Can support and education for smoking cessation and reduction be provided effectively by midwives within primary maternity care?
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.
References (65)
How can I deal with missing data in my study? Australia New Zealand
Journal of Public Health
(2001)- et al.
A meta-analysis of randomised trials of prenatal smoking cessation interventions
American Journal of Obstetrics & Gynecology
(1994) - et al.
Falling by the waysidea phenomenological exploration of perceived breast-milk inadequacy in lactating women
Midwifery
(1999) - et al.
A randomised controlled trial of smoking cessation intervention in pregnancy in an academic clinic
Obstetrics & Gynecology
(1996) - et al.
Smoking cessation in pregnant women
Obstetric & Gynaecological Clinics of North America
(2001) - et al.
Evaluation of antenatal smoking cessation programs for pregnant women
Australia New Zealand Journal of Public Health
(1998) - et al.
Evaluation of a motivational smoking cessation intervention for women in public health clinics
Preventive Medicine
(1999) - et al.
Improving disclosure of smoking by pregnant women
American Journal of Obstetrics and Gynecology
(1991) - et al.
Partner's smokinga major determinant for changes in women's smoking behaviour during and after pregnancy
Public Health
(1996) - et al.
Effects of a smoking cessation program for pregnant women and their partners attending a public hospital antenatal clinic
Australia New Zealand Journal of Public Health
(1998)