Research projects

Smoking cessation during pregnancy Project

Researchers: Katherine Everett, Dr Krisela Steyn, Zaino Petersen.
Medical Research Council, Cape Town.

Background
Smoking during pregnancy is a serious and preventable cause of a number of adverse maternal, fetal and infant outcomes. It is associated with increased risk of premature rupture of membranes, abruptio placentae, placenta previa and pre-term delivery. It also increases the risk for low birthweight, stillbirth, neonatal death and Sudden Infant Death Syndrome (SIDS). Studies in South Africa have shown that disadvantaged, coloured pregnant women have alarmingly high rates of smoking and consequently, high rates of smoking related pregnancy complications and low birth weight babies. Around 47% of coloured women smoke during pregnancy, as compared with 4% of black women and 3% of Indian women.

Women are more predisposed to make an attempt to stop smoking during pregnancy than at any other time of their lives out of concern for their unborn babies and because of increased social and family support. This offers the health care provider a unique window of opportunity in which to encourage and support cessation. However, at present, the state health services in South Africa do not have any policies or programmes that specifically encourage and support pregnant women to quit smoking. Even basic information on the risks of smoking during pregnancy is not available.

Aim of project
The overall purpose of this project is the development and evaluation of a smoking cessation intervention for pregnant women attending public sector antenatal clinics in South Africa. The primary target group of this intervention is disadvantaged, coloured pregnant women who attend public sector antenatal clinics, as they constitute the group needing urgent intervention. For the purposes of developing an effective, acceptable and appropriate intervention, formative research has been conducted by the MRC with coloured pregnant women, as well as with the midwives and obstetricians who provide antenatal care for these women. The intervention will be developed on the basis of these research findings and international best practice guidelines.

Research findings
Our research with antenatal care providers in the public sector has shown that the prevailing approach to cessation intervention is limited to information and advice giving, often delivered in an authoritarian manner. In their interactions with women, most midwives and doctors assume a dominant role and prescribe what decisions and action the pregnant women should take from their professional point of view. When women fail to comply with their advice, they became exasperated or despondent, often blaming women’s negative attitudes towards cessation for their lack of success.

It was clear from the research with pregnant women that this authoritarian communication style has the potential to be counterproductive and provoke patient disagreement, resistance and avoidance. A patient centred method, such as Motivational Interviewing, where the patient is given opportunities to actively participate in the discussion, identify and resolve their feelings of ambivalence about behavioural change and where their individual concerns and values are respected is likely to be more effective. Interviews with coloured pregnant women on their attitudes towards smoking cessation counselling confirmed that they felt more comfortable with a patient centred approach. The research also revealed that some women concealed their smoking from midwives because they wanted to avoid being “lectured”, “scolded” or made to feel guilty. The fact that they did not expect practical or emotional support for quitting was an added disincentive to disclosing their smoking status and the extent to which they smoked.

Despite midwives’ difficulties in communication with pregnant women, our research showed that pregnant women strongly endorse the role of the midwife in smoking cessation counselling. For example, in the survey conducted by the MRC in 2002, 91% of coloured pregnant women said that midwives were a trusted source of information on smoking and 91% stated that they would like to participate in a smoking cessation programme if it were delivered by midwives as a part of routine antenatal care. Midwives are therefore seen as needing to play a central role in the proposed smoking cessation intervention. However, of critical importance is the training of midwives and in a more effective and acceptable approach to smoking cessation counselling.

Training in patient centred approaches
It is clear that antenatal care providers could benefit from training in patient centred education methods, theories of behavioural change and in the use of best practice smoking cessation guidelines. A change in the manner in which they address smoking cessation in pregnancy is likely to elicit a more favourable positive response from pregnant women. Midwives and doctors also need greater insight into how pregnant women perceive their smoking, their concerns about quitting and their feelings of guilt and anxiety. Training which addressed these difficulties in smoking cessation practice would enable them to experience interactions about smoking cessation in a more constructive and rewarding way. The challenge is to not further burden midwives and doctors, but to ensure that the time they do spend discussing smoking with pregnant women is more constructive. Exposing health care providers to the principles and methods of Brief Motivational Interviewing could be particularly helpful in changing their attitudes towards pregnant smokers and their approach to behavioural change counselling.

The use of peer educators, trained in smoking cessation counselling, is also worth consideration when envisaging a potential intervention. The advantages of using peer counsellors in health education is that they are less likely to be authoritarian in their approach and because women can identify more closely with them, they have the potential for positive role modelling and increasing perceived social support. They also tend to have the ability to disseminate information in a way that is easily understood by their peers and, perhaps, more consonant with their values. It is possible that such peer educators could receive more in depth training in Brief Motivational Interviewing as they would be able to spend more time counselling pregnant women.

Update of project
The formative research for the development of the intervention has been completed and is in the process of being written up. The intervention itself will be developed during the course of 2005 and is scheduled for piloting in two public sector antenatal clinics in Cape Town 2006. The training of midwives in Motivational Interviewing methods has begun, with midwives attending two workshops during 2004. Further training of the midwives involved in the piloting of the intervention will take place in late 2005.

This work was carried out with the aid of a grant from RITC-Research for International Tobacco Control, an international secretariat, housed in the International Development Research Centre, Ottawa, Canada.

Contact details of principal researcher: Katherine Everett, Chronic Diseases of Lifestyle Division, Medical Research Council, Cape Town.
Telephone numbers: 031 9380423 or 021 7615274.
E mail: Murphy@mindspring.co.za