Health promotion is defined by the World Health Organisation (WHO) (2016) as enabling others to have control of their health. Indeed, Naidoo and Willis (2000) state that health promotion is providing people with education of the necessary skills to instil confidence to make health changes. Midwives have a duty to promote wellbeing and empower women to make positive changes and decisions concerning their health (Nursing and Midwifery Council (NMC), 2015). Smoking, according to Public Health England (PHE) (2014), is England's biggest cause of mortality and ill health, resulting in 80,000 premature deaths a year. This article will examine smoking in terms of health promotion, reflecting on a scenario that occurred within the community setting. It will follow the structure of the Circular Transactional Model (Arnold and Boggs, 2011). This model acknowledges communication is dyadic and therefore should be reciprocal (Pagano and Ragan, 1992). To provide confidentiality, the service user in the incident will be known by the pseudonym of Sarah; the trust will be referred to as Trust A (NMC, 2015).
Case study
The incident was the first postnatal routine home visit to Sarah in the community. There was a midwife, student midwife, Sarah and her baby, partner and mother present at the incident. Sarah had a normal vaginal delivery of a live female infant. On entering the property it was evident that someone had been smoking in the house. Sarah's antenatal records revealed that Sarah and her partner were smokers. Her carbon monoxide (CO) screening had been recorded as 22 parts per million (ppm) and according to her records, Sarah had declined referral for smoking cessation services. The smoking status of Sarah at the time of delivery and in the postnatal records was recorded as an ex-smoker. The student midwife attempted to raise the issue of smoking when Sarah admitted that she and her family smoked within the house.
Upon raising the topic, it was apparent that Sarah was opposed to the conversation. She demonstrated a change in body language while avoiding eye-contact by looking down at her baby. This negative gesture of nonverbal communication could be interpreted as a lack of willingness to stop smoking or could have been a coincidence (Lorimer, 2014). Sarah may have experienced embarrassment from being aware of the risks of smoking to both her and her baby, potentially feeling judged by the student midwife. This also suggested that the student midwife and Sarah had different agendas. A lack of agreement on the agenda could lead to problems in developing a relationship between the woman and the student midwife.
Adolescence and smoking
Sarah was an adolescent, aged 19. According to HM Government (2010), women who are teenage mothers or are in lower socioeconomic groups are more likely to smoke during pregnancy. Social groups are formed in the adolescent years, and there can be a pressure to be accepted (Bowden, 2006). At this time, there can be experimentation, such as with smoking. Adolescents are nearly six times more likely to smoke during pregnancy than women over the age of 35 (PHE, 2014). There is a belief that smoking contributes to having a baby of a lower birth weight (less than 2500g), which may therefore cause an easier and less painful delivery (Bottorff et al, 2014; Flemming et al, 2014). In the UK, 1 in 14 babies are born with a low birth weight, leading to health problems in both the short and long term (HM Government, 2010). A baby with a low birth weight can develop circulatory conditions and dependent diabetes (Dunkley-Bent, 2006). According to Flemming et al (2014), smoking can also help prevent weight gain, which could be desirable to an adolescent under social pressure to be thin. Despite women being made aware of these risks, adolescents may not perceive them as risks, and instead view these problems as positive outcomes (Mackinnon, 2007), and associate smoking with pleasure and comfort (Flemming et al, 2014). The lack of smoking cessation services tailored to adolescent groups could be a barrier to women, preventing them from taking control of their health (Mackinnon, 2007; Borland et al, 2013).
‘Women often find that when reducing or quitting smoking alone, there is a change of relationship with their partner, which may include a loss of intimacy and a feeling of being socially separated from them’
Environment
The interaction took place in Sarah's home. Unlike a busy postnatal ward, the home environment allows privacy of conversations. However, a home environment still contains distractions (Brown et al, 2005). In this incident, the distractions included the presence of her family and baby, which could have impeded frank communication (Deane-Gray, 2014). Smoking was the social norm in Sarah's household, as both her partner and mother smoked. Having close relatives and a partner who smoke makes it more challenging for women to quit smoking (Fang et al, 2004; National Institute for Health and Care Excellence (NICE), 2010; Flemming et al, 2014). In an attempt to resolve the issue of her family affecting Sarah's willingness to quit smoking, advice on smoking cessation was provided by the student midwife to Sarah and her family. Women often find that when reducing or quitting smoking alone, there is a change in their relationship with their partner, which may include a loss of intimacy and a feeling of being socially separated from them (Flemming et al, 2014). The NMC (2016) states that midwives should promote health and wellbeing to all women and their families. However, Sarah could have been hindered from considering smoking cessation by the fact that smoking is a social norm in her household.
Risks of smoking in the postpartum period
The student midwife attempted to discuss the risks of smoking in the infant's environment with Sarah and her family. Smoking during the postnatal period can have adverse effects for the infant, such as an increased risk of Sudden Infant Death Syndrome (SIDS), as 21% of incidences of SIDS are a result of maternal smoking (Shah et al, 2006). Exposure of the infant to smoke in the postpartum period can lead to respiratory problems such as asthma, a greater risk of being overweight and neuro-developmental disorders (Banderali et al, 2015). If Sarah was already aware of the risks, yet had decided to continue smoking, the student midwife potentially bombarding her with this information could have caused Sarah to feel judged and disengage. Flemming et al (2014) found health professionals provided either too little or too much pressure for smoking cessation, resulting in women failing to quit smoking. The role relationship between a woman and the midwife should be that of equals.
Midwife–woman relationship
Building a relationship with women can be challenging. In the community setting, there are time pressures affecting the amount of time spent with each woman and therefore the amount of information that can be provided (Yelland, 2010). This can make women feel rushed and not listened to. In this incident, it was the first time both the midwife and the student midwife had met Sarah. Time constraints limited the duration of the meeting. A longer session would have benefited Sarah, and helped the midwife and the student midwife develop a relationship with her. Edwins (2008) found that women are experiencing a lack of continuity of care.
Without pre-existing relationships, Page (2014) states it is even more important for the health professional to build rapport with women, enabling a trusting relationship to be formed and reciprocated. This would allow women to respond to advice provided by midwives, creating a positive impact on their health and wellbeing. Price (2013) suggests that to build rapport with women, it is vital that midwives actively listen to women's concerns and responses instead of just providing information. This includes assessing body language. This was the case when Sarah changed her body language while discussing smoking cessation, which potentially may have lead to a breakdown in communication. If successful active listening had been achieved by the student midwife, it would have reduced the risk of misunderstanding (Deane-Gray, 2014). Kiger (1995) states that active listening involves being attentive, allowing the woman to feel listened to and understood through the use of nonverbal communication such as gestures, body language and facial expressions. According to Deane-Gray (2014), more than 65% of communication is nonverbal. Verbal communication only equates to 7% of the meaning that is being broadcast (Price, 2013). During communication, participants continually transmit both verbal and nonverbal cues while attempting to decode the other participant's cues (Pagano and Ragan, 1992). Losing eye contact with Sarah reduced the potential for active listening and successful communication.
Basics of communication approach
The student midwife was aware of Egan's (2002) SOLER principles, which assist in providing effective communication. The acronym SOLER stands for:
This is an aid which focuses on nonverbal communication (Stickley, 2011). In adherence with the SOLER acronym, the student midwife sat squarely in relation to Sarah during their interaction. The student midwife also had open body language, with her legs uncrossed, and arms to her sides, in order to appear more welcoming when communicating. According to the SOLER principle, leaning forward would have encouraged Sarah to believe that the student midwife was engaged and listening to her (Stickley, 2011). Despite the student midwife's open posture, Sarah's was closed, with her head down, looking away from the student midwife and cuddling her baby. The discussion between Sarah and the student midwife initially involved eye contact, which Sarah lost after the student discussed the risks of smoking. The student midwife was not relaxed during the conversation, as this was her first interaction where a household smelt of smoke. Stickley (2011) compared the SOLER principles to a new acronym, SURETY, which stands for:
As the student midwife followed the SOLER principles, sitting squarely to the woman, this could have caused Sarah to feel vulnerable, which could explain why eye contact was lost and there was a negative change in her body language (Stickley, 2011). The concept of sitting at an angle (Figure 1) makes the interaction comfortable, providing personal space. During the interaction, the student midwife did not touch Sarah due to the distance between them and judged it was not suitable to do so.
Local campaigns
In Sarah's local area, the amount of women smoking at the time of delivery is below the national average of 10.6% at 7% (PHE, n.d.). The statistics of this region may be below average because of the local government campaigns in place, including the ‘Love Your Bump’ campaign funded by the local council (2015). This campaign focuses on making women aware of the effects on the baby when both women and family smoke while the woman is pregnant, aiming for smoking cessation. This campaign is run within the local hospital, throughout the maternity ward and in leaflet form as part of the maternity notes.
In spite of such campaigns, there still seem to be potential pockets of deprivation where women continue to smoke at the time of delivery. The accuracy of the PHE statistics could be questioned, as women may be falsely reporting their smoking status (Khashan et al, 2010). This has been demonstrated in the case study in this article, as Sarah was recorded as a nonsmoker at the time of delivery when she was actually a current smoker.
To prevent the misreporting of smoking, a CO test enables an honest reading of levels of carbon monoxide within the body. Following NICE (2010), a CO reading either above 3 or between 6 and 10 parts per million should be referred to the National Stop Smoking Service (Smoke Free, 2016). This in itself shows the variation, and therefore confusion, of the guidelines for who should be referred. Women may feel the midwife does not trust them if they are asked to do a CO test, affecting the midwife's rapport with the woman. However, the explanation for the CO test could be delivered differently. O'Gorman (2011) suggests that the suggestion of the CO test should focus on how harmful CO exposure can be to women and their infants, and that this exposure can be from a faulty boiler, a type of machinery, or through smoking and second-hand smoke.
Smoking and breastfeeding
Sarah was breastfeeding during the incident but was considering artificial feeding. On request, following UNICEF UK guidance (2014), appropriate breastfeeding advice was provided by the student midwife to Sarah on positioning and attachment. Women who smoke are more likely to breastfeed for a shorter duration (Banderali et al, 2015). Flemming et al (2014) suggest this is due to the lack of advice provided to women of the risks of smoking and breastfeeding. Jones (2013) states that despite smoking, breast milk has far more benefits than formula and therefore should still be promoted. However, smoking cessation is still advised as nicotine, a chemical within cigarettes, inhibits prolactin levels, preventing the stimulation of alveolar cells to produce breast milk (Dunkley-Bent, 2006). Smoking cigarettes during lactation can also cause health problems for the infant. The level of nicotine found in breast milk is double than that of maternal serum (Banderali et al, 2015), and the metabolism of nicotine in infants is not known. Flemming et al (2014) state that breastfeeding provides a motive for smoking cessation for women with the idea that chemicals from smoking can affect the breast milk. An infant who is exposed to smoke is twice as likely to suffer from colic (Reijneveld et al, 2000). The infant may also suffer sleep disruptions, either a result of exposure to smoke or from levels of nicotine if breastfed (Banderali et al, 2015).
Guidelines
In the local Trust's antenatal guidelines, there is the option (where applicable) to offer nicotine replacement therapy (NRT) or referral for smoking cessation to women. However, the same Trust's postnatal guidelines only suggest that midwives make the woman aware of the increased risk of SIDS if the woman or her partner are smokers and are co-sleeping, with the requirement to refer for smoking cessation. According to NICE (2010), there should be help for women, their partner and family for up to a year after childbirth. It could be questioned whether there is as much focus on women remaining abstinent from smoking in the postnatal period as there is in the antenatal period. Flemming et al (2014) stated that health professionals were more involved in smoking cessation during pregnancy than in the postpartum period. This could relate back to the lack of continuity in the postpartum period in the community setting, and the lack of rapport between the woman and the midwife. Thyrian et al (2006) state that of the women who quit smoking while pregnant, 48% relapse within six months of delivery. Furthermore, up to 90% of women relapse one year after giving birth (NICE, 2010). This suggests that even though women know the risks of smoking during pregnancy, less are aware of the risks of smoking in the infant's environment. This could be because of a lack of education or through personal choice.
The role of midwives
The student midwife was not aware of Very Brief Advice (VBA), produced by the National Centre for Smoking Cessation and Training (NCSCT) at the time of the incident (Locker, 2012). VBA's process entails asking the smoking status of the woman, advising on how to stop and then offering help for smoking cessation. Using VBA enables those who decide they want support for smoking cessation to have the information provided, yet women who do not demonstrate interest are not provided with this information (Locker, 2012). After the midwife discussed the possibility of referral and what it involved, Sarah declined the referral.
It is the midwife's role to provide education and awareness of health promotion, improving the woman's health and wellbeing (Chief Nursing Officers, 2010). Midwives are an easily accessed health professional for women and their families and are able to provide information and education on health promotion and wellbeing (Manning, 2006). Similarly, Murphy (2013) suggests it is the midwife's role to provide information to empower women to make informed choices that improve their health. The Chief Nursing Officers (2010) suggest that midwives have a responsibility to recognise women who are at risk and may need information on a health promotion subject and potentially referral. The student midwife had identified that Sarah was at risk and needed to discuss the health promotion topic of smoking. As well as being an advocate for women, midwives should also broaden their teaching to the woman's partner and relatives, as this is the woman's social environment (Kiger, 1995; Chief Nursing Officers, 2010). The student midwife attempted to do this by discussing the risks of smoking with Sarah and her family.
Conclusion
This article has highlighted the lack of smoking advice within the postpartum period and what midwives should be providing for women during this time. To conclude, the interaction between the midwife, student midwife, and Sarah was partially successful. The student midwife was successful in knowing the limitations of her knowledge when discussing smoking cessation with Sarah. In the postnatal period, there are constraints restricting effective communication, particularly time constraints on midwives and a lack of continuity of care. Even though continuity of care could improve the communication and woman-midwife relationship, it is not always possible. The statistics for the local area being lower than the national average for smoking, it is not certain whether they are accurate or a demonstration of the success of local campaigns. Midwives' interaction with women enables health promotion to be provided to both the woman and the family, with family involvement being discussed to improve success rates for smoking cessation. Sarah did not accept referral for smoking cessation yet might have done so if the student midwife and midwife had followed some of the strategies discussed through this article, such as SURETY and VBA. The student midwife's awareness of these strategies can now improve any future interactions discussing smoking or other relating health promotion topics.