Women and Birth
Volume 22, Issue 1 , Pages 35-40, March 2009

What do midwives need to understand/know about smoking in pregnancy?

School of Nursing & Midwifery, Faculty of Health, University of Newcastle, Callaghan, NSW 2308, Australia

Received 21 September 2008; received in revised form 7 November 2008; accepted 7 November 2008.

Article Outline

Summary 

Aim

This paper seeks to help midwives more fully understand smoking in pregnancy, particularly from a midwifery partnership perspective.

Method

Using the midwifery philosophy of partnership as a framework for reviewing literature on smoking in pregnancy, we explored the literature on nicotine metabolism and addiction in general, and the changes that occur in pregnancy. Quit smoking interventions commonly used were examined to see if knowledge about addiction and the physiological adaptations of pregnancy are incorporated into anti-smoking efforts aimed at pregnant women.

Results

Quitting is harder for the pregnant woman because the physiological adaptations of pregnancy increase the clearance of nicotine thus lowering nicotine levels and increasing the desire to smoke. Women who continue to smoke generally have fewer external sources of pleasure and satisfaction in their lives, which, when combined with the physiological and emotional challenges of pregnancy, means that they are less likely to quit smoking and remain abstinent. These factors do not appear to be taken into account for pregnant smokers. The concept of partnership between women and midwives during anti-smoking interactions is lacking.

Conclusion

Midwives are in a position to support women and their families in all health related issues, including smoking cessation. We recommend that midwives ask permission before making enquires about sensitive issues such as smoking. When discussing smoking with pregnant women, midwives work within the philosophy of midwifery, with the emphasis on building trust and maintaining relationships. Great sensitivity is required and as much as possible the conversation should be a dialogue, not a monologue.

Keywords: Pregnancy, Addiction, Nicotine, Midwifery, Smoking

 

Back to Article Outline

Introduction 

In this paper we argue that women find quitting smoking physiologically1 and psychologically2 more difficult during pregnancy. We examine nicotine metabolism and addiction explicit to pregnancy so that midwives might better understand the issues surrounding smoking in pregnancy. First, the role that nicotine plays in women feeling pleasure and satisfaction is presented. Next, the physiological adaptations to pregnancy and alterations to nicotine metabolism are discussed. The research showing the link between low socioeconomic status and continuing to smoke during pregnancy is examined. Finally, anti-smoking interventions employed during pregnancy are considered from the perspective of their compatibility with the Midwifery Partnership model of care.

Pregnancy is seen as an opportunistic teaching moment3, in which health professionals, including midwives, attempt to persuade4 women to quit smoking. A smoker is defined as a person reporting to have smoked at least 100 cigarettes during their lifetime and currently smoking ‘everyday’ or ‘some days’.5 In relation to pregnancy, a smoker is defined as a woman who smokes one or more cigarettes at any time during her pregnancy.6 Health professionals, often assume pregnancy is a time when women find it easier to quit smoking because they have the added motivation of having a baby. This assumption is not based on evidence and, as we argue below, this baby-centric view is often unhelpful. Well-designed quit smoking interventions in pregnancy have been extensively studied using randomised controlled trials. A Cochrane review showed that, on average a 6% increase in quit rates compared with standard care.7 This is a very modest improvement in quitting. The quitters are more likely to be educated, middle-class, married women; which leave a large proportion of women still smoking after the intervention has been delivered.8, 9, 10, 11, 12, 13, 14 This paper seeks to help midwives more fully understand smoking in pregnancy; particularly from a midwifery partnership perspective.

Back to Article Outline

Dopamine, pleasure and addiction 

Dopamine is a neurotransmitter that is most commonly associated with the pleasure system of the brain. It is a key regulator of behavioural adaptation and anticipatory processes required for actions taken because of the intention to gain pleasure.15 A dopamine release provides temporary feelings of enjoyment. Ordinary, daily activities like eating, seeing, socialising, creating art or craft, dancing and making love all produce dopamine releases.16 People who obtain their dopamine via activities that promote and/or maintain health and well-being are less likely to acquire dopamine responses through actions based on addiction.16

Dopamine is responsible for positive reinforcement responses that provoke repetition of particular behaviours. Any action or substance metabolised that produces a sense of well-being or satisfaction will activate the release of dopamine thus strengthening the gratification or ‘feel good’ sensation associated with the experience.17

Dopamine appears to be involved in all addictive behaviour.16 Nicotine provides women with limited internal and/or external sources of ‘feel good’ experiences capable of activating a dopamine release and therefore a temporary feeling of satisfaction.18 People who have experienced life traumas, who live in stressful and/or abusive situations or who lack love and companionship are much more likely to turn to maladaptive sources to provide their dopamine.16

Addiction may be defined as a “persistent substance use in the face of cumulative costs, such as psychological distress, social conflict and physical harm to health”.19 This definition is inclusive of the pregnant woman's existence in a social world that abhors smoking in pregnancy, the health risks associated with smoking for the woman and her baby, and the shame and guilt often cited by women who are unable to quit during pregnancy.2, 20

Addiction is often linked with terms such as ‘uncontrollable’ and ‘irresistible cravings’.21 Yet these terms may be describing an individual's response to their environment at a particular point in time.21 The person is motivated to react in a specific way within that context. Motivational theory suggests people are motivated to feel good by acquiring positive reinforcements or to reduce the possibility of feeling bad by minimising negative reinforcements.22 A positive reinforcement may be explained as follows. A person inhales the smoke from a cigarette. Nicotine in the smoke triggers the brain's nicotinic receptors and a flood of dopamine results in a feeling of satisfaction.21 As the time increases since the final inhalation of the cigarette, dopamine levels drop until the person feels discontented, unsatisfied or bad. To stop the negative feelings associated with low levels of dopamine the person is motivated to obtain another dopamine release initiated by nicotine and so another cigarette is lit.

Back to Article Outline

Smoking and nicotine addiction 

Nicotine is delivered to the Central Nervous System via arterial circulation within 10–20s following inhalation of tobacco smoke.18 Nicotine activates nicotinic acetylcholine receptors in the brain. Specifically the effect occurs in the mesocorticolimbic dopaminergic system that projects into the nucleus accumbens and prefrontal cortex from the ventral tegmental area. Initially nicotinic acetylcholine receptor activation produces a cascade of actions resulting in a dose-dependent increase in dopamine levels16; a euphoric state of being results.

Tolerance to nicotine occurs over time, with increasing amounts of nicotine being required to satisfy the activation requirements of the nicotinic acetylcholine receptors. Over time the body increases the number of receptors available for activation. This process is called up-regulation23, 24 and may explain the short-term intensity of withdrawal symptoms experienced by persons who are physiologically addicted to smoking. Withdrawal is experienced within hours of abstaining, with the half-life of nicotine being 120min.18, 24

The act of smoking tobacco involves both positive and negative reinforcements.21 The positive reinforcement occurs with the inhalation of tobacco smoke and the anticipated feelings of satisfaction. The negative reinforcement occurs with the person's desire to abstain from the dissatisfied feelings associated with withdrawal.25 The discursive practice of addictive behaviour involves a ‘feel good’ and a ‘feel bad’ binary with people dipping in and out of states of feeling good or feeling bad. In binaries one is always valorised over another.21 For the pregnant woman, ironically, her feel good state involves a behaviour sanctioned as ‘bad’ by the general public and the health care workers with whom she must interact throughout her pregnancy.

Regular smokers become conditioned to the anticipated positive reinforcement associated with smoking. They anticipate a ‘feel good’ sensation following a cigarette and as such are conditioned to certain cues associated with smoking. Cues often linked with smoking are rising in the morning, coffee and lunch breaks, driving home, following dinner, and when the children have been put to bed.24 These cues incite an anticipated ‘feel good’ positive reinforcement. Smoking at these times is pre-conditioned and often the hardest to resist when abstaining.

Persons attempting to quit smoking often cite withdrawal symptoms such as increased stress and anxiety as the reason for their relapse.26 Withdrawal is a stressor for individuals and as such initiates the release of cortisol-releasing factor (CFR) in the nucleus accumbens. Cortisol-releasing factor increases the individual's drive to feel good by a negative reinforcement of the anxiety associated with abstaining.23 Therefore, persons endeavouring to stop smoking have to overcome the anticipated positive reinforcement or conditioned cues as well as the augmented negative reinforcement drive.

Back to Article Outline

Nicotine, hormonal adaptation and pregnancy 

Nicotine levels are similar in male and female smokers, although women may smoke fewer cigarettes.24 The comparable nicotine readings are the result of slower nicotine clearance mechanisms in non-pregnant females.24 During pregnancy, nicotine metabolism accelerates, with nicotine clearance increasing by 60% and cotinine clearance increasing by 140%.1 The increase in nicotine clearance makes the physiological/addictive aspect of quitting or reducing tobacco intake during pregnancy more difficult. Blood levels of nicotine decrease at a faster rate hastening the experiences of physiological withdrawal. The increase in cotinine clearance also has implications for researchers validating smoking cessation interventions. Using cotinine measurements calibrated on non-pregnant persons who smoke as validation is flawed. Measuring reductions in nicotine or cotinine levels may reflect faster clearance mechanisms rather than actual drops in consumption.1, 27

In addition, smoking patterns during pregnancy and childbirth are affected by hormonal adaptation which alter taste sensation.28 Many women who quit smoking spontaneously during pregnancy experience an aversion to the taste and smell of tobacco.23, 29 Normal taste and smell return quickly following birth.28 This physiological occurrence coincides with the large number of women resuming smoking within 3 months after birthing.14, 28, 30 Current anti-smoking interventions and health care professionals delivery of such interventions largely ignore the physiological barriers specific to quitting during pregnancy.

Back to Article Outline

Smoking during pregnancy and socioeconomic status 

Smoking during pregnancy is compellingly linked with a woman's socioeconomic status and level of education,13 employment status,11, 12, 13 relationships and socialisation with other smokers,9, 10 and perceived lack of social support.9 Women's concern for personal safety, financial security and feelings of emotional isolation also impacts on smoking behaviour.8 Low socioeconomic status restricts potential sources of satisfaction, and so alternative sources may be sought. “Because satisfaction cannot be stored, it must continually be renewed”,16(p22) women with limited access to sources of socially acceptable dopamine triggers are at greater risk of seeking maladaptive sources such as smoking, alcohol, gambling and risk taking.16

Socioeconomically disadvantaged women cite addiction, habit and stress (especially during pregnancy) as a reason for continued smoking during pregnancy.31 Health risks associated with smoking are considered distant in relation to the immediate gratification experienced with smoking for these women.28, 32, 33, 34, 35 Pregnancy is not seen by women as a good time to quit because they view smoking as one of the best ways to deal with stress, depression and anxiety, and the additional pressures of motherhood. Women state that smoking helps relaxation and weight control practices.33 The inability to quit when societal expectations are high reinforces the negative stigma associated with smoking and pregnancy.8, 9, 11, 13, 36 Drug use, such as smoking, is a response to a state of personal, social breakdown. Escape from the daily stress and hardship of economic disadvantage appears to correlate with higher smoking rates and lower quit rates among smokers.37 Smoking in turn predisposes to poorer health and poorer birth outcomes for the woman and baby.38, 39

People who smoke refer to the benefits of smoking. There is anecdotal evidence that stress is reduced, with anxiety and mood being improved by smoking. People who smoke also claim that motivation and concentration is superior following a cigarette.18, 24 These claims are partly supported by research, with motor function, cognitive functioning and visual perception being enhanced after a cigarette.24 This strengthens the positive reinforcement attained via the dopamine feedback mechanism and may account for a person's desire to maintain a habit that is considered unhealthy.

The links between adverse pregnancy outcomes and poverty, independent of smoking, are becoming clearer. There is a growing body of knowledge regarding the correlation between poor birth outcomes and poor maternal nutrition,40, 41 low socioeconomic status, low level of education,42 periodontal disease.43, 44, 45, 46, 47 Despite research identifying poverty as a key factor in adverse outcomes during pregnancy and birth, the emphasis of quit interventions is still on women's smoking behaviour rather than their socioeconomic status and lack of support.

Back to Article Outline

Quit programs and pregnant women 

Women are expected to be knowledgeable about health issues related to pregnancy, birthing and mothering; including the impact of smoking on health. The sources of knowledge available can be problematic for the woman because the focus of most anti-smoking information is based on the assumption that smoking is a lifestyle choice rather than an addiction.48 The lifestyle choice assumption shifts the focus from addiction as a public health issue to one of individual blame. Polices and programs that are delivered authoritatively by doctors and midwives absolves the State of responsibility for providing real assistance to women who are addicted to nicotine.49 The lifestyle choice assumption also makes the woman responsible for any adverse pregnancy outcomes that may be associated with smoking.

Anti-smoking campaigns are designed to inform, shock, or shame smokers into quitting.2, 4, 7, 24 The campaigns rarely take into account low self-esteem, low self-efficacy, poverty, stress and increased caring responsibilities that are common among women who continue to smoke in pregnancy.48 The problem is that unless individual factors are taken into account the health promoting opportunity is wasted. Emily Gilbert conducted research with young women who smoke.48 She concluded that when anti-smoking programs are discordant with the value system of the individual, the person tends to alleviate the incompatibility through separating the self. Alternately, the smoker may amend the received messages to maintain their own view of themselves which, at the time includes being a smoker.48 For women who face emotional, financial or physical challenges on a day-to-day basis, long-term health problems associated with continued smoking are a distant concern when weighed against their immediate problems and the potential relief gained from smoking.50 Being in command of risk taking behaviours such as smoking may be the only instance in which control may be exerted in an otherwise uncontrollable existence.48

Back to Article Outline

Quit smoking interventions and midwifery practice 

Smoking and smoking cessation advice is discussed most often during the first antenatal visit.51 There is generally no negotiation of when and how anti-smoking interventions will be discussed. Consent to broach the subject is not expected by the data system or hospital antenatal record that midwives uses. One Australian study showed the midwives did not seek permission before asking questions about smoking behaviours.52 Expected documentation is limited to recording if the woman smokes and if so, how many per day. The woman's response to the intervention is not usually documented.52

What happens during a standard antenatal visit in relation to smoking is most often based on a cognitive behavioural or educational model of change.7, 17, 18 midwives who follow the instructions given in standard quit smoking campaigns, focus primarily on the ill effects for the unborn baby.7 A focus on the baby is more akin to a medical model of care. A midwifery philosophy, in contrast, focuses holistically on the woman's health and well-being, which of course incorporates the baby's well-being).53, 54 Indeed, the competency standards for midwifery state the midwife “plans and evaluates care in partnership with the woman”(competency 3, element 3.3).54 This competency, when applied to quit smoking interventions, would mean listening to the woman; involving her in decision-making and documenting outcomes, including the woman's response to the quit smoking interaction.

The woman's desire to smoke is not considered in standard antenatal quit smoking interventions. However, pleasure and desire are at the centre of addictive behaviour. Desire and pleasure are shaped through discursive and interactive practices.55 When considering health professional interventions with people who have addictions, Sterling claims that, “the most successful interventions do not deny the sense of need. Rather they find ways to satisfy it by enlarging positive social interactions and reviving the sense of connectedness.”16(p29). This view is consistent with a midwifery philosophy and opens up possibilities to assist women in positive ways. Midwives are in a position to support women and their families through an extended role as a social network facilitator.56 Women would gain a greater sense of control or agency by supporting each other.56

Back to Article Outline

Discussion 

Health authorities grant health professionals the power to attempt to persuade women into changing their lifestyles.4 Midwives are in a unique position, in that they have an opportunity to establish and maintain a relationship with women over a long period of time. Health authorities however, see the first few moments as a time to teach to a captive audience.57 We are arguing that this is an exercise of power over the women, not a partnership of power-sharing and joint decision-making.58 Use of antenatal visits as teachable moments for smoking cessation when women have not attended the health service specifically for their smoking behaviour may be inappropriate.4 Indeed, delivering an anti-smoking message may be seen as judgemental and patronising: this alone could be the basis for not attending follow-up antenatal visits.59

If what happens in standard antenatal visits is not good enough, what should midwives be doing instead? We are not in a position to have all the answers, but a good place to start is a discussion with the woman is from a base of partnership philosophy. The midwife who is committed to partnership practice believes that the woman is best positioned to care for her baby. Attempts by midwives to care for the baby without the woman's full involvement and consent are, we believe, both futile and disempowering. Consent seeking is consistent with the Australian Nursing and Midwifery Council Competencies that the midwife should obtain informed consent for midwifery interventions.54

We suggest that midwives should be aiming for a sensitive and supportive discussion. Treating women sensitively and supportively is even more crucial when dealing with what is often a shameful personal behaviour such as smoking. Ideally, anti-smoking interventions employed within a Midwifery Partnership model of care would begin with a request to engage in a discussion about smoking. For example “Is it O.K. if I ask you about smoking?”

Back to Article Outline

Conclusion 

This paper put forward the concepts of addiction in relation to women and pregnancy. It was revealed that nicotine metabolism is altered during pregnancy with increased nicotine clearance causing pregnant women to physiologically withdraw faster. In addition to the physiological barriers to quitting, pregnant women face increased psychological and emotional hardships associated with the mothering and caring roles. Continued smoking during pregnancy is also linked to low socioeconomic status. Women, therefore, experience added difficulties when attempting to quit while pregnant. Current anti-smoking interventions are based on health professional's understanding of the risks or harm of smoking and the dissemination of that information. Smoking behaviour, however, may not be just an issue of information dissemination. The psychological issues related to addictive conduct and behaviour change is more important.60 Approaches aimed at changing the smoking behaviour of pregnant women are based on strategies employed for non-pregnant smokers. They are brief and delivered didactically.61 We recommend that midwives ask permission before making enquires about smoking. When discussing smoking with a pregnant women, great sensitivity is required and as much as possible the conversation will be a dialogue; not a monologue.

Back to Article Outline

References 

  1. Dempsey D, Jacob P, Benowitz NL. Accelerated metabolism of nicotine and cotinine in pregnant smokers. Journal of Pharmacology Experimental Therapeutics. 2002;301(2):594–598
  2. McCurry N, Thompson K, Parahoo K, O’Doherty E, Doherty A. Pregnant women's perception of the implementation of smoking cessation advice. Health Education Journal. 2002;61(1):20–31
  3. McBride C, Curry S, Lando H, Pirie P, Grothaus L, Nelson J. Prevention of relapse in women who quit smoking during pregnancy. American Journal of Public Health. 1999;89:706–711
  4. Ng N. Professional: smoking cessation programme: an ethical analysis. Modern Midwife. 1997;7(8):23–27
  5. CDC. National Center for Disease Control and Prevention. National Health Interview Survey (NHIS): Glossary of Terms [online], 2007 [cited July 3 2007]; Available from URL: http://www.cdc.gov/nchs/about/major/nhis/tobacco/nhis_togloss.htm.
  6. Cottler L. Comparing DSM-III-R and ICD-10 substance use disorders. Addiction. 1993;88:689–696
  7. Lumley J, Oliver S, Chamberlain C, Oakley L . Interventions for promoting smoking cessation during pregnancy. Cochrane Database of Systematic Reviews. 2004;4:Art. No.: CD001055
  8. Colman GJ, Joyce T. Trends in smoking before, during, and after pregnancy in ten states. American Journal of Preventive Medicine. 2003;24(1):29–35
  9. Lindqvist R, Ãberg H. Who stops smoking during pregnancy?. Acta Obstetricia et Gynecologica Scandinavica. 2001;80(2):137
  10. Siahpush M. Why is lone-motherhood so strongly associated with smoking?. Australian & New Zealand Journal of Public Health. 2004;28(1):37–42
  11. Paterson J, Neimanis I, Bain E. Stopping smoking during pregnancy. Canadian Journal of Public Health. 2003;94(4):297
  12. Siahpush M, Borland R, Scollo M. Factors associated with smoking cessation in a national sample of Australians. Nicotine & Tobacco Research. 2003;5(4):597–602
  13. Hakansson A, Lendahls L, Petersson C. Which women stop smoking?. Acta Obstetricia et Gynecologica Scandinavica. 1999;78(3):217
  14. Severson H, Andrews J, Lichtenstein E, Wall M, Zoref L. Predictors of smoking during and after pregnancy: a survey of mothers of newborns. Preventive Medicine. 1995;24:23–28
  15. Schmidt S. Nicotine addiction. Journal of Addictions Nursing. 2004;15(2):15
  16. Sterling P. Principles of allostasis: optimal design, predictive regulation, pathophysiology and rational therapeutics. In:  Schulkin J editors. Allostasis, homeostasis, and the costs of adaptation. Cambridge: Cambridge University Press; 2004;
  17. Nieoullon A, Coqueral A. Dopamine: a key regulator to adapt action, emotion, motivation and cognition. Current Opinion Neurology. 2003;16(Suppl. 2):23–29
  18. Lowinson J, Ruiz P, Millman R, Langrod J. Substance abuse. A comprehensive textbook. 4th ed.. Philadelphia: Lippincott Williams & Wilkins; 2005;
  19. West R. Theories of addiction. Addiction. 2001;96(1):3–13
  20. Lendahls L, Öhman L, Liljestrand J, Håkansson A. Women's experiences of smoking during and after pregnancy as ascertained two to three years after birth. Midwifery. 2002;18(3):214–222
  21. Gifford E, Humphreys K. The psychological science of addiction. Addiction. 2007;102(3):352–361
  22. Glautier S. Measures and models of nicotine dependence: positive reinforcement. Addiction. 2004;99(s1):30–50
  23. Orleans C, Slade J. Nicotine addiction: principles and management. New York: Oxford University Press; 1993;
  24. Munafo M, Drury M, Wakley G, Chambers R, Murphy M. Smoking cessation matters in primary care. Abingdon: Radcliffe Medical Press; 2003;
  25. Van der Riet P. Massaging cancer patients and their experience of embodiment. Townsville: James Cook University; 1999;
  26. Koob G. Stress, corticotropin-releasing factor and drug addiction. Annals of the New York Academy of Sciences. 1999;897:27–45
  27. Hukkanen J, Dempsey D, Jacob P, Benowitz NL. Effect of pregnancy on a measure of FMO3 activity. British Journal of Clinical Pharmacology. 2005;60(2):224–226
  28. Pletsch PK, Kratz AT. Why do women stop smoking during pregnancy? Cigarettes taste and smell bad. Health Care for Women International. 2004;25(7):671–679
  29. Tortora G, Anagnostakos N. Principles of anatomy and physiology. 6th ed.. New York: Harper and Row; 1990;
  30. Stotts AL, DiClemente CC, Carbonari JP, Mullen PD. Postpartum return to smoking: staging a “Suspended” behaviour. Health Psychology. 2000;19(4):315–323
  31. Hunt S. Pregnancy, poverty and health care. Edinburgh: Books for Midwives; 2004;
  32. Irwin L, Johnson J, Bottorff J. Mothers who smoke: confessions and justifications. Health Care for Women International. 2005;26(7):577–590
  33. Pletsch P, Morgan S, Pieper A. Context and beliefs about smoking and smoking cessation. American Journal of Maternal Child Nursing. 2003;28(5):320–325
  34. Stillman S. Smoking and quitting smoking: crucial issues for women. Australian Journal of Primary Health - Interchange. 1998;4(3):
  35. Isohanni M, Oja H, Moilanen I, Koiranen M, Rantakallio P. Smoking or quitting during pregnancy: associations with background and future social factors. Scandinavian Journal of Social Medicine. 1995;23(1):
  36. Lu Y, Tong S, Oldenburg B. Determinants of smoking and cessation during and after pregnancy. Health Promotion International. 2001;16(4):355–365
  37. Castles A, Adams E, Melvin C, Kelsch C, Boulton M. Effects of smoking during pregnancy: five meta-analyses. American Journal of Preventive Medicine. 1999;16(3):208–215
  38. Begley A. Barriers to good nutrient intakes during pregnancy: a qualitative analysis. Nutrition and Dietetics. 2002;59(3):175–180
  39. Scott J. Maternal nutrition and pregnancy outcome. Nutrition and Dietetics. 2002;59(3):173–174
  40. Andersen A, Mortensen L. Socioeconomic inequality in birth outcomes: what do the indicators tell us, and where do we find the data?. Canadian Medical Association Journal. 2006;174(10):1429–1430
  41. Luo Z-C, Wilkins R, Kramer MS. Effect of neighbourhood income and maternal education on birth outcomes: a population-based study. Canadian Medical Association Journal. 2006;174(10):1415–1420
  42. Green NS, Damus K, Simpson JL, Iams J, Reece EA, Hobel CJ, et al. Research agenda for preterm birth: recommendations from the March of Dimes. American Journal of Obstetrics and Gynecology. 2005;193(3):626–635
  43. Boggess KA, Moss K, Murtha A, Offenbacher S, Beck JD. Antepartum vaginal bleeding, fetal exposure to oral pathogens and risk for preterm birth at <35 weeks of gestation. American Journal of Obstetrics and Gynecology. 2006;194(4):954–960
  44. Michalowicz BS, Hodges JS, DiAngelis AJ, Lupo VR, Novak MJ, Ferguson JE, et al. Treatment of periodontal disease and the risk of preterm birth. New England Journal of Medicine. 2006;355(18):1885–1894
  45. Moliterno L, Monteiro B, Figuerdo C, Fischer R. Association between periodontitis and low birth weight: a case control study. Journal of Clinical Periodontology. 2005;32:886–890
  46. Boggess KA, Beck JD, Murtha AP, Moss K, Offenbacher S. Maternal periodontal disease in early pregnancy and risk for a small-for-gestational-age infant. American Journal of Obstetrics and Gynecology. 2006;194(5):1316–1322
  47. Boggess KA, Lieff S, Murtha AP, Moss K, Beck J, Offenbacher S. Maternal periodontal disease is associated with an increased risk for preeclampsia. Obstetrics & Gynecology. 2003;101(2):227–231
  48. Gilbert E. Contextualising the medical risks of cigarette smoking: Australian young women's perceptions of anti-smoking campaigns.. Health, Risk & Society. 2005;7(3):227–245
  49. Marshall H, Woollett A. Fit to reproduce? The regulative role of pregnancy texts. Feminism Psychology. 2000;10(3):351–366
  50. Denscombe M. Uncertain identities and health-risking behaviour: the case of young people and smoking in late modernity. British Journal of Sociology. 2001;52(1):157–177
  51. Walsh R, Redman S, Adamson L. The accuracy of self-report of smoking status in pregnant women. Addictive Behaviors. 1996;21(5):675–679
  52. Ebert L, Fahy K. Why do women continue to smoke in pregnancy?. Women and Birth. 2007;20(4):161–168
  53. ACM . Philosophy for midwifery. Australian College of Midwives; 2004;
  54. ANMC . National competency standards for the midwife. Australian Nursing and Midwifery Council; 2006;
  55. Davies B. The problem of desire. Social problems. 1990;37(4):501–516
  56. Squires C. The social context of birth. Abingdon: Radcliffe Medical Press; 2003;
  57. McBride C, Emmons K, Lipkus I. Understanding the potential of teachable moments: the case of smoking cessation. Health Education Research. 2003;18(2):156–170
  58. Guilliland K, Pairman S. The Midwifery partnership: a Model for Practice. Department of Nursing and Midwifery, Victoria University of Wellington, Wellington; 1995.
  59. Fahy K. Marginalised mothers. PhD. Brisbane: University of Queensland; 1996.
  60. Ortendahl M. Smoking as a decision among pregnant and non-pregnant women. Addictive Behaviors. 2006;31(10):1806–1819
  61. Pickett K, Wakschlag L, Lanting D, Bennett L. Fluctuations of maternal smoking during pregnancy. Obstetrics & Gynecology. 2003;101(1):140–147

PII: S1871-5192(08)00105-4

doi:10.1016/j.wombi.2008.11.001

Women and Birth
Volume 22, Issue 1 , Pages 35-40, March 2009

Article Tools