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| Journal of the New Zealand Medical Association,
14-March-2008, Vol 121 No 1270
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Supporting
pregnant women to quit smoking: postal survey of New Zealand general
practitioners and midwives’ smoking cessation knowledge and
practices
Marewa Glover, Janine Paynter, Chris Bullen, Kay
Kristensen
Smoking in pregnancy is the single most preventable cause of
pregnancy complications such as miscarriage, pre-term birth, and
stillbirth.1,2 Smoking increases the risk of
sudden infant death syndrome and has adverse effects on children’s
physical and mental development.3,4
Smoking cessation programmes should be available in all
maternity care settings because they have been shown to increase smoking
cessation, reduce preterm birth, and increase birth
weight.5 Indeed,
the New Zealand Ministry of Health (MoH) considers that pregnant women are a
priority group.6
Despite strong evidence of the harms of smoking in pregnancy
and of the benefits of stopping smoking, a survey in 2003 found that 22% of
pregnant New Zealand women who smoked were smoking around the time of
conception.7 The
proportion of Māori women smoking at conception was twice this estimate
(55%).7 The MoH has an ambitious goal to reduce
this figure to 30% or lower by 2008.8
Pregnancy offers a unique opportunity for smoking cessation
interventions due to an increased motivation to stop and likely increased number
of contacts pregnant women have with health
professionals.7,9,10 Motivation to quit is
highest in the first trimester,5,10,11 but
despite this approximately one-third of pregnant women smokers continue to smoke
during pregnancy,9 and 21% of women who quit
during pregnancy relapse prior to
delivery.12
One published survey of cessation services provided for
pregnant women has been conducted in New
Zealand.13 This survey, conducted in 2001,
randomly sampled 274 GPs and 184 midwives—65% of GPs and 95% of midwives
asked most of their pregnant patients about smoking. More than three-quarters of
the respondents considered smoking cessation advice as an important part of
their job.
Half of the GPs and midwives surveyed reported offering
smoking cessation advice. Midwives were significantly less likely than GPs to
feel comfortable or confident giving smoking cessation advice. Low numbers (24%)
of midwives and GPs reported that NRT was appropriate for pregnant women.
Since the 2001 survey, smoking cessation support for
pregnant women and smoking cessation practice has changed. The MoH now funds
training programmes to improve the provision of smoking cessation counselling
and support given by lead maternity carers (LMCs) and other health
professionals. Culturally appropriate cessation support for Māori, Aukati
Kai Paipa, has also been funded.
Smoking cessation guidelines were developed in 2000, revised
in 2002,14 and have been revised again in
200715 to provide healthcare workers with
up-to-date evidence-based guidance. Accordingly, in the third quarter of 2006 we
undertook a survey of New Zealand health professionals providing care to
pregnant women to identify their knowledge and practices in regard to smoking
cessation advice and support. This paper reports on the findings from that
survey.
MethodWe obtained a sample of 376 GPs randomly selected by
computer programme from a national database of all New Zealand GPs (Atlantis
Ltd), and a random sample of 446 registered midwives from the Midwifery Council
of New Zealand’s database.
The online White Pages® telephone directory website
was searched to obtain address details for the selected midwives, but because of
missing data a second random selection from the original list was required to
obtain a final sample of 397 registered midwives with postal addresses.
We constructed a questionnaire around six domains of
enquiry, comprising participant demographic characteristics and each of the
‘Five As’ (Ask, Assess, Advise, Assist, Arrange)
recommended in the 2002 New Zealand Guidelines for smoking
cessation.14 The questionnaire comprised
closed- and open-ended questions, so participants could write comments if they
desired, and was pre-tested for comprehension and ease of completion by two GPs
and two midwives.
The questionnaire, participant information sheet,
consent form, a competition entry form and prepaid reply envelope were mailed
out to the selected participants in September 2006, and re-sent to those who had
not responded one month later. We entered the responses in a Microsoft Excel
spreadsheet and analysed the data using simple EpiInfo 2000 software. Multiple
entries for ethnicity were reduced to a single category using Statistics New
Zealand’s prioritisation standard (NZ Māori, Pacific Island, Asian,
Pakeha/NZ European, Other).
We obtained approval to conduct the study from the
University of Auckland Human Participants Ethics Committee and funding support
from the MoH.
ResultsResponse rates and sociodemographic and practice
characteristics—Responses were received from 147/376 (39%) of the
GPs and 203/355 (57%) of the midwives, an overall response rate of 48%. Surveys
returned unopened due to an incorrect address were removed from the midwives
denominator. Two GPs and one midwife responded to the survey despite not having
been invited. These were excluded from the response rate calculation but their
results are included in the analyses because their data could not be separately
identified and removed.
The demographic characteristics of the respondents are shown
in Table 1. The vast majority of GPs and midwives were European/Pakeha, with
very small numbers of Māori, Pacific, Asian, and other ethnicities. Most
respondents (71%) were aged between 35–54 years with similar proportions
of GPs and midwives in each age group.
Almost all (99%) of midwives were female compared to just
under half (46%) of the GPs. Responses were received from GPs located in all
District Health Board (DHB) regions throughout New Zealand with the exception of
Wairarapa, and from midwives in all 21 DHB regions.
Employment arrangements were markedly different: almost all
(91%) of the GPs, but only a small proportion (3%) of midwives, worked under the
auspices of a primary health organisation (PHO). Twenty-two percent of GPs and
45% of midwives stated that they practiced independently. A small number of GPs
(11%) but almost two-thirds of midwives (60%) worked under the auspices of a
DHB. No midwives and only 7% of GPs worked for a Māori provider. Ten
percent of GPs and almost 20% of midwives estimated that half or more of their
clients were Māori.
Involvement in confirming
pregnancy—GPs were significantly more likely to see women to
confirm pregnancy than midwives (99% compared with 55% respectively; RR 1.66,
95% CI 1.48–1.86) and were more likely to see them in the first trimester
(73% of GPs compared with 60% of midwives; RR 1.67, 95% CI 1.49–1.87).
Twenty-three percent of midwives said they usually see women for the first time
in the second trimester and 17% in the third trimester.
Asking about
smoking—Almost all midwives (98.5%) and fewer, but most, GPs
(84.5%) reported that the smoking status of their patients was routinely
recorded on the patient’s record. High proportions of GPs (97%) and
midwives (95.5%) reported that they considered asking about smoking in pregnant
patients to be part of their role.
GPs were significantly more likely than midwives to ask
about smoking status at the first visit (92% vs 82%; RR 1.12, 95% CI
1.03–1.21). A key reason given for not asking about smoking was
the short time available, as there were always a number of important topics to
discuss. Other respondents stated that they didn’t see pregnant women
until late in pregnancy or postnatal so didn’t ask.
Several GPs commented that asking and recording smoking
status was the responsibility of the practice nurse and some noted that they
usually only see women once for confirmation of pregnancy.
Table 1. Demographic profile of GPs and
midwives participating in the survey
Advising about stopping smoking—High
proportions of both GPs (94.5%) and midwives (90%) reported usually asking
pregnant patients who smoke if they wished to stop but there were important
differences in the advice given.
GPs were significantly more likely than midwives (71% vs
11%; RR 6.50, 95% CI 4.32–9.77) to report advising such patients to stop
smoking completely. Conversely, midwives were significantly more likely than GPs
(80% vs 28%; RR 2.86, 95% CI 2.18–3.74) to advise cutting down initially
with a view to stopping altogether.
A small proportion of midwives (6%) said that they only
advise cutting down smoking. Similarly high proportions of both GPs and midwives
(90% and 95% respectively) stated that they usually discuss the adverse effects
of smoking during pregnancy with smoking patients at the first visit.
Discussing smoking with pregnant
women—GPs were significantly more likely than midwives to give
stop smoking advice to pregnant women who are known smokers at each antenatal
visit as opposed to discussing it only when raised by the woman (69% vs 47%; RR
1.45, 95% CI 1.20–1.75). Five GPs (3%) and 21 midwives (11%) reported that
they discuss smoking at a pre-arranged time set up for that purpose.
Arranging cessation support—GPs and
midwives were equally more likely than not to provide cessation counselling (65%
vs 61%; RR 1.07, 95% CI 0.91–1.26). Figure 1 shows their responses to a
question about the effectiveness of various stop smoking medications.
Nicotine replacement (NRT) patch was considered by both GPs
and midwives to be the most effective mode of treatment although almost half the
GPs thought nicotine gum would be effective for pregnant women. More GPs than
midwives considered pharmacotherapy as being effective treatments for pregnant
women than midwives. Acupuncture and hypnosis were considered effective by about
the same number of midwives that considered NRT patch and gum effective.
The number of GPs rating acupuncture and hypnosis as
effective was somewhat lower than the number rating NRT patch and gum as
effective but the proportion of GPs doing so was lower than for midwives. Of
concern is that a considerable number of GPs (33) and midwives (74) indicated
they knew little about the effectiveness for pregnant women of the list of
cessation treatments.
GPs and midwives were also asked how likely they were to
recommend a particular treatment. Figure 2 shows that the likelihood of
recommending particular treatments compared favourably with those treatments
considered to be most effective. There was no difference between GPs and
midwives in their likelihood of recommending NRT patches to a pregnant woman who
smokes (RR 1.01, 95% CI 0.80–1.27) but GPs were significantly less likely
to refer pregnant smokers for acupuncture than midwives (34% vs 50.5%
respectively; RR 0.67, 95% CI 0.50–0.90). Almost half of the midwives
surveyed stated that they were likely or very likely to recommend acupuncture
and hypnotherapy.
Figure 1. Perceived effectiveness in pregnant
women of various smoking cessation treatments by GPs and midwives (with 95%
confidence intervals)
 Figure 2. Proportions of GPs and midwives
likely or very likely to recommend a particular cessation
treatment
 Awareness of New Zealand
Guidelines for Smoking Cessation—GPs (70%) and midwives (61%)
were equally likely to be aware of the New Zealand Guidelines for smoking
cessation.14
Arranging referral to
specialist smoking cessation providers—Table 2 shows the
cessation support services most likely to be recommended by respondents. GPs
were significantly more likely than midwives, or very likely, to refer pregnant
women to Quitline (RR 1.20, 95% CI; 1.09–1.31). The next
preferred source of cessation support for GPs was to refer women to practice
nurses (65%).
Only 26.5% of GPs were likely or very likely to refer women
to a Māori cessation provider, and almost one-third (31%) said they
didn’t know of any such service. Few GPs were likely to refer women to a
Pacific Island cessation provider or Seventh Day Adventist cessation programmes,
but again a large proportion of the GPs did not know of these services. Some
participants said that they referred clients to other DHB services or hospital
run programmes. A few said they had used Quitline in the past but not
all reported having had a good experience with this service.
Smokechange was strongly supported by midwives but not by GPs.
Smokechange is a personalised, motivational intervention programme
designed to encourage pregnant women to cut down their smoking as a pathway to
stopping smoking.16
Table 2. Likelihood (%) of referral to a
selected cessation provider
GP=general practitioner, MW=midwife.
Smoking cessation-related
training—The training experiences of GPs and midwives differed
markedly. Almost two-thirds of GPs but just over one-third of midwives indicated
that they had undertaken training in smoking cessation (Table 3). A quarter of
GPs and 16% of midwives recalled undertaking training in the use of the
Guidelines for smoking cessation.14
A third of GPs but fewer than 5% of midwives had received
training in the provision of NRT. However, almost a half of the midwives
surveyed stated that they had received training in provision of cessation advice
to pregnant women who smoke. Sixty-seven respondents (19%) had completed other
forms of training, 23 (9% of the total) naming courses provided by Education for
Change Ltd. Some had attended courses provided by the New Zealand College of
Midwives, PHO, or DHB providers and a few had attended courses in the UK and
Australia, or had attended courses provided by the manufacturers of
pharmaceutical products used in smoking cessation treatment.
Table 3. GPs and midwife participation in
cessation-related training
Education for Change Ltd was the most frequently used
provider of cessation training for midwives (46%) whereas the National Heart
Foundation was used more by GPs (but only 9.5% reported attending the course).
Nearly a quarter (24%) of GPs and 17% of midwives said that smoking cessation
was covered in their basic training. Thirty-nine percent of GPs and 17% of
midwives had undertaken smoking cessation-related training with providers other
than those funded by the Ministry of Health. Only 14% of GPs and 3% of midwives
indicated that they were registered Quitcard providers.
DiscussionSurveys of GPs and maternity health professionals in the UK
have indicated that while most routinely ask about smoking at the first
antenatal visit, far fewer advise pregnant smokers on how to stop, and even
fewer monitor and review those still
smoking.9,17
In a 1995 UK study, 96% of health professionals stated that
they asked about and recorded the smoking status of pregnant women and explained
the risks of smoking to pregnant smokers when they saw them for the first time.
However, fewer (67%) advised pregnant smokers on how to stop and less than half
(47%) monitored and reviewed smoking status throughout
pregnancy.9
In a more recent survey in the UK, McEwan and White found
that 96% of GPs and 99% of nurses accepted that intervening to support cessation
was part of their role and routinely recorded the smoking status of patients.
However, only 50% of GPs and 71% of nurses advised patients to stop smoking on
most occasions.17
This study has identified areas of progress in smoking
cessation treatment for pregnant women, but also reveals some opportunities for
improvement. The good news is that high proportions of midwives and GPs reported
always asking about smoking. This is consistent with earlier studies which found
that 65–74% of New Zealand GP obstetricians and 95% of midwives asked most
or every woman about smoking status13 and
suggests that more GPs may be asking about smoking than before.
We found that GPs were significantly more likely than
midwives to ask about smoking status at the first visit for pregnancy.
Nevertheless, almost all respondents saw it as part of their role to ask about
smoking in pregnant patients.
Changes to maternity care funding over recent years has lead
to a dramatic reduction in the number of GPs providing antenatal care. Despite
this, we found that GPs are still involved in confirming pregnancies and usually
see pregnant women for this service during the first trimester. It isn’t
until the second trimester that pregnant women nominate their LMC, usually a
midwife.
Māori women who smoke are most likely to attempt to
stop smoking within 2 weeks of finding out they are pregnant, usually in the
first trimester11 and there is no reason to
suspect that this is any different for non-Māori women. Health
professionals involved in confirming pregnancy therefore need to be actively
promoting smoking cessation and providing stop smoking assistance to pregnant
women.
This study suggests that GPs are far more likely than
midwives to be in this pivotal position, that is, upon confirmation of a
pregnancy. Fortunately, this survey shows that GPs are also likely to offer
appropriate advice—to stop smoking. Despite this, efforts to reduce
smoking in pregnancy to date have largely focused on midwives of whom over half
have not received training in this area.
Another concern is our finding that midwives were
significantly more likely than GPs to advise women to cut down on their smoking
with a view to quitting rather than to stop smoking completely, with a small
number reporting that they do not advise reducing or quitting at all. While most
GPs and midwives reported discussing the effects of smoking during pregnancy and
effects on the fetus with pregnant women who smoke, GPs were significantly more
likely than midwives to discuss smoking at every visit.
According to a recent literature
review18 of cessation treatments, GPs and
midwives should discuss smoking at every visit, advise their pregnant patients
to stop smoking altogether and refer them to a dedicated cessation service.
Cessation training and advice for midwives should give greater emphasis to the
importance of advising and supporting pregnant women to stop smoking completely.
The most recent New Zealand Guidelines for smoking
cessation15 recommend either referral to
smoking cessation services, if the health professional has limited time and/or
expertise, or providing support that incorporates setting a quit date, advising
complete abstinence, arranging medication if appropriate and arranging a
follow-up within a week. Our survey suggests that there has been an increase in
the proportion of midwives providing cessation advice and counselling: 61% in
our study compared with 55% in 2001.13
This study supports other local research suggesting that
practice nurses are an important provider of smoking cessation
support.7 There is emerging evidence that
nurses can have a similar impact to doctors when providing smoking cessation in
primary care.19 As McLeod et al concluded this
work should be adequately resourced, not only within practices but also at
regional and national levels, to strengthen a commitment to smoking cessation in
primary care.7
Awareness of and referring women to the Quitline
for cessation assistance appears to have increased markedly since an unpublished
New Zealand survey by Cowan in 2000 when only around 60% of GPs and 44% of
midwives had heard of Quitline.20 In
our study only one GP and 3% of midwives said they did not know about the
Quitline.
Almost a third of GPs and midwives did not know of any
Māori smoking cessation providers. Consistent with this, respondents
indicated that they wanted more information about these services. We also found
low awareness of and referral to Pacific Island cessation services, but this is
likely to be because only a few Pacific Island cessation providers exist and
most of these are in the Auckland region.
Knowledge of the effectiveness of using NRT for pregnant
women appears to have improved since 2001 when only 24% of GPs and midwives
thought NRT was appropriate for use during
pregnancy.13
In our survey, the form of NRT considered most effective and
most likely to be recommended by both GPs and midwives was the patch. However,
intermittent forms of NRT are now considered preferable for pregnant women
because they deliver a lower total daily dose of nicotine than patches and are
therefore less likely to lead to potential adverse effects on the
fetus.21,22
We found high support for the use of acupuncture and
hypnosis among respondents, thus suggesting a widespread lack of knowledge of
effective smoking cessation methods. GPs appeared to know more about a wider
range of cessation products and treatments and were more likely to identify
effective cessation methods than midwives, who were also significantly more
likely than GPs to refer pregnant women who smoke for acupuncture to assist
quitting, despite absence of evidence for this approach.
As was found in a 2001
survey,13 many respondents wanted better access
to training, especially in the provision of cessation treatments such as NRT in
pregnancy and during breastfeeding. Education for midwives based on the
Guidelines for smoking cessation and an increased effort to raise the
proportion of GPs and midwives who have read and practice according to the
Guidelines has the potential to improve knowledge and use of cessation
methods which are supported by evidence.
Our survey has a number of limitations. Firstly, the
response rates were low, especially for GPs. This may reflect the extent to
which GPs are being approached by researchers in general rather than a
particular reluctance to respond to questions about their management of pregnant
patients who smoke.
Some GPs may not have responded because they do not provide
care for pregnant women. Despite this the study population was similar to the
wider population of GPs and midwives with regard to age group and sex suggesting
that it was representative in these factors at least. However, very few
Māori GPs or midwives participated and even fewer were of Pacific Islands
ethnic groups.
Midwives from larger urban centres may have also been
under-represented due to the way the database was constructed. Secondly, our
study relied on self reported responses so respondents may have provided the
answers they expected the researchers to want, and engaged in smoking cessation
interventions more or less often than they reported. However, as it was made
clear to participants that the survey was anonymous we would not expect this to
be a major source of bias.
With regards to strengths, the study methodology is
consistent with earlier New Zealand surveys and has provided a useful and
comparable snapshot of current provider knowledge, awareness and
practices.
ConclusionsThe knowledge and practices of New Zealand GPs and midwives
with regard to many dimensions of smoking cessation appears to be improving, but
there is still considerable scope for greater alignment with evidence-based
practices.
Training in the provision of cessation advice has largely
been targeted at midwives but women are still seeing GPs to confirm their
pregnancy in the first trimester, the very time when they should be receiving
advice and support to stop smoking or referral to smoking cessation providers.
Practice nurses are now playing an important role in smoking
cessation and should have greater access to appropriate training. Training for
midwives in cessation needs to be based on the current evidence for effective
smoking cessation support. Whilst many midwives undervalue the importance of
stopping smoking completely when pregnant, this study found there was a
willingness to improve knowledge of effective smoking cessation
treatments.
Competing interests: None known.
Author information: Marewa Glover,
Director, Auckland Tobacco Control Research Centre, Auckland; Janine Paynter,
Researcher/Policy Analyst, Action on Smoking and Health New Zealand, Auckland;
Chris Bullen, Associate Director, Clinical Trials Research Unit, School of
Population Health, University of Auckland, Auckland; Kay Kristensen, Research
Consultant, Hamilton.
Acknowledgements: The study was funded by
the Ministry of Health. We also thank the general practitioners and midwives who
participated in this study; and Andrea King, Karin Batty, Billie Harbridge,
Sarah Haines, Becky Freeman, Te Hotu Manawa Māori, Department of Pacific
Health, University of Auckland, Ngati Whatua o Orakei Health, The Midwifery
Council of New Zealand, Research Director, Department of Primary Healthcare and
General Practice, Wellington School of Medicine and Health Sciences, Education
for Change Ltd, Smoking Cessation Specialist, National Heart Foundation of New
Zealand.
Correspondence: Dr Marewa Glover, Social
and Community Health, School of Population Health, University of Auckland,
Private Bag 92019, Auckland, New Zealand. Fax: +64 (0)9 3035932; email: m.glover@auckland.ac.nz
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