Sunday, June 27, 2010

Dilemma of the Month: Smoking

Victoria attends her first prenatal visit with her midwife at a birthing center when she is 20 weeks pregnant. While taking the client’s history, the midwife discovers that the mother has been smoking throughout the pregnancy. The midwife reviews the risks of cigarette smoking with her new client, but the client is not receptive to quitting. The midwife attempts to negotiate with the mother, by encouraging her to cut back her use from a pack to half a pack per day. The mother makes no promises, but the midwife is hopeful that a change will occur by the next visit.

When Victoria returns for her monthly prenatal visit, the midwife inquires about changes in the mother’s smoking habits. Victoria reveals that she gave a half-hearted try to cut back, insisting that her baby is fine. She goes on to tell the midwife that her own mother had smoked during her pregnancies, and all of the children were healthy. The midwife listens to her client’s justifications, but is dissatisfied with her behavior. Again, she reviews the risks of smoking with the mother. She relates her concerns for Victoria’s baby, to whom she is also responsible. Victoria remains resistant to altering her smoking behavior.

How should the midwife proceed? We welcome your comments.


  1. I think that ultimately it is up to the mother to make the decision about the care of herself and her baby.
    If the mother has been well educated by the midwife on the risks of smoking and it has been documented, then the outcome is up to the mother.
    However hard it may be for the midwife to carry the weight of the outcome of the baby and mother's health, it is still something that must be released for the mother to make the decision on.
    If this is not acceptable then the mother should be referred to someone else who can care for her and her baby.

  2. I've contemplated this with many things--mothers who smoke pot, smoke cigarettes, drink many cups of coffee, think that after the first trimester it's okay to drink 2 or 3 alcoholic beverages, are gaining way, way too much weight and don't care, etc.

    We each have our lines in the sand where we are not comfortable giving care when the client doesn't care...and as I've had to say several times, you just have to tell them to seek other care that you are not willing or agreeable to give your time, energy and care to someone who will not change or modify their behavior. The goals are not the same and you are the one who will be to blame.

    In order to do this ethically, you need to clearly state why you are discontinuing care--the sooner the better as far as stating your boundaries.

  3. I dont think it would be ethical to dump this client! The woman needs encouragement and support not rejection. The midwife offers the best advice based on current research and thereby the woman is empowered to make her own decision, to take responsibilty for her decisions...and she remains engaged in services which otherwise she might not access. She contiues to recieve quality care for the remainder of the antenatal period, the post-natal period, and hopefully returns for future pregnancy which time she might be ready to make changes...

  4. Hi, a note from the book authors... Thanks to everyone for your comments! These dilemmas are not easily resolved, and we don't always agree on the best course of action. Chapter 9 of Professional Ethics in Midwifery Practice deals directly with issues on client non-compliance and termination of care (a subject so complex that we needed a whole chapter to discuss, so a blog post would be insufficient). As we can see from the comments here, client autonomy, beneficence, and informed choice are all key issues. We welcome more comments!

  5. The reason that I am a non-smoker today, is that a caring midwife drew her line in the sand. She told me that she would love to catch my baby in my home if I would agree to quit (not cut back, quit) smoking and I did.

    She told me that she didn't think smoking was ethically wrong or that it smelled foul. She didn't tell me it was bad for my heart or for my lungs.

    She told me she wasn't comfortable in attending a homebirth for a newborn baby who could very possibly have health issues for no reason but cigarette smoke.

    She told me the hospital and all the emergency measures within, were best for a baby born to a smoker.

    This was about 12 years ago and I am so thankful to her for her honesty about her feelings.

  6. Just saw this relevant post: