How should midwives discuss smoking behaviour in pregnancy with women of low educational attainment?

To understand how women with low educational attainment perceived the fact of their smoking during pregnancy in order to be able to construct suitable counselling programmes.

Qualitative study using tape-recorded interviews.

Clinic north of Stockholm, Sweden.

Thirteen women who had given birth during the previous months and who had smoked during pregnancy.

All of the women were aware that smoking presented risks to the fetus. Several had themselves experienced the damaging effects of smoking on the fetus. However, many talked about other women who had smoked and still given birth to healthy babies. Nevertheless, the majority felt guilty because they smoked, partly because it made them feel as though they were 'bad people' and partly out of concern for the baby. Most of the women stated that warnings and moralising from midwives did not make them cut down their smoking; on the contrary, many smoked more.

None of the women had reached the stage where they felt motivated to stop smoking. Realistically speaking, probably only a few of them would be able to change their smoking habits during pregnancy. The interviews, however, showed the significance of a client/patient-centred methodology, based on the client's/patient's outlook and social situation. A potentially successful strategy could be to co-ordinate client/patient-centred methodology with cognitive behavioural programmes. An important task is also to confirm and strengthen these women in their roles as mothers-to-be and to introduce the subject of smoking in such a way that the women choose to reduce their smoking as much as possible, given the individual's own ability and social situation. These women might benefit from being confirmed in their maternal role despite the fact that they smoke. Group discussions, where they could 'think it over', would also be of significance, considering the influence of social norms.