The adverse effects of smoking in pregnancy include miscarriage, ectopic pregnancy, stillbirth and birth defects (Royal College of Obstetricians and Gynaecologists, 2015). According to NHS Digital (2018), around 11% of pregnant women in England were known smokers at the time of giving birth in 2017/18, down from 16% in 2006/07. The Royal College of Midwives (RCM) (2019a) also noted that 15% and 16% of pregnant Northern Irish and Welsh smokers, respectively, continued to smoke in pregnancy, while in Scotland, 29.8% of pregnant women in the most deprived areas were smokers at booking, compared to 6.0% in the least deprived areas.
The guidance from the National Institute for Health and Care Excellence (NICE) (2010) for midwives to identify pregnant women who smoke and refer them to NHS Stop Smoking Services, from which they can opt out, is welcome. Midwives should ‘[a]ssess the woman's exposure to tobacco smoke through discussion and use of a carbon monoxide (CO) test. Explain that the CO test will allow her to see a physical measure of her smoking and her exposure to other people's smoking’ (NICE, 2010: 9).
However, according to the RCM, ‘almost 70% of Heads of Midwifery have reported that they are without a stop smoking specialist midwife’ (RCM, 2019b), and while Campbell (2017) records the determination of Public Health England (PHE) to eradicate smoking among pregnant women and NHS staff, he identifies a less emphatic approach from Janet Fyle, the RCM's professional policy adviser.
Fyle suggests that the NHS should acknowledge that some women, particularly those from deprived areas, smoke to relieve stress associated with imminent childbirth, and that: ‘We cannot ignore the psychological, social or economic circumstances of new mothers when developing strategies for how we communicate the risks of smoking and health care’ (Campbell, 2017). Similar views prompted a PHE official to deplore ‘a kind of misguided sympathy’ (Campbell, 2017).
Do ‘opt-out’ referrals in pregnancy to NHS stop smoking services work? Campbell et al (2016: 1) evaluated one UK hospital Trust that ran an ‘opt-in’ referral system, and found that ‘adding CO screening with “opt-out” referrals as women attended ultrasound examinations doubled the numbers of pregnant smokers setting quit dates and reporting smoking cessation.’ The authors concluded that ‘opt-out’ referrals with CO screening could greatly improve smoking cessation rates.
Another study found that monitoring CO motivated women to quit, that opt-out referral was acceptable and, ‘[w]hen linked to a professional discourse of caring and concern, the intervention prompted women to take action’ (Jones et al, 2018: 121). With such robust evidence, why is there a lack of stop smoking specialist midwives?
Given this context, Bowden (2019) asks, are we justified in introducing CO testing to encourage smoking cessation in pregnant women? Routine CO testing, argues Bowden (2019), doubts the ability of pregnant women to truthfully report whether they smoke, and may challenge their abilities to make good health choices for themselves and their future children. Bowden (2019) advocates supportive and empowering approaches to antenatal care as the most effective means of reducing rates of prenatal harm.
However, Jones et al (2018: 121) offer a telling insight: when women who continued to smoke or failed to meet appointments were given visual demonstrations of the adverse effects of CO on the fetus, ‘Most women accepted the need for this hard-hitting approach, and although distressing, they expressed gratitude for it.’
Nevertheless, successful application of the evidence highlighting the importance of smoking specialist midwives is unfortunately blunted if such health professionals are in short supply.