Elsevier

Midwifery

Volume 20, Issue 1, March 2004, Pages 37-50
Midwifery

Can support and education for smoking cessation and reduction be provided effectively by midwives within primary maternity care?

https://doi.org/10.1016/S0266-6138(03)00051-2Get rights and content

Abstract

Objective:

to test the hypothesis that appropriate interventions delivered by midwives within usual primary maternity care, can assist women to stop or reduce the amount they smoke and facilitate longer duration of breast feeding.

Design, setting and participants:

in a cluster randomised trial of smoking education and breast-feeding interventions in the lower North Island, New Zealand, midwives were stratified by locality and randomly allocated into a control group and three intervention groups. The control group provided usual care. Midwives in the intervention groups delivered either a programme of education and support for smoking cessation or reduction, a programme of education and support for breast feeding or both programmes. Sixty-one midwives recruited a total of 297 women.

Interventions:

structured programmes provided by midwives.

Findings:

women receiving only the smoking cessation or reduction programme were significantly more likely to have reduced, stopped smoking or maintained smoking changes than women in the control group, at 28 weeks and 36 weeks gestation. Women receiving both the smoking cessation and breast-feeding education and support programmes were significantly more likely than women in the control group to have changed their smoking behaviour at 36 weeks gestation. There was no difference in rates of cessation or reduction between the groups in the postnatal period. There was no difference in rates of full breast feeding between the control and intervention groups for women who planned to breast feed.

Key conclusions:

education and support by midwives, as part of primary midwifery, can facilitate smoking cessation and reduction during pregnancy.

Introduction

Peri-pregnancy child health can be improved by a reduction in maternal smoking (Windsor et al., 1999; Lumley et al., 2001; Walsh et al., 2001) and increased duration of breast feeding (Ershoff et al., 1990; Li et al., 1993; Horta et al., 1997; Kramer et al., 2001). In New Zealand 25% of women smoke during pregnancy (Ford et al., 1993; Wellington Women's Hospital, 1998), with higher rates for those in lower socio-economic groups and for Maori (Ministry of Health, 1999). Women who smoke are also less likely to continue to breast feed than their non-smoking counterparts (Minchin, 1991; McLeod et al., 2002).

In New Zealand primary maternity care is delivered by midwives alone or in conjunction with another midwife (case-load type), or less often with a general practitioner or obstetrician. Women are able to choose their maternity care provider. Primary maternity care is publicly funded and there is no fee for women attending a midwife or general practitioner. Income for health-care providers depends on the number of women choosing them for their maternity care. In most cases the same provider or combination of providers delivers antenatal, intranatal and postnatal care. Antenatal care and postnatal visits are not in hospital clinics and are often in the woman's own home. An on-going professional relationship develops between the pregnant woman, her family and her midwife (Cookson, 1998; Pairman, 1998).

Pregnancy-specific smoking cessation programmes have been developed (Dolan-Mullen et al., 1994; Secker-Walker et al., 1995; Hartmann et al., 1996) but there is ongoing debate over whether structured smoking cessation programmes are best delivered to pregnant women by smoking cessation counselling removed from other pregnancy care (Ford et al., 2001; Lancaster and Stead, 2001) or by trained health-care providers in usual clinical settings (Manfredi et al., 1999; Lumley et al., 2001). Both approaches have the potential to be effective in primary care (Lancaster et al., 2000).

In New Zealand the midwife is in an excellent position to deliver a focussed brief intervention within a holistic health-care model. At policy level it is now expected that smoking cessation advice will be delivered as part of antenatal care (Ministry of Health, 2000). However, at the time of the study, ‘usual’ smoking cessation activity by maternity care providers was variable. In a recent New Zealand survey most doctors and midwives responding regarded provision of smoking cessation advice as an integral part of their job, but only half reported giving smoking cessation advice to every pregnant woman who smoked. Less than half had received any formal smoking cessation training (Webster et al., 2002). Health professionals have identified clients’ resistance and lack of time as barriers to providing smoking cessation advice (McLeod et al., 2000). Concern about resistance from women has additional implications in an environment where women are able to select the midwife they will attend.

There is need to evaluate the effect of the delivery of health promotion education and advice by midwives in the New Zealand primary maternity care environment. In this paper findings from a cluster randomised trial evaluating structured programmes to support smoking cessation or reduction and increased breast-feeding duration delivered by their midwife to women who smoke are described.

Section snippets

Participants

All 121 midwives in selected localities in the lower North Island of New Zealand were invited to take part in the study. Midwives were eligible to take part if they planned to continue to practice for the next 12 months. Midwives ascertained the smoking status of women registering with them for maternity care, explained that they were taking part in a study to assess ways of helping women with smoking reduction and breast feeding, and asked women who had smoked at the time they conceived to

Enrolment and allocation

Participant flow through the study is shown in Fig. 1. Women were recruited by 61 of the 80 (76%) midwives who received training. Six of the midwives who did not recruit women reported registering no eligible women over the study period. Data on the total number of new registrations for the 12 months prior to the study were available for 16 midwives. These midwives recruited an estimated 65% of eligible women into the study based on an average rate of smoking at conception of 25%.

Recruitment

Discussion

Many smoking cessation interventions for pregnant women reported in the literature have been developed and evaluated in secondary care or clinic-based settings. In New Zealand with primary care midwifery and continuity of care and carer there is potential for midwives to effectively deliver health promotion messages, and they are increasingly being expected to do so. However, it is essential that the effectiveness of the delivery of health promotion messages by midwives be evaluated in the

Acknowledgments

The MEWS study team thanks all midwives and women involved in the study. The study would not have been possible without their help. The MEWS study was funded by the Health Research Council of New Zealand and the maternity provider organisation ‘Matpro’. Financial assistance for resource production was received from the Health Funding Authority, the Health Sponsorship Council and the Cancer Society of New Zealand.

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