This report aims to discuss the purpose of Public Health England (PHE) and the short- and long-term implications of smoking during pregnancy and childhood. Besides, it will explore the role of the midwife in health promotion, the parent-infant attachment in correlation to local and national guidelines and communication strategies that influences behavioural changes.
Government Agenda
Public Health England (PHE) is a government agency within the UK; the main purpose of PHE is to protect and improve the nation’s health and wellbeing. They thrive to reduce inequalities through working with the National Health Services (NHS) and local authorities to implement and deliver specialist services to improve the health of the general public (Public Health England, 2019).
The publication of Public Health Outcomes Framework (2013) put in place new direction for the health care system with an importance on ‘improving and protecting the nation’s health while improving the health of the poorest fastest this links with the NHS outcome framework who place great emphasis on preventing premature death and treating and caring for people in a safe environment and protecting them from avoidable harm. PHE uses indicators to examine trends within the public health through data collection, which is carried out every three years, these indicators divided into four domains.
Domain 1: Improving the wider determinants of health
Domain 2: Health improvement
Domain 3: Health protection
Domain 4: Healthcare, public health and preventing premature mortality
Domains 2 and 4 are indicative in the implementation and provision to influence and combat smoking in pregnancy. Domain 2 place great emphasis on supporting people to make a healthy lifestyle choice to reduce inequalities such as low birth weight of term babies, breastfeeding, smoking prevalence and smoking status at the time of delivery. While domain 4 aims to reduce people living with preventable ill health and premature deaths by improving the health outcome of babies first year of life through antenatal and neonatal intervention service delivered by local authorities support mothers with socioeconomic background and health behaviour that can impact the infant health. The national ambition by 2020 is for a smoke-free generation where the prevalence of smoking to 5% or below and that all pregnancy is smoke-free (Department of Health, 2017). The public health strategy 2020-2025 seen in (appendix 1) aim to promote a smoke-free society and a healthy start in life. According to better births care bundle( Cumberlege (2016), early intervention is key the reducing incidence of smoking in pregnancy and gap inequality to improve health outcome by reduction stillbirth caused by smoking in pregnancy. Public health England aims to reduce smoking in pregnancy 6% by 2030, through collaborative working on a national and local level to renovate and improve maternity care and bring about safe equity of care for all and provide more opportunities to access services. (Department of Health, 2017; NHS Improvements, 2017; Public Health England, 2019a; The Royal College of Paediatrics and Child Health, 2017).
Smoking is defined as the act of inhaling and exhaling the fumes from tobacco products (Rose & Hilton, 2020). Smoking is seen as a major contributor in ill health and death, it is reported that smoking contributes to an estimated 489,300 hospital admissions and an estimated 77,900 deaths per year (Office for National Statistics, 2019).
Smoking is also linked to inequality and poor health outcomes and yet 10.4% of women smoke at the time of delivery (Office for National Statistics, 2019). Smoking and inequalities are codependent as smoking is more common in people from a low socioeconomic background World Health Organisation (2014), people who suffer from mental health are more likely to smoke Mental Health Task Force (2016) and that children are likely to smoke if their parents smoke (National Health Service, 2017). Smoking harms health as smoking is associated with increased risk in heart attacks, it’s the leading cause of lung, stomach, mouth and throat cancers, causes fertility issues in men and women, causes brittle bone and osteoporosis in women and increases the chance of having a stroke by 50% this can be seen in (appendix 4) (National Institue for Health and Care Excellence, 2014) . Smoking in pregnancy is said to cause 2200 premature births, 5000 miscarriages and 300 perinatal death each year (Smokefree Action, 2017). Additionally, it is contagious behaviour and are often seen higher amongst those from deprived socio-economic background.
Smoking during pregnancy and childbirth and its effects
It is well evident that smoking in pregnancy negatively impacts maternal and foetal health, as smoking is associated with increased risk of stillbirth, placental abruption, miscarriages, ectopic pregnancies, low birth weight and preterm birth (Royal College of Physicians, 2013). It has been found that mothers who smoke were likely to experience deep vein thrombosis, stroke, pulmonary embolism, myocardial infarction and are 15 times likely to have bronchitis. (Roelands et al,. 2009).
Maternal smoking is found to increase the risk of paediatric cardiovascular mortality to the offspring Leybovitz-Haleluya (2018), having a child with cleft lip and pallet Barbosa (2015), poorer outcomes in children and higher risk for neurological related hospitalisation and attention deficit hyperactivity disorder (ADHA) (Gutvirtza et al. 2019). Animal studies conducted by Xiao (2007) demonstrated that nicotine increase vascular resistance and decrease uterine blood flow and that prolonged exposure to nicotine can disturb brain development. Other studies have identified that smoking during pregnancy is linked with sudden infant death syndrome Shah (2006), childhood obesity von Kries (2002) and childhood asthma (Neuman et al. 2012). According to the Royal College of Obstetricians and Gynaecologists (2015), maternal smoking attributes to 1/3 of stillbirth and neonatal deaths.
The role of the midwife in promoting Health, parent-infant attachment and how communication strategies can elicit change in behaviour
Midwife role
Pregnancy is regarded as a teachable period and during this period midwives and maternity services play an important role in the health and social care of the pregnant woman and her family. Midwives are the first point of contact for the woman and her family during pregnancy and research suggest that women are more receptive in behavioural changes (Murin et al. 2011). Its is therefore essential that midwives provide evidence-based information to educate and support women to make informed choices about their healthcare and wellbeing. such as smoking cessation. It is the duty of all health professional from preconception to motherhood to promote effective healthcare (PHE, 2019b). However, there are specific guidelines detailed in the PHOF (2013) that outlines the midwife involvement in the reduction of health inequalities by helping people to make healthy choices, the prevention of premature mortality and reducing the gap between communities.
According to the NMC (2018), the midwife’s role is to provide person centre evidence-based care, to act as advocates to the woman and her family and cater to her physical, social and psychological wellbeing. Therefore midwives should be knowledgeable about the health and social care need of the local community, have a good understanding of the local health and social care system and be vigilant in the identification of women at risk and act quickly and appropriately in supporting her and her family to access the necessary services (Chief Nursing Officers of England, Northern Ireland, Scotland and Wales, 2010). The midwife’s role is therefore embedded in Public Health as they aid in addressing inequalities by working in a multidisciplinary team to provide education, awareness and wellbeing to the woman and her family. It is therefore vital that the midwife can identify women at risk of smoking during pregnancy and refer promptly, according to NICE (2010) every woman should be offered CO2 testing at booking and every subsequent appointment and a referral made when necessary. Also, she should be provided with information on the benefits of stop smoking as well as the effect smoking has on herself and unborn child in a person-centred approach.
The current approach in supporting women to stop smoking in pregnancy depicted in (appendix 6); NICE (2019) explains the importance pregnancy women smoking status via CO2 testing; referring made to stop smoking service; where clear consistent person-centred care is provided by trained stop smoking advisor to women and her family to assess and address social care need and provide the right avenue to stop smoking whether non-pharmacological or pharmacological ie the use of Nicotine replacement therapy or cognitive behavioural therapies. Data obtained by non-stop smoking service reports that 44% of pregnant women who set a quit date done so successfully and that 63% of all pregnant women who quit smoking were confirmed via CO2 monitoring (NHS Digital, 2020). There is no specific guideline on smoking in pregnancy at Trust A, however, they do follow NICE (2010) in CO2 and refer women to non-stop smoking service where appropriate but CO2 testing is not routinely carried out at every appointment.
It is well evident that the quality of care women receive from maternity service during pregnancy and the perinatal period greatly influences the life chances of babies, especially those with complex needs like smoking (Zeitlin et al., 2009). However, maternity services are struggling and incapable of providing the level of care needed due to lack of funding, workforce and pay caps resulting in many women having little or no access to the support they need; according to a survey conducted by The Royal College of Midwives ( 2018), there is a shortage of 3500 midwives in England and some maternity unit report closure for 10 or more times on occasions.
Anderson (2018) reports that about 40% of local authorities in England are cutting stop smoking services, underfunding in these services reduces the support midwives has in encouraging safe pregnancies as there is little or no services to refer women. This can be observed in areas where access to stop smoking services are limited compared to those that are not. There are over 300 non-stop smoking services in Hertfordshire and Hertfordshire health improvement service (2019) offer pregnant women the chance to quit smoking from 12 weeks and if they attend the full programme and quit smoking they receive £300 shopping vouches compared to Norfolk where there is no incentive and non-stop service are not easily accessible in all areas see (appendix 2). This can be observed in smoking status at delivery which 6.3% in Hertfordshire compared to 13.4% in Norfolk see (appendix 3). This was echoed in a meta-analysis which concluded that financial incentives decrease the number of women smoking in late pregnancy (Chamberlain et al. 2017).
Communication strategies
Evidence has shown that women are more receptive to change in behaviour if midwives take a non-judgemental approach (Grice & Baston, 2011). The midwife should utilise every encounter were possible to build a trusting professional relationship through effective and sensitive communication to influence the quality of interaction between self and woman (Allison, 2012). Making every contact count (MECC) is an evidence-based method introduced by public health to improve people health and wellbeing by encouraging a change in behaviour through competent and confident healthcare worker, MECC engage people in conversation about addressing risk factor such as smoking ( (PHE, 2018)). This approach is a requirement of NHS contracts and is embedded in NHS long term plan (2019) which places great importance on increasing available support to enable people to manage and improve their health whilst enabling that behavioural intervention is accessible to all.
Piper (2005) behaviour change agent suggest change through education, where the midwife uses health education to empower the individual to be more motivated and responsive to change. Other evidence suggested that motivational interviewing, cognitive behavioural support and structured self-help and support from evidence-based stop-smoking services support pregnant women to quit smoking (NICE, 2010; NICE 2018a; NICE 2018b). However, it has also been established that Stigma from friends, family, strangers and health professionals may lead to hidden smoking habits (Grant et al. 2018). Therefore conducting CO2 testing for all women ensure that everyone is screened, smoking status confirmed and appropriate support is provided. This posses a barrier to women obtaining evidence-based support to stop smoking. McAndrew (2012) found that women from a deprived area and low socioeconomic background are more likely to smoke in pregnancy compare to people of less deprived. This coincides with (Grant et al. 2018; Mental Health Task Force, 2016; NHS England, 2019).
Parent infant attachment
The midwife plays a vital role in infant feeding choices and close relationship building as they are the initial point of contact for pregnant women and their families (Murin et al. 2011). Midwives must adhere NMC (2018) which dictates that the woman and her family first must be supported with evidence-based information enabling her to make informed choices about herself and her baby’s health. Midwives are encouraged to comply to the BFI standards with regards to skin to skin contact, relationship building, encouraging a close and loving relationship and having structured programmed to encourage and support breastfeeding (UNICEF, 2013). Having a meaningful conversation antenatally and postnatally encourages a parent to create a bond with their baby; antenatally stroking and talking to bump aid in fetal brain development and postnatally being close and responding to cues and cuddling provides comfort and calmness to baby and parent (NICE 2018a; NICE 2017;UNICEF, 2013 ).
There has been a wealth of evidence that suggests keeping baby close and provide skin to skin contact is essential in initiation of breastfeeding and maintaining of breastfeeding, keeping mother and baby calm, it aids in having and maintaining a close relationship (Moore et al. 2016). This was reiterated by Crenshaw (2014) who suggests it best practice to keep mother and baby close. It is evident that having a close mother-baby relationship aid in neurological, emotional and physical development as evidence suggests that early and often interaction between parent and child provide has a positive impact on their development Gerhadt (2014) while Moore (2017) found that children who had less physical contact were more distress as an infant and underdeveloped for their age. This stresses that 1001 critical days (2015) is essential as the initial experience in a baby's life shape the social and emotional development.
Breastfeeding is known to provide beneficial health outcomes for the infant and their mothers and it vital that midwives inform the mother about the benefits as the component of breast milk protects the infant as it contains growth factor that aid in growth and development of the baby's gut, it has enzymes that aid in digestion and destroys bacteria, it contains viral fragments that help to develop the infant immune system, it contains antibodies of mother pass infections and hormones that support baby's immature immune system (UNICEF,2013). In the mothers breastfeeding for less than 12 months significantly reduce the risk of breast and ovarian cancer (Chowdhury et al. 2015; UNICEF UK, 2012). Also, the longer and greater number of children and breastfeeding for a little at 3 months is associated with a reduction in the risk of ovarian cancer (Li et al. 2014; Luan et al. 2014; Modugno et al. 2019).
Maternal smoking is also associated with asthmas incidence in children and adolescence Thacher (2014), however, breastfeeding for as little a four months is known to reduce the risk of asthma (Scholtens et al . 2009). This has been observed in (Appendix 6) as hospital admission due to asthma was higher in areas that were worst off or more deprived highlighted in red. It is recommended that mother continue breastfeeding if they smoke as the level of nicotine that in breastmilk decline significantly after 30 mins of smoking (Calvaresi et al. 2016). Stopping smoking before or during pregnancy decreases the risk of infant mortality, stopping early attributes to the greatest benefits for the child and stopping at any period results in health improvements (The Royal College of Paediatrics and Child Health, 2017). Interestingly, breastfeeding alone could save the NHS £21 million and eliminate illness (UNICEF UK, 2012).