Smoking in pregnancy

Introduction

The purpose of this essay is to identify a public health issue with a woman I cared for in practice. Using a health promotion model to critically analyse the woman’s needs and outline the midwifery care given to address the issue. Discussing health promotion, theories influencing midwife practice and the role of the midwife in public health and health promotion.

For the purpose of maintaining confidentiality in accordance with the Nursing and Midwifery Council (NMC) the code: standards of conduct performance and ethics for nurses and midwives (NMC 2008), the pseudonym Miss will be used to refer to my client. Different source of literature will be used to support my discussion throughout the essay.

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Scenario

Miss Yardley, a young woman of white British origin, twenty one year old primipara, eleven weeks plus four days gestation according to her last menstrual period. She attended the maternity booking clinic with her long term partner for history taking. She lived with her partner in a private accommodation though recently both she and her partner had moved in with her mother who lives in a council rented apartment, as they could no longer afford payment for their flat. She was unemployed due to a recent redundancy from the company she had worked in since leaving secondary school aged sixteen. Her partner is employed but on a low paid salary as a call centre operator. On several occasions she had searched for new employment with no success. She expressed not to have any medical or obstetric problems. Miss Yardley expressed that she used to drink alcohol only on social occasions but stopped when she became aware of the pregnancy. She willing expressed when asked regarding smoking that she smoked up to fifteen cigarettes a day or more depending on how she was feeling emotionally. She tried quitting on one occasion though due to overwhelming personal issues at the time was unable to give up smoking. Her partner never smoked but her mother smoked up to ten cigarettes a day. She expressed willingness to quit smoking but felt worried that she may not be able to completely give up as she tends to be drawn to smoke more when stressed and now that she is unemployed there is more time available for her to smoke.

The public health issue from the case study

The importance of smoking as a public health issue has been identified in various key policies and strategy papers. The government white paper on tobacco 1998: smoking kills targets pregnant women as a priority group requiring intervention. According to the Department of Health (a smoke free future) ‘smoking remains one of few modifiable risk factor in pregnancy’ (DH, 2010, p.22), it states that smoking rates are highest in routine and manual groups, lower socioeconomic groups and certain minority and vulnerable groups. In the mid 1950 smoking levels between socioeconomic groups were similar, however since the 1960 onwards the more advantaged socioeconomic group acted in response to increasing evidence about the harmful effects of tobacco use (DH 2011). Figure 8 (in appendix) in the strategy shows correlation between the prevalence of smoking and net income. Therefore reducing smoking rates in these groups of people has been identified as a critical factor in reducing health inequalities. The good practice guide 3 (Public health agency 2010) also indicates a clear link between smoking in pregnancy and social disadvantage, it states evidence indicates while women know that tobacco use is damaging their health, for many smoking is a means of coping with poverty, disadvantage and lack of control over aspects of life. In contribution to social disadvantage, the highest prevalence of smoking is noted in the 20-34 age group (Office for National Statistics (ONS), 2006).The most recent white paper Healthy lives, healthy people (DH 2011) sets to reduce national rates in smoking amongst pregnant women to 11 percent from the current 2009/10 rate of 14 percent. It states that tobacco smoking remains one of the most significant public health challenges in England.

Cost

Smoking has remained prominent in public health globally and it continues to be a major factor for health inequalities in the UK. The world health organisation (WHO), 2011) states over the cause of the 21th century, tobacco use could kill a billion people or more unless urgent action is taken. The need for support identified in various literature and government strategy to enable pregnant women to maintain healthy lifestyles during and after pregnancy has impacted in my decision to identify smoking as a public health need for my client.

Impact of smoking in pregnancy

Maternal smoking is not only harmful during pregnancy but has a long term effects on the baby after birth, 4000 chemicals of which some are marked irritant properties and some 60 are known or suspected to be carcinogenic can be found in tobacco smoke (WHO, 2004). Some of the risk associated with smoking during pregnancy includes intrauterine growth restriction, placenta previa, and abruptio placentae (Vanderhoeven and Tolosa 2010). Poor outcomes such as preterm rupture of membranes, low birth weight and perinatal mortality have been highlighted (Vanderhoeven et al, 2010). Lagan and Casson 2010, indicates smoking to be associated with increased risk of miscarriage, respiratory problems for the child and sudden infant death (SID). Research carried out by University College London (UCL) concluded that babies born to women who smoke are at increased risk of having certain birth defects such as missing or deformed limbs, clubfoot, gastrointestinal, skull and eye defects and cleft lip or palate (Campbell 2011). Babies born of mothers who smoke have frequent respiratory problems at birth and in their first year, they are at risk of developing asthma and a higher rate of stillbirth is noted (Viccars, 2009).

Miss Yardley smokes 15 or more cigarettes a day and her mother is also identified as a smoker, this puts the unborn baby at risk of effects due to direct smoking and passive smoking. Mitchell et al (citied in Viccars, 2009) states that babies of women who smoke 15 cigarettes a day have 15 times greater risk of dying from SID compared to babies of non-smokers.Further research showed a link between smoking during pregnancy and low levels of high density lipoprotein (HDL) cholesterol in children whose mother’s smoked whilst pregnant. It concluded that they had 10-15 percent risk of experiencing heart disease compared to children with non smoking mothers (Health express, 2011).

From the discussion above it is evident the issue of smoking would need to be addressed at each opportunity with Miss Yardley when providing care and advice. This would enable screening and monitoring of smoking status, education on the effects of smoking to the outcome of her pregnancy and adequate support to ensure effects to pregnancy and the general health of mother and baby is eradicated or minimised.

Health promotion models

WHO defines health promotion a process of enabling people to increase control over and to improve, their health. It implies that the ideology moves beyond a focus on individual behaviour towards a wide range of social and environmental interventions. Naidoo and Wills (2010), states ‘health promotion is based on theories about what influences people’s health and what are effective interventions or strategies to improve health. There are five different approaches to health promotion, medical, behaviour change, educational, client approach and societal change approach (Scriven 2010). Different health promotion models have been developed to enable a planned intervention to improve health.

Tannahill model (Downie et al 1996 citied in Naidoo and Wills 2009), addresses health promotion over three overlapping spheres of activity, preventive education, prevention and health protection. The model suggest that all approach interlink, in practice this could be difficult to implement and due to the overlapping of spheres, focus on what needs to be achieved could be confused. The prevention sphere of the model relies mainly on the medical approach , Barnes (2009) suggest that medical approach could be perceived as a top down approach and that when providing health promotion intervention client involvement is necessary to help maintain individual focus (client centred care).

In comparison, the Tones model which is an empowerment model sets to enable people to gain control over their own health (citied in Naidoo and Wills, 2009). ‘Tones consider education to be the key in empowering both lay and professional people’ (Naidoo et al 2009).The empowerment approach relies on educating client and the information conveyed would be highly medicalised to show importance of the issue. In relation to Miss Yardley who has tried but failed to quit smoking, empowering her through the use of education to convey the risk of smoking though unavoidable as a health professional, could have a counter active effect. Dunkley (2000), states that the aim of mass campaign is to raise awareness, however it may increase feeling of guilt and stress which may be relieved by the aid of another cigarette. Therefore the effectiveness of this model’s approach for my client is questioned.

Tones and Tannahill model both mainly makes use of the medical and educational approach, this makes it difficult to address socioeconomic factors that have documented risk with smoking. As my clients issue is related to smoking and there is a socioeconomic factor present, it would be inapplicable to use these models of health promotion.

During the booking appointment, Miss Yardley willing expressed to have tried quitting with no success and that she would like to quit though factors such as not having a job contributed to her smoking. ‘Nicotine addiction is identified as a major factor for women continuing to smoke during pregnancy’ (Lagan et al 2010). There is a link between stress and the use of tobacco as a relieve method. Gorman (2008) states ‘that smoking represents a significant challenge for pregnant women, as it compounds the stress of pregnancy and may be further complicated by additional factors such as disadvantage’. McCurry et al 2002 (citied in Lagan et al 2010) also indicates smoking to be a mechanism of coping with disadvantage, stress and perceived lack of control over life. According to Earp and Ennett (1991) an ecological perspective implies that behaviour results from interaction of both individual and environmental factors (Citied in Lagan et al, 2010). Various literatures have made use of behaviour model when planning intervention for smoking. Prochaska and DiClemente’s trans-theoretical model (Naidoo et al, 2009); will be used to manage the care of Miss Yardley. The model describes the process of change; it is derived from their work on encouraging change in additive behaviours (Naidoo el at, 2009). This model is applicable to my client has it addresses her behaviour which is the main attribute in smoking and enables a woman centred approach. Woman centred care is expressed as choice, control and continuity of care in the Changing Childbirth report (DH, 1993 cities in Leap 2009).Behavioural change approach enables the use of communication and counselling, empowerment, decision making, fostering community groups and social support networks (Dunkley 2000). The process of change includes precontemplation, contemplation, preparing to change, making change and maintenance.

The woman’s needs and midwifery care involved

All care given was in accordance with the National institute for health and clinical excellence (NICE, 2010): public health guidance 26.

Precontemplation: in this stage change to lifestyle has not been considered. Miss Yardley has progressed from this stage has she identified willingness to try quitting. This shows the limitation of the model when used with an individual who is thinking of changing.

Contemplation: the individual is thinking about change. The client’s willingness indicated readiness for change, adequate information was giving during the booking appointment through leaflets and other forms of resources. Due to the step by step structure of the model, it was easy to identify the stage of change.

Preparing to change: Miss Yardley has read all the information given and had taken up the referral. Though she continued to smoke but expressed to have cut down to 10 cigarettes a day. This shows the effectiveness of the model, though she is not at the point of change the use of counselling and information regarding risk has empowered some form of change.

Making the change: a date was choose. She had cut down from 10 to about 8 a day depending on her moods; she maintained her appointment with the specialist.

Maintenance: there is a possibility of relapse at this stage as change is not a smooth process (Naidoo et al, 2009). In Miss Yardley’s case change would have to be assessed through to the postnatal period, in order to determine adequate health improvement.According to

At booking, Miss Yardley’s pregnancy was considered low risk, which meant that her care was given mainly in the community. Her exposure to smoking was identified through discussion. Carbon monoxide test was not carried out as it is unavailable in the located hospital. Information regarding the risk of smoking in pregnancy to her and the unborn child was explained and information leaflets and contact numbers to relevant smoking services given. Passive smoking was addressed and the effects pointed out. The benefits of stopping smoking to her health and that of the pregnancy outcome were highlighted, financial benefit was also explained. The need to quit, rather than cut down was explained. Informed consent was given and referral made to the community smoking cessation midwife. Encouragement and praise was given at this stage. As she identified her mother to be a smoker, information on how to reduce passive smoking was explained and relevant stop smoking service contact were given to help her mother. The pregnancy book by the Department of Health was given for general education on pregnancy and the section on rights and benefits was highlighted to help with benefits as she was unemployed. Care given was accurately recorded in accordance with NMC code (2008) to enable continuity of care.

At 28 weeks plus four days, she was seen for a routine follow up antenatal appointment with the midwife. She expressed to be well, no concerns regarding fetal movement noted, no abnormalities detected with other routine examination such as symphysis fundal height measure. The appointment was used as an opportunity to assess her exposure to smoke, and to identify whether smoking cessation was maintained. Benefits of quitting were further stressed and encouragement was given. From her appointment with the smoking specialist, it was evident from documentation that improvement were being made in regards to the carbon monoxide readings as she had reduced the amount of cigarette smoked and was preparing to achieve a set date.

The role of midwife in public health and health promotion

Midwives have been identified as health professional responsible for identifying this target group of smokers (pregnant women).Midwives have access to the life cycle of very important group of people; therefore they play a part in the government target of reducing smoking in pregnancy (Pollock 2003). Partnership with woman is essential in achieving health promotion and maintaining government set public health targets. According to Leap, (citied in Ebert et al, 2009), ‘midwives reported their role as facilitating choice and empowering women through partnership and effective communication’. the midwifery partnership model of care Communication is an important role for midwives, in health promotion it enables continuity of care through adequate documentation, verbal interaction with women enables relationship to be formed which further improves women centred care approach. Byrd (2006) ‘states that relationship are able to persist trust and attachment developing as long as people fulfil perceived obligations of behaviour and communication’ (Ebert et al 2009). Multidisciplinary team working to enable adequate care is provided is also a vital role of midwives in health promoting and improving public health.Midwives and nurses frequently utilise holistic concept of health to underpin practice (Beldon and Crozler 2005). Therefore when provide health promotion it is important that the women’s needs is addressed holistically in accordance with midwifery practice and not based on medical interpretation.

Conclusion

In conclusion, it is evident that smoking during pregnancy is an important aspect of public health and therefore an important part of midwifery practice. In particular, health promotion in daily practice is required to prevent any further complication to mothers and their unborn babies. Smoking is a major public health issue that continues to contribute to social and health inequalities.Working with Miss Yardley enabled me to provide care tailored to her needs and goal set to quit smoking and were identified by the client. Though I was unable to follow her care care through, I feel adequate support provided through the smoking cessation referral would enable her to maintain her set goal and improve her health and that of the unborn child.

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