacco users during their antenatal visits13. This, however, is not practiced due to the scarcity of relevant literature that focuses on tobacco cessation strategies in India10. On thorough review of the training modules for ASHAs, ANMs and CHOs, no relevant content was found related to tobacco cessation advice such as its harmful effects on pregnancy, screening and counselling techniques or information on referral centres111819202123. This could also be one of the reasons that might have led them not to perceive tobacco use during pregnancy as a threat. However, health workers showed an inclination to be trained10.

Overburdened healthcare system: Healthcare providers raised concerns regarding antenatal care services being overburdened, with multiple healthcare programmes running parallelly, leading to competing demands. Although pregnant tobacco users were ‘highly interested in receiving cessation services’, these could not be provided because the clinics lacked a system to provide cessation services, thus leading to a ‘missed opportunity’10. Another study reported ‘insufficient human resources’ as one of the main challenges in screening and identification of pregnant tobacco users at antenatal clinics7.

Inaccessible cessation centres/clinics: From 13 TCC in 20028, the number of TCCs has increased to 429 across Indian states17. These centres are located in district hospitals and provide free pharmacotherapy and counselling services to those who want to quit tobacco17. Due to their attachment to district hospitals or tertiary care hospitals, these centres are lesser known to the communities at large and are accessible only to the patients visiting these hospitals15. However, according to the last updated list, five States, namely Chandigarh, Daman and Diu, Lakshadweep, Madhya Pradesh and Meghalaya, are yet to have tobacco cessation facilities under NTCP17.

A study conducted at antenatal clinics situated in the PHCs of Mumbai reported that the users desirous of help for quitting did not find tobacco screening and cessation services at these PHCs. The healthcare providers did advise known tobacco users to quit but did not know where to refer these women10.

Government quit lines and websites are not always accessible to women belonging to low socioeconomic backgrounds who are keen on quitting tobacco habits5.