Smoking During Pregnancy and Its Association with Maternal Health Among Women of Reproductive Age in Alabama: An Analysis Using the Three Delays Model and PRAMS Phase 8 Data

Background/Objectives: Smoking during pregnancy endangers maternal and infant health outcomes, posing significant risks such as preterm birth and developmental complications. Applying the Three Delays Framework, this study examines how smoking behaviors impact maternal health in Alabama, focusing on barriers to prenatal care. Methods: This cross-sectional study utilized PRAMS Phase 8 data collected from 2016 to 2021, comprising 533 observations from the Alabama Department of Public Health. Prenatal care barriers were categorized into three domains: seeking, reaching, and receiving care. Analyses included descriptive statistics, hierarchical clustering of barrier items, derivation of an informational barrier latent score using item-response theory (θ_info), and multivariable logistic regression adjusted for age, race/ethnicity, income, and BMI. Results: Multivariable logistic regression analysis revealed that informational barriers (OR = 2.42, p < 0.001) and system-level barriers (OR = 1.77, p = 0.047) were significant predictors of adverse maternal health outcomes. In the baseline model, which included sociodemographic covariates, prenatal smoking was not significantly associated with poor maternal health (OR = 0.83, 95% CI [0.58, 1.17]). After adjusting for informational, structural, and system barriers, the association further attenuated and remained non-significant (adjusted OR = 0.72, 95% CI [0.50, 1.03]). Conclusions: While smoking during pregnancy remains a modifiable health behavior, informational and system barriers emerged as the more immediate determinants of poor maternal outcomes in this cohort. Addressing these barriers through targeted prenatal education initiatives and system-level improvements can enhance care utilization and improve maternal and infant health outcomes, even among pregnant smokers.