Background
Methods
Design
Search methods
Data extraction and quality appraisal
Method of synthesis
Phase of meta-ethnography | Processes involved |
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Phase 1 Reading the studies | Developing an understanding of each study’s context and findings. |
Phase 2 Determining how the studies are related | Comparing contexts and findings across and between studies. |
Phase 3 Translating the studies into one another | Mapping similarities and differences in findings and translating them into one another; the translations represent a reduced account of all studies. (First level of synthesis) |
Phase 4 Synthesising translations | Identifying translations that encompass each other and can be further synthesised; expressed as ‘lines of argument’. (Second level of synthesis) |
Results
Source Paper (n = 9) | Country setting | Aim | Participants | Methodology | Indicative finding | Quality Score (out of 32) |
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Abrahamsson A, Springett J, Karlsson L et al (2005) [26] | Sweden | To describe the qualitatively different ways in which midwives make sense of how to approach women smokers | Midwives (n = 24) purposively sampled, who had been offered training in person-centred methods. Experience 2-24 years | Phenomenology | Midwives used different approaches to address smoking with pregnant women. Four different ‘story types’ were identified: avoiding, informing, friend-making and co-operating. | 25 |
Aquilino ML, Goody CM, Lowe JB (2003) [31] | USA | To examine the perspectives of Women, Infants & Children (WIC) clinic providers on offering smoking cessation interventions for pregnant women | Four focus groups (n = 25) consisting of WIC nurses (n = 14), dieticians (n = 9) and social workers (n = 2). Three participants revealed that they smoked | Data collected via focus groups and analysis was undertaken using ‘code mapping’ | Factors affecting WIC staff’s provision of smoking cessation information were: time, competing priorities, staff approaches to clients, staff training, nature of educational materials and client concerns. | 24 |
Borland T, Babayan A, Irfan S et al (2013) [32] | Canada | To explore how Ontario’s cessation policy, programming and practice encourage or discourage the provision and uptake of support by women | Key informants (n = 31) from provincial organisations that offer cessation, maternal and/or child health support to women across Ontario | Data collected by semi-structured in-depth interviews. Data were analysed using thematic interpretive analysis | Key barriers to providing cessation support included: the absence of a provincial cessation strategy and funding; capacity issues; lack of a programme that was woman-centred, included the social determinants of health and the needs of specific groups; inconsistent practice; geographical factors. | 27 |
Bull (2007) [27] | UK | To explore the role of midwives and health visitors in the prevention of smoking during pregnancy and early parenthood | Health visitors (n = 16) and midwives (n = 7) | Data were collected via two focus groups and analysed using qualitative content analysis | Midwives and health visitors are willing to accept professional responsibility for smoking cessation work with their patients. They perceive their role as being limited by the socio-economic circumstances of their clients and recognise that they additionally must be ‘ready to change’. | 20 |
Ebert M, Freeman L, Fahy K et al (2009) [28] | Australia | To determine how midwives interact with women who smoke in pregnancy in relation to the women’s health and well being | Community midwives (n = 7) each with a minimum of 6 years’ experience (research initially wanted to looked at midwife/woman dyads but no women were recruited). | Interpretive interactionism design and analysis. Data collected through two individual interviews with each midwife. | Whilst midwives acknowledge they need to engage in woman centred dialogue during smoking cessation interactions, more commonly the engagement was limited to predictable, planned and computer prompted interactions. | 19 |
Herberts C & Sykes C (2011) [29] | UK | To identify and juxtapose midwives’ perceptions of providing stop-smoking advice and pregnant smokers’ perceptions of stop-smoking services | Midwives (n = 15) recruited from 2 acute trusts in the borough of Camden (19th most deprived borough in England) | Three focus groups centred on the key question ‘How do you feel about talking to pregnant women about smoking cessation?’ Data analysed using constructs of grounded theory | Midwives identified both barriers and facilitators to providing stop-smoking advice. Barriers included: fear of being seen to judge women, putting pressure on women, threatening the professional relationship, lack of education to provide support, insufficient time. Facilitators included: being more experienced, being an ex-smoker, having sufficient levels of relevant knowledge, time, a good relationship with the woman and continuity of care. | 29 |
* Herzig K, Danley D, Jackson R et al (2006) [33] | USA | To explore prenatal providers’ methods for identifying and counselling pregnant women to reduce or stop smoking, alcohol use, illicit drug use and the risk of domestic violence | Obstetricians/gynaecologists (n = 40), nurse midwives (n = 5), nurse practitioners (n = 3), registered nurse, working in HMO (n = 1), private practice, community health clinics, hospitals and academic centres | Six focus groups with 6-11 participants in each, questioning led by an open-ended question guide. Data were analysed using a subjective, interpretive ‘editing style’ of analysis | Participants talk of specific risk prevention methods used with pregnant women who smoke (amongst the 4 risk factors studied), citing a patient centred collaborative style as particularly helpful. Harm reduction strategies rather than abstinence were recommended, along with incorporating the wider family. | 26 |
* Herzig K, Huynh D, Gilbert et al (2006) [34] | USA | To explore prenatal providers’ methods for addressing four behavioural risks in their pregnant patients: alcohol, drug use, smoking and domestic violence | Obstetricians/gynaecologists (n = 40), nurse midwives (n = 5), nurse practitioners (n = 3), registered nurse, working in HMO (n = 1), private practice, community health clinics, hospitals and academic centres | Six focus groups with 6-11 participants in each, questioning led by an open-ended question guide. Data were analysed using a subjective, interpretive ‘editing style’ of analysis | The study addresses each of the four behavioural risks. Smoking was seen as the ‘easiest’ risk to address, but its addictive quality proved challenging to overcome. | 26 |
McLeod D, Benn C, Pullon S et al (2003) [30] | New Zealand | To explore the midwife’s role in providing education and support for changes in smoking behaviour during usual primary maternity care | Midwives (n = 16) with between 5-20+ years in practice, who had been part of a RCT of education and support for pregnant women who smoke. Midwives had either received smoking cessation training as part of the trial (n = 9), or had received no such training (n = 7) | Data were collected through individual interviews. Midwives additionally completed a postal questionnaire, asking about education, training, smoking status, and perception of barriers to delivering smoking cessation advice | Providing smoking cessation support was seen as part of the midwife’s role, but it was perceived as difficult to start conversations on the subject, to identify women who would be receptive and to support them. There was concern over the impact of providing cessation advice on their relationship with women. | 25 |
Professional role
Experience-based facilitators to smoking cessation
‘…it didn’t have to be a big issue, but I think you could still get your message across fairly succinctly just by bringing it up reasonably frequently, but just little jabby thoughts.’ Midwife [30]‘…I’ll say ‘Okay, all you have to do this month is just not smoke in the car.’ That will count for a percentage…and they’ll come back, and say ‘Okay, I only smoked in the car one time,’ and that’s okay.’ Obstetrician [33]‘If they say they’ve thought about giving up and that it’s hard now, then you have to say it’s good they’ve thought about it…I try to make the most of the positive things they’ve done.’ Midwife [26]
‘When you ask if they smoke, they sigh and say it’s not good, because they know the question’s coming. I explain and show the leaflet about how dangerous it is and that they must think about the baby.’ Midwife [26]‘I think sometimes focusing on that really positive thing -- breast feeding your baby -- allows messages about smoking to be drip fed in.’ Midwife [30]
‘We try not to be judgmental and I try not to pass judgment, but I just tell them that whatever you do that baby’s getting, so if you're getting your little smoke on, they’re getting their little smoke on, too.’ [31]‘It makes a difference to talk to the women. It may not be our joy to see any change, but change may happen another time. In the meantime I want to keep her and her foetus as safe as possible.’ Nurse Midwife [33]
‘…I say that the baby becomes smaller due to the lack of nourishment, that it has a smaller refrigerator, thinner arteries. If they still don’t get it I show them a pretty horrible picture.’ Midwife [26]‘Sometimes I even draw a picture, very crudely, of a red blood cell and carbon monoxide and oxygen, how it [smoking] knocks off the oxygen so the body has to make more, and they seem to understand that.’ [31]
‘No way to get to them, it hasn’t actually been talked about. Like the woman I see right now, I mean her partner smokes like a chimney and it is not helping her at all… but I never see him.’ Health Visitor [27]
‘I think one of the patient’s real barriers to success is the spouse or somebody living with them who is still smoking, so I’ll give out prescriptions for the patch to husbands.’ Obstetrician [33]
Health professionals’ roles and skills
‘It’s part and parcel of the job. No, it’s an intrinsic part of it…I mean pregnancy and childbirth is such a holistic period that you can’t compartmentalise and just deal with one aspect.’ Midwife [30]
‘We haven’t been trained about how to do it, so you get it wrong don’t you?’ Health Visitor [27]‘I could use more information. There’s new stuff every day that relates to smoking, so I know there’s new and up-to-date stuff that we probably don’t know about.’ [31]‘Sometimes you don’t know what to do. You don’t want to scratch the surface if you can’t follow it up.’ Midwife [26]
‘Not enough time and not a special interest of mine since they don’t stop smoking.’ Midwife [27]‘We have too much to do with booking and like everyone else says it takes too much time and I don’t know what works!’ Midwife [27]
‘Well the women don’t like using it so compliance is an issue. Are we all pinning our hopes on something that doesn’t do the trick?’ Midwife [27]‘…if there [was a] dictum or policy that comes down that says, ‘We fully support the use by prenatal women of nicotine replacement under recommendation from pharmacists,' that would go a long way to providing additional support and services.’ Key informant [32]
The relationship with the pregnant woman
‘…you have a special relationship with the woman because you meet so many times. You want to be professional and… create a sense of security… You don’t want to be known as a nagging old cow.’ Midwife [26]
‘If people sort of give you the impression from the beginning that they are not interested in changing their smoking habits then I think it could be detrimental to our relationship if I was to bring it up every time.’ Midwife [30]‘I do talk about smoking cessation with them, reinforcing what they’ve already heard, sometimes…they’re receptive to it and other times, it’s like they have heard it from everyone that day and it’s almost like you can see the door closing.’ [31]
‘Yes, maybe I should get to grips with the smoking because it isn’t good for the baby or the mother. I feel bad about not doing it, but… I’ve chosen not to because I want to keep the mother’s trust.’ Midwife [26]
‘I really think you have to be frank in what you say. Of course you make them feel guilty. You do it automatically in a way.’ Midwife [26]‘It’s one of those topics that’s hard to talk about…they think you’re lecturing them on something bad and…[they] immediately get defensive.’ [31]
‘Those that were interested in trying to give up smoking were…quite appreciative that somebody was trying to take the time and effort to try and help them’ Midwife [30]
Appreciation of women’s lives and the context of their smoking
‘Sometimes it’s just not the right time. And they know, they know what they’re doing and um yeah, and some people are in such awful situations that it’s sort of like it’s their only bit of self-indulgence and yet…’ Midwife [30]‘Sometimes they have so many stressors in their life that they just don’t think they can give it (smoking) up, and that’s probably true.’ [31]
‘(Name) started at age six when she used to light cigarettes from the coal range for her mother who stayed in bed.’ [30]
‘…he just carried on smoking in the house, in the lounge, and that girl really wanted him to smoke outside, but he was just the male bulshie, and I wasn’t going to cross him. I mean you can feel vibes.’ Midwife [30]
‘I don’t recall that I ever saw many women who completely stopped [smoking]. ..We always said that any reduction is an improvement and will help with the outcome of the baby…’ [31]‘I mostly encourage them to cut down I don’t think stopping is a good option for the majority of women. The odd one will stop but yeah. There’s confirmed smokers who will never stop.’ Midwife [30]
‘I looked at my own statistics and then rang my own women round, and asked them if they’d gone back to smoking when the baby was delivered and sadly the majority had.’ Midwife [30]
‘I think it is very difficult… to give up for pregnancy is about giving up for the baby, and I don’t think there is any preparation or support about how to give up long term as a non-smoker afterwards.’ Health Visitor [27]
‘I had one [patient] who was on methadone and also smoked… I said, “....You’re early in your first trimester. You can’t smoke…” she said, “What are you talking about, I can’t smoke?” She was expecting a conversation about the methadone.’ Obstetrician/Gynaecologist [34]
Organisational context
Organisation of services
‘We don’t have the resources, we don’t have the clinicians, we don’t have the tobacco replacement system…We don’t have any of those.’ Key informant [32]
‘Different ways [are needed] other than the medical model of giving advice which clearly doesn’t work with this group of women…It is not seen within the social context of how they are living; just the health field.’ Health Visitor [27]
‘How can we be expected to change that [poverty-related smoking]! It is quite frightening when local Trusts are being performance monitored and you are held accountable to them when in fact the causes are way outside your control.’ Health Visitor [27]
‘You should be training a lay person, like an ex-smoker, as they maybe more accepted for being there and showing concern. A mother herself maybe could help others to quit.’ Health Visitor [27]‘I tell them that I did it so they can jolly well do it too. Because I’ve smoked. That is actually quite a valuable tool.’ Midwife [30]
Organisation of individual practice
‘One of the questions in our booking-in database asked specifically “Do you smoke?” and if it is a “Yes”, then there are more questions that go on from that and if it is a “No”, then that’s it.’ Midwife [28]
‘There’s a lot to be done in the 15 min that we have. We do heights and weights, and we have a lot of paperwork to do along with trying to teach as much as we can… it’s difficult.’ [31]
‘Whatever you do it always comes down to the labour and that is it…which is fine but giving up smoking isn’t their concern.’ Midwife [27]