Health Promotion: Giving up Smoking in Pregnancy Introduction The object of this assignment is to critically appraise a health promotion initiative related to midwifery practice. The initiative chosen is a NHS Health Scotland leaflet entitled ‘Smoking: giving up during pregnancy: a guide for pregnant women who want to stop smoking’ (NHS Health Scotland 2003). It will be referred to as the ‘initiative’ or the ‘leaflet’ throughout this assignment. The World Health Organisation (WHO) identified that health promotion was a way of equipping people to have more power enabling them to make choices in regard to improving their well-being (WHO 1986).
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Ewles and Simnett (2003) determine from this, that the fundamental elements of health promotion are improving health and empowerment. The Scottish Office paper ‘Towards a Healthier Scotland’ (1999) recommended making more health promotion available for pregnant smokers. This appraisal will systematically review the literature relating it to the health promotion initiative chosen using Ewles and Simnett (2003) Five Approaches to Health Promotion model. It will furthermore evaluate the midwife’s role in promoting the issue highlighted and conclude with a summary and any proposals to improve future practice.
Critical Appraisal The Scottish Office paper ‘Towards a Healthier Scotland’ (Scottish Office 1999) recommends reducing the numbers of women smoking during pregnancy from 29% to 20% in the next 5 years. According to the Health Education Authority (1999) the rate for smoking in pregnancy in the UK was 30% however nearly 90% classified smoking as dangerous to their unborn child. Johnston et al (2003) point out that smoking is the main preventable cause of disease and disability in the fetus and newborn.
Around 13 000 individuals die from smoking in Scotland each year (NHS Health Scotland and ASH Scotland 2004a). This initiative is based on the normative needs concept as it is influenced by expert opinion and government policies (Ewles and Simnett 2003). Epidemiological evidence in its favour allows the initiative to be evaluated by reduction in the mortality and morbidity (Naidoo and Wills 2000). This is cost effective because the initial resources for implementing the smoking cessation will be significantly less than the cost of hospitalisation later in life (NHS Health Scotland and ASH Scotland 2003).
The leaflet that will be critiqued (appendix 1) is aimed at pregnant women who currently smoke but who want to give up. It is split into five sections titled: pregnancy and smoking; stopping smoking; tips for stopping; stopping smoking is worth it and thinking about your smoking. The Ewles and Simnett (2003) model comprises of five approaches to health promotion; medical approach; behaviour change approach; educational approach; client-centred approach and societal change approach.
The behaviour change approach is the main focus for this initiative, although it does utilise aspects of all approaches. The behaviour change approach as described by Ewles and Simnett (2003) is a way of encouraging changes in an individual’s attitudes and beliefs to take up a healthier lifestyle. It is, however considered by some, to be more forceful depending on the degree of encouragement and persuasion utilised (Crafter 1997, Norton 1998). The behaviour change approach uses a number of models to guide health promoters to facilitate clients to achieve a positive outcome.
The Stages of Change Model (Prochaska and DiClemente 1984 as cited by Ewles and Simnett 2003) is a five stage cyclical model that has been found to be particularly useful in work with addictive behaviours (Naidoo and Wills 2000). This cycle incorporates a pre-contemplation stage where the individual is unaware of any need for change or has no interest in changing (Ewles and Simnett 2003). At this stage the midwife would assess whether the woman is genuinely not interested in stopping smoking at present and respect this decision but inform her she will be asked throughout her pregnancy about her smoking status (Crafter 1997, Dunkley 2000).
The leaflet may still be issued as having the information readily at hand may prompt the individual to think about stopping smoking. The advantages of leaflets mean they allow individuals to read through them at their own pace (Ewles and Simnett 2003). The second stage is the contemplation stage where the individual is motivated to consider changing their behaviour, maybe she reads the leaflet and attempts to seek information (Naidoo and Wills 2000). The role of the midwife at this stage would be to determine why the woman smokes and what barriers she may face in stopping smoking (Dunkley 2000).
The leaflet facilitates this by allowing the woman to question why she smokes and how she feels about it. It also seeks to establish what the woman feels is good and bad about smoking and how she anticipates changing her behaviour towards smoking. It has been suggested (McLeod et al 2003) that some midwives find it difficult to broach the subject of smoking particularly with women who have no desire to stop and those who are still considering stopping.
However McLeod et al (2003) found from their qualitative study that women expected to be asked about smoking during routine antenatal care and indeed they felt it was part of the midwives role to ask. The preparation stage is where the woman is committed to giving up smoking. She may seek extra help and is likely to attempt change soon (Dunkley 2000). If the woman is in this planning stage she may benefit from smoking cessation services, which the midwife can offer such as Smokeline, or other local services.
Within the leaflet is a free phone number for Smokeline (HEBS 2003) who offer advice and issue the booklet ‘Aspire to Stop Smoking’ (HEBS and Action on Smoking and Health Scotland 2001). This supporting information helps the woman to discover what she can do to help herself to stop smoking. NHS Health Scotland and ASH Scotland (2004b) challenge the reliability of answers to questions Midwives and other health promoters may be asking individual’s with regard to their interest in stopping smoking as that individual may feel that agreeing is what is expected.
Hesitancy in answering may be indicative of reluctance to commit to stopping at present, so ensuring they understand that there are many options available in the future can enhance the chance of them stopping (NHS Health Scotland and ASH Scotland 2004b). The midwife would continue to support the individual during this time offering advice and encouragement (Crafter 1997) and also would remind the patient of the importance of social support from partners and friends (NHS Health Scotland and ASH Scotland 2004b).
The findings from a study by McLeod et al (2003) concur with the need to have partner involvement. They found that although the women were supported by the midwives there was a failing in educating the partners to the women’s needs while trying to stop smoking (McLeod et al 2003). Moreover Thompson et al (2004) would like to see this expanded out with the antenatal setting. This issue has been addressed in part by the initiative, which encourages the woman to seek partner involvement to support her at this time (HEBS 2003).
The penultimate stage is the making the change stage this is when the woman is taking action (Naidoo and Wills 2000). NHS Lothian (2002) supports making a date to stop and sticking to it. One of the options is nicotine replacement therapy (NRT), which has caused debates over its place in smoking cessation during pregnancy (Dunkley 2000, McNeill et al 2001). McNeill et al (2001) found that using NRT, although not recommended in pregnancy, could be beneficial, as all the pollutants from actual cigarettes would not be delivered to the mother or the fetus. The final stage is the maintenance stage.
It is vital that the midwife maintains good support through the postnatal period as Pollock (2003) found that 60% of women who give up during pregnancy restart smoking within 1 month of birth. Encouragement from the midwife to eat a sensible a diet (Crafter 1997) and use diversionary tactics like regular brushing of teeth and saving cigarette money up for treats (NHS Lothian) helps the woman to stay stopped. The leaflet in its favour mentions how other smokers managed to stop and what they have done to help themselves. In this final stage there is room for relapse or slipping.
The leaflet lets individuals know it is ok to relapse but encourages them to learn from this. It also mentions some of the side effects that women may experience from nicotine withdrawal. The medical approach to health promotion aims to ensure individuals are disease and disability free (Ewles and Simnett 2003). This approach could be viewed as paternalistic, where professionals decide what is best for an individual (Crafter 1997) and as pregnancy is not a state of ill health (Dunkley 2000) it brings into question its validity in midwifery care.
However women could jeopardise the health of themselves and their unborn child if they are involved in risk taking behaviour such as smoking during pregnancy. The initiative mentions some of the health risks involved such as miscarriage and low birth weight babies (HEBS 2003) but favourably does not go into detail to avoid victim-blaming. Within the medical approach such initiatives as General Practitioner’s or other health professionals advocating smoking cessation during consultations is found to be more useful than no mention at all (HEBS 1998) resulting in approximately 2% of smokers stopping long term.
Recommendation 1. 2 of the Smoking Cessation Guidelines for Scotland (NHS Health Scotland and ASH Scotland 2004a) states that a midwife should ascertain a patient’s smoking status and discourage them from smoking at the earliest opportunity. The midwife should also offer support and treatment to aid cessation (NHS Health Scotland and ASH Scotland 2004a). Crafter (1997) identifies the need for midwives to give unbiased information, however justifies the obligation to educate women about damaging behaviour such as smoking during pregnancy.
Facts specific to smoking in pregnancy are not included in the leaflet such as smoking in the first 3 months of pregnancy accounts for a quarter of low birth weight babies (Scottish Executive 2001). An educational approach to health promotion is giving individuals information to discover the health benefits or detriments for themselves (Ewles and Simnett 2003). Crafter (1997) argues that there can be no true educational approach when it comes to smoking in pregnancy because midwives would be unable to remain neutral due to the fact that evidence is available that clearly shows smoking is detrimental.
Naidoo and Wills (2000) explain that the educational approach differs from the behaviour change model, as the educational model does not use encouragement to achieve its aims. NHS Health Scotland and ASH Scotland (2004b) concur with this view advocating that it is not the role of the midwife to persuade but to inform. They go on to defend the use of facts in conjunction with the leaflet. The National Institute for Clinical Excellence (2003) also emphasise the need for women to be informed of the risks, which can make a purely educational approach unattainable in relation to smoking cessation.
The information could be available to patient who enquire about if for them to discover the advantages and disadvantages for themselves with the midwife advising them of where to find resources. In a study by Pullon et al (2003) it showed how suitable resources helped educate women to stop smoking. Critically however it appeared that the midwives concerned were involved in a more behavioural change role as then conclusion commented on the midwives powerful influence (Pullon et al 2003).
The client-centred approach facilitates health promotion of things that the client feels will be of benefit (Ewles and Simnett 2003), this could mean that an individual may not consider that smoking cessation is an issue they want to address and as such the topic may never be discussed. This model is said to facilitate autonomy (Dunkley 2000) but as such the leaflet may never be looked. If however the client felt that smoking cessation was something she was interested in, the midwife would be able to offer any help that was available to her to empower the woman to achieve her objective (Crafter 1997).
The societal change approach focuses on changing the whole society not just individuals within it (Ewles and Simnett 2003). Implementation of changes at community level or above looks to bring about changes to the attitudes and beliefs about smoking during pregnancy to the population. This would include laws such as that to be introduced in spring 2006 banning anybody smoking in enclosed public spaces in Scotland (Scottish Executive 2004).
The majority of pregnant smoker’s are age 16-24 and low socio-economic groups highlighting the important fact that deprivation and inequality increase the incidences of smoking and of teen pregnancy (Lazenbatt et al 2000, NHS Health Scotland and ASH Scotland 2003). Conclusion Midwives play an important role in promoting the health and wellbeing of individuals and their families and delivery of health education (Scottish Executive 2001). The initiative appeared to have some weaknesses as a stand-alone leaflet, however as part of a multi-dimensional approach it emerged favourably.
The midwife must endeavour to gain trust and support to deliver the required service and promote empowerment (Dunkley 2000). She must take care not to alienate the women that require her help. There must be a trusting relationship built up between the midwife and the woman to achieve a positive outcome. Approximately 20% of smoking mums give up during pregnancy and of them over 50% who gave up attributed it to being pregnant (HEA 1999) this indicates further that women want to stop and indeed manage successfully to stop smoking.