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Smoking In Pregnant Women in the United Kingdom
Smoking is one of the leading causes of avoidable death, with treatments for smoking related illnesses, financially burdening the NHS an estimated £1.5 billion per year (Twigg, 2004). Smoking is defined as the inhalation of the smoke of burning tobacco in cigarettes, pipes and cigars. A smoking habit is a physical addiction to tobacco products. It has also now been agreed by several health experts that habitual smoking is a psychological addiction and one with adverse health consequences (TheFreeDictionary.com, 2016). Some individuals are casual or social smokers, (so smoke only occasionally) for example in a social situation or to relieve stress. Despite the existence and awareness of targets to reduce smoking during pregnancy in the United Kingdom, problems still remain. In 2013, 11 percent of pregnant women aged 16 to 49 were smokers and 34 percent were ex-smokers (an ex-smoker is defined as an adult who used to smoke regularly but no longer does) (hscic,2015).
This assignment is going to explore the health needs of pregnant women who smoke during pregnancy in the United Kingdom. The concept of “need” is one of subjectivity, variability and constant change (Cowley et al., 2000). There are many different theoretical understandings of what needs are and how they can best be met. These include Ponsioen (1962), who asserts that it is society’s first responsibility to meet the basic survival needs of its members (biological, social, emotional and spiritual). Maslow’s (1943) Hierarchy of Needs defines the needs of life in an order in which needs have to be satisfied (Kendall and Bryar, 2012). Therefore lower needs must be satisfied before higher needs can be addressed to enable individuals to reach their full potential (Thrower, 2002). In order to address the health issues that arise for both the mothers and neonates, health needs assessments need to be undertaken, which will be explained in the forthcoming section.
Health needs assessment
Recognising the health needs of people and communities leads to the availability of flexible health services, with increased accessibility (Naidoo & Wills, 2000). Carrying out health needs assessment requires careful preparation, the availability of relevant information and clear and effective communication across multidisciplinary teams (Jack and Holt, 2008).
A health needs assessment is a systematic method which is applied to identify the unmet healthcare needs of a population and then make changes to address those unmet. It is an assessment that aims to improve health, encompassing the concept to benefit from an intervention. A needs assessment helps to guide decision making, providing a systematic perspective for decision-makers, allowing for interdisciplinary solutions for complex solutions to be implemented.
There are three key approaches involved in undertaking a health needs assessment (HNA) and these can be comparative, corporate and/or epidemiologically based. The comparative approach compares the levels of services being provided between populations, accounting for local population characteristics such as demographics, mortality and morbidity. The corporate component of the HNA focuses on demands, wishes and perspectives of the professionals, alongside the political and public views. Encouraged by the 1989 reforms, it emphasises the importance of the public voice and forming partnerships and collaborations that support more involvement from all parties. However, a disadvantage of this approach is that differences between need and demand appear blurred at times. The third approach, combines epidemiological approaches with patient’s perspectives, involving the assessment of the effectiveness and cost-effectiveness of interventions. Thus, looking at what can be and should be done as well as what can be afforded.
Maslow’s hierarchy of needs (1943) and Bradshaw’s classification of needs are two pivotal assessment tools that have been applied to many health care needs, helping to prioritise and address unmet needs. The theory of Humanism states that we are all like seeds with the potential to grow, if all our needs are met. Maslow proposed the Hierarchy of Needs in an attempt to address what human beings need. The needs are usually depicted as a pyramid, as he believed that certain needs must be addressed and met before other needs manifest. Bradshaw’s classification focuses on four main needs: 1) Felt-the individuals perceptions of variations from normal health 2) Expressed- this is when the individual seeks help to overcome any variations from their normal health 3) Normative-this involves the professional defining interventions appropriate to address the expressed need 4) Comparative- a comparison between needs for size, severity, cost etc. is undertaken.
The concept of “health needs” is relatively recent, especially in respect to components such as health promotion or public health (Sakellari, 2012). The objectives of health needs assessments is to reduce health inequalities, as well as improving population health (Porter, 2005). Individual health needs are constantly challenged, stressed and even enhanced by lifestyle, genetic predispositions and the ecological environment (Watkinson, 2002). Hence, a holistic approach not focus on just a single problem or issue is required; as health needs assessment is a complex and interactive process (Appleton and Cowley, 2008). In order to accommodate for those populations that are hard to reach, an extension of the health needs assessment system, Health Needs Mapping has been formulated. Health Needs Mapping (HNM) can be used to improve and design outreach to particular populations, for example the South Asian population. HNM collates information from multiple sources, linking socio-economic and lifestyle data, with disease registries and GP practice as well as incidence of illness, incorporating hospital statistics.
Risks and impact of smoking during pregnancy
Smoking is the leading preventable cause of morbidity and death among infants and women (Coleman et al., 2012). Even though the known adverse effects during pregnancy and birth outcomes associated with smoking during pregnancy such as placental abruption, miscarriage, congenital abnormalities, low-birth weight, neonatal and sudden infant death as well as increased risks of congenital anomalies, smoking during pregnancy remains prevalent (Hackshaw et al., 2011). Many women continue throughout the pregnancy, with approximately 17% in England and Wales (ONS, 2006) and 14% in the USA (Tong et al., 2009). In 2012, Beenstock et al., (2012) reported how around 5, 000 miscarriages and 300 perinatal deaths per year result from maternal smoking in the United Kingdom (Beenstock et al., 2012).The true prevalence of maternal smoking during pregnancy however is likely to be much higher, as under-reporting by mothers who smoke is apparent, due to the stigma attached to smoking during pregnancy. The detrimental effects of smoking during pregnancy are not only physiological, but they also include negative consequences on educational and behavioural performance such as issues related to hyperactivity and attention (Lumley et al., 2015). Additional negative consequences encompass increased risk of respiratory infections, asthma, high blood pressure and early onset of diabetes. Pregnant women are also more likely to continue to smoke throughout their pregnancy if they live in a household where there are others, especially their partner smokes (Penn and Owen, 2002). Research has also shown, that shaving a partner who smokes, results in a higher relapse rate amongst pregnant women making it much harder to quit (Fang et al., 2004).The cessation of smoking during pregnancy is thus crucial for both maternal and fetal health (Coleman et al., 2012).
Despite the existence and awareness of targets to reduce smoking during pregnancy in the United Kingdom, problems still remain. Research findings have shown that firstly the majority of women who quit smoking (between 10-45%), do so without the implementation of a formal intervention (Greaves, et al., 2003; Lawrence et al., 2005). Also, the majority of these individuals who quit tend to women who less addicted, more highly educated, older and also less likely to have a partner who smokes (Greave set al., 2003). The formal support that is offered to women who have smoked before and/ or during pregnancy, would be of greatest benefit for those women who are unable to quit on their own. Some of the main reasons why women fail to quit during their pregnancy include lack of understanding regarding the risks associated with smoking during pregnancy, the fear of weight gain, factors related to withdrawal and addiction (Greaves et al., 2003).
There is still some uncertainty over whether maternal smoking is associated with birth defects. Hackshaw et al., (2011) thus sort to address this uncertainty and conducted the first comprehensive systematic review to establish which specific malformations are associated with smoking (Hackshaw, Rodeck and Boniface, 2011). Their findings displayed significant positive associations between maternal smoking and neonatal cardiovascular/heart defects; muscoskeletal and limb reduction defects to name a few. It was concluded that those birth defects whose onset is positively associated with maternal smoking must now be included in public health education materials, encouraging more women to quit smoking before or during pregnancy (Hackshaw, Rodeck and Boniface, 2011).
Smoking reduction and cessation, especially during pregnancy is a key area of focus for policy makers; reflecting their understanding that reducing smoking during pregnancy is not only necessary to protect children from exposure to the damaging effects of second hand smoke, but also, the policies shall aim to reduce the risk that the children will follow in the parental footsteps of smoking, and becoming smokers themselves (BMA, 2007)In order to address the health issues that arise for both the mothers and neonates, health needs assessments need to be undertaken. These help guide the successful implementation of interventions that aim to promote and improve the quality of life amongst the whole population through health promotion and disease prevention (W.H.O., 1998)
In early pregnancy, smoking is known to increase the incidence of miscarriage (Quinton, Cook and Peek, 2008) and in otherwise low risk women, smoking during pregnancy is known to increase the risk of vascular complications (Salafia and Shiverick, 1999). Woman who continue to smoke during pregnancy are also at increased risk of delivering babies with intrauterine growth restriction (IUUGR) and increased perinatal morbidity and mortality (Quinton, Cook and Peek, 2008). These complications are thought to arise due to a reduction in blood flow and decreased perfusion to the placenta with resultant placental injury). This increased occurrence may occur because of apoptosis and decreased invasion of the cytotrophoblast with a resulting increase in placental dysfunction (Quinton, Cook and Peek, 2008).
Prevalence: impact of demographics and socio-economic status
The information provided from the Infant Feeding Survey, which is carried out in the UK every five years, presents information regarding the prevalence of smoking during pregnancy in UK (hscic, 2015), encompassing age, socio-economic classification and demographical locations.
There is an evident regional divide in the prevalence of smoking during pregnancy in the United Kingdom, with higher rates in poorer socioeconomic areas. Every year 70, 000 are affected by smoking, and NHS data from 2015 shows that 27.2 per cent of expectant mothers in Blackpool smoked throughout the whole pregnancy, compared with 2.1 per cent in Westminister. The latest findings show that one in five women in Darlington , Tees and Durham area report having smoked during pregnancy compared with one in twenty women in London. Although the overall rate has fallen to less than 11% in England, the Smoking In Pregnancy Challenge Group report urges the need of a national target below 6 per cent by 2020.
The rates of women smoking during pregnancy differ significantly with socioeconomic status and age impacting the prevalence (Bauld, 2008). For example, data has shown that expectant mothers who are 20 years or under are more than three times more likely to smoke before and during pregnancy, in comparison to mothers aged 35 years or over (Bauld, 2008).Additionally, those mothers in manual and routine occupations are more than four times more likely to smoke than those in managerial and professional occupations, (accounting for 29 per cent and 7 per cent respectively) (ONS, 2006) In the USA, 20 per cent of pregnant women aged ,25 years smoked versus 9 percent among those aged ≥35 years (Tong et al., 2009).
Demographics no doubt has an impact on the prevalence of smoking. Investigating the statistics on womens smoking ststus at the time of delivery in Englnad (third quarter 2015), Amongst the 209 clinical commissioning groups, smoking prevalence at delivery ranged from 25.0 percent in NHS Blackpool to 1.3 percent in NHS Central London (Westminster) (hscic, 2015).
Addressing the cause of smoking during pregnancy
The National Institute for Health and Care Excellence has published specific guidelines regarding the cessation of smoking in pregnancy and following childbirth (NICE, 2010). These guidelines state that all contact that is made with a pregnant woman who smokes, this includes pre-conceptual care meetings, antenatal appointments etc. are all valuable opportunities to encourage the mother to quit.
Funded by the Department of Health, the NHS Stop Smoking Services are local services that provide accessible, evidence-based cost effective support to individuals who want to quit smoking. The involvement of an interdisciplinary team of qualified health care professional’s is pivotal in addressing the impact of smoking during pregnancy. Midwives play a crucial and role in promoting smoking cessation, supporting the mothers and their families. The targets that have been proposed to reduce the proportion of mothers smoking during pregnancy, both at local and national levels reflect government awareness of the adverse effects of smoking during pregnancy that result in an estimated 4, 000 deaths per year in the United Kingdom. These include miscarriage, still born, greater number of preterm and low weight babies, as well as a sudden increase in attention deficit hyperactivity disorder, asthma and sudden infant death. (RCP, 1992, Charlton, 1996; Bastra et al., 2003).
Published in March 2011, one of the key national ambitions in the Tobacco Control Plan is “to reduce rates of smoking throughout pregnancy to 11 per cent or less (measured at time of giving birth) (Gov.UK, 2011). Smoking during pregnancy is associated with serious pregnancy-related health problems, these encompass an increased risk of miscarriage, premature birth, still birth, sudden unexpected death in infancy and other complications during labour (Nice, 2011).
The challenge of accurately obtaining figures that represent the extent of smoking that takes place during pregnancy is something that is faced by many countries globally, including the United Kingdom (Bauld, 2008). With prevalence figures being drawn from the infrequently conducted infant feeding survey, also relying on self- report data collected from women following delivery (Information Centre, 2007); these are additional needs that must be met.
Midwives have a crucial role in influencing smoking cessation in pregnancy. The National Institute for Health and Clinical Excellence (NICE) in England have recommended behaviours specifically for midwives. These entail the delivery of information to women about the risks to the unborn child, the use of a carbon monoxide breath test, and to refer all pregnant women who smoke to stop-smoking (Beenstock et al., 2012).
The findings from the meta-analysis undertaken by Lumly et al. (2009),show that behavioural support for smoking cessation helps pregnant women to stop smoking, improving birth outcomes (Lumley et al., 2009). Although, behavioural support may contribute to improved health outcomes, considerable concerns about whether medications that have been used and shown to improve cessation rates amongst non-pregnant women are also effective during preganancy (Coleman et al., 2012). The presence of potential teteraogenicity have thus prevented smoking cessation drugs such as varenciline and bupropion, being clinically trialled in pregnant women. These concerns are not as great in nicotine replacement therapy, as this form of therapy only contains tobacco, whereas tobacco smoke contains this alongside many other toxins.
Coleman et al., investigated the efficacy and safety of the nicotine patches during pregnancy as the Nicotine-replacement therapy has been found to be effective for smoking cessation outside pregnancy (Coleman et al., 2012). However, Coleman et al., 2012 did not find that the addition of a nicotine patch (15 mg per 16 hours) to women who smoked during pregnancy to significantly affect the rate of abstinence from smoking until delivery, any more than the placebo. There was no conclusive evidence to support whether the NRT had either a harmful or beneficial effect on birth outcomes. The use of NRT is recommended by several sets of guidelines for smoking cessation in pregnancy; despite this good evidence to support these recommendations is lacking. The general belief is that NRT is less harmful than smoking (Benowitz et al., 2000) (Colemann et al., 2012);
Most of the malformations associated with maternal smoking have physical and psychological morbidity for the infant and parents, often lifelong and with significant healthcare service costs for hospitalisations (Russo and Elizhauser, 2004; Robbins et al., 2007; Wehby and Cassell, 2010). Thus, it is essential that information is not only readily available but also readily available for both non-preganant and pregnant women. In accordance to the data from the Health and Social Care Information Centre (hscic, 2015), each year smoking during pregnancy causes an estimated: 2, 200 pre-mature births; 5, 000 miscarriages and 300 still born. Relatively few public health educational materials mention birth defects as a possible outcome among pregnant women who smoke, and those that do are hardly ever specific. This is probably because of uncertainty over whether congenital defects are causally associated with maternal smoking (Wyszynski et al., 1997; Little et al., 2004).
Also the majority of literature on the harmful effects of smoking in pregnancy focus on complications, such as fetal death, fetal growth restriction and prematurity. The mechanisms (Werler et al., 1985; Talbot, 2008; Rogers, 2009) associated with these complications are much less understood but are thought to include: carbon monoxide binding to haemoglobin so that less oxygen is available for placental and fetal tissues, leading to fetal hypoxia; the vasoconstrictor action of nicotine causing reduced blood flow to the placenta and disturbance of endothelial function in the maternal circulation (Quinton et al., 2008) as well as, presumably, in the fetal circulations. So in spite of knowledge and extensive research being available and being undertaken, greater understanding of the mechanism that lead to these complications, needs to be further understood. This shall assist in the health needs of those pregnant women who have smoked prior, during and post-pregnancy,
In conclusion, maternal smoking in pregnancy is an important risk factor for several major birth defects. These specific defects should be included in public health educational information to encourage more women to quit smoking before or early on in pregnancy, and to particularly target younger women and those from lower socioeconomic groups, in which smoking prevalence is the greatest.
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