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EDITORIALS: Rona Campbell and Deirdre J Murphy Smoking in pregnancy BMJ 2009; 338: b2188 [Full text]

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Smoking During Pregancy: the dilemma persists

Uki A. Atkinson   (25 June 2009)

Smoking in Pregnancy

Ekaete F Asuquo   (29 June 2009)

Smoking During Pregancy: the dilemma persists 25 June 2009
Uki A. Atkinson, Junior Research Fellow UWI School of Nursing Send response to journal: Re: Smoking During Pregancy: the dilemma persists	Dear Editor, The thoroughly researched and documented effect(s) of tobacco-smoking during pregnancy on the unborn fetus is an area of vital importance and I thank you for bringing it to the fore once again. Despite the numerous interventions and media campaigns, obstetricians and midwives world-wide continue to focus their efforts on encouraging pregnant women to stop smoking. Is it that we underestimate the complex issues behind the choice to persist smoking in the face of gentle prodding, sound advice or forceful evidence? Research has suggested that factors such as age of the expectant mother, education, poverty, whether her partner smokes and having the “addictive” gene that predisposes some people to heavy smoking all affect a woman’s ability to quit smoking during pregnancy. These are multifaceted issues which in my opinion, are difficult to address during regular antenatal visits with providers of prenatal care. I note the findings from the systematic review quoted in your editorial and disagree with the notion that the ineffectiveness of mid- wife led interventions to reduce maternal smoking could be due to reservations about addressing the issue while attempting to build rapour with clients early in their pregnancy. It borders on suggesting that midwives rank the importance of good client relations above the health of both the mother and unborn child. There is a distinct difference between the midwifery and medical (obstetric) models of care, with the former being traditionally more relationship-intensive than the latter. Midwives pay keen attention to the process and experience of pregnancy and its impact on the fetus, labour, delivery, and maternal development. As such, they invest time to help and support a mother to recognize and change aspects of their lifestyle that are detrimental to the health of their unborn baby. An article in the Journal of Midwifery and Women’s Health (1999) highlights the difference in the approach of obstetricians who mainly focus on the fetus and screening for pathology. A study by Aaronson (1987) concluded the opposite of the one cited in your editorial. It stated that women who had obtained prenatal care at a facility by either midwives or obstetricians, felt that their midwife care providers held significantly stronger opinions about the importance of health-promotion behaviors, including abstinence from smoking, and offered more support to help the women conform to those behaviors, as compared to the women who obtained their prenatal care from obstetricians. But this commentary is not seeking to prove whether midwives or obstetricians obtain a better success rate in smoking cessation. Rather, I agree that strategies to address this behavior early in pregnancy and beyond childbirth need to be intensified to lower the burden of preventable conditions on health systems and government budgets. Perhaps incorporating psychologists and social workers as part of the interventions could result in more favorable outcomes. Uki. A. Atkinson Competing interests: None declared
Smoking in Pregnancy 29 June 2009
Ekaete F Asuquo, Lecturer University of Calabar, Nigeria Send response to journal: Re: Smoking in Pregnancy	Thanks for this write up. I believe it is time smoking effects be limited to the perpetrators of this dangerous practice and that the future generation (innocent unborn and newborns)be free from this maternal short coming. Of utmost concern is the suggestion that cluster randomized trials of midwives fail to show that their intervention in pregnancy can reduce maternal smoking. Midwives' precedence in health care has never been to build relationships alone, but preference is always given to the well- being of the mother and infant. I suggest that if interventions are well focused, the window period of stopping smoking for the benefit of the fetus could be utilized for antenatal clients to completely stop smoking. These interventions should not only focus on the immediate need to stop smoking, but look at more long-term efforts to encourage and convince mothers of the benefits of stopping the habit for life – their own and that of their children. It is high time that the dialogue and debate about this issue yield better results and interventions. Ekaete Francis Asuquo Competing interests: None declared