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Summary of the proposal
Posttraumatic stress disorder (PTSD) is common following trauma, and low-income and minority women are at particularly high risk for both exposure to trauma and development of PTSD. PTSD rates are up to 24% during pregnancy for high-risk women who are racial minorities, teens, less educated or poor. PTSD in pregnancy, even after controlling for demographic factors, increases the odds for poor pregnancy and birthing outcomes, such as ectopic pregnancy, miscarriage, preterm labor, and low birth weight. PTSD is also associated with cigarette smoking while pregnant, a behavioral alteration with adverse perinatal outcomes. A recent study demonstrated the additive effect of smoking and PTSD on the cortisol levels among pregnant women [2, 3]. Though 50% of women quit smoking during first trimester, women with lifetime PTSD who are pregnant continue to smoke because they experience the soothing effects of elevated cortisol on the stress response system that comes with continued smoking.. This proposed program is the first of its kind to address and combat the issue of pregnant women with PTSD and their associated smoking cessation difficulties. Our program proposes to identify PTSD pregnant women smokers with the help of questionnaire and bio-analyte assessment and administer smoking cessation interventions that are trauma-informed. The project will be run initially as a pilot in a public hospital located in Georgia which serves a large proportion of low-income patients. For such a project, more resources will be needed than we can hope to raise. We are sending you this proposal in the hope that you will be able to support our work.
Scope of the problem
Perinatal outcomes are indicative of the health of a society’s population. Maternal psychosocial stress has been implicated as one of five pathways to the adverse perinatal outcome of premature birth, lower birth weight and is also a risk factor in the fetus for early lifespan morbidity and mortality. PTSD is a severe form of psychological stress. In the United States the prevalence of PTSD is twice as high among pregnant women than women generally. The term PTSD appears in a variety of contexts in the literature, including its application with women during the perinatal period (referred to as perinatal posttraumatic stress disorder or PPTSD). In the United States 9% of the women giving birth are diagnosed with PPTSD and an additional 18% are documented as at risk. Recent studies in large prenatal clinic samples showed significant associations of PTSD with preterm birth or shorter gestation, especially in current as opposed to lifetime remitted PTSD, PTSD with depression, and PTSD that is subsequent to childhood maltreatment or military sexual trauma [1, 6]. Three percent to 14% of women entering prenatal care have current PTSD and these women are more likely to be African American, pregnant as a teen, living in poverty, with high school education or less, and living in higher crime areas. PTSD experiences result in alterations of the stress regulation system including the hypothalamic pituitary axis (HPA) and cortisol has been used as a measure of HPA axis functioning. Because in utero elevations in HPA axis hormones are associated with adverse perinatal outcomes slower infant mental development and adverse consequences to lifespan health, cortisol is an important biomarker for perinatal and developmental outcomes[7-9].
PTSD is associated with cigarette smoking while pregnant, a behavioral alteration with adverse perinatal outcomes. As of 2017, 14.0% of adults in the United States reported smoking cigarettes, with somewhat higher rates reported among those who are younger (10.4%–16.5%), identify as non-Hispanic Black or African Americans (14.9%), with an education level of high school or lower (23.1 % to 36.8%) and live in poverty (21.4%). According to a national survey conducted in the United States in 2017, 10.4% of pregnant women smoke cigarettes with some variation by race, ethnicity and location . Smoking has been associated with numerous adverse pregnancy and birth outcomes, including placenta previa, placental abruption, intrauterine growth restriction, low birth weight, and perinatal mortality. Previous exposure to stressful life events may not be sufficient to increase the risk of cigarette smoking during pregnancy, however, women who have elevated trauma-related symptoms or probable PTSD and smoke before conception may fail to quit after conception. In a study exploring the relationship between PTSD symptoms and prenatal smoking behavior in a sample of low-income, minority women residing in an urban setting, the prevalence of reported cigarette use during pregnancy was 15.6% . Among women who smoke in pregnancy, those with PTSD have the highest cortisol levels thereby leading to adverse perinatal outcome. Women with PTSD continue smoking despite all the pressure to quit during pregnancy because they experience the soothing effects of elevated cortisol on the stress response system that comes with continued smoking. Given that such traumatic behaviors enhance risk for continued tobacco use during pregnancy, a trauma-informed approach to smoking cessation in preconception care may ultimately reduce the likelihood of smoking during pregnancy.
Currently available smoking cessation program in the state of Georgia is the Georgia Tobacco Quit Line which provides free and confidential, professional tobacco cessation counseling services to Georgia adults, pregnant women and teens (ages 13 and older). Screening at-risk pregnant women should include assessment of the individual’s emotional response to potentially traumatizing events as well as severity of posttraumatic symptoms. That smoking before pregnancy is such a strong predictor of smoking during pregnancy and exposure to traumatic life events is sufficient to increase pre-pregnancy smoking suggests that assessment of how smoking may be used to cope with the emotional sequelae of these events should occur in the primary or preconception care of women. Hence, trauma-informed smoking cessation programs seem strongly warranted, especially in the context of maternity care, where the adverse outcomes of smoking are so personally and economically costly to mothers and children.
The intention of the proposed program is to use the Grady Health System’s obstetrics services to pilot our approach. Grady Health System is the largest public hospital–based health system in the Southeast, providing more than 200 specialty and subspecialty health care clinics. The nucleus of Grady’s service area is Fulton and DeKalb counties in Atlanta, where Grady contracts to provide care for the medically underserved. The Grady Memorial Hospital’s obstetrics services include complete care for pregnant women which is provided in their prenatal clinics.
Three percent to 14% of women entering prenatal care have current PTSD and these women are more likely to be African American, pregnant as a teen, living in poverty, with high school education or less, and living in higher crime areas. Women attending the obstetrics clinic at Grady Memorial Hospital, aged 13 or older, able to speak English without an interpreter, have a confirmed pregnancy less than 28 weeks’ gestation, are Medicaid eligible and willing to participate in the saliva specimen procedure will be invited to participate in this program. Participants will be assessed by trained personnel for PTSD with the Life Stressor Checklist- Revised (LSC-R) questionnaire . The LSC-R is a 30 item index of lifetime trauma exposure developed especially to include life events that are not usually considered but are important stressors in women’s lives. Examples of such items include being unwillingly separated from children and experiencing an abortion or miscarriage. In the LSC-R the number of lifetime trauma exposures is calculated by summing the positively endorsed stressor items. The type of lifetime trauma is determined by the positive report of exposure to the trauma. The LSC-R has demonstrated good criterion-related validity with diverse populations of women and easily understood.
Along with PTSD screening the participating women will also be screened for their tobacco smoking habit with the question: which of the following statements best describes your cigarette smoking? A. I have never smoked, or I have smoked fewer than 100 cigarettes in my lifetime. B. I stopped smoking before I found out I was pregnant, and I am not smoking now. C. I stopped smoking after I found out I was pregnant, and I am not smoking now. D. I smoke some now, but I cut down on the number of cigarettes I smoke since I found out I was pregnant. E. I smoke regularly now, about the same as before I found out I was pregnant .
Participants who are identified as self-reported current smokers and has a trauma history according to the LSC-R will be invited to provide a sample of their saliva for cortisol and cotinine testing. Saliva will be collected using the passive drool method. The specimen collection kit will include Salivette tubes (Sarstedt, Newton, North Carolina) and an instruction sheet at seventh grade reading level. After collection we will record the time and date of specimen collection, and attention will paid to keep the samples cold in order to avoid bacterial growth in the specimen. Samples will be refrigerated within 30 minutes, and feezed at or below -20ºC within 4 hours of collection. Collected saliva will be tested quantitatively for salivary cortisol and cotinine using enzyme linked immunoassay kit.
Based on previous literature women who are both diagnosed with PTSD and continue to smoke in pregnancy had the most elevated levels of cortisol (mean = 0.257). Hence, for our program salivary cortisol cutoff values is set at 0.20 g/dL for pregnant women smokers who have PTSD. Salivary cortisol levels are unaffected by salivary flow rate and are relatively resistant to degradation from enzymes or freeze-thaw cycles. Studies consistently report high correlations between serum and salivary cortisol, indicating that salivary cortisol levels reliably estimate serum cortisol levels. Cortisol production has a circadian rhythm, with levels peaking in the early morning and dropping to lowest values at night. However, levels rise independently of circadian rhythm in response to stress.
The presence of cotinine in biological fluids indicates exposure to nicotine. Because of the long half-life of cotinine it has been used as a biomarker for daily intake, both in cigarette smokers and in those exposed to secondhand tobacco smoke. There is a high correlation among cotinine concentrations measured in plasma, saliva, and urine, and measurements in any one of these fluids can be used as a marker of nicotine intake. Testing the salivary cotinine would help in addressing the issue of social desirability bias that could possibly occur for self-reported smoking status among pregnant women. The optimal serum cotinine in the US population based on National Health and Nutrition Examination Surveys (NHANES) from 1999 to 2004, are set at 3.08 ng/ml for adults (sensitivity 96.3%, specificity 97.4%) and 2.99 ng/ ml for adolescents (sensitivity 86.5%, specificity 93.1%), and for our program we used these levels as our cut-off values for salivary cotinine .
For women who are biochemically confirmed to have elevated levels of cotinine and cortisol above the cut-off values, our program proposes the implementation of smoking cessation interventions which should be trauma-informed. PTSD-affected participants will be provided in- person trauma-informed smoking cessation counselling. Use of trauma-informed approaches creates safety, choice, and connection for women who access tobacco reduction and cessation services. In a nonjudgmental way, trained personnel who use trauma-informed approaches build support and awareness about how smoking is often a coping mechanism and offer alternative strategies for growth, healing, and wellness, thereby helping them to experience safety and choice and develop positive coping skills. This approach helps to recognize the links between trauma and violence and tobacco use, identifies the needs for physical and emotional safety and for choice and control in decision making and emphasize women’s strengths and offer personal choice and control over the intervention approach and goals.
Counselled participants on their subsequent monthly prenatal visits will be invited to repeat saliva specimen collection to test for repeat saliva cotinine levels. Participants with successful smoking cessation confirmed by salivary cotinine levels of 0 ng/mL at each subsequent prenatal visit will be given a 50$ CVS gift card as a financial incentive for smoking cessation. In September 2014, CVS Health became the first national retail pharmacy chain to stop selling tobacco products, and hence we chose CVS gift card for our incentive program. Though the approval for paying pregnant smokers to quit may seem to be low among the general public, studies show that smokers are more positive in their views about paying pregnant smokers to quit and its likely effectiveness. In a review of 72 smoking cessation controlled trials it was demonstrated that the most effective smoking cessation intervention appeared to be providing financial incentives, which helped around 24% of women to quit smoking during pregnancy. Studies also show that women offered in person counselling sessions found the personal contact the most important element in the intervention. Therefore we predict that our multi-intervention model will improve the success of smoking cessation among pregnant smokers with PTSD.
Currently available smoking cessation program in the state of Georgia is the Georgia Tobacco Quit Line which provides free and confidential, professional tobacco cessation counseling services to Georgia adults, pregnant women and teens (ages 13 and older), but it does not cater towards the specific needs of PTSD pregnant women. In the US, we have developed guidelines recommending all pregnant women receive interventions to promote smoking cessation in pregnancy. These guidelines generally incorporate a number of interventions, and are currently based on the “5 A’s”. The American College of Obstetrics and Gynecologists recommends that obstetric health care providers screen all patients to determine whether they smoke, and offer treatment for smoking cessation. Despite evidence of effectiveness of interventions in pregnancy and development of guidelines, widespread implementation of smoking cessation interventions in pregnancy in clinical settings remain the exception rather than the norm. PTSD rates are up to 24% during pregnancy for high-risk women who are racial minorities, teens, less educated or poor, and the prevalence of smoking among these women is approximately 16% [1, 12]. Although many women spontaneously quit smoking during pregnancy, evidence suggests that this is less likely among those with lower socioeconomic status, fewer resources, and less social support which contributes to their PTSD diagnosis. This reinforces the need for more complex, tailored, and intensive interventions for smoking reduction and cessation for PTSD pregnant women. In a synthesis of qualitative research on perceived barriers to the provision of smoking cessation advice, health care providers felt limited in their ability to address social factors, such as poverty, partner and family smoking, and lack of social support, associated with smoking during pregnancy and often believed that in this context, smoking cessation was unlikely to be successful or sustainable[23, 24]. It is clear not only that PTSD women who smoke during pregnancy require more sensitive treatment on a range of intersecting issues but that health care providers require more comprehensive guidance as well. Multi-intervention model program such as the proposed program which incorporates both questionnaire and bio-analyte, improve the sensitivity of the program, and help further address the co-occurring disorders, addictions, psychosocial stressors, poverty, and domestic violence that may make smoking cessation during pregnancy more difficult and coping behavior seem more necessary.
In summary we are requesting financial support from your organization for the training and implementation of our program. This project is specifically aimed at ensuring that every pregnant women suffering from PTSD and struggling with smoking cessation during pregnancy in this country has the social, psychological and material support required to ensure promotion of maternal and fetal wellbeing. We believe that the context in which we are operating makes such a project an imperative. Our intention is to pilot the project in Georgia’s largest public hospital providing care for the medically underserved, as a model for replicability by other agencies. The emphasis on community-based projects makes it likely that the project will be sustainable at community level. Our intervention programs is the first of its kind to incorporates both questionnaire and bio-analyte, further helping us address the co-occurring disorders, addictions, psychosocial stressors, poverty, and domestic violence that may make smoking cessation during pregnancy more difficult and coping behavior seem more necessary.
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