Understanding the experiences, perspectives and values of indigenous women around smoking cessation in pregnancy: systematic review and thematic synthesis of qualitative studies

About one in eight non-indigenous women smoke during pregnancy, while almost half of indigenous women smoke while pregnant [1‐4]. Smoking in pregnancy increases pregnancy and neonatal complications including miscarriage, pre-term delivery, placental complications, low birth weight, and anatomical abnormalities [5, 6]. Smoking during pregnancy is a major risk factor for sudden unexpected death in infancy (SUDI), particularly when associated with infant bed sharing [7, 8] and this is well noted among indigenous babies [8‐11].

Many smoking cessation initiatives have been developed to decrease smoking in pregnancy [12‐16], including interventions specifically for indigenous women [14, 17]. Despite these interventions and related policies, programmes, and regulations, smoking among indigenous women remains a serious health problem internationally. Effective health interventions require an understanding of the social context of the problem and of the target audience. Understanding therefore, the experiences and values of indigenous women is crucial to ensuring that future interventions and policy better align with the preferences of indigenous women for smoking cessation. To date, many women have reported wanting to stop smoking but feeling unable to quit, being unaware of services or finding them difficult to access, and expressing concerns about being stigmatised once identified as a smoker [18‐20].

This systematic review of qualitative studies aims to describe indigenous women’s experiences, perceptions, and values related to stopping smoking in pregnancy in order to inform the development of programs and interventions that respond to the needs, concerns and preferences of indigenous women.

The search identified 485 unique records (Fig. 1). Of these, seven studies involving 250 pregnant indigenous women were included (Fig. 1). Four studies (57%) were from Australia, and three (two reporting from the same study) were conducted in New Zealand (43%). The participants’ age ranged from 14 to 53 years. Four studies involved face to face interviews, two used focus groups, and one study involved both methodologies (Table 1).

The comprehensiveness of reporting varied across the included studies (Table 2). The relationship established between the researchers and participants, member checking and whether repeat interviews were conducted was not described in any studies. Methods for recruiting women, the sample size, and participant quotations were reported in all seven studies. Two studies reported the presence of data saturation, field notes, and the duration of interviews.

This systematic review has synthesised perspectives, attitudes, expectations, and experiences of indigenous women from qualitative research investigating smoking cessation in pregnancy. We found only seven eligible studies involving 250 indigenous women from Australia and New Zealand. We had also searched for studies from Canada, Taiwan and the United States - developed countries where the indigenous peoples have been colonised and where we might have expected to see some common experience with widespread social and socio-economic marginalisation, and gross health inequities [32]. Despite those similarities there are vast differences in delivery of health services between and within these countries, ranging from mainstream services who are generally unable to meet indigenous need to indigenous health care systems that are under-resourced and struggle to cope with demand [33]. The delivery of smoking cessation programs is similarly diverse.

We identified three central themes across these services. First, realising well-being and creating agency were expressed as giving the best start to baby, pride in being a healthy mum, and the importance of female role models and family support. Second, understanding the drivers for smoking included the impact of the stress and chaos indigenous women often experience in their lives, the relative social acceptability of smoking within indigenous communities, the pervasive forces of guilt and judgment and the lack of information and knowledge to support decision-making. Finally, the women identified their appreciation for culturally responsive approaches to cessation valuing programs designed specifically for and by indigenous people that were easily accessible and that acknowledged the need for programs to provide an alternative to smoking.

These findings broadly reflect those found in a systematic review of Aboriginal and Torres Strait Islander women [34] in which social norms and stressors within the Aboriginal community perpetuated tobacco use and there was insufficient knowledge provided to smokers in ways that supported smoking cessation. Another systematic review also indicated that community-based knowledge of the harmful effects of smoking did not translate into smoking cessation [35]. The findings in the present systematic review suggest that this knowledge might be effectively translated by building on the self-agency and determination of woman to have a healthy baby, be healthy mums and incorporating the views of influential female peers into programs. Our review indicates that current smoking cessations programs need to be closer aligned to the values of indigenous women and communities.

Other studies have reported the challenges faced by health professionals to delivering smoking cessation advice and care during pregnancy [36, 37]. Lack of support from health professionals has previously been reported as a common barrier to smoking cessation during pregnancy and for indigenous peoples, the pervasive effect of cultural and historical norms [38].

Women in these studies experienced receiving inconsistent information and education from health care professionals and others in their community, as has been previously described [35]. This inconsistency in information caused confusion and doubt about the potential harms of smoking, especially if women had known of other “healthy” babies whose mothers had smoked. Women also recommended programs would be more successful if they helped them to address some of the wider issues that led to their smoking and also include other activities that replaced smoking and strengthened a sense of community. Acknowledging the absence of evidence to support smoking cessation in pregnant Aboriginal and Torres Strait Islander women, Gould [40] developed a pragmatic guidance for health practitioners that includes: screening the patient, counselling, initiation of NRT, making a personal Quit Plan, follow-up support, and utilising ancillary resources. Although this guide may respond to some needs, we recommend a more culturally responsive approach that includes collaboration and partnership with indigenous people built on cultural values. This approach has been successful in New Zealand in the Safe Sleep SUDI prevention programme designed around Safe Sleep devices that were able to be deployed in the shared bed to prevent sudden infant death [41, 42]. This program utilised traditional crafts (weaving with flax) to support a traditional value (bed-sharing) that was widely supported by Māori women elders in the creation of this safe infant sleep space and thus addressing cultural needs and increasing support available to new mothers. The findings of this review suggest that this kind of cultural resonance and support is needed for smoking cessation during pregnancy developing a culturally meaningful and accessible programme that provides support and is empowering of pregnant indigenous women.

Understanding successful interventions and linking these to the results of this review will help to build stronger smoking cessation programs that specifically target indigenous women. Future research should include the development of smoking cessation programs built on successful interventions that align with the findings of this review.

Future interventions and smoking cessation programmes might be more effective and acceptable to indigenous women and families when they harness self-agency and the desire for a healthy baby, recognise the high value of culturally responsive approaches and indigenous peer involvement and embed a social focus in place of smoking as a way to maintain community support and relationships. Development and evaluation of smoking cessation programs for pregnant indigenous women and families is warranted.