Indigenous women and smoking during pregnancy: Knowledge, cultural contexts and barriers to cessation
Introduction
Despite the fact that Indigenous people are a minority population in many of their countries of origin, they are over-represented in smoking-related prevalence, morbidity and mortality statistics. Such disparities are evident in the Indigenous populations of New Zealand, the U.S. and Canada (Bramley et al., 2005, Trovato, 2001), and are particularly pronounced in Australia (ABS, 2006). Despite extensive activity discouraging smoking in Australia, tobacco use among pregnant Indigenous women remains disproportionately high, with many detrimental effects on the mother and child. A study of pregnancy outcomes among Indigenous women in Perth, Western Australia, found that 60–65% of the women smoked during pregnancy (Eades, Read, & Bibbulung Gnarneep Team, 1999). Investigation of 426,344 pregnant women in New South Wales found that 58% of Indigenous mothers smoked during pregnancy (Mohsin & Bauman, 2005).
In data collected from five Australian states and territories, 52% of Indigenous mothers giving birth in 2003 reported smoking during pregnancy, compared with 16% of non-Indigenous mothers (Laws, Grayson, & Sullivan, 2006). Smoking during pregnancy was most prevalent in Indigenous teenage mothers (42%) and decreased with maternal age (Laws et al., 2006). This age gradient is pertinent given that the Indigenous teenage fertility rate is more than four times that of the total Australian population, with 23% of Indigenous births to mothers aged less than 20 years (AIHW, 2006a).
Smoking is the greatest preventable cause of premature death and disease among Indigenous Australians, who are up to eight times more likely to die from smoking-related diseases than non-Indigenous Australians (Cunningham, 1997). Indigenous women have a significantly shorter average life expectancy (AIHW, 2003), with major social implications arising from the premature death of mothers and grandmothers. Divergent mortality trends are evident from infancy, with the perinatal mortality rate for babies born to Indigenous women twice as high as that for babies born to non-Indigenous women (AIHW, 2006b). Indigenous babies are twice as likely to be born preterm or of low birthweight (Laws et al., 2006, Trewin and Madden, 2003) and nearly eight times more likely to die from sudden infant death syndrome (Freemantle et al., 2006). Smoking during pregnancy is a significant risk factor for all of these causes of childhood morbidity and mortality (Laws et al., 2006).
Indigenous smoking prevalence has plateaued at over 50% in the last decade (ABS, 2006), and has failed to mirror the declines seen in the Australian population overall. The high prevalence of smoking magnifies the effects of passive smoking, which is implicated in the higher rates of asthma and respiratory illness (Australian Centre for Asthma Monitoring, 2005) and glue ear experienced by Indigenous children (Menzies School of Health Research, 2001).
Health interventions require an understanding of the context of the problem if they are to be appropriately targeted and effective (Rychetnik, Frommer, Hawe, & Shiel, 2002). As such, smoking behaviour cannot be artificially separated from the contexts in which Indigenous people live and the complex issues that impinge on their health and wellbeing (Brady, 2002, Briggs et al., 2003). While Indigenous people smoke for many of the same reasons as smokers generally, there are other factors contributing to higher smoking prevalence. These include colonisation, dispossession, and racial discrimination, as well as socioeconomic inequalities in education, employment, income and housing (Briggs et al., 2003, Ivers, 2001).
Research and consequent health policy is often limited by a conservative epidemiological approach that does not account for the social and cultural determinants of health (Stanley, 2002). While socioeconomic differences in smoking prevalence have long been observed, it is only more recently that the nature of influence of socioeconomic and psychosocial factors on smoking in pregnancy have begun to be distilled (Bull et al., 2007, DiGiacomo et al., 2007). In the Indigenous related literature, studies have more often focused on the relationship between maternal smoking and poor child health outcomes rather than contextual factors in women's lives that increase the likelihood of smoking. Yet for Indigenous people, social and cultural norms can normalise and reinforce tobacco use (Briggs et al., 2003) and influence the perceived benefits of quitting (Ivers, 2001). Indigenous people readily identify smoking as a mechanism for coping with stress and other pressures and tend to rank it as a low priority relative to other health, social and systemic issues (Briggs et al., 2003, Wood, 2001).
There is evidence that Indigenous people are less personally aware of the specific health effects of tobacco and have poorer access to health advice and services that support smoking cessation (Ivers, 2001). Even evidence-based strategies, such as brief intervention from health professionals or nicotine patches, are often not effective when transferred to an Indigenous context (Ivers, 2004). While culturally appropriate interventions to quit smoking are important, these need to be complemented by strategies that increase the salience of smoking cessation among Indigenous people (Miller & Wood, 2001).
The literature purports that pregnancy, particularly first time pregnancy, increases motivation to quit smoking (Penn & Owen, 2002), providing an opportunity for intervention due to more frequent contact with health professionals (Hellerstedt et al., 1998). However, women who experience multiple social disadvantages are more likely to smoke in pregnancy and the least likely to respond to cessation interventions (Floyd et al., 1993, McDermott and Graham, 2006). High smoking rates among family and friends are a further barrier to cessation among Indigenous people (Miller & Wood, 2001), particularly when non-participation in a group of smokers may lead to feeling isolated and alienated (Briggs et al., 2003). Having a male partner who smokes has a negative influence on a woman's attempts to reduce smoking during pregnancy (Palma et al., 2007).
Section snippets
Aims
The primary aims of the study were to investigate among Indigenous women:
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contextual experiences of smoking;
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issues, perceptions and attitudes regarding smoking during pregnancy;
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awareness and knowledge of the risks relating to smoking during pregnancy;
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barriers and potential mechanisms to support smoking cessation;
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attitudes towards smoking and smoking cessation among people who work with pregnant Indigenous women and new mothers.
Methods
Focus groups and in-depth interviews were used to investigate the views and experiences of both Indigenous women of childbearing age and AHWs. A reference group comprising seven women from the Perth Indigenous community provided input into the research questions, recruitment and interpretation of results. The methodology was also informed by consideration of the literature relating to Indigenous research (Dickson, 2000, Meadows et al., 2003). The study was a collaboration between Indigenous and
Results
This paper reports key findings relating to the context surrounding cigarette smoking in pregnancy among Indigenous women, awareness and knowledge of risks, attitudes and barriers to cessation, experiences of quitting and communications from health professionals. Unless specified otherwise, the term participant denotes the concurring views of community participants [W] and Aboriginal Health Workers [AHW].
Discussion
One of the key aims of this study was to explore the place of smoking in pregnancy within the broader context of Indigenous Australian's lives and the array of social determinants that influence their health. Although focused on pregnancy among Indigenous women in Australia, many of the emergent contextual issues have some resonance with the literature pertaining to Indigenous health internationally, as well as with a growing recognition of social context within the tobacco control paradigm (
Concluding comments
While this qualitative research provides a wealth of information, much of it raises questions and challenges that are without easy answers. The high prevalence of smoking among Indigenous people is perpetuated by social, family, and environmental norms and reinforced by life journeys and circumstances. Smoking in pregnancy among Indigenous women is a challenge that needs to be handled with sensitivity, given other issues that may have more immediate or serious repercussions for Indigenous
Acknowledgements
The authors thank Tracey Eades, the research team and community reference group for assistance, Dr Anne Read and reviewers for manuscript advice and those who assisted with recruitment or participated. Healthway provided financial support.
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