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Contents lists available at ScienceDirect

Women and Birth journal homepage: www.elsevier.com/locate/wombi

QUALITATIVE

Missed opportunities: A qualitative exploration of the experiences of smoking cessation interventions among socially disadvantaged pregnant women Jenni Gamble a,*, Julian Grant b, George Tsourtos a a b

Public Health, School of Health Sciences, Flinders University, Sturt Road, Bedford Park, South Australia, Australia School of Nursing and Midwifery, Flinders University, Sturt Road, Bedford Park, South Australia, Australia

A R T I C L E I N F O

Article history: Received 18 September 2014 Received in revised form 8 November 2014 Accepted 8 November 2014 Keywords: Smoking cessation Pregnancy Disadvantage Antenatal care Feminist inquiry

A B S T R A C T

Background and aim: Pregnant women who smoke are rarely consulted in the design and evaluation of the interventions that target them. In Australia, women will typically be counselled for smoking cessation as a part of routine antenatal care. However this approach achieves only modest rates of cessation. This study aimed to privilege the perspectives of women from low socioeconomic backgrounds who are most likely to smoke during pregnancy and who are less likely to quit spontaneously. Methods: Guided by feminist principles, in-depth interviews were undertaken with a purposive sample of six pregnant women, who resided in lower socioeconomic status areas in South Australia. Their experiences and views of being part of a smoking cessation intervention in metropolitan Adelaide were explored. Transcriptions were thematically analysed using an inductive approach and an open coding framework. Findings: An over-arching theme of ‘missed opportunities’ and four inter-related sub-themes encapsulated the predominantly negative experiences of the intervention for the women. The women’s interest in quitting was hindered by a didactic communication style employed by maternity care professionals. The participants’ information and support needs were reported as being superficially managed by maternity care professionals or Quitline workers who provided care in routine ways. Conclusions: These findings indicate that smoking cessation interventions and associated Quitline support needs to become more personalised and sensitive to the needs of women who face barriers posed by complex socio-economic disadvantage. These findings have important policy and practice implications for Australian public maternity care settings where smoking cessation interventions are embedded. ß 2014 Australian College of Midwives. Published by Elsevier Australia (a division of Reed International Books Australia Pty Ltd). All rights reserved.

1. Introduction Reducing smoking prevalence during pregnancy is a priority target in the Australian National Tobacco Strategy.1 Smoking in pregnancy is a significant public health issue because of the many serious adverse health effects for both mother and child. These outcomes include placental abruption and miscarriage for mothers, and, preterm birth.2,3 Pre-term birth is associated with

* Corresponding author at: Public Health, Flinders University, GPO Box 2100, Adelaide, 5001, South Australia, Australia. Tel.: +61 872218418. E-mail address: [email protected] (J. Gamble).

a low birth weight and is the leading cause of neonatal mortality.2 It is also responsible for up to half of all paediatric neurodevelopmental problems.2 Low birth weight is associated with poorer post-natal health outcomes (coronary heart disease, type 2 diabetes, and obesity) that can persist into adulthood.2,4 A key strategy to tackle maternal smoking are psychosocial interventions embedded into antenatal care that routinely identify women who smoke and counsel them to quit.5 There is clear evidence that these psychosocial interventions in pregnancy work, albeit with modest efficacy.2,5 These interventions are based on psychosocial theories of behaviour change, and use methods such as health education and counselling to motivate and support women to stop smoking.5 This approach has been widely adopted

http://dx.doi.org/10.1016/j.wombi.2014.11.003

1871-5192/ß 2014 Australian College of Midwives. Published by Elsevier Australia (a division of Reed International Books Australia Pty Ltd). All rights reserved.

Please cite this article in press as: Gamble J, et al. Missed opportunities: A qualitative exploration of the experiences of smoking cessation interventions among socially disadvantaged pregnant women. Women Birth (2014), http://dx.doi.org/10.1016/ j.wombi.2014.11.003

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in developed countries including United States, Canada, Australia, United Kingdom and New Zealand.5–8 The interventions are delivered by maternity care professionals and are often augmented with referral to Quitline for additional cessation information and counselling support for interested women.5,9 In Australia, Quitline is part of a national network of telephone smoking cessation counselling services. Evidence from the most recent systematic review of smoking cessation interventions in pregnancy shows that traditional approaches of information giving and advice about risks is not likely to be sufficient for pregnant women who smoke.5 Women are more likely to benefit from psycho-social interventions if: tailored for their needs, delivered positively rather than punitively, and supplemented with other psychosocial support strategies such as incentives and peer support.5 While reviews of interventions such as these demonstrate efficacy, they fail to consider contextual factors that could potentially improve their efficacy in reducing smoking among pregnant women.10 The impetus for current research is to improve the quality and effectiveness of interventions for pregnant women who are most likely to smoke and the least likely to quit, such as women from disadvantaged backgrounds.2,5,11–13 In Australia, as well as other developed countries, maternal smoking during pregnancy is strongly linked to disadvantage and lower socioeconomic status.14,15 For example in South Australia, nearly half (43%) of women who identified as smoking at the outset of antenatal care in pregnancy resided in geographic areas within the lowest quintile of the Social-Economic Index for Areas (SEIFA index) compared to just 6% of women living in the most advantaged areas.16 A further 23% of women resided in the next most disadvantaged SEIFA quintile. Clearly, developing effective interventions that target women who smoke during pregnancy and live in disadvantaged circumstances is important. To date, the evidence regarding behavioural smoking cessation interventions in pregnancy focuses heavily on quit rates as an outcome. This homogenising approach does not enable consideration of the complex contexts of women’s lives. The perspectives of pregnant women who reside in disadvantaged areas will contribute to ensuring that public health interventions are sensitive to the needs of the women they are targeting. It will also deepen the evidence base of what works in smoking cessation for particular population groups such as women from low socioeconomic backgrounds.14,17 Currently there is scant attention paid to the perspectives of pregnant women who smoke and are from socio-economically disadvantaged backgrounds about their experiences of smoking cessation interventions in the published literature. A critical review of the literature identified only a few international, qualitative studies that detail the views or experiences of smoking cessation interventions among socio-economically disadvantaged pregnant women.18–22 Several international studies exploring smoking cessation interventions in antenatal settings for women from disadvantaged backgrounds employed a collaborative client/ woman-centred approach tailored to the needs of the women.18–20 As a result the women felt more empowered to attempt quitting and the interventions were highly regarded by participants.18–20 Moreover, these studies showed that the communication style of the maternity care professional underpinned whether women felt well supported enough to contemplate quitting. A collaborative style meant that women felt empowered and not pressured to make changes.18–20 Conversely, a didactic, judgemental approach resulted in women minimising and under-reporting their smoking to avoid scrutiny and negative judgements in antenatal settings.21 Studies where disadvantaged women were canvassed for their thoughts on how cessation interventions could be more effective identified that it was essential understand and respect the context

of women’s lives.21,22 An additional oversight is that pregnant women who smoke are not often involved in the design and evaluation of smoking cessation interventions and services that target them. This study explores pregnant women’s experiences of smoking cessation interventions in order to improve cessation support. It is informed by post-structuralist feminist ideas. Post-structuralist feminism focuses on how issues of knowledge, power, difference, and discourse intersect and entwine in the lives of women.23 Poststructural theory proposes that knowledge and power are interdependent and contextual; created and sustained within human experience.24 Acceptance by society of power relationships is underpinned by the knowledge and practices, the discourses that support them.24 Recognising different meanings and developing new understandings of discourses can serve to disrupt and displace dominant or oppressive forms of knowledge.25 Feminist poststructuralism simultaneously pays attention to the descriptions of life, through the authentic yet mediated accounts of women’s lived experiences, as well as listening for the discursive, cultural and social forces that shape the conditions of possibility for those experiences.26 In this way feminist post-structuralism can highlight awareness to issues that underlie inequities in women’s healthcare. It pays close attention to language as a means for exposing un-questioned assumptions underpinning our concepts of truth and to produce and sustain inequitable and oppressive forces and institutions.24 This feminist stance carries an overt political agenda to poststructural theorising by addressing questions of ‘‘. . .how social power is exercised and how social relations of gender, class, and race might be transformed’’27(p20). In discussing smoking and pregnancy, pregnant women’s voices are often marginalised and silenced within the dominant, biomedical discourses of healthcare, and research and tobacco control. Pregnant women’s perspectives can provide an alternative and contributing discourse that can challenge the existing systems of knowledge and meaning that have gained status and currency as truth.24 In this study, the voices and language of a small group of socio-economically disadvantaged pregnant women are privileged, recorded, and analysed to create an alternative expression of the reality of smoking cessation interventions. The objectives of this study were to explore and describe the women’s: 1. experiences of smoking cessation intervention(s), 2. perceptions of smoking cessation intervention efficacy, and 3. views for improving smoking cessation interventions in pregnancy

2. Methods Feminist research has traditionally employed qualitative research methods and approaches because they privilege women’s voices and create alternative understandings of women’s lives and health.28 Additionally, the social justice dimension of qualitative methods brings the perspective of those who are often silenced to the fore.29 In this study, the perspectives of the most disadvantaged pregnant women were sought in order to learn more about improving smoking cessation interventions in pregnancy. Feminism is also an openly political and transformative process and feminist principles can be used where the aim is to catalyse change in healthcare practice.30 The feminist lens of this study aimed to identify the specific healthcare needs of a vulnerable group. It privileged the perspectives of socio-economically disadvantaged women to be heard for the explicit purpose of improving practice for the benefit of women.31

Please cite this article in press as: Gamble J, et al. Missed opportunities: A qualitative exploration of the experiences of smoking cessation interventions among socially disadvantaged pregnant women. Women Birth (2014), http://dx.doi.org/10.1016/ j.wombi.2014.11.003

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In-depth, face to face interviews were employed to facilitate understanding of the lived experience of the women.29 Semistructured interviews were undertaken by the first author, who has experience working in health and welfare with marginalised women. An interview guide was developed based on the objectives of the study and current literature. Typically, the interviews evolved throughout the process of interview and during the iterative process of analysing the data. Feminist research is concerned with power and authority inherent in the research process.32 Therefore, reflexivity, or the focusing in on the researcher’s ‘positionality’ within the research process is important to recognise, examine, and understand how the researcher’s own social background, and assumptions affect their research practice.32 The interviewer actively engaged reflexively with the women’s voices and perspectives. She declared her personal background and interests in the topic to the women. She also verified some of her tentative interpretations of their perspectives during the interviews by checking back with the women. Rigour in qualitative research relates to the ‘trustworthiness’ or quality of the inquiry.29,33 Rigour was enhanced by using first person accounts in interpreting and presenting the data. Transcripts of interviews were checked against the audio recorded interviews for accuracy. All the women in this study confirmed and validated that the transcripts reflected their perspectives and experiences.34 In addition, the rich descriptions in this study provide detail about the participants and the research setting, as well as the methods and processes that contribute to the trustworthiness of the study. This research received ethical approval from Flinders University Social and Behavioural Research Ethics Committee (SBREC approval number 6188) in August 2013. In addition, permission to undertake the study using Quitline data was gained from Cancer Council South Australia in July 2013. The women were also assured of anonymity by using pseudonyms in the findings, reassured that they could withdraw from the study at any time, and offered a referral for further support if necessary. 2.1. Participants The purposive sample included six women that matched the selection criteria of: smoking daily, being pregnant, experience of at least one health-worker-delivered intervention for smoking cessation during their pregnancy, and residing in a metropolitan area of Adelaide within the lowest quintile of the SEIFA index.35 Five women were identified and recruited from the South Australian Quitline client database. One woman was recruited opportunistically through another participant via snowball sampling and was not a Quitline client. For all other participants, a female Quitline counsellor experienced in qualitative health research, telephoned the women with an offer to participate in the study. Interested women were sent an information package about the research including consent forms for their consideration. Table 1 below depicts some background information about the women.

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2.2. Data collection The women who participated in this study were pregnant and socio-economically disadvantaged, and are considered a vulnerable group in terms of access and participation. The six women were interviewed and asked questions about their experiences of smoking cessation interventions in the context of their antenatal care, and any associated Quitline support. The interviews were arranged to be convenient and comfortable for participants. All women chose to conduct the interview in their homes. Care was taken to build rapport and trust with the women, both before, and during the 45–60 min interviews. This occurred over the course of two conversations. Firstly the interviewer telephoned the women to introduce herself and arrange the interview. Opportunities to build rapport were taken during this phase. Later, in the face to face context, the interviewer also took some time before the interview commenced to clarify the purpose of the study, answer any questions, share background information and discuss the goal for women’s inclusiveness in the research process. Women were also invited to choose their own pseudonym but none of the participants chose this option. During the interviews, the interviewer utilised active (reflective) listening skills to convey her genuine interest and empathy, and encouraged the women to share the narratives of their experiences. The interviewer’s clarifying questions and reflections confirmed that the women felt listened to and understood. Field notes were taken prior to and after the interview. In keeping with reflexive, feminist practice, the interviewer offered to share her own motivations for undertaking the study with interested participants. The interviews were recorded and transcribed by the first author. The transcripts were returned to the women for review in order to ensure accurate accounts of their interviews. All of the women were partnered with men, however only Dianna, Beth and Monique were living with their partner. All the women held a government health care card that entitled them access to lower cost healthcare and medicines. They all lived in public housing, including Briony, Michaela and Helen who were living temporarily with their parent(s). In South Australia, public housing is low cost rental accommodation provided to low income households by the state government. 2.3. Analysis Analysis involved an inductive, data driven approach. The themes were generated from the data using the six-step process described by Braun and Clark where no pre-existing coding framework is used.36 Familiarisation with the data involved reading and re-reading the data including both field notes and transcriptions. This process provided the initial open coding where data were named and given meaning. Coded transcripts were reviewed and preliminary themes were defined and refined several times after further re-reading the entire data set. This ensured that the women’s perspectives were genuinely represented. Agreement on labelling for most themes was reached through discussion

Table 1 Participant background information (pseudonyms have been used to protect the identity of participants). Pseudonyma

Age

Parity

Antenatal smoking interventions

Quitline

Smoking status at interview

Briony Helen Beth Michaela Monique Dianna

18 19 19 23 29 38

First baby (23 weeks) First baby (20 weeks) First baby (28 weeks) First baby (22 weeks) Third baby (35 weeks) Fourth baby (34 weeks)

2 2 2 2 1 1

No Referred Referred Referred Self-referred Referred

Quit – no support Smoking Smoking Smoking Smoking Quit – in last 4 weeks

a

Pseudonyms have been used to protect the identity of participants.

Please cite this article in press as: Gamble J, et al. Missed opportunities: A qualitative exploration of the experiences of smoking cessation interventions among socially disadvantaged pregnant women. Women Birth (2014), http://dx.doi.org/10.1016/ j.wombi.2014.11.003

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between the three analysts. A final thematic map consisted of one over-arching theme and four sub-themes. Using the fifteen point checklist of criteria for thematic analysis described by Braun and Clark,36 the findings of this study aimed to make sense of the data through analysis and interpretation rather than paraphrasing or describing. The analytic narrative is balanced with illustrative extracts that aim to convey an organised and clear story about women’s experiences of smoking cessation interventions. The researchers’ personal characteristics, agendas for change, professional expertise in smoking cessation, tobacco control and health promotion are inextricably bound to the interpretation of the women’s experiences.31 As such our perspectives as researchers are acknowledged where appropriate in line with the post-structural feminist principles of contextualising researcher assumptions to explicate notions of power, knowledge and difference.28 3. Findings 3.1. Missed opportunities The accounts of smoking cessation interventions from the women were imbued with a sense of the opportunities that were missed and this became the over-arching theme. Women aspired to quit, and were reaching out for: information, support to quit, and for respectful and collaborative partnerships with the professionals who worked with them. However, many opportunities were missed to provide women with the information and support they needed to make informed decisions about smoking and cessation during pregnancy. The interviewer noted this when interviewing and her field notes noted ‘‘if only Monique knew about NRT!’’ ‘‘Quitline not listening very well’’ . . . ‘‘Dianna could’ve done with more calls’’. The women invariably acknowledged and accepted the health risks associated with smoking in pregnancy. All the women described smoking using expressions such as a ‘‘risk’’ or ‘‘harmful’’ to the baby. Moreover, the women accepted that their maternity care professionals would or should raise the issue of smoking with them in order to discuss the risks. However, the women’s narratives were peppered with ‘‘I wish’’, ‘‘I would’ve liked . . .’’ These sentiments conveyed the idea that the women missed out, needed more, or that things could have been done differently. The women also had ideas for improving smoking cessation interventions and support services, suggesting that there were opportunities to do more for women who were considering smoking cessation in pregnancy. Four inter-related sub-themes of missed opportunities for ideal smoking cessation care and support: ‘Tell me something I don’t know’, ‘Feels like pressure’, ‘They judge too quickly’ and ‘What women want’. 3.2. Tell me something I don’t know Key opportunities for information sharing were often reported as being missed because the quitting information was reported to be filtered according to the maternity care professional’s or Quitline worker’s agenda. Women often heard what they already knew rather than what they wanted to know. For example, the women were clearly aware of the harm associated with smoking but despite their pre-existing knowledge, being ‘lectured’ to about the risks was not uncommon. Briony (aged 18) describes this experience in her first antenatal interaction with a general practitioner; ‘‘. . . it annoyed me a lot actually because I told him I am smoking but I’m giving up! And I know all the problems but he continued to

lecture me anyway. Even when I knew everything he was saying . . . But it’s his job! . . .’’ Moreover, the women’s interest and capacity to undertake behaviour change was complicated by the lack of comprehensive cessation information personalised to their needs. ‘‘Tell me something I don’t know’’ is a quote from Michaela, aged 23, who articulated very clearly that the experts like the midwives and Quitline workers she consulted had given her a great deal of advice and information about smoking cessation that she already knew. ‘‘. . . they just tell me stuff I already know and it’s like . . . well tell me something I don’t know!’’ A collaborative relationship where the women’s unique information needs were identified and fulfilled adequately was not evident in most women’s accounts of intervention. For example, the women’s accounts also readily identified that they needed more information about using pharmacotherapy (Monique, Michaela and Beth) and more personalised information about the effects of smoking on the foetus (Helen, Monique). For some women, smoking was not raised after their first antenatal visit when they may have been more ready to discuss smoking cessation (Beth, Dianna and Helen). 3.3. Feels like pressure Opportunities were also missed because of the pressure some women perceived. This pressure related to a didactic and authoritarian communication style from some maternity care professionals that underpinned the imperative that they should stop smoking. Michaela describes the stress she experienced that was associated with her first antenatal appointment with a midwife; ‘‘. . . but as soon as they start like . . . what feels like pressure . . . it just makes you want to have a cigarette even more.’’ The style of some maternity care professionals was reported to be coercive. Helen, aged 19, reported being hesitant about quitting because of a miscarriage that she related to quitting abruptly in a previous pregnancy. She said she raised these concerns at her first antenatal appointment but reported that her concerns were ignored, effectively dismissed by the midwife, who lectured her about the need to quit and insisted she accept a referral to Quitline. Helen describes this experience; ‘‘She actually sort of said she is going to give them (Quitline) my number pretty much . . .She didn’t exactly give me a choice really! . . . Yeah she was just like well I’m going to contact Quitline for you and ok . . . Yeah well I wasn’t really going to argue’’ Feelings of intimidation and coercion were also expressed by Michaela. She described these feelings about her interaction with the midwife at an antenatal appointment; ‘‘. . . Yeah, she just full, like full staring into my eyes . . .like penetrating . . . that’s what it felt like! Yeah . . .I was just looking at her . . . Her eyes were just locked on mine when she was telling me (referring to the harm to the baby from smoking) and I was just like . . . OK! I thought stop looking at me! . . . mmm . . . I was just like yeah OK! I really do want to quit!’’(Said in an exaggerated meek voice to convey her feeling of being cowed) This kind of pressure was expressed predominantly by the younger women in the study having their first baby. Briony, aged 18, Helen aged 19, and Michaela aged 23 were all troubled by the experience of an authoratively delivered lecture from maternity care professionals at their first antenatal contact. Briony described feeling ‘‘annoyed’’ at the ‘‘big rap from the doctor’’ and Michaela as

Please cite this article in press as: Gamble J, et al. Missed opportunities: A qualitative exploration of the experiences of smoking cessation interventions among socially disadvantaged pregnant women. Women Birth (2014), http://dx.doi.org/10.1016/ j.wombi.2014.11.003

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feeling the ‘‘pressure’’ from the midwife, while Helen described feeling ‘‘pushed’’. She agreed to a Quitline referral just to ‘‘get it out of the road’’. This kind of pressure and the resulting disempowerment meant that the opportunity was missed to build a respectful and collaborative relationship where the women could have their individual smoking cessation information and support needs met. 3.4. They judge too quickly The third theme, they judge too quickly reflected the opportunities that were missed for workers to understand and work with, the complexities of social disadvantage, addiction and the normalisation of smoking in the women’s lives. The women’s accounts indicated that the expectations, particularly from maternity care professionals, were that women should just quit. While all the women aspired to quit, only three had managed to do so at some stage in their current pregnancy. Monique’s outlook captures the weight of expectation and her sense of not being understood in her failure to stop smoking; ‘‘People’s perceptions that you smoke because you can’t be bothered or you are being selfish and it’s on a whole bunch of different levels, its such psychological and emotional mental things you’ve got to battle let alone being pregnant, it’s not a simple as putting down your pack of cigarettes and not having any more. I wish it was but it’s not, so people don’t, they judge too quickly.’’ The context of the women’s lives became more apparent through their accounts. The women articulated the stress of pregnancy itself as well as other daily burdens that were barriers to quitting. Smoking was a response to this stress. ‘‘I do have my times when I stress out too much and do have a cigarette.’’ (Beth) ‘‘I think pregnancy is a huge stress. . . a huge stress which is going to make you smoke even more.’’ (Michaela) The normalisation of smoking in the women’s lives was profound. Every woman had a partner who smoked and additionally most of their families smoked. Beth said she was the first woman in her entire family to attempt to quit during pregnancy. Dianna encapsulates the embedded nature of smoking in her life when she says that she managed to finally quit smoking . . . ‘‘only in the last month . . . but still it’s hard because my partner smokes, and the kids stress me out . . . it’s just like argh! . . . and then you go down town and there’s people smoking and it’s like argh! But I’ve got the spray (nicotine mouth spray) and everything’’ The context of the women’s lives, their level of addiction as well as the normalisation of smoking was not well considered by some maternity care professionals and Quitline workers. Dianna suggested that peer (group) support from ‘‘women who have been there and done that and know how hard it is actually is’’ would be a helpful for women like herself struggling to maintain abstinence.

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‘‘just put over to the Quitline’’ as Dianna reported. While the opportunity for extra support from the Quitline was valued, Dianna and Helen reported that they wanted more consistent and personalised Quitline support; for example, calls when they needed them, rather than being routinely contacted by the Quitline counsellor at scheduled times. Helen reported that the Quitline counsellor needed to be more sensitive to her needs stating; ‘‘When I first spoke to her (Quitline counsellor) . . . maybe if she turned around and said that she would call me in a couple of days . . . it might have helped rather than a couple of weeks. . . . Yeah I really did want to quit and if I had talked to her a bit more . . . trusted her a bit more then . . . when he (boyfriend) got locked up, well, I could’ve been already starting to quit and by the time he got locked up I would’ve been over the whole frantic stage . . .’’ Michaela said she ‘‘wished’’ she had more specific information tailored to her needs from her midwife; ‘‘I just wish she just told me what it could . . . that’s all I wanted to know . . . just what it could do to my baby if I continue smoking and then after that, it’s my choice.’’ Furthermore, a lack of consistent, evidenced based information and support about pharmacotherapy options were also clearly identified by the women. The women were confused by a lack of information or misinformation about using Nicotine Replacement Therapy (NRT) in pregnancy despite it being approved for use.37 Monique insisted that ‘‘the problem is, when you are pregnant you can’t take any nicotine replacement therapies’’. This was her belief after investigating her pharmacotherapy options with several sources including a pharmacist, her general practitioner and the Quitline. However she said ‘‘I wanted to give up but I can’t without those extra medical supports . . . but I can’t use them in the state I’m in’’. Beth concurred that pharmacotherapy was off-limits in pregnancy and was relying solely on Quitline for cessation support. However, she said that if there was ‘‘something that pregnant people could use . . . I would have definitely used that . . . there were times when I needed it’’. Conversely Dianna received information and support from a local pharmacist and successfully used a nicotine replacement product to quit. She had tried several types of NRT previously but settled on a new product and finally managed to quit at 32 weeks. She noted, ‘‘It’s hard without anything!’’ In addition to their experiences of intervention, the women’s views about alternative smoking cessation interventions or strategies were canvassed. Financial incentives for smoking cessation among pregnant women shows promise as an intervention approach.5,11 The women in this study were universally enthusiastic about financial incentives being helpful. Moreover, more intensive support options including face to face individual peer counselling and support groups were welcomed by the women, if not for themselves, then for other women struggling to stop smoking.

3.5. What women want

4. Discussion

What women want reflects the information and support participants desired but was absent from the interventions that they were involved in with both maternity care professionals and Quitline workers. The ideas in this theme represent what participants’ quitting experiences might look like if opportunities were not missed. The women wanted more openings for collaborative and respectful discussions with the maternity care professionals instead of being ‘‘rushed’’, as Helen stated, or simply

The findings indicated that opportunities were missed to give socio-economically disadvantaged women a better chance to achieve their aspirations of smoking cessation. For disadvantaged women, smoking cessation during pregnancy can be a window of opportunity for social progression and a ‘springboard to a healthier lifestyle’.38 For several women in this study it was the first time they had considered changing their smoking behaviour. Research shows that attempting smoking cessation is more likely during the

Please cite this article in press as: Gamble J, et al. Missed opportunities: A qualitative exploration of the experiences of smoking cessation interventions among socially disadvantaged pregnant women. Women Birth (2014), http://dx.doi.org/10.1016/ j.wombi.2014.11.003

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first pregnancy. The probability of quit attempts decline in subsequent pregnancies making antenatal interventions particularly important to catalyse change in marginalised groups.39,40 The women’s accounts identify some of the ways in which opportunities were missed for smoking cessation support in the antenatal setting and by Quitline. A didactic communication style that made women feel judged and disempowered, coupled with inconsistent information about smoking cessation options for pregnancy, are argued as barriers to optimal care. When the women perceived the communication as didactic, or one-way, they tended to experience the maternity care professional’s intervention or Quitline support more negatively; as unwanted advice, reflected in the theme ‘tell me something I don’t know’ and as intimidatory, reflected in the theme ‘feels like pressure’. Throughout both of these themes women also felt judged. ‘What women wanted’ was practical, personalised information and support delivered in a manner that suited their circumstances, and understood the complexities of their lives. While the women did not use the word ‘authoritarian’ in describing the approach used by the Quitline workers, a one-way communication style that presumed the women’s information and support needs was nevertheless evident. As a result some women (Michaela, Helen and Monica) discontinued using the service after feeling that the Quitline workers were not sufficiently responsive to their needs. The advice driven and time limited approach that some Quitline workers used when working with the women is at odds with best practice in counselling. An empathic, personalised approach to working with people is a fundamental component of the professional counselling relationship.41 This approach may have identified that the women in this study were attempting to stop smoking in particularly difficult circumstances and enabled workers to be more sensitive to each woman’s unique needs. A systematic review of qualitative studies exploring barriers to quitting smoking during pregnancy concluded that while women from disadvantaged backgrounds were largely aware of the health consequences of continuing to smoke during pregnancy, knowledge alone was not sufficient to motivate them to quit.40 The findings of this study concur by identifying a range of barriers to quitting including the influence of family and social networks, and the negative perceptions and/or experiences with the provision of cessation support. Some of the reasons that individual behavioural interventions may not as effective for pregnant women smokers from disadvantaged backgrounds may also be that interventions have the effect of being judgmental and alienate women and most importantly, that women perceive they are powerless to change the environmental factors that increase the risk of smoking and undermine quitting.10,39 Some of the women’s experiences in this study exemplified a judgmental approach and resultant alienation. Once a woman is alienated there is little opportunity to support the development of self-efficacy required for behaviour change. Further, the challenging style of some health workers can increase feelings of ‘defensiveness’ which in turn erodes self-efficacy.41,42 Yet within Australian maternity care settings, an authoritarian, educational communication style in relation to smoking, that is brief and focused on the ill-effects of smoking to the baby is common.43 For women in this study, an authoritarian, educational approach appeared to be at the expense of a more holistic or woman-centred view of health. This suggests that the women’s welfare was considered secondary to that of the foetus and that there was an expectation that women would put the needs of her foetus before her own. This implicit discourse of the ‘good mother’ who puts her own needs behind those of her children places additional, moralising pressure on women to conform to these expectations, and customarily causes discomfort and stress for women who cannot conform.44 Ideals about being a ‘good mother’

are imbedded in powerful discourses based on patriarchal assumptions that ascribe women’s value as vessels of reproduction and nurturing at the expense of the woman’s personhood.45 This notion of being a good mother was also imbued in the women’s accounts. Most women described the ‘risks’ to their baby from smoking and this underscored their aspirations to stop smoking and protect their baby. However, several of the women were struggling to stop smoking and felt the pressure of the implicit aspersions that cast women who continue to smoke in pregnancy as ‘bad’ mothers. This put the women in a difficult position. Monique felt that people ‘‘judge too quickly’’ and did not understand how difficult it can be to stop smoking. Helen said that she wanted to be ‘‘. . .like the best mum I can be’’. This ‘good mother’ discourse is entangled in another moralistic discourse pervasive in health settings; that is the individualisation of health risk behaviours. This discourse assumes that individuals should shoulder responsibility for risk factors and the behaviours that are associated with ill-health such as smoking, drinking alcohol and eating to excess,46 and that people ought to aspire to a healthy lifestyle.47 Moreover, it is further assumed that all people have equal control over their behaviour, regardless of socioeconomic and cultural factors.44,46 The narratives of the women in this study who had not managed to stop smoking reflected their desire to change and their aspirations to a healthier lifestyle and pregnancy. They highlighted the difficulties inherent in stopping smoking, making it clear that it was not their ‘‘choice’’ to continue to smoke. Monique said it was not that she could not ‘‘be bothered’’ or that she was ‘‘being selfish’’ for continuing to smoke but she felt it was impossible for her to stop without pharmacotherapy support. A moralising dimension of smoking cessation interventions for pregnant women in Australia is also likely to be commonplace. The ‘right’ of health professionals to be authoritarian and moralise about health issues is perpetuated through their disciplinary power.48 A discrete and separate body of knowledge is one of the key tenets of a group’s capacity to claim professional status, thus providing disciplinary power.49 Knowledge and power are inextricably intertwined whereby health and other professional workers are afforded power by virtue of society’s acceptance of their professional knowledge and the authority it confers.48 So when unquestioned discourses about being a good mother and personal responsibility for being healthy are layered together through information giving, it is possible to see how midwives and other health professionals understand themselves to be fulfilling their duty of care in relation to smoking cessation. Further, these discourses reinforce a belief that by giving women standardised information about risks and exhorting them to fulfil their duty as ‘good mothers’ and quit for the sake of their baby, that women will be sufficiently motivated to stop smoking. Interestingly, a didactic and authoritarian approach to working with pregnant women around any lifestyle factor, such as smoking is contradictory to the midwifery model of care that advocates a woman-centred, partnership approach where the woman’s needs and autonomy are paramount.43 This approach creates a sound foundation for a collaborative relationship where women can explore information about the risks of continued smoking in pregnancy and consider the possibilities for smoking behaviour change. As the majority of health professionals providing care to the participants were midwives, their approach raises concerns around the professional preparation and integration of care concepts within midwifery education. There is now increasing recognition that patient experiences in health care settings can contribute to disparities in use of services, adherence to treatment, and prevention strategies.50 The young women’s experiences of smoking cessation interventions in this study align with recent Australian research highlighting that perceptions of discrimination that included feelings of being

Please cite this article in press as: Gamble J, et al. Missed opportunities: A qualitative exploration of the experiences of smoking cessation interventions among socially disadvantaged pregnant women. Women Birth (2014), http://dx.doi.org/10.1016/ j.wombi.2014.11.003

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judged and being treated disrespectfully among pregnant women receiving antenatal care in public maternity settings were much higher for women under twenty-five and for those who smoked.50 This indicates a vulnerability to authoritarian approaches to smoking cessation interventions in maternity care settings for young women. More research is required to explore this possibility more thoroughly. The results of this study also raise questions about the current capacity of maternity care professionals to intervene on sensitive topics such as smoking. Health authorities grant health professionals the right and the role of intervening and attempting to influence pregnant women to change their behaviour and stop smoking.43 However, intervention requires skill and capacity on the part of health professionals to deliver health information in non-judgmental and enabling ways that supports women to make informed choices for themselves and their unborn child.51 For women who are already vulnerable through their youth and low socio-economic status, respectful and collaborative relationships with maternity care professionals are crucial to give young women the opportunity to discuss issues related to their pregnancy and its impact on their lives.52 These findings provide an impetus to midwives and other maternal health professionals to reflect on the values and attitudes they hold towards women who smoke in pregnancy and how they exercise their authority and power. Feelings of being patronised or judged only served to alienate the women from relationships with the professionals who are well placed to provide valuable information and support to them. The women’s vulnerability as young, disadvantaged pregnant women was reinforced and opportunities for their empowerment disabled through authoratively delivered interventions. These findings support other researchers who conclude that success depends less on any one type of intervention but rather the delivery of empathic, personalised smoking cessation support sustained over time and across different forms.53 As some contemporary midwifery educators suggest, a smoking cessation intervention should be more like a conversation; ‘‘. . . a dialogue; not a monologue’’ (p. 39) and congruent with midwifery models of empowering, holistic and women-centred care for women.43 Opportunities were also missed to assist the women who aspired to stop smoking due to the lack of clear, consistent information and support for smoking cessation in pregnancy. Quitting or reducing tobacco smoking is more difficult during pregnancy because nicotine is metabolised faster during pregnancy, hastening the experience of physiological withdrawal.43 Additionally, the women were contemplating cessation or attempting to quit in community and family environments where daily stressors were high and smoking was normalised, greatly increasing the difficulty of stopping smoking.38,54 Hence the need for unambiguous, expert information, and consistent support. However, the expectations by health professionals that women should quit, alongside the lack of information about cessation options, left women believing they had to rely on their own sheer determination or willpower to quit. The women invariably expressed frustration at the perceived lack of options or resignation that there was simply nothing left to try. In turn, their failure to successfully quit eroded their self-efficacy and left them feeling judged for failing to quit. It is not surprising then that the women in this study were also keen to increase the variety and intensity of support options. For example, the women were interested in broader pharmacotherapy options to support their smoking cessation. They were confused by a lack of information or misinformation about using Nicotine Replacement Therapy (NRT) despite its approval for use in pregnancy.37 This suggests the need for clearer guidelines about NRT use. Interventions in the antenatal settings invariably left

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women to discover the options for cessation for themselves. According to the women’s accounts, even Quitline workers varied considerably in their knowledge about NRT and specific pregnancy cessation options. Some of the options identified by the women as helpful have been endorsed with evidence that they contribute to improving the success of smoking cessation for pregnant women from disadvantaged backgrounds. These include peer support,5,18,19 financial incentives for cessation5,11 and subsidised pharmacotherapy.20 The findings from our study add to a broad consensus that the ‘one size fits all’ psychosocial intervention approach has limited efficacy, particularly for pregnant women from socio-economically and other disadvantaged backgrounds. For these reasons, there is a pressing need for more quality, tailored and targeted interventions that take account of women’s cultural, psychosocial and socioeconomic backgrounds.2,5 4.1. Limitations The sample group of women was relatively small and not recruited from the full range of public birthing settings in South Australia. While these qualitative findings offer important insights about why smoking cessation interventions may not be effective, they are not generalisable. In addition, the study would have been strengthened by following the women up after birth and devoting more time to data collection; encouraging the fullest spirit of a feminist research approach that is inherently unrushed and collaborative in nature. For example, the richness of women’s accounts of smoking cessation interventions may have been improved by a more overt feminist agenda of working collaboratively with the women for empowerment and change. It is also recommended that recruitment of women involve a wider range of maternity care settings to make any further study findings more relevant to context. 5. Conclusion This is the first Australian study to explore and describe in detail how smoking cessation interventions are experienced by socioeconomically disadvantaged pregnant women. It is recognised that there is a pressing need to increase smoking cessation among this group in order to address health disparities. The findings from this small study support feminist ideals of improving healthcare for women by illustrating that the aspirations of these pregnant women for smoking cessation can be easily undermined by interventions that lack sensitivity. These women’s experiences provide subtle yet significant insights about the importance of psychosocial intervention delivery that is aimed at changing their smoking behaviour. The results of this study illustrate the gaps and inconsistencies of smoking cessation information delivered to pregnant women. Therefore, consideration for policy and practice should be given to providing more personalised interventions and support that are sensitive and tailored towards the needs of socio-economically and otherwise disadvantaged women. Enhancing the capacity of maternity care professionals and any associated cessation support services, such as Quitline, to deliver more empathic and personalised information has the potential to improve both the experiences of pregnant women as well as cessation outcomes. Meaningful inclusion and consultation with pregnant women in the design and delivery of these public health interventions targeted at them will also ensure sensitivity to their needs. A key consideration for improving the quality of delivery of smoking cessation interventions is through the professional development of communication and counselling skills for maternity care professionals in public maternity settings where most

Please cite this article in press as: Gamble J, et al. Missed opportunities: A qualitative exploration of the experiences of smoking cessation interventions among socially disadvantaged pregnant women. Women Birth (2014), http://dx.doi.org/10.1016/ j.wombi.2014.11.003

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socio-economically disadvantaged women will access antenatal care. Empathic communication and counselling skills are congruent with midwifery competencies and values. Moreover these skills have utility for other health and lifestyle behaviours that impact on perinatal outcomes including other drugs and alcohol and obesity. Increasingly the maternity care workforce is being asked to intervene on these matters in the interests of public health. There are acknowledged barriers to translating research findings about interventions that promote smoking cessation in pregnancy into routine policy and practice.5 However, considering the views of pregnant women who reside in disadvantaged areas is likely to be important if smoking cessation programmes are to be effective for this target population. The development of customised smoking cessation programmes, in consultation with the pregnant women, would provide clearer, and more consistent information about quitting for disadvantaged pregnant women.

19.

20. 21.

22. 23. 24. 25.

26. 27.

Conflict of interest The authors declare no conflict of interest.

28.

29.

Acknowledgements

30.

This study was undertaken as a dissertation for Master of Public Health (Public Health Research). A very special thanks to the women who participated in this study for sharing their experiences and building knowledge of smoking cessation for pregnant women.

31.

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Please cite this article in press as: Gamble J, et al. Missed opportunities: A qualitative exploration of the experiences of smoking cessation interventions among socially disadvantaged pregnant women. Women Birth (2014), http://dx.doi.org/10.1016/ j.wombi.2014.11.003