Smoking cessation care during pregnancy: A qualitative exploration of midwives’ challenging role

ProblemThe majority of South Australian pregnant women who smoke do not quit during pregnancy. Additionally, the prevalence of smoking is higher among pregnant women living in socially disadvantaged areas.BackgroundUnderstanding challenges in midwives’ provision of smoking cessation care can elucidate opportunities to facilitate women’s smoking cessation.AimWe aimed to understand midwives’ perspectives on current practices, perceived barriers and facilitators to delivery of smoking cessation care, and potential improvements to models of smoking cessation care.MethodsAn exploratory qualitative research methodology and thematic analysis was used to understand the perspectives of midwives in five focus groups.FindingsFour themes were generated from the data on how midwives perceived their ability to provide smoking cessation care: Tensions between providing smoking cessation care and maternal care; Organisational barriers in the delivery of smoking cessation care; Scepticism and doubt in the provision of smoking cessation care; and Opportunities to enable midwives’ ability to provide smoking cessation care.DiscussionA combination of interpersonal, organisational and individual barriers impeded on midwives’ capacities to approach, follow-up and prioritise smoking cessation care. Working with women living with disadvantage and high rates of smoking, the midwife’s role was challenging as it balanced delivering smoking cessation care without jeopardising antenatal care.ConclusionProviding midwives with resources and skills may alleviate the sense of futility that surrounds smoking cessation care. Provision of routine training and education could also improve understandings of the current practice guidelines.     

My quitting stories: A qualitative study exploring Aboriginal women’s experiences of smoking cessation and preventing relapse in the context of pregnancy

BackgroundMost women who give up smoking during pregnancy relapse to smoking postnatally. Evidence on strategies that are helpful in maintaining smoking cessation during and beyond pregnancy is limited.AimThis paper aims to explore Aboriginal women’s experiences of quitting smoking, relapsing, and preventing relapse, focusing on the strategies they applied for attaining and maintaining abstinence and the support they received.MethodsQualitative interviews were conducted between October 2020 and June 2021, in urban New South Wales, Australia, with 12 Aboriginal women who either smoked tobacco or quit smoking and had been pregnant in the last five years. Aboriginal Research Assistants recruited participants, participated in data collection and data analysis. Data were thematically analysed.ResultsMajor themes that emerged from the data include: a) aspiration to be abstinent; b) strong mindset; c) strategies to stay smoke-free; d) supports received; and e) service and policy recommendations. Protecting children from second-hand smoke had salience for the maintenance of abstinence. Having a strong mindset was perceived as a prerequisite to staying smoke-free. Use of multiple coping strategies in combination was frequently expressed. Knowledge about tobacco-related harms, the way nicotine dependence works, and the available support options was empowering and enabled informed decision making and actions around smoking cessation.ConclusionThis qualitative study conducted with 12 Aboriginal women revealed that Aboriginal women employ multiple strategies (cognitive, behavioural and social) to quit smoking and stay smoke-free. The strategies warrant further exploration with different Aboriginal communities across Australia and consideration of inclusion in smoking cessation care.     

Women from migrant and refugee backgrounds’ perceptions and experiences of the continuum of maternity care in Australia: A qualitative evidence synthesis

BackgroundWomen who were born overseas represent an increasing proportion of women giving birth in the Australian healthcare system.ProblemWomen from migrant and refugee backgrounds have an increased risk of poor pregnancy and birth outcomes, including experiences of care.AimTo understand how women from migrant and refugee backgrounds perceive and experience the continuum of maternity care (pregnancy, birth, postnatal) in Australia.MethodologyWe conducted a qualitative evidence synthesis, searching MEDLINE, CIHAHL, and PsycInfo for studies published from inception to 23/05/2020. We included studies that used qualitative methods for data collection and analysis, that explored migrant/refugee women’s experiences or perceptions of maternity care in Australia. We used a thematic synthesis approach, assessed the methodological limitations of included studies, and used GRADE-CERQual to assess confidence in qualitative review findings.Results27 studies met the inclusion criteria, representing women in Australia from 42 countries. Key themes were developed into 24 findings, including access to interpreters, structural barriers to service utilisation, experiences with health workers, trust in healthcare, experiences of discrimination, preferences for care, and conflicts between traditional cultural expectations and the Australian medical system.ConclusionThis review can help policy makers and organisations who provide care to women from migrant and refugee backgrounds to improve their experiences with maternity care. It highlights factors linked to negative experiences of care as well as factors associated with more positive experiences to identify potential changes to practices and policies that would be well received by this population.     

The maternity experiences of women seeking asylum in high-income countries: a meta-ethnography

ProblemThe maternity care experiences and perinatal outcomes of women seeking asylum in high-income countries (HICs) are poorer than the general population of pregnant women in that HIC. There is a paucity of literature on the maternity experiences of women seeking asylum in HICs.BackgroundThere is an increasing number of women seeking asylum in HICs due to escalating violence and human rights abuses. Asylum-seeking women are a distinct group whom are likely to have different needs to refugees or migrants as a result of their undocumented status.AimThis literature review aimed to explore the emotional, physical and health information needs of women seeking asylum in the perinatal period in HICs, to provide insights to better address their maternity needs.MethodA meta-ethnography described by Noblit and Hare, was applied to analyse the studies, to reflect the voices of women seeking asylum, hosted in HICs in their perinatal period.FindingsEight studies were included in the review. The overarching theme was ‘just having to survive.’ Four sub-themes were revealed which highlighted the vulnerability of asylum-seeking women. They included: ‘I was never sure if I had understood’, ‘feeling ignored and alone’, ‘ongoing dislocation and recurrent relocation’ and ‘knowing there’s someone who cares for you’.DiscussionImproved maternity care for women seeking asylum requires culturally appropriate respectful maternity care and supportive strategies such as consistent access to language services.ConclusionIt is recommended that future research is targeted to explore the maternity experience of women seeking asylum in HICs, such as Australia.     

The needs of women and their partners regarding professional smoking cessation support during pregnancy: A qualitative study

BackgroundDespite the health risks of smoking, some women continue during pregnancy. Professional smoking cessation support has shown to be effective in increasing the proportion of pregnant women who quit smoking. However, few women actually make use of professional support.AimTo investigate the needs of women and their partners for professional smoking cessation support during pregnancy.MethodsSemi-structured interviews were held with pregnant women and women who recently gave birth who smoked or quit smoking during pregnancy, and their partners, living in the north of the Netherlands. Recruitment was done via Facebook, LinkedIn, food banks, baby stores and healthcare professionals. The interviews were recorded, transcribed and thematically analysed.Results28 interviews were conducted, 23 with pregnant women and women who recently gave birth, and five with partners of the women. The following themes were identified: 1) understanding women’s needs, 2) responsibility without criticism, and 3) women and their social network. These themes reflect that women need support from an involved and understanding healthcare professional, who holds women responsible for smoking cessation but refrains from criticism. Women also prefer involvement of their social network in the professional support.ConclusionFor tailored support, the Dutch guideline for professional smoking cessation support may need some adaptations. The adaptations and recommendations, e.g. to involve women and their partners in the development of guidelines, might also be valuable for other countries. Women prefer healthcare professionals to address smoking cessation in a neutral way and to respect their autonomy in the decision to stop smoking.     

Maternity health care: The experiences of Sub-Saharan African women in Sub-Saharan Africa and Australia

Background

Increasing global migration is resulting in a culturally diverse population in the receiving countries. In Australia, it is estimated that at least four thousand Sub-Saharan African women give birth each year. To respond appropriately to the needs of these women, it is important to understand their experiences of maternity care.

Aboriginal Wingadhan Birrang (woman’s journey) of smoking cessation during pregnancy as they participate in the ICAN QUIT in pregnancy pilot step-wedge trial

BackgroundAddressing smoking cessation during pregnancy among Aboriginal women is a national priority under the Closing the Gap campaign. There is a need to measure and report interventions to support Aboriginal women during pregnancy.AimTo quantitatively assess women’s smoking experiences over a 12 week ICAN QUIT in Pregnancy program.MethodsAboriginal women and/or women expecting an Aboriginal baby reported their smoking experiences through repeated cross-sectional survey at baseline, four weeks, and 12 weeks. Self-reported nicotine dependence measures (heaviness of smoking index, strength of urges and frequency of urges to smoke), intentions to quit smoking, quit attempts, use of nicotine replacement therapy were gathered as well as a carbon-monoxide measure at each time point.ResultsExpectant mothers (n = 22) of Aboriginal babies participated from six Aboriginal Community Controlled Health Services between November 2016 and July 2017. At 12 weeks women reported (n = 17) low heaviness of smoking index 1.21 with high strength of urges 2.64 and frequency of urges 3.00; 12/13 (92%) reported likely/very likely to quit smoking, made a mean 1.67 number of quit attempts, three women (13.6%) quit smoking (validated); 5/16 (31%) reported using nicotine replacement therapy.DiscussionParticipating women made multiple quit attempts demonstrating motivation to quit smoking. Smoking cessation interventions should be tailored to address high strength and frequency of nicotine dependence despite low consumption.ConclusionProlonged smoking cessation support is recommended to address physical, behavioural and psychological aspect of smoking. Cessation support should address previous quitting experiences to assess smoking dependence and tailoring of support.Trial registrationAustralian and New Zealand Clinicial Trials Registry (Ref #ACTRN12616001603404).     

‘No sugar’, ‘no junk food’, ‘do more exercise’ – moving beyond simple messages to improve the health of Aboriginal women with Hyperglycaemia in Pregnancy in the Northern Territory – A phenomenological study

BackgroundGlobally, rates of hyperglycaemia in pregnancy are highest among Indigenous women. The highest prevalence has been documented among Aboriginal women in the Northern Territory of Australia. Despite knowledge of this for over two decades, there has been very limited examination of the specific needs and experiences of Aboriginal women regarding this condition.QuestionHow do Aboriginal women with hyperglycaemia in pregnancy understand and experience this condition, and how can their care be improved?MethodsA phenomenological methodology underpinned semi-structured in-depth interviews with 35 Aboriginal women and seven health professionals across the Northern Territory. Data were inductively analysed.FindingsThe findings revealed that in general, participants in this study could recite simple health messaging regarding diabetes (e.g. ‘no sugar’), but many lacked in-depth knowledge and this affected the management of their condition. Nevertheless, many identified pregnancy as a powerful motivator for change, signalling scope to improve health messaging. Women consistently expressed the need for diabetes education that was culturally appropriate, a clear desire for maternity care that was family-centred, based on respectful relationships with the same care provider, and respected Aboriginal ways of knowing and being.ConclusionExisting health messaging around hyperglycaemia in pregnancy has limited reach with Aboriginal women in the Northern Territory. Reducing the burden of hyperglycaemia in pregnancy among these women requires a sustained commitment to redesign of maternity and diabetes care to incorporate the cultural and social context of women’s lives.     

Are pregnant women with asthma receiving guideline-recommended antenatal asthma management? A survey of pregnant women receiving usual care in Australia

BackgroundAsthma affects 12.7% of pregnant women in Australia. Key recommendations for asthma management during pregnancy include: 4–6 weekly review of lung function, medications, written asthma action plan, inhaler device technique, current asthma control and triggers; smoking cessation and vaccination advice. It is unknown if these key recommendations are provided to pregnant women with asthma in Australia.AimTo explore usual antenatal asthma management (usual care) in Australia and the inclusion of key recommendations.MethodPregnant women with asthma were invited to complete an online survey distributed in 2 antenatal clinics and via social media platforms from July 2017-Jan 2019.ResultsThe survey was completed by 142 pregnant women with asthma. 87(61%) were enrolled in an asthma management clinical trial and were therefore not receiving ‘usual’ care. Data presented is from 55(39%) women receiving usual care at survey completion. Of these women, 36% did not have their asthma reviewed during their pregnancy, 31% had a written asthma action plan, 11% had lung function assessed, 38% had an asthma medication review and 35% had their inhaler technique reviewed. 65% were not questioned about their asthma symptoms, 85% were not asked about asthma triggers, 96% were not given information about vaccinations and 95% did not receive smoking cessation information.ConclusionsOverall, the key recommendations for antenatal asthma management were not always provided for this sample of pregnant women receiving usual care. Improved knowledge and implementation of these key recommendations by health professionals may alter this situation and improve maternal and infant outcomes.     

Developing a best practice model of refugee maternity care

BackgroundAbout one third of refugee and humanitarian entrants to Australia are women age 12–44 years. Pregnant women from refugee backgrounds may have been exposed to a range of medical and psychosocial issues that can impact maternal, fetal and neonatal health.Research questionWhat are the key elements that characterise a best practice model of maternity care for women from refugee backgrounds? This paper outlines the findings of a project which aimed at developing such a model at a major maternity hospital in Brisbane, Australia.Participants and methodsThis multifaceted project included a literature review, consultations with key stakeholders, a chart audit of hospital use by African-born women in 2006 that included their obstetric outcomes, a survey of 23 African-born women who gave birth at the hospital in 2007–08, and a survey of 168 hospital staff members.ResultsThe maternity chart audit identified complex medical and social histories among the women, including anaemia, female circumcision, hepatitis B, thrombocytopenia, and barriers to access antenatal care. The rates of caesarean sections and obstetric complications increased over time. Women and hospital staff surveys indicated the need for adequate interpreting services, education programs for women regarding antenatal and postnatal care, and professional development for health care staff to enhance cultural responsiveness.Discussion and conclusionsThe findings point towards the need for a model of refugee maternity care that comprises continuity of carer, quality interpreter services, educational strategies for both women and healthcare professionals, and the provision of psychosocial support to women from refugee backgrounds.     

Experiences and needs of women from ethnic minorities in maternity healthcare: A qualitative systematic review and meta-aggregation

ObjectivesTo consolidate the available evidence around ethnic minority women’s experiences and needs when accessing maternity care.MethodsA qualitative systematic review and meta-aggregation of qualitative data were conducted. Nine electronic databases were searched for qualitative or mixed-methods studies from the inception of each database until January 2022. Using the Nested-Knowledge software, meta-aggregation was conducted according to the Joanna Briggs Institute (JBI) data synthesis approach to identify all potential intersections between different themes. Methodological quality of included studies was assessed using the JBI Qualitative Assessment and Review Instrument (JBI-QARI) and the mixed-methods appraisal tool (MMAT) checklists for qualitative and mixed-methods studies, respectively.ResultsTwenty-two studies (nineteen qualitative and three mixed-methods) were included. All studies were of good methodological quality. An overarching theme ‘the struggles and fears of ethnic minority women’ was identified. The negative experiences with maternity care were attributed to barriers including ineffective communication, cultural and religious insensitivity, inattentiveness and disregard for women’s needs, and isolation-related impact due to the COVID pandemic.ConclusionsOverall, our review highlighted several significant gaps between the care provided and the expected care among ethnic minority women accessing maternity care services. This mismatch between their expectations and care resulted in negative experiences, as the women reported being discriminated against and disrespected. There is an urgent need to develop and implement maternity care policies that are inclusive of needs of the ethnic minority women to optimize their maternity care experience.     

Remote access and care: A comparison of Queensland women's maternity care experience according to area of residence

BackgroundThis study fills a gap in the literature with a quantitative comparison of the maternity care experiences of women in different geographic locations in Queensland, Australia.MethodData from a large-scale survey were used to compare women's care experiences according to Australian Standard Geographical Classification (major city, inner regional, outer regional, remote and very remote).ResultsCompared to the other groups, women from remote or very remote areas were more likely to be younger, live in an area with poorer economic resources, identify as Aboriginal and/or Torres Strait Islander and give birth in a public facility. They were more likely to travel to another city, town or community for birth. In adjusted analyses women from remote areas were less likely to have interventions such as electronic fetal monitoring, but were more likely to give birth in an upright position and be able to move around during labour. Women from remote areas did not differ significantly from women from major cities in their satisfaction with interpersonal care. Antenatal and postpartum care was lacking for rural women. In adjusted analyses they were much less likely to have booked for maternity care by 18 weeks gestation, to be telephoned or visited by a care provider in the first 10 days after birth. Despite these differences, women from remote areas were more likely to be breastfeeding at 13 weeks and confident in caring for their baby at home.ConclusionsFindings support qualitative assertions that remote and rural women are disadvantaged in their access to antenatal and postnatal care by the need to travel for birth, however, other factors such as age were more likely to be significant barriers to high quality interpersonal care. Improvements to maternity services are needed in order to address inequalities in maternity care particularly in the postnatal period.     

The perceptions and practices of Thai health professionals providing maternity care for migrant Burmese women: An ethnographic study

BackgroundAcross the globe, many women including economic and humanitarian migrants receive inadequate antenatal care. Understanding the difficulties that migrant women encounter when accessing maternity care, including the approach of health professionals, is necessary because inadequate care is associated with increasing rates of morbidity and mortality. There are very few studies of migrant women’s access to and experience of maternity services when they have migrated from a low- to a middle-income country.AimTo examine the perceptions and practices of Thai health professionals providing maternity care for migrant Burmese women, and to describe women’s experiences of their encounters with health professionals providing maternity care in Ranong Province in southern Thailand.MethodsEthnography informed the study design. Individual interviews were conducted with 13 healthcare professionals and 10 Burmese women before and after birth. Observations of interactions (130 h) between health care providers and Burmese women were also conducted. Data were analysed using thematic analysis.FindingsThe healthcare professionals’ practices differed between the antenatal clinics and the postnatal ward. Numerous barriers to accessing culturally appropriate antenatal care were evident. In contrast, the care provided in the postnatal ward was woman and family centered and culturally sensitive. One overarching theme, “The system is in control’ was identified, and comprised three sub-themes (1) ‘Being processed’ (2) ‘Insensitivity to cultural practices’ and, (3) ‘The space to care’.Discussion and conclusionsThe health system and healthcare professionals controlled the way antenatal care was provided to Burmese migrant women. This bureaucratic and culturally insensitive approach to antenatal care impacted on some women’s decision to engage in antenatal care. Conversely, the more positive examples of woman-centered care evident after birth in the postnatal ward, can inform service delivery.     

Why do women continue to smoke in pregnancy?

Smoking during pregnancy not only impacts on the woman's health but that of her unborn child. Women most likely to continue smoking throughout pregnancy are generally of lower age, socio-economic status, level of education and occupational status. Women who continue to smoke during pregnancy often feel criticized by society. They feel guilt and personal conflict at not quitting. Lack of long-term positive outcomes from anti-smoking campaigns may result form ignorance surrounding socio-economically disadvantaged women's life circumstances. Current interventions often ignore the emotional and psychological stressors associated with pregnancy; they do not address the altered physiological processes that occur during pregnancy. A review of the literature pertaining to women who smoke throughout pregnancy is presented. Women want an individualised approach to smoking cessation advice, with health care workers having knowledge of the woman's social situation and viewpoints. This paper reveals that the woman's perspective has largely been ignored. Indeed health care professionals have attempted to manipulate women to stop smoking rather than engage in mutually respectful dialogue.