Health promotion within the midwifery profession
This essay will focus on smoking and diet in relation to health promotion within the midwifery profession. Smoking and diet are two main areas of health promotion, which are addressed within the role of the midwife. Smoking and types of diet are both choices which women choose to make, both of which can affect their own health and the health of their child. Smoking is known to have negative effects on pregnancy. There have been many recent public health campaigns which encourage smoking cessation; the reasons for this will be discussed in relation to maternal and fetal heatlh. Diet is an extensive topic and an unhealthy diet can affect pregnancy in various ways. The subtopics of vitamin deficiencies and obesity will be discussed as they are both relevant to today's population of women within the UK.
It is a midwives role to promote a healthy diet and lifestyle; as set out by The Royal College of Midwives, and the Nursing and Midwifery council, whom provide rules, regulations and standards which midwives must adhere to when practicing. Evidence based guidelines are also set out by the National Institute for Clinical Excellence, Centre for Maternal and Child Enquiries and the Royal College of Obstetricians and Gynaecologists to improve the way in which midwives practice. Both rules and guidelines aim to provide training which enable midwives to promote a healthy diet and lifestyle to optimise the health of the woman and her developing fetus prior to and during pregnancy.
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Being healthy means different things to different people. There are many different definitions of health. The medical model, now common in the 20th century, defines health as being the absence of illness and presence of a good bodily function. However, this definition does not take into account social or mental factors and focuses on treatment rather than prevention which may be considered as reductionist and negative (Scriven 2010). Whereas a holistic definition, by The World Health Organisation (1948), states that health is 'a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity'. Even though the holistic model may be praised for acknowledging that mental and social factors effect health, WHO's definition has been heavily criticised for being too idealistic and would consider many people unhealthy (Scriven 2010). In relation to midwifery it is important to promote health, as a 'healthy' diet and lifestyle prior to and during pregnancy improves the chances of a successful pregnancy.
It is a midwives' role to promote health and wellbeing of women and their babies (NMC, 2008). Health promotion, as described by Scriven (2010), is said to be 'improving, advancing, supporting, encouraging and placing health higher on personal and public agenda's'. Midwives use health promotion models and approaches to enable a common value to be made clear; allowing all team members to work towards the same goal. As a result, effective communication between midwives is more likely, and therefore the quality of health promotion given to women is improved (Bowden 2006). Commonly, Tannahill's model of health promotion, developed by Downie et al (1996), lends itself well to midwifery practice. The model mainly focuses on health education, health protection and preventing ill-health. These three main topics overlap; in which health promoting activities may fall. Child vaccination programmes implemented by the NHS is an example of health protection overlapping with ill-health prevention that occurs in practice (Bowden 2006).This example emphasises the positive feature of the model; being able to carry out both objectives of improving health and preventing disease (Sykes 2007). The educational approach is often used within this model whereby the midwife gives facts and information to the women who may then choose to act on the information given, or not (Bowden 2006). Similarly, the behaviour change approach is commonly used in midwifery when encouraging women to change her attitudes or beliefs to adopt a healthier lifestyle (Bowden 2006). There are many health promotions approaches and models. However, no specific model is relevant to every woman. Each woman will have individual needs and therefore requires an individual assessment in relation to health promotion.
Recently smoking has been the centre of health promotion. It is generally accepted that smoking in pregnancy has detrimental effects on fetal growth. Conter et al (1995) found that women who smoked cigarettes during pregnancy were more likely to have a baby with a lower birth weight than babies born to women who did not smoke during pregnancy. Carbon monoxide, inhaled in cigarette smoke, combines more readily with haemoglobin than oxygen (Sherwood, 2006). As a result, the maternal blood supplies less oxygen to the fetus for growth and development; often resulting in low-birth-weight babies. Lumley et al (2009) undertook a systematic review and concluded that methods which encourage women to quit smoking while pregnant reduce the amount of women who continue to smoke in late pregnancy, as well as reducing low birth weights and pre-term birth. However, some women may argue that it is desirable to have a smaller baby as they assume labour will be shorter and less painful, and therefore will not stop smoking. The midwife must explain that this is untrue and there are serious health implications to herself and her child. It is well-known that babies born with a low-birth weight are more likely to die in their first year of life, or require special educational needs during childhood (RCM 2003).
Maternal smoking is thought to increase the risk of miscarriage. Abnormal placentation is a cause of spontaneous abortion of which is linked to increased blood pressure; an adverse effect of smoking (Stables and Rankin, 2010). However, research findings are inconclusive. Similarly, maternal smoking is known to increase the likelihood of sudden infant death syndrome (SIDS). Blair et al (1996) found that the risk of sudden infant death rose with maternal smoking. Postnatal infant exposure to tobacco smoke was also seen to increase the likelihood of SIDS. It can therefore be concluded that antenatal care that encourages smoking cessation during pregnancy and reduces exposure to tobacco smoke in the postnatal environment may help to reduce stillbirths and infant deaths. However, the link between smoking and SIDS is not directional as the causes of SIDS are not yet known.
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Considering the possible consequences of smoking in pregnancy, it is important that midwives offer help and support to women and their families to encourage smoking cessation. NICE (2010) has recommended that midwives should breath test pregnant women for carbon monoxide levels at booking and antenatal appointments. However, this method may be unreliable as carbon monoxide levels fall quickly in expired breath, and therefore is likely to fail to observe carbon monoxide levels associated with low-levels of smoking. Furthermore, such a test may be considered invasive as some women may not want to disclose their smoking status or. Many women may also feel discouraged to attend antenatal appointments in fear of being judged by the midwife if they have not, or do not want to quit smoking. This may prevent midwives from promoting health if they do not get to speak to, support and educate the women during their antenatal visits.
Alternatively, all smoking pregnant women should be given guidance and referred to NHS Stop Smoking Services (NICE 2010). Such services are designed to provide evidence-based non-judgemental support to people who want to stop smoking. It is the responsibility of the midwife to refer women to another practitioner if their health or wellbeing would benefit from doing so (NMC 2008). This may include referral to an especially trained midwife to support pregnant women in stopping smoking. This may enable women to see the same midwife regularly, enabling a midwife-woman relationship to be formed. Therefore women may feel a greater level of support provided by the midwife; increasing the likelihood of smoking cessation. Yet a shortage of midwives may prevent this and instead become a barrier to the further improvement of effective health promotion and smoking cessation services.
Successful smoking cessation not only involves educating pregnant women, but their families too. Ashford et al (2009) suggested that it is significantly important that a woman's partner and family are well educated by health professionals about the effects of second hand smoke to maintain a smoke-free home to prevent postpartum relapse rates. It is the responsibility of the midwife to ensure that the pregnant woman and her family are aware of the psychological and physical effects of passive smoking. In response to this, a midwife may offer information to women and her family regarding nicotine replacement therapy to encourage cessation. Smoking cessation advice given with the provision of nicotine replacement therapy is a typical intervention in relation to the prevention health education domain of the Tannahill model (Sykes 2007).
For most smokers motivation to stop smoking is key. Yet for many women and their partners the presence or planning of a pregnancy is sufficient motivation (Heggie 2006). However, in practice, the midwife may not only provide information about the health benefits of smoking cessation, but the social and financial too. Financial savings can be large and seen quickly, a possible appealing factor to stopping smoking. Socially, women may be able re-build relationships with non-smoking friends; a good source of support to prevent smoking relapse (Heggie 2006). Considering time constraints which often cause a barrier to effective health promotion by the midwife, discussions related to smoking may be brief or an information overload. The midwife may use visual aids such as leaflets, pictures and tables may improve the likelihood that the information is understood, hopefully improving the likelihood that the woman would choose to quit smoking. When encouraging women to quit smoking, the midwife commonly uses educational and behaviour-change models, to inform and encourage women to improve their lifestyle for the benefit of her own and the health of her baby.
It is equally important that midwives provide pregnant women with information on diet and nutrition as well as smoking in relation to promoting health. It is essential that a pregnant woman has a good nutritional intake, prior to conception and during pregnancy as the developing fetus requires basic nutritional substances for the development of vital structures and systems (Stables and Rankin, 2010).
It is generally advised that pregnant women should consume a balanced diet, rich in fruit, vegetables, dairy and starchy carbohydrates. A poor nutritional intake can lead to deficiencies which can cause fetal deformities. An example of this is folic acid; a vitamin essential for the development of DNA and the nervous system. A deficiency of folic acid in early pregnancy can lead to neural tube defects such as spina bifida. During the first 4 weeks of pregnancy, the neural tube is developing, which is often before a woman realises she is pregnant. It would then be recommended to take folic acid as soon as possible, up until 12 weeks of pregnancy, as well as eating a range of foods rich in folic acid such as leafy green vegetables, citrus fruits and fortified cereals (Hunter et al, 2003).
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Similarly, vitamin D is also important during pregnancy. Women who are not regularly exposed to sunlight or do not eat fish nor dairy, may have a deficiency in vitamin D. Vitamin D assists with the absorption of calcium, essential for the formation of the developing bones and teeth of the fetus (Hunter et al, 2003). However, a randomised control trial conducted by Abdel-Aleem et al (2009) concluded that there are no noticeable effects on fetal or infant growth born to women who received calcium supplementation during pregnancy. Yet, it is difficult to generalise these findings to western cultures as participants were from eastern cultures such as India, South Africa and Vietnam.
In contrast, women who over-eat are also at risk during pregnancy. Obesity is becoming an increasing problem for women within the UK. The NHS UK obesity statistics (2010) state that in 2008 25% of women aged 16 and aver were classed as obese. Pregnant women with a Body Mass Index of â‰¤30 kg/m2 at the first antenatal consultation are considered obese (CMACE & RCOG, 2010). In obesity, fatty deposits to build up within the arteries, causing blockages. This can cause hypertension, of which can increase the chances of preeclampsia; a hypertensive disorder of pregnancy. O'Brien et al (2003) found that the risk of preeclampsia doubled in women with a greater pre-pregnancy body mass index. In response to many findings suggesting that obesity has adverse effects on pregnancy, it may be concluded that pre-pregnancy healthy eating advice and weight loss programmes may be beneficial.
Due to the extensive effects that diet can have on pregnancy, it is important that the midwife addresses the importance of a healthy diet to women in her care. It is essential that midwives consider a woman's lifestyle in relation to her diet. Many women may have a busy lifestyle where they are unable to regularly exercise and prepare meals with fresh ingredients; possibly a contributing factor of obesity. The Centre for Maternal and Child Enquiries and The Royal College of Obstetricians and Gynaecologists (2010) released guidelines in relation to the management of women with obesity in pregnancy. This allows specific guidelines for midwives to follow to provide extra support for women with obesity. Even though the guidelines focus on pregnant women with a body mass index greater than 30 kg/m2, the recommendations can be adapted for women whose body mass index is just below this obesity threshold if considered beneficial.
The midwife should spend time during the booking interview to explaining the importance of specific nutrients in relation to her own and her baby's health. NICE (2008) suggests that all pregnant women should be advised of the importance of folic acid supplementation prior to and during the first 12 weeks of pregnancy. All women should also be informed about where to get folic acid, which foods contain folic acid, and the recommended daily dose of 400 micrograms per day to prevent less-educated women from not accessing the supplement. Supplementation of pre-pregnancy folic acid is an example of the prevention of ill-health and disease domain of the Tannahil's model that occurs in practice (Bowden 2006). Also, it is important a midwife explains which foods should be avoided and why.
However, women may choose not to eat nutrient-rich foods because they do not like them. In response, a midwife should provide information on practice alternatives and changes to encourage a healthier diet. Again, this is an example of the behaviour-change and educational models in practice. However, some suggestions may be costly, for example, increasing fruit and vegetable intake or extra nutritional supplements. Hence the midwife should have an up-to-date knowledge of financial benefits that pregnant women can claim, to prevent less economically advantaged women in from being disadvantaged.
Again, time restraints may be a barrier to providing health related information to enable women to make informed choices about their diet. Therefore the midwives communication must be effective to ensure that women understand the information. It is part of a midwives role to communicate effectively (NMC 2008). 'More than one form of communication is more effective in increasing understanding, than only using one' (Kerr et al, 2005). In practice, the midwife may therefore discuss a nutritional need then provide leaflets and web addresses with references so women can access further information to enable their informed choice. In addition, during booking, the midwife provides a free copy of 'the pregnancy book' to every woman. The book aims to provide extra information and support for expectant mums and partners, Different aspects of pregnancy are explained to optimise the health and wellbeing of the mother and baby.
NICE (2008) states that all pregnant women should receive information regarding the importance of their own and their baby's health during the booking interview and antenatal appointments. Often this includes discussing the woman's smoking status, diet and the environment which effects this. This includes assessing a women and her baby, providing up to date and accurate information in relation to their health, and if necessary referral to other health related services. The midwife is responsible for updating her own knowledge and skills to ensure that women receive the most up to date care and information. When delivering effective care, the midwife must ensure that she treats each woman as an individual, with respect, dignity, and kindness to enable women to trust her midwife with her health and wellbeing (NMC 2008).
In conclusion, the midwife has a vital role in promoting health in relation to smoking and diet. Smoking and a poor diet during pregnancy can have serious adverse effects on the mother and baby. Often the main point of contact during pregnancy, the midwife provides essential information and support to women and her family with the health of the mother and baby at heart. By adhering to rules, standards and guidelines the midwife can ensure that the care provided is of the highest standard. Midwives understand that each woman is an individual and her needs are assessed on an individual basis, with a non-judgemental, caring nature. It is essential that a midwife fulfils her role in promoting a balanced, healthy diet and lifestyle prior to and during pregnancy to improve the chances of a successful pregnancy outcome.
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