Health professionals are missing the mark on smoking guidelines for pregnant women, with a major overhaul needed, Susan Perlen discovered.
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‘Working for a number of years as a midwife and manager in a public hospital that provided maternity services, I have seen that pregnancy is a wonderful opportunity to care for women during a really special time in their lives.
It is during this time health professionals can make a real difference to the outcome for women and their babies. Passing on the importance to patients of stopping smoking — in my case, to pregnant women — is essential in improving infant health outcomes such as pre-term births and low birth weight.
My PhD looks at how the Victorian ante-natal smoking cessation guidelines, which were developed in the early 2000s, have been working in Victorian public maternity hospitals.
A cornerstone of these guidelines are the ‘5 As’ (steps to ask, assess, advise, assist and ask again about smoking behaviour). My research used a mixed methods approach where I analysed Victorian population-based data from a survey of recent mothers.
The questionnaire was posted to women during a five-to-six week period after delivery in 2008. The questionnaire used a design to encourage greater disclosure of smoking behaviour by giving women a range of options to describe their smoking status.
An example question was, “During your recent pregnancy, which of the following best describes you?”
The options given were smoking the same as before, cutting down, smoking more, smoking once in a while, quitting smoking and having never smoked. Asking about smoking using this measure has been found to increase disclosure by 40 per cent.
This data informed the interviews that I had with doctors and midwives at two public maternity hospitals to look at their attitudes towards the current smoking cessation guidelines.
Women in my study are categorised as receiving community-based care or hospital-based care. Community-based care includes those receiving all of their ante-natal care with community-based clinicians such as general practitioners.
My research shows that stop smoking advice and support is inconsistent and varies according to the model of care a woman is enrolled in. An example of this discrepancy is 62 per cent of women enrolled in hospital-based care received written information about how to stop smoking compared to 37.9 per cent of women in community-based care.
Smoking is a complex issue and an addiction for many. Pregnancy does not automatically mean that a woman is driven to stop smoking.
In fact, the added chaos in a woman’s life can make stopping smoking much harder. The most surprising fact I discovered during my research was that despite all of the training and guidance available to professionals involved in caring for pregnant women, only 9.4 per cent of women reported receiving all of the ‘5 As’.
I was also surprised to find that of the women receiving public ante-natal care, 24 per cent of them reported smoking during pregnancy.
I was impressed by the fact that 93.4 per cent of women were asked about smoking and more than 80 per cent of women were told about the harmful effects of smoking.
When I put all of this information together, it showed me that while we are doing some things very well we still have some major gaps.
My thesis demonstrates that the smoking cessation guidelines in Victoria have been poorly implemented. There needs to be a ‘whole of systems’ approach to thinking about improvements.
This means considering the interactions between health organisations, health professionals and patients. The key recommendations from my PhD address six major areas to improve the current guidelines.
This includes the development and application of a ‘whole of systems’ approach, training, smoking cessation resources, data systems, flow of communication between GPs and public maternity hospitals, and tailored approaches to specific populations.
Organisations and health professionals are struggling to provide smoking cessation advice and support in line with the current guidelines.
There is little innovation or guidance from the Victorian Department of Health to support hospitals. Funding constraints have resulted in Quit Victoria having limited capacity to provide ongoing training.
My study shows there has been little return on investment from previous statewide training initiatives, suggesting that a new approach needs to be considered for future training.
It is important to remember that Australia is leading the way with its tobacco frameworks and smoking bans. More can be done, but this just shows how complex an issue smoking is.’
► Dr Susan Perlen is a Research Manager at Murdoch Childrens Research Institute in Melbourne. Her thesis is titled: “An investigation of the implementation of Victorian smoking cessation guidelines in public antenatal care services”.
* My PhD is an irregular series in which The Citizen speaks with recent Melbourne University PhD graduates.