Some lessons from Swedish midwives' experiences of approaching women smokers in antenatal care

Midwives' experiences of discussing health behaviour change within routine maternity care: A qualitative systematic review and meta-synthesis

PROBLEM

Behaviours, such as smoking, alcohol use, unhealthy diet, lack of physical activity and vaccination non-adherence may lead to adverse pregnancy outcomes.

BACKGROUND

Pregnancy has been identified as an opportune time for midwives to support women to make health behaviour changes.

AIM

To synthesise existing qualitative research exploring midwives' experiences of discussing health behaviour change with women within routine care.

METHODS

A systematic search was conducted across: Maternity and Infant Care, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, and Applied Social Sciences Index and Abstracts. Thematic analysis was used to synthesise the data. A professional and public advisory group provided feedback during the synthesis stage.

FINDINGS

Twenty-two studies, published between 2005 and 2023, which represented findings from eight countries, were included in the review. The meta-synthesis revealed three themes: The midwife-woman relationship; Reflective and tailored behaviour change communication; Practical barriers to behaviour change conversations. This led to one overarching theme: Although midwives recognised the importance of behaviour change discussions, these conversations were not prioritised in clinical practice.

CONCLUSION

Health behaviour change discussions were de-prioritised in midwives' clinical practice. Future research should explore intervention development to support midwives with their health behaviour change communication.

Smoking cessation care during pregnancy: A qualitative exploration of midwives' challenging role

PROBLEM

The majority of South Australian pregnant women who smoke do not quit during pregnancy. Additionally, the prevalence of smoking is higher among pregnant women living in socially disadvantaged areas.

BACKGROUND

Understanding challenges in midwives' provision of smoking cessation care can elucidate opportunities to facilitate women's smoking cessation.

AIM

We aimed to understand midwives' perspectives on current practices, perceived barriers and facilitators to delivery of smoking cessation care, and potential improvements to models of smoking cessation care.

METHODS

An exploratory qualitative research methodology and thematic analysis was used to understand the perspectives of midwives in five focus groups.

FINDINGS

Four themes were generated from the data on how midwives perceived their ability to provide smoking cessation care: Tensions between providing smoking cessation care and maternal care; Organisational barriers in the delivery of smoking cessation care; Scepticism and doubt in the provision of smoking cessation care; and Opportunities to enable midwives' ability to provide smoking cessation care.

DISCUSSION

A combination of interpersonal, organisational and individual barriers impeded on midwives' capacities to approach, follow-up and prioritise smoking cessation care. Working with women living with disadvantage and high rates of smoking, the midwife's role was challenging as it balanced delivering smoking cessation care without jeopardising antenatal care.

CONCLUSION

Providing midwives with resources and skills may alleviate the sense of futility that surrounds smoking cessation care. Provision of routine training and education could also improve understandings of the current practice guidelines.

Pregnant and postnatal women's experiences of interacting with health care providers about their tobacco smoking: a qualitative systematic review

OBJECTIVE

The objective of this review was twofold: (i) to comprehensively identify the best available evidence about the experiences of women who smoked tobacco during pregnancy or postnatally (or both) concerning health care providers' interactions with them about their smoking, when such interactions occurred during contact for prenatal or postnatal health care in any health care setting; and (ii) to synthesize the research findings for recommendations to strengthen health care providers' interventions regarding smoking during pregnancy and smoking during the postnatal period.

INTRODUCTION

Maternal tobacco smoking during pregnancy and maternal tobacco smoking postnatally pose serious health risks for the woman, fetus, and offspring, whereas maternal smoking cessation has beneficial health effects. Given the importance of health care providers' interactions with pregnant and postnatal women for smoking cessation care, it is essential to understand women's experiences of such interactions.

INCLUSION CRITERIA

Studies considered for this review had qualitative research findings about the experiences of women who smoked tobacco during pregnancy or postnatally (or both) in relation to health care providers' interactions with them about their smoking.

METHODS

The review was conducted using the JBI approach to qualitative systematic reviews. Published studies were sought through 6 academic databases (eg, CINAHL, MEDLINE). Unpublished studies were searched in 6 gray literature sources (eg, ProQuest Dissertations and Theses, Google Scholar). Reference lists of retrieved records were also searched. The searches occurred in October and November 2020; no country, language, or date limits were applied. Study selection involved title and abstract screening, full-text examination, and critical appraisal of all studies that met the inclusion criteria for the review. Study characteristics and research findings were extracted from the included studies. Study selection and extraction of findings were conducted by two reviewers independently; differences between reviewers were resolved through consensus. The research findings were categorized, and the categories were aggregated into a set of synthesized findings. The synthesized finding were assigned confidence scores. The categories and finalized synthesized findings were agreed upon by all reviewers.

RESULTS

The 57 included studies varied in qualitative research designs and in methodological quality (from mostly low to high). There were approximately 1092 eligible participants, and 250 credible and unequivocal research findings. The research findings yielded 14 categories and 6 synthesized findings with low to very low confidence scores. Some women who smoked tobacco during pregnancy and some women who smoked tobacco postnatally lacked supportive interactions by health care providers regarding their smoking; other women experienced supportive interactions by health care providers. Women were adversely impacted when health care providers' interactions lacked supportiveness, and were beneficially impacted when interactions were supportive. Women varied in openness to health care providers' interactions regarding their smoking, from not being receptive to being accepting, and some women wanted meaningful health care provider interactions.

CONCLUSIONS

Although confidence in the synthesized findings is low to very low, the evidence indicates that supportive health care provider interactions may facilitate positive smoking behavior change in pregnancy and postnatally. It is recommended that health care providers implement accepted clinical practice guidelines with women who smoke prenatally or postnatally, using an approach that is person-centered, emotionally supportive, engaging (eg, understanding), and non-authoritarian.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42020178866.

Health providers' and pregnant women's perspectives about smoking cessation support: a COM-B analysis of a global systematic review of qualitative studies

Background

Smoking cessation in pregnancy has unique challenges. Health providers (HP) may need support to successfully implement smoking cessation care (SCC) for pregnant women (PW). We aimed to synthesize qualitative data about views of HPs and PW on SCC during pregnancy using COM-B (Capability, Opportunity, Motivation, Behaviour) framework.

Methods

A systematic search of online databases (MEDLINE, EMBASE, PsycINFO and CINAHL) using PRISMA guidelines. PW’s and HPs’ quotes, as well as the authors’ analysis, were extracted and double-coded (30%) using the COM-B framework.

Results

Thirty-two studies included research from 5 continents: twelve on HPs’ perspectives, 16 on PW’s perspectives, four papers included both. HPs’ capability and motivation were affected by role confusion and a lack of training, time, and resources to provide interventions. HPs acknowledged that advice should be delivered while taking women’s psychological state (capability) and stressors into consideration. Pregnant women’s physical capabilities to quit (e.g., increased metabolism of nicotine and dependence) was seldom addressed due to uncertainty about nicotine replacement therapy (NRT) use in pregnancy. Improving women’s motivation to quit depended on explaining the risks of smoking versus the safety of quit methods. Women considered advice from HPs during antenatal visits as effective, if accompanied by resources, peer support, feedback, and encouragement.

Conclusions

HPs found it challenging to provide effective SCC due to lack of training, time, and role confusion. The inability to address psychological stress in women and inadequate use of pharmacotherapy were additional barriers. These findings could aid in designing training programs that address HPs’ and PW’s attitudes and supportive campaigns for pregnant smokers.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-021-03773-x.

Conceptualizing patient-centered care for substance use disorder treatment: findings from a systematic scoping review

BACKGROUND

Despite ongoing efforts aimed to improve treatment engagement for people with substance-related disorders, evidence shows modest rates of utilization as well as client-perceived barriers to care. Patient-centered care (PCC) is one widely recognized approach that has been recommended as an evidence-based practice to improve the quality of substance use disorder treatment. PCC includes four core principles: a holistic and individualized focus to care, shared decision-making and enhanced therapeutic alliance.

AIMS

This scoping review aimed to explore which PCC principles have been described and how they have defined and measured among people with substance-related disorders.

METHODS

Following the iterative stages of the Arksey and O'Malley scoping review methodology, empirical (from Medline, Embase, PsycINFO, CINAHL and ISI Web of Science) and grey literature references were eligible if they focused on people accessing treatment for substance-related disorders and described PCC. Two reviewers independently screened the title/abstract and full-texts of references. Descriptive analyses and a directed content analysis were performed on extracted data.

FINDINGS

One-hundred and forty-nine references met inclusion from the 2951 de-duplicated references screened. Therapeutic alliance was the most frequent principle of PCC described by references (72%); this was consistently defined by characteristics of empathy and non-judgment. Shared decision-making was identified in 36% of references and was primarily defined by client and provider strategies of negotiation in the treatment planning process. Individualized care was described by 30% of references and included individualized assessment and treatment delivery efforts. Holistic care was identified in 23% of references; it included an integrated delivery of substance use, health and psychosocial services via comprehensive care settings or coordination. Substance use and treatment engagement outcomes were most frequently described, regardless of PCC principle.

CONCLUSIONS

This review represents a necessary first step to explore how PCC has been defined and measured for people accessing substance use disorder treatment. The directed content analysis revealed population and context-specific evidence regarding the defining characteristics of PCC-principles that can be used to further support the implementation of PCC.

Barriers to and facilitators of smoking cessation in pregnancy and following childbirth: literature review and qualitative study

BACKGROUND

Although many women stop smoking in pregnancy, others continue, causing harm to maternal and child health. Smoking behaviour is influenced by many factors, including the role of women's significant others (SOs) and support from health-care professionals (HPs).

OBJECTIVES

To enhance understanding of the barriers to, and facilitators of, smoking cessation and the feasibility and acceptability of interventions to reach and support pregnant women to stop smoking.

DESIGN

Four parts: (1) a description of interventions in the UK for smoking cessation in pregnancy; (2) three systematic reviews (syntheses) of qualitative research of women's, SOs' and HPs' views of smoking in pregnancy using meta-ethnography (interpretative approach for combining findings); (3) semistructured interviews with pregnant women, SOs and HPs, guided by the social-ecological framework (conceptualises behaviour as an outcome of individuals' interactions with environment); and (4) identification of new/improved interventions for future testing.

SETTING

Studies in reviews conducted in high-income countries. Qualitative research was conducted from October 2013 to December 2014 in two mixed urban/rural study sites: area A (Scotland) and area B (England).

PARTICIPANTS

Thirty-eight studies (1100 pregnant women) in 42 papers, nine studies (150 partners) in 14 papers and eight studies described in nine papers (190 HPs) included in reviews. Forty-one interviews with pregnant women, 32 interviews with pregnant women's SOs and 28 individual/group interviews with 48 HPs were conducted.

MAIN OUTCOME MEASURES

The perceived barriers to, and facilitators of, smoking cessation in pregnancy and the identification of potential new/modified interventions.

RESULTS

Syntheses identified smoking-related perceptions and experiences for pregnant women and SOs that were fluid and context dependent with the capacity to help or hinder smoking cessation. Themes were analysed in accordance with the social-ecological framework levels. From the analysis of the interviews, the themes that were central to cessation in pregnancy at an individual level, and that reflected the findings from the reviews, were perception of risk to baby, self-efficacy, influence of close relationships and smoking as a way of coping with stress. Overall, pregnant smokers were faced with more barriers than facilitators. At an interpersonal level, partners' emotional and practical support, willingness to change smoking behaviour and role of smoking within relationships were important. Across the review and interviews of HPs, education to enhance knowledge and confidence in delivering information about smoking in pregnancy and the centrality of the client relationship, protection of which could be a factor in downplaying risks, were important. HPs acknowledged that they could best assist by providing support and understanding, and access to effective interventions, including an opt-out referral pathway to Stop Smoking Services, routine carbon monoxide screening, behavioural support and access to pharmacotherapy. Additional themes at community, organisational and societal levels were also identified.

LIMITATIONS

Limitations include a design grounded in qualitative studies, difficulties recruiting SOs, and local service configurations and recruitment processes that potentially skewed the sample.

CONCLUSIONS

Perceptions and experiences of barriers to and facilitators of smoking cessation in pregnancy are fluid and context dependent. Effective interventions for smoking cessation in pregnancy should take account of the interplay between the individual, interpersonal and environmental aspects of women's lives.

FUTURE WORK

Research focus: removing barriers to support, improving HPs' capacity to offer accurate advice, and exploration of weight concerns and relapse prevention. Interventions focus: financial incentives, self-help and social network interventions.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42013004170.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Improving implementation of the smoking cessation guidelines with pregnant women: How to support clinicians?

OBJECTIVE

this study aimed to explore the enablers and barriers to implementation of the Australian smoking cessation in pregnancy guidelines. These guidelines direct clinicians to follow the 5As of cessation: Ask, Advise, Assess, Assist and Arrange follow-up.

DESIGN

semi-structured interviews based on the Theoretical Domains Framework (TDF) elicited clinicians' views and experiences of implementing the guidelines.

SETTING

antenatal care in the NSW public health system.

PARTICIPANTS

27 maternity service managers, obstetricians and midwives.

FINDINGS

participants confirmed that implementation of the smoking cessation guidelines was sub-optimal. This was particularly the case with Assist and Arrange follow up at the initial visit, and with following any of the 5As at subsequent visits. Key barriers included systems which did not support implementation or monitoring, lack of knowledge, skills and training, perceived time restrictions, 'difficult conversations' and perceiving smoking as a social activity. Enablers included clinicians' knowledge of the harms of smoking in pregnancy, clinicians' skills in communicating with pregnant women, positive emotions, professional role and identity, the potential of training and of champions to influence practice, and systems that regulated behaviour.

KEY CONCLUSIONS

these findings will contribute to the development of a multifaceted intervention to support clinicians in implementing the guidelines.

IMPLICATIONS FOR PRACTICE

Building on existing strengths, antenatal care providers may be supported in implementing the guidelines by working with systems which remind and support implementation, the clear reframing of smoking as an addiction, knowledge and skills development and by realizing the potential of leadership to maximise the impact of reinforcement and social influence.

Smoking Cessation Support by Text Message During Pregnancy: A Qualitative Study of Views and Experiences of the MiQuit Intervention

Introduction:

SMS text messaging is increasingly used for delivering smoking cessation support and pilot studies suggest this may also be useful in pregnancy. This study explores the views of women who received a tailored text messaging cessation intervention (MiQuit) during pregnancy, focusing on acceptability, perceived impact, and suggestions for improvements.

Methods:

Semi-structured interviews were undertaken with 15 purposively sampled women who had received the MiQuit intervention during pregnancy as part of a randomized controlled trial. Data were analyzed thematically.

Results:

Three main themes were identified: “impact”, “approach,” and “optimization.” Participants described an immediate, yet often short-lived, impact from the texts that distracted and delayed them from smoking and they perceived that texts focusing on the development of and risk to the baby generated more enduring emotional impacts. Most women found receiving support by text preferable to face-to-face cessation support, with participants citing the greater regularity, convenience, and non-judgmental style as particular advantages. Participants would have preferred a longer support program with increased tailoring, greater customization of text timings and consideration of cutting down as an alternative/precursor to quitting.

Conclusion:

Pregnancy-specific cessation support by text message was well received and participants considered the support increased their motivation to stop smoking. The focus on the developing baby, the regularity of contact and the provision of gentle, encouraging messages were highlighted as particularly important elements of the program.

Implications:

This study adds further evidence to the acceptability and perceived positive impact of text-messaging programs in aiding smoking cessation in pregnancy. The findings indicate that for some women, this type of support is preferable to face-to-face methods and could be utilized by health professionals, either in addition to current methods or as an alternative. This study is also relevant to researchers developing health-related text programs to consider participants’ desire for greater tailoring. Further research is required into adapting and continuing text support for women postpartum.

CE: Original Research: The Experiences of Pregnant Smokers and Their Providers

: Background: The U.S. Department of Health and Human Services' initiative Healthy People 2020 targets tobacco use, including smoking during pregnancy, as a continuing major health concern in this country. Yet bringing the U.S. Public Health Service's 2008 clinical practice guideline, Treating Tobacco Use and Dependence, into routine prenatal care remains challenging. Our previous nurse-managed intervention study of rural pregnant women found no significant cessation effect and significant discordance between self-reported smoker status and urinary cotinine levels.

PURPOSE

The overall purpose of this follow-up study was to increase our understanding of the experiences of pregnant smokers and their providers. No qualitative studies could be found that simultaneously explored the experiences of both groups.

DESIGN AND METHODS

This qualitative descriptive study used focus group methodology. Nine focus groups were held in two counties in upper New York State; six groups consisted of providers and three consisted of pregnant women. Four semistructured questions guided the group discussions, which were audiotaped and transcribed verbatim. Transcripts were read and coded independently by six investigators. Themes were identified using constant comparative analysis and were validated using the consensus process.

RESULTS

The total sample consisted of 66 participants: 45 providers and 21 pregnant women. Most of the providers were white (93%) and female (93%). A majority worked as RNs (71%); the sample included perinatal and neonatal nursery nurses, midwives, and physicians. The pregnant women were exclusively white (reflecting the rural demographic); the average age was 24 years. All the pregnant women had smoked at the beginning of their pregnancies. Four common themes emerged in both the provider and the pregnant women groups: barriers to quitting, mixed messages, approaches and attitudes, and program modalities. These themes corroborate previous findings that cigarette smoking is used for stress relief, especially when pregnancy itself is a stressor, and that pregnant women may feel guilty but don't want to be nagged or preached to.

CONCLUSIONS

These results have implications for how smoking cessation programs for pregnant women should be designed. Health care providers need to be cognizant of their approaches and attitudes when addressing the subject of smoking cessation. Specific educational suggestions include "putting a face" to the issue of tobacco use during pregnancy. More research is needed on how best to implement the 2008 clinical practice guideline in specific populations.

Antenatal Clinic and Stop Smoking Services Staff Views on "Opt-Out" Referrals for Smoking Cessation in Pregnancy: A Framework Analysis

Introduction: UK guidance recommends routine exhaled carbon monoxide (CO) screening for pregnant women and "opt-out" referrals to stop smoking services (SSS) of those with CO ≥ 4 ppm. We explored staff views on this referral pathway when implemented in one UK hospital Trust. Methods: Seventeen semi-structured interviews with staff involved in the implementation of the new referral pathway: six antenatal clinic staff (before and after implementation); five SSS staff (after). Data were analyzed using framework analysis. Results: Two themes were identified: (1) views on implementation of the pathway and (2) impact of the pathway on the women. Generally, staff felt that following training, referrals were less arduous to implement and better received than expected. The majority believed this pathway helped engage women motivated to quit and offered a unique chance to impart smoking cessation knowledge to hard-to-reach women, who might not otherwise contact SSS. An unexpected issue arose during implementation-dealing with non-smokers with high CO readings. Conclusions: According to staff, the "opt-out" referral pathway is an acceptable addition to routine antenatal care. It can help engage hard-to-reach women and educate them about the dangers of smoking in pregnancy. Incorporating advice on dealing with non-smokers with high CO into routine staff training could help future implementations.

What helps or hinders midwives to implement physical activity guidelines for obese pregnant women? A questionnaire survey using the Theoretical Domains Framework

OBJECTIVE

to investigate barriers and facilitators to physical activity (PA) guideline implementation for midwives when advising obese pregnant women.

DESIGN

a cross-sectional, self-completion, anonymous questionnaire was designed using the Theoretical Domains Framework. this framework was developed to evaluate the implementation of guidelines by health care professionals. A total of 40 questions were included. These were informed by previous research on pregnant women's and midwives views, knowledge and attitudes to PA, and supported by national evidence based guidelines. Demographic information and free text comments were also collected.

SETTING

three diverse NHS Trusts in the North East of England.

PARTICIPANTS

all midwives employed by two hospital Trusts and the community midwives from the third Trust (n=375) were invited to participate.

MEASUREMENTS

mean domain scores were calculated. Factor and regression analysis were performed to describe which theoretical domains may be influencing practice. Free text comments were analysed thematically.

FINDINGS

192 (53%) questionnaires were returned. Mean domain scores were highest for social professional role and knowledge, and lowest for skills, beliefs about capabilities and behaviour regulation. Regression analysis indicated that skills and memory/attention/decision domains had a statistically significant influence on midwives discussing PA with obese pregnant women and advising them accordingly. Midwives comments indicated that they felt it was part of their role to discuss PA with all pregnant women but felt they lacked the skills and resources to do so effectively.

KEY CONCLUSIONS

midwives seem to have the necessary knowledge about the need/importance of PA advice for obese women and believe it is part of their role, but perceive they lack necessary skills and resources, and do not plan or prioritise the discussion regarding PA with obese pregnant woman.

IMPLICATIONS FOR PRACTICE

designing interventions that improve skills, promote routine enquiry regarding PA and provide resources (eg. information, referral pathways) may help improve midwives' PA advice.

Health professionals' perceptions of the barriers and facilitators to providing smoking cessation advice to women in pregnancy and during the post-partum period: a systematic review of qualitative research

BACKGROUND

Reducing smoking in pregnancy is a policy priority in many countries and as a result there has been a rise in the development of services to help pregnant women to quit. A wide range of professionals are involved in providing these services, with midwives playing a particularly pivotal role. Understanding professionals' experiences of providing smoking cessation support in pregnancy can help to inform the design of interventions as well as to improve routine care.

METHODS

A synthesis of qualitative research of health professionals' perceptions of the barriers and facilitators to providing smoking cessation advice to women in pregnancy and the post-partum period was conducted using meta-ethnography. Searches were undertaken from 1990 to January 2015 using terms for maternity health professionals and smoking cessation advisors, pregnancy, post-partum, smoking, and qualitative in seven electronic databases. The review was reported in accordance with the 'Enhancing transparency in reporting the synthesis of qualitative research' (ENTREQ) statement.

RESULTS

Eight studies reported in nine papers were included, reporting on the views of 190 health professionals/key informants, including 85 midwives and health visitors. The synthesis identified that both the professional role of participants and the organisational context in which they worked could act as either barriers or facilitators to an individual's ability to provide smoking cessation support to pregnant or post-partum women. Underpinning these factors was an acknowledgment that the association between maternal smoking and social disadvantage was a considerable barrier to addressing and supporting smoking cessation

CONCLUSIONS

The review identifies a role for professional education, both pre-qualification and in continuing professional development that will enable individuals to provide smoking cessation support to pregnant women. Key to the success of this education is recognising the centrality of the professional-client/patient relationship in any interaction. The review also highlights a widespread professional perception of the barriers associated with helping women give up smoking in pregnancy, particularly for those in disadvantaged circumstances. Improving the quality and accessibility of evidence on effective healthcare interventions, including evidence on 'what works' to support smoking cessation in disadvantaged groups, should therefore be a priority. PROSPERO 2013: CRD42013004170.

Pregnant Women's Experiences and Views on an "Opt-Out" Referral Pathway to Specialist Smoking Cessation Support: A Qualitative Evaluation

INTRODUCTION

Smoking in pregnancy remains an important and costly public health concern with policy makers worldwide researching methods to aid cessation. UK government guidelines recommend implementation of an "opt-out" (ie, whether requested or not) referral pathway for pregnant smokers to specialist smoking cessation support using carbon monoxide (CO) screening. This study explores the views of pregnant smokers who experienced this new pathway in one UK hospital trust.

METHODS

Eighteen semi-structured telephone interviews with women who experienced the opt-out pathway were undertaken. Data were analyzed thematically.

RESULTS

Three themes were identified relating to expectations, acceptability and impact of the pathway. Women were generally very accepting of the CO testing especially when it met their prior expectations and was perceived as being a routine component of antenatal care. They considered the visual feedback from the CO monitoring improved their motivation to quit. Views on the automatic referral for cessation support were divided with questions raised as to the removal of choice, with many women also expressing dissatisfaction about perceived lack of contact by Stop Smoking Services (SSS) following referral.

CONCLUSION

The opt-out pathway is potentially an acceptable addition to current practice. The women considered CO monitoring to be the most valuable element of the pathway. Women keen to engage with SSS desired a more efficient system of contact.

IMPLICATIONS

This study presents a unique insight into pregnant women's views on the implementation of opt-out referrals for smoking cessation. Introducing CO testing and opt-out referrals at the time of antenatal ultrasound examination can potentially increase motivation to stop smoking in pregnancy. The findings demonstrate that facilitating access to SSS was not always achieved, and further refinement is needed to ensure more effective contact procedures. Ensuring all women are fully informed prior to the CO testing may further improve both the impact of the opt-out referral pathway and the chance of successfully engaging with SSS.

Midwives' strategies in challenging dietary and weight counselling situations

OBJECTIVE

By enhancing maternal nutritional status, midwives can help women lower the risks of pregnancy complications and adverse birth outcomes as well as improve maternal health during pregnancy and in the long run. Dietary counselling is, on the other hand, not reported to be effective. Poor communication and conflicting messages are identified as possible barriers to adherence with recommendations. Midwives' experiences of providing dietary advice and counselling during pregnancy are sparsely reported. The aim of this study was therefore to explore midwives' strategies when faced with challenging dietary counselling situations.

METHODS

Seventeen midwives from different parts of Sweden and working within antenatal health care were interviewed by telephone. The interviews were analysed using qualitative content analysis.

RESULTS

Challenges were commonly experienced when counselling women who were overweight, obese, had eating disorders or were from different cultures. The midwives talked in terms of "the problematic women" when addressing counselling problems. Strategies used in challenging counselling situations were Getting acquainted; Trying to support and motivate; Pressure to choose "correctly"; Controlling and mastering; and Resigning responsibility.

CONCLUSIONS

The results indicate that Swedish midwives' counselling strategies are quite ambiguous and need to be questioned and that counselling of vulnerable groups of women should be highlighted. We could identify a need for education of practicing midwives to develop person-centred counselling skills.

How midwives tailor health information used in antenatal care

OBJECTIVE

to examine the informal approaches taken by midwives and other antenatal staff to adapt health communication to the needs of their patients, as well as their perception of the barriers faced when trying to provide tailored health promotion.

DESIGN

qualitative research methods (participant observation, individual and group interviews) were utilised to gain an understanding of how media and communication resources were used in practice within the study hospital.

SETTING

a major metropolitan teaching hospital located in the Northern suburbs of Adelaide, South Australia.

PARTICIPANTS

individual semi-structured interviews with antenatal staff (n=8) were combined with group interviews (n=2; total number of staff=13), and observational research.

FINDINGS

midwives and other antenatal staff use a range of strategies to meet the perceived health literacy level of their patients. However, their attempts to tailor health information to individual needs are frequently based on incomplete information about patients' health literacy, may be inconsistent in delivery and content and are seldom assessed to determine whether communication has been understood or led to patient behaviour change.

KEY CONCLUSIONS

midwives fully recognise the need to adapt standard printed materials to meet the diverse health literacy needs of patients but lack the resources required to evaluate whether these adaptations have positive effect.

IMPLICATIONS FOR PRACTICE

midwives' commitment to improving health communication provides a latent resource that institutions can build on to improve health outcomes for patients with low health literacy. This requires improvements in health communication training, willingness to use a range of validated instruments for measuring health literacy, and commitment to use of innovative approaches to health promotion where these have been shown to have a positive impact on health behaviours.

Pregnant smokers’ perceptions of specialist smoking cessation services

Introduction: Women who continue to smoke during pregnancy are at risk of smoking-related diseases, maternity complications and expose the foetus to risks of perinatal mortality and morbidity. The number of women smoking at the time of delivery is estimated at 13.5% in England and 15.8% in the West Midlands. However, the prevalence can be elevated in certain areas, such as north Solihull.

Aims: This research consults past, current and non-users of specialist smoking cessation services and reports pregnant women's views of smoking cessation delivery and potential service developments.

Methods: Focus groups were conducted with 19 participants with experience of prenatal smoking.

Findings: Data was analysed using thematic analysis. The main themes included: (1) improving access to clear, sensitive information on smoking and pregnancy; (2) perceptions of existing services; (3) improving current services: the right delivery and the right person; and (4) encouraging participation of pregnant smokers.

Conclusions: In this area, pregnant smokers wanted easily-accessible, empathetic, non-judgemental and flexible support more than incentives or rewards to quit smoking. They also stated a preference for group cessation support as they believed that peer support would be advantageous.

Information giving and education in pregnancy: a review of qualitative studies

Studies of childbirth education have universally failed to take into account the quality of the education provided to women and their families and whether its style of delivery meets women's preferences and needs. The present study sought to determine which educational approaches are most welcomed by women and most helpful to them in learning about labor, birth, and early parenting. A systematic survey of peer-reviewed studies on antenatal education, published in English from 1996-2006 and which sought women's views and experiences, was conducted. Findings confirm women's preference for a small-group learning environment in which they can talk to each other as well as the educator and can relate information to their individual circumstances.

What helps and hinders midwives in engaging with pregnant women about stopping smoking? A cross-sectional survey of perceived implementation difficulties among midwives in the North East of England

BACKGROUND

Around 5,000 miscarriages and 300 perinatal deaths per year result from maternal smoking in the United Kingdom. In the northeast of England, 22% of women smoke at delivery compared to 14% nationally. Midwives have designated responsibilities to help pregnant women stop smoking. We aimed to assess perceived implementation difficulties regarding midwives' roles in smoking cessation in pregnancy.

METHODS

A self-completed, anonymous survey was sent to all midwives in northeast England (n = 1,358) that explores the theoretical explanations for implementation difficulties of four behaviours recommended in the National Institute for Health and Clinical Excellence (NICE) guidance: (a) asking a pregnant woman about her smoking behaviour, (b) referring to the stop-smoking service, (c) giving advice about smoking behaviour, and (d) using a carbon monoxide monitor. Questions covering Michie et al.'s theoretical domain framework (TDF), describing 11 domains of hypothesised behavioural determinants (i.e., 'knowledge', 'skills', 'social/professional role/identity', 'beliefs about capabilities', 'beliefs about consequences', 'motivation and goals', 'memory', 'attention and decision processes', 'environmental context and resources', 'social influences', 'emotion', and 'self-regulation/action planning'), were used to describe perceived implementation difficulties, predict self-reported implementation behaviours, and explore relationships with demographic and professional variables.

RESULTS

The overall response rate was 43% (n = 589). The number of questionnaires analysed was 364, following removal of the delivery-unit midwives, who are not directly involved in providing smoking-cessation services. Participants reported few implementation difficulties, high levels of motivation for all four behaviours and identified smoking-cessation work with their role. Midwives were less certain about the consequences of, and the environmental context and resources available for, engaging in this work relative to other TDF domains. All domains were highly correlated. A principal component analysis showed that a single factor ('propensity to act'), derived from all domains, explained 66% of variance in theoretical domain measures. The 'propensity to act' was predictive of the self-reported behaviour 'Refer all women who smoke……to NHS Stop Smoking Services' and mediated the relationship between demographic variables, such as midwives' main place of work, and behaviour.

CONCLUSIONS

Our findings advance understanding of what facilitates and inhibits midwives' guideline implementation behaviours in relation to smoking cessation and will inform the development of current practice and new interventions. Using the TDF as a self-completion questionnaire is innovative, and this study supports previous research that the TDF is an appropriate tool to understand the behaviour of healthcare professionals.

Knowledge, attitudes and other factors associated with assessment of tobacco smoking among pregnant Aboriginal women by health care providers: a cross-sectional survey

Background

As with many Indigenous peoples, smoking rates among Aboriginal Australians are considerably higher than those of the non-Indigenous population. Approximately 50% of Indigenous women smoke during pregnancy, a time when women are more motivated to quit. Antenatal care providers are potentially important change agents for reducing the harms associated with smoking, yet little is known about their knowledge, attitudes or skills, or the factors associated with providing smoking cessation advice.

Methods

This paper aimed to explore the knowledge and attitudes of health care providers caring for pregnant Australian Aboriginal women with regard to smoking risks and cessation; and to identify factors associated with self-reported assessment of smoking. A cross-sectional survey was undertaken with 127 staff providing antenatal care to Aboriginal women from two jurisdictions: the Northern Territory and New South Wales, Australia. Measures included respondents' estimate of the prevalence of smoking among pregnant women; optimal and actual assessment of smoking status; knowledge of risks associated with antenatal smoking; knowledge of smoking cessation; attitudes to providing cessation advice to pregnant women; and perceived barriers and motivators for cessation for pregnant women.

Results

The median provider estimate of the smoking prevalence was 69% (95%CI: 60,70). The majority of respondents considered assessment of smoking status to be integral to antenatal care and a professional responsibility. Most (79%) indicated that they assess smoking status in 100% of clients. Knowledge of risks was generally good, but knowledge of cessation was poor. Factors independently associated with assessing smoking status among all women were: employer service type (p = 0.025); cessation knowledge score (p = 0.011); and disagreeing with the statement that giving advice is not worth it given the low level of success (p = 0.011).

Conclusions

Addressing knowledge of smoking risks and cessation counselling is a priority and should improve both confidence and ability, and increase the frequency and effectiveness of counselling. The health system must provide supports to providers through appropriate policy and resourcing, to enable them to address this issue.

Will an adverse pregnancy outcome influence the risk of continued smoking in the next pregnancy?

OBJECTIVE

The purpose of this study was to study the effect of pregnancy outcomes on risks of continued smoking in subsequent pregnancy.

STUDY DESIGN

Cohort study of first and second single births among 98,778 Swedish women who were daily smokers in first pregnancy.

RESULTS

In all, 70.2% of women continued to smoke in second pregnancy. Compared with women with a previous normal pregnancy outcome, risk of smoking in second pregnancy was increased among women with a previous small-for-gestational-age birth (adjusted odds ratio [OR], 95% CI 1.28 [95% CI 1.19-1.37]), and reduced among women who had experienced a stillbirth (OR 0.76 [95% CI 0.63-0.93]) or an infant death because of congenital malformations (OR 0.67 [95% CI 0.49-0.92]. A previous preterm birth, Sudden Infant Death Syndrome, and other causes of infant death did not influence risk.

CONCLUSION

A previous adverse pregnancy outcome has only a modest influence on smoking habits in the successive pregnancy.

Midwives’ attitudes to counselling women about their smoking behaviour during pregnancy and postpartum

OBJECTIVE

to investigate the attitudes of midwives to counselling women about their smoking behaviour during pregnancy and postpartum.

DESIGN

survey using postal questionnaires.

SETTING

the entire federal state of Mecklenburg-West-Pomerania in Germany.

PARTICIPANTS

189 midwives constituting 77% of all midwives working in that State.

FINDINGS

midwives reported that they assessed smoking behaviour regularly (77%), addressed the consequences of smoking (70%) and advised women to quit. Among the midwives, 81% saw low chances of success and parents' expectations as the biggest barriers to counselling. Midwives reported that about 28% of women quit following their advice.

KEY CONCLUSIONS

smoking and exposure to environmental tobacco smoke are seen as prominent health threats that midwives reported they addressed routinely, including giving advice to stop smoking.

IMPLICATIONS FOR PRACTICE

midwives should be supported in learning effective intervention strategies to further strengthen their work. They are a target population to deliver brief smoking interventions.