Save their babies - help them quit

Scientists around the world are unanimous: smoking during pregnancy is potentially deadly for the unborn baby. And health authorities can do more to help moms-to-be quit. IZELLE THEUNISSEN reports.

Quitting smoking before or during pregnancy is one of the most important steps a mom-to-be can take to make sure she delivers a healthy baby.

Research done at Tygerberg Hospital in Cape Town found that smoking during pregnancy was associated with an 8% increase in pre-term delivery and a three-fold increase in abruption placentae - a complication during pregnancy in which the placenta (which feeds the unborn child) prematurely separates from the wall of the uterus. These two conditions are the most common causes of death in unborn and newborn babies.

Even for mothers who are aware of these risks, giving up smoking is a terrible struggle. But fortunately, there's a glimmer of hope.

'Even a few minutes spent discussing smoking with a pregnant woman can mean the difference between another puff and kicking the habit,' says Ms Kathy Everett, a researcher in the MRC's Chronic Diseases of Lifestyle Research Unit. She bases her opinion on American research, which has found that a structured smoking cessation intervention of only 5- 7 minutes, using guideline procedures, can significantly improve cessation rates among pregnant women.

This would certainly suit South African health care workers in public health facilities, who are pushed for time and resources.

'At the moment the state health services don't have any policies or programmes to encourage pregnant women to stop smoking, or to provide them with the support they need. Basic information on the risks of smoking during pregnancy isn't even available,' she says.

Ms Everett is part of an effort by the MRC's Chronic Diseases of Lifestyle Research Unit (CDL) to develop such a programme and assess whether it is feasible to integrate it into routine antenatal care. The CDL unit's work focused on disadvantaged coloured women, as studies have shown that smoking rates during pregnancy are particularly high among this group (see box 1).

The unit has conducted surveys among the women, their midwives and their doctors to gauge their interest in a smoking cessation programme. Pregnant women (of whom 47% were still smoking and 15% had stopped during pregnancy) gave a clear endorsement for such a programme: 94% of them said that they would be willing to participate, and almost all the women felt that their midwives and obstetricians should play a central role.

Almost all (99%) of the midwives interviewed felt that educating their patients about the risks of smoking during pregnancy was within their scope of work. Most midwives reported that, although they did discuss smoking with their patients during the first antenatal visit, 58% of them said they didn't know enough while 24% reported not feeling confident about discussing it with the women.

In general, the midwives were open to receiving training in smoking cessation counseling. However, they were concerned about having increasingly little time to do health education because of the acute shortage of nursing staff in the public health sector.

The doctors interviewed also reported that they lacked the counseling skills needed to effectively encourage pregnant women to quit smoking. They also felt that the staff shortages in the public sector antenatal services left them with too little time and too high a stress level to provide the counseling. 'In general, we found that the current staff and budget cuts within the public health services leave doctors and midwives frustrated and too demotivated to tackle any new health education activities,' says Ms Everett.

So what does she recommend? 'I think the structured approach as outlined in the Clinical practice guideline for treating tobacco use and dependence (see box) could be very helpful. The intervention only takes a few minutes of the busy clinicians' time. Health care workers need training in these methods and we also need to convince them that this intervention can be effective. Even small increases in smoking cessation rates have clinical significance,' she says.

Dr Everett thinks health authorities also need to do their bit to ensure the success of the programme. 'Addressing the issue of smoking needs to become a standard of good practice within the health service. Obstetricians and midwives need opportunities to enhance their communication skills. Also, the authorities should provide self- help materials for pregnant smokers, tailored to their cultural background.

'I think it's essential that policy makers promote this intervention so that every pregnant smoker attending a public sector antenatal service receives appropriate information and support throughout her pregnancy.'

Fact file
Smoking during pregnancy raises the risk for:

• Low birth weight - babies born to smoking moms weigh (on average) 250 grams less than those born to non-smokers. This is because of intra-uterine growth restriction. The more and longer a mom smokes, the lower her baby's birth weight. This, in turn, puts the baby at risk for illness and early death.
• Abruptio placentae - this is a complication in pregnancy in which the placenta (which feeds the unborn child) prematurely separates from the wall of the uterus.
• Placenta previa - here the placenta is implanted in the lower part of the uterus (instead of the upper part), thereby obstructing the cervical opening to the vagina. This can cause bleeding late in pregnancy and a cesarean section might be necessary.
• Pre-term delivery.
• Stillbirth.
• Neonatal death - when a newborn baby dies within 28 days after birth.
• Sudden Infant Death Syndrome (SIDS) - when an apparently healthy baby suddenly dies during its sleep.

The 5 A's to help her quit
The Clinical practice guideline for treating tobacco use and dependence is structured in five steps. Each of these steps is designed to take about one minute of the clinician's time. Step 4 will take approximately three minutes. The steps are:

1. Ask - ask the patient whether she smokes. If she stopped before or when she found out she was pregnant, congratulate her and again stress the benefits of not smoking. If she's still smoking, proceed to ...
2. Advise - advise the patient to quit in a strong, personalised manner. Discuss the risk of smoking to the unborn baby and stress the benefits of quitting.
3. Assess - assess the willingness of the woman to quit within the next 30 days. If she is ready to quit, proceed to the next step. If not, give information to build motivation and confidence to make a quit attempt in future.
4. Assist - assist the patient by offering practical advice on quitting strategies, prompt her to seek support within her social circle (especially from her partner) and provide self-help materials.
5. Arrange - arrange for a follow-up contact where smoking status is reassessed and further support is given.