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Reducing Smoking in Pregnancy Among Maori Women:‘‘Aunties’’ Perceptions and Willingness to Help
Tineke van Esdonk • Marewa Glover •
Anette Kira • Annemarie Wagemakers
� Springer Science+Business Media New York 2013
Abstract Maori (the indigenous people of New Zealand)
women have high rates of smoking during pregnancy and
42 % register with a lead maternity carer (LMC) after their
first trimester, delaying receipt of cessation support. We
used a participatory approach with Maori community
health workers (‘‘Aunties’’) to determine their willingness
and perceived ability to find pregnant Maori smokers early
in pregnancy and to provide cessation support. Three
meetings were held in three different regions in New
Zealand. The aunties believed they could find pregnant
women in first trimester who were still smoking by using
their networks, the ‘kumara-vine’ (sweet potato vine), tohu
(signs/omens), their instinct and by looking for women in
the age range most likely to get pregnant. The aunties were
willing to provide cessation and other support but they said
they would do it in a ‘‘Maori way’’ which depended on
formed relationships and recognised roles within families.
The aunties’ believed that their own past experiences with
pregnancy and/or smoking would be advantageous when
providing support. Aunties’ knowledge about existing
proven cessation methods and services and knowledge
about how to register with a LMC ranged from knowing
very little to having years of experience working in the
field. They were all supportive of receiving up-to-date
information on how best to support pregnant women to
stop smoking. Aunties in communities believe that they
could find pregnant women who smoke and they are
willing to help deliver cessation support. Our ongoing
research will test the effectiveness of such an approach.
Keywords Community health workers � Lay health
workers � Pregnancy � Smoking cessation �Indigenous
Introduction
Tobacco smoking during pregnancy contributes to a range
of adverse pregnancy outcomes [1]. Maternal smoking
increases ill-health risks for offspring during childhood,
adolescence and adulthood and it also has more immediate
consequences including miscarriage [2, 3], premature birth
[4], stillbirth [5, 6], retarded foetal growth [7], sudden
unexpected deaths in infancy [8] and infant respiratory
infection [9]. Dixon et al. [10] found that smoking preva-
lence among pregnant Maori women (the indigenous peo-
ple of New Zealand) is among the highest in the world with
43.5 % smoking at first registration with a lead maternity
carer (LMC) and 34 % still smoking at discharge. Effective
interventions are needed to optimise pregnancy health and
reduce the risk of poor health outcomes, in particular
among indigenous populations [11].
Stopping smoking, a modifiable risk factor, as early in
pregnancy as possible delivers the greatest health gain.
T. van Esdonk
Master Student Health and Society, Wageningen University,
Wageningen, The Netherlands
M. Glover � A. Kira
Centre for Tobacco Control Research, Social and Community
Health, University of Auckland, Auckland, New Zealand
M. Glover (&)
Centre for Tobacco Control Research, School of Population
Health, University of Auckland, Private Bag 92019,
Auckland 1142, New Zealand
e-mail: [email protected]
A. Wagemakers
Health and Society, Department of Social Sciences, Wageningen
University, Wageningen, The Netherlands
123
Matern Child Health J
DOI 10.1007/s10995-013-1377-8
First trimester is optimum for quitting, it is a period when
motivation to quit may be highest [12, 13] and the time
when intervention is needed [14–16]. However, Maori
pregnant women have low rates of engagement with the
healthcare system with 42 % delaying registration with a
LMC until after first trimester (1–12 weeks after concep-
tion) [17]. Reasons for late engagement with healthcare are
that pregnancy is often not planned among Maori women
and some women wait to see if they will carry past the first
3 months [12]. New Zealand’s Ministry of Health has set a
target that 90 % of pregnant women who smoke will be
offered cessation advice and support preferably from the
time they confirm their pregnancy with a LMC or in gen-
eral practice [18]. Late registration with an LMC means
that some women do not receive cessation support until
later in pregnancy [12].
Community health workers (CHWs) may be able to help
with closing the gap between pregnant Maori smokers and
the health sector. CHWs have an intimate understanding of
their community’s socio-cultural background, experiences,
challenges, and strengths, and are in a unique position to
provide peer support for community members [19]. Inter-
nationally, CHWs are known by many other names, for
example lay health advisors, community health advisors,
community health aides, natural helpers, peer educators
and peer outreach workers [20–22]. Previous research
shows positive results using CHWs to provide smoking
cessation [23, 24]. English et al. [23] found that the
development and implementation of a perinatal tobacco
cessation intervention driven by lay health advisors in a
community-based setting was both feasible and valuable.
Yuan et al. [24] found that lay health influencers were
willing and able to tailor cessation interventions based on
individual smoker characteristics and social and environ-
mental contexts.
In New Zealand, Maori CHWs or ‘‘aunties’’ form an
integral part of the health workforce acting as the interface
between the health sector and Maori communities [22, 25,
26]. These aunties are already active in their communities
and commonly work voluntarily for the benefits of the
whanau (extended family). District Health Boards (DHBs)
recognise the importance of CHWs in promoting and
assisting quitting smoking [27, 28]. In order to reduce
smoking in pregnancy, Northland DHB has recommended
that CHWs be provided with smoking cessation support
training [28].
The role of CHWs is complex and varied [22, 29],
involving for example, being a role model, advocate and
administrator [29]. Additionally, CHWs work across a
range of health topics, for example, diabetes prevention,
child health, drug use and smoking cessation [29]. It is
unknown, however, whether aunties are willing and able to
support pregnant Maori smokers to register with a LMC
and to quit smoking. Therefore, the aim of this paper was to
investigate the aunties’ views on (1) finding smoking
pregnant Maori women in their first trimester (2) providing
the pregnant smokers with support and (3) what education
and training they would need.
Methods
The AWHI Study
The data reported in this paper was collected during the
developmental phase of the Auahi Kore Whakahaere
Hapunga (facilitating smokefree pregnancy) Initiative
study (AWHI). The word awhi in the Maori language
derives from awhina which means ‘to help’. A qualitative
participatory approach was chosen due to the exploratory
nature of the study, but also because collaborative research
has been identified as a key strategy in effectively reducing
health disparities in underserved and indigenous commu-
nities [19, 30–32]. Community-based participatory
research supports community health promotion by involv-
ing community members, using their knowledge, skills,
and resources, and creating culturally and linguistically
competent programs [19, 30].
Design
In the developmental phase of the AWHI study qualitative
data was collected at three hui (Maori meetings). Hui are a
qualitative data collection method in studies with Maori
[33–35] and are comparable with focus groups. The choice
for qualitative research was to allow for a deeper under-
standing about the aunties’ opinions and the reasons why
and how they think they can help pregnant women who
smoke.
Participants and Recruitment
Different Maori voluntary support organisations, in New
Zealand, work to improve the conditions of whanau in their
communities, such as the Maori Women’s Welfare League
(MWWL) and Ringa Atawhai. Key contacts (e.g. Chair,
Branch Presidents or members) of Ringa Atawhai and some
MWWL branches were approached to gauge interest in the
AWHI study and to help with recruitment of aunties using
convenience sampling. Written materials were provided for
distribution to members associated with each organisation/
branch, inviting their participation. The members of these
support organisations are mainly female and therefore all
hui participants were female. The predominant female
membership is historical dating back to traditional roles
[though each iwi (tribe) had its own kawa (local customs/
Matern Child Health J
123
rules)] and the practical division of labour especially when
paid work was more likely to be secured by men leaving
women to oversee health and social wellbeing.
Thirteen, 6 and 6 aunties, a total of 25 aunties, attended
2–2.5 h hui which were held in three locations in New
Zealand: Dargaville (a rural–metropolitan sized town),
Hamilton (an urban sized city) and Rotorua (an urban
metropolitan sized city).
Procedures
The hui served as an introduction for the AWHI study and
were organised for aunties who were willing to participate
in the study. Each hui began with formal protocols,
including the welcoming of participants, as appropriate for
the location of the hui. The protocols were followed by
whakawhanaungatanga (introductions establishing tribal
and familial connections), an overview of the study, and an
explanation of the research objectives and hui process.
Participants were given an information sheet and signed a
consent form. Hui topics were discussed in a qualitative
and exploratory way and the sequence of the topics was
flexible during hui. Flexibility and the open style of the hui
allowed the respondents to talk without being steered in a
certain direction, which led to informal, narrative conver-
sations which could be used to tailor the AWHI study to the
needs and wishes of the aunties. The aunties were
encouraged to ask questions related to smoking, nicotine
replacement therapy (NRT), the AWHI study or anything
else throughout the hui.
Measures
The hui were guided by a schedule covering three main
themes (Table 1).
Data Analysis
Digital recordings of the hui were transcribed (TvE),
checked for accuracy (MG) and sent back to the aunties for
feedback. The final transcripts were read to identify themes
and sub-themes inductively using thematic analysis [36].
An inductive approach was used because of the exploratory
nature of the study. Two researchers (TvE and MG) man-
ually coded the transcripts independently. Afterwards,
emerging key themes and any discrepancies were discussed
and resolved by consensus. Quotes from the transcripts are
used to illustrate the themes identified.
Ethical Approval
Ethical approval was granted by the Central Health and
Disability Ethics Committee.
Results
All 25 aunties were Maori females (Table 2). They ranged
in age from 35 to 87 years.
Finding Pregnant Women who Smoke in their First
Trimester
The aunties were positive that they could find first-tri-
mester pregnant women who smoke. They mostly did not
have experience doing this, but as one aunty said: ‘‘there is
the potential amongst all the members, they all have heaps
of mokos [grandchildren] and the wider whanau, because
that is what we are all about… we just don’t keep it in our
own whanau’’.
When brainstorming about how to find pregnant women
early in pregnancy, the aunties said they would use their
networks: ‘‘it is the same with our immunization program,
it just means a bit of networking’’. This would involve
sharing news about the aunties’ own family and catching
up with people, they would ‘‘talk to people that we do
know, whanau members, get out there and talk to people’’:
So I guess there is a lot enquiring after people, you
know when you are with somebody or when you are
going somewhere, how is that son and how is this one
and how is that one and then you get a lot of
information.
The aunties also said they would use the kumara-vine
(gossip): ‘‘be nosey and you are allowed to be nosey,
because you are old’’. Facebook was also mentioned by one
Table 1 Discussion themes
Main themes Examples of questions
Finding smoking pregnant
women in their first trimester
Do you think you can find smoking
pregnant women in their first
trimester and how?
Support for smoking pregnant
women
What would be the benefits of being
an aunty when finding and
supporting the pregnant women?
Education and training needs Are you familiar with LMCs in your
area?
Table 2 Participant demographics
Number of participants Age range (years)
Hui 1 13 aunties 35–75
Hui 2 6 aunties 45–55
Hui 3 6 aunties 54–87
Matern Child Health J
123
of the groups as an important medium used by their chil-
dren and grandchildren. One aunty reported ‘‘well, every-
body found out that [X] was pregnant on Facebook’’.
Furthermore, the aunties would listen to their instinct: ‘‘I
think because we are all aunties anyway, we know these
things [who is pregnant] instinctively.’’ Some aunties paid
heed to traditional tohu (signs/omens) that someone was
pregnant. They referred to having dreams: ‘‘yeah in our
family […] then they say someone is hapu (pregnant),
because they had this dream’’. Other examples of tohu
were: ‘‘when there is parsley outside the front door, or a
kingfisher bird is seen or when the first baby sucks his or
her toes: my moko was in her car seat and put her foot in
her mouth. Oh no, who is pregnant moko?’’ These tohu
differ between families. Further, the aunties would look at
women in the age group likely to get pregnant: ‘‘and it is
the age group too you can capture the target group’’.
A barrier to finding pregnant women who had recently
found out they were pregnant could be that some women
do not tell people that they are pregnant straight away. Fear
of miscarriage was thought to be one reason for this:
‘‘because they want to make sure that they are alright after
the 3 months?’’ One aunty said pregnant women do select
people to tell:
Yeah, that is at the stage where [X] is at the moment,
she doesn’t want to tell her dad, because she had some
trouble during her first pregnancy, and she is not quite
sure whether she is going to get to the three months, so
she is waiting and then she will tell her dad, but she
has told everybody else. She has told the aunties.
Supporting Pregnant Women who Smoke to Quit
The aunties were willing to provide pregnant women with
support. The aunties present at the hui in Rotorua had past
experience running a marae (Maori meeting house) based
parenting program for 22 years. The aunties present dur-
ing the other two hui did not have experience with pro-
viding support to pregnant women although some aunties
mentioned that they had been encouraging pregnant
women to look after themselves. They referred to for
example mentioning ‘‘don’t miss any appointments’’ or
telling the women ‘‘get up you have got to do some
exercise’’.
The aunties did have experience providing support to
parents as they were involved in other programs for
example promoting immunization. The aunties emphasized
that they would approach and provide support in ‘‘the
Maori way’’ which pays heed to tikanga (defined by
Bowers et al. [37] as a set of values that should govern the
most appropriate way to act in a given situation). They also
said it was important to involve the whanau: ‘‘see
everything is whanau oriented now. So you have got to
awhi (help) that mum to give her that choice now that is
what it is about now aye, it is about them’’. Being whanau,
that is related to potential mums, was seen as an important
motivation for the aunties to provide support: ‘‘maybe that
is your niece and you want her to stop’’. Finally, a face to
face approach was considered best when engaging with the
mums: ‘‘we use a lot of, the kanohi ki te kanohi (face to
face), the kanohi ki te kanohi is really the best’’.
To be able to provide support, the aunties mentioned the
importance of connecting, engaging and forming relation-
ships with the pregnant women. They emphasized ‘‘being
yourself’’, ‘‘creating trust’’ and using a ‘‘personal touch’’.
Staying in frequent contact with the mums they were
supporting was also seen as important: ‘‘yeah, just ring
them every day, ring them or text them, that is really
effective that way, they don’t have that support from the
whanau’’. Being an aunty enabled forming relationships:
There is just something about the person [aunty] why
they [the pregnant women] go there, it has got
nothing to do with their mother not being good
enough, but because we have those connections with
each other, they feel comfortable.
Most of the aunties had experienced pregnancy them-
selves and many of them also had experience with giving
up smoking. Self-disclosure of their personal experience
was seen as an important adjunct to communicate the
message to pregnant women. Some of the aunties said they
wanted the mums to have a healthier pregnancy than they
had themselves:
For me I think it would be to encourage them not to
go down the track that I went down […] it is just my
experience, because there were a lot of things that
went wrong during my pregnancies too.
However, the aunties who were current smokers felt
conflicted about delivering the message to stop smoking:
‘‘for me I am never going to tell a young person to give up,
when I am still smoking, you know what I mean. I am
contradicting, right?’’ Other aunties present thought that
the aunties who were smokers could still help, the differ-
ence being that the women they want to help are pregnant:
‘‘they are pregnant and you know what harm it can do,
even though you smoke, you are trying to stop them from
smoking saying don’t hurt your baby.’’
Education and Training Needs
The aunties differed in their levels of knowledge of
addiction to smoking and cessation support. A few partic-
ipants were Quitcard (subsidised NRT exchange card)
Matern Child Health J
123
providers that requires them to have developed compe-
tencies in cessation support and cessation products. Other
aunties had no experience with either using or prescribing
NRT. The aunties who had less knowledge about cessation
support, wanted more information. In particular, because
support which is currently available differs compared to
when the aunties were pregnant themselves: ‘‘nowadays
they have all the other things going, so yeah, educating the
aunties, the nannies and everybody else on what is avail-
able for the young mothers today especially during their
pregnancy’’. These aunties were also interested in becom-
ing Quitcard providers: ‘‘yeah [it would be useful to be a
Quitcard provider] because you could be right there and
then give it to the hapu (pregnant) mums’’. ‘‘Then we can
also [prescribe] that for the rest of the whanau—that will
save us a lot of time if we can do that.’’ The aunties would
want to encourage mums to use the support that exists now.
However, some aunties were reluctant to support use of
NRT:
I am not sure if I want to introduce them to the loz-
enges or all that sort of things, because I am not really
into that myself; however, I would like to introduce
anything else such as maybe ‘go for a light walk’.
Some aunties were unaware that pregnant women could
book in with a midwife before 11 weeks. The majority,
were also not aware that many pregnant Maori women
register late with a LMC: ‘‘I never knew there was a
problem registering with a midwife’’. The aunties referred
to barriers pregnant women experience when they want to
go to the LMC: ‘‘because my daughter-in-law […] she
couldn’t afford to get on a bus to go to a midwife’’ or
‘‘another hinder for them getting to a midwife is that they
stay too far out of town’’. Aunties reported that they had
taken pregnant women to midwives in the past: ‘‘we used
to take them a lot to their appointments, otherwise they
wouldn’t get there’’. The aunties felt sufficiently knowl-
edgeable about who the LMCs are in their area, although
they said they changed regularly: ‘‘yes we do [know who
the midwives are]. There is a Maori group. Three of us at
least or all of us actually, we have worked in that area for
years’’. Additionally, the aunties could find other services
which might be useful for the pregnant women in their own
areas, such as cessation providers and nutrition advisors.
Discussion
The aunties in this study believed they were well placed
locally to find ‘‘hard to reach’’ smoking pregnant Maori
women in first trimester. They did not have experience
doing so, but they believed their existing networks, their
instincts, listening to gossip and talking to women of peak
child-bearing age would help them to find women early in
pregnancy. Furthermore, the aunties were willing to pro-
vide cessation support and facilitate registration with a
LMC. Additionally, the aunties expressed their interest in
increasing their knowledge and skills for example by
becoming Quitcard providers. Given the complexity and
variability of the work carried out by aunties, it was
essential to find out more about what pregnancy and ces-
sation support they currently provide and if they were
willing to help the pregnant women who smoke, in order to
develop an acceptable intervention to trial. However, the
findings presented here have wider relevance to healthcare
services wanting to better connect with pregnant Maori
women perhaps by collaborating with aunties.
Supporting pregnant women in a Maori way in accor-
dance with tikanga was important to the aunties. The
importance of incorporating tikanga was also found in
previous studies [38], for example in a study describing a
nutrition and physical exercise health promotion program
for Maori [39]. Greenaway and Witten [38] concluded that
Maori projects gained strength which included the local
context, experiences, cultural values and tikanga in order to
reinforce identity and provide a strong and consistent sense
of purpose. Conway et al. [40] referred explicitly to the
importance of whanaungatanga (relationships) and
involvement of the whanau (extended family). The aunties
in this study also believed connecting and kinship links
were an important contributor to their ability to locate,
engage and effectively support health behaviour changes
among pregnant Maori women.
The findings of this study are in line with previous
research showing that CHWs’ strengths are their familiar-
ity with the local culture and their unique ability to reach
and mobilize members of the community [19, 20, 41–43].
These introductory hui built support for the AWHI study
and resulted in recruitment of ten aunties who will be
involved in the ongoing study and delivery of the trial
intervention to pregnant Maori smokers. Aunties who
smoke, however are unlikely to be involved as they didn’t
feel it was right for them to provide stop smoking mes-
sages. That they felt it hypocritical for them to do so is
consistent with a commonly held value among Maori that
people should ‘‘walk the talk’’. Having integrity as a role
model is a valued quality among Maori [44]. To be able to
‘‘walk the talk’’ has also been identified as a common
reason motivating Maori to quit smoking [45].
The NZ government has set a goal to be smokefree by
2025, defined as ‘‘a smoking prevalence of less than 5 %,
with tobacco being difficult to obtain and children not
exposed to smoking’’ [46]. At the current cessation rate of
3 % per year [47] and with the apparent halt in the decline of
Maori smoking (no decrease was observed between 2006 and
2011 [48]), the smokefree 2025 goals will not be reached.
Matern Child Health J
123
Therefore, wide-reaching, cost-effective interventions are
needed. CHWs already exist and support their community,
and, they mostly work voluntarily and therefore could be
engaged and resourced at far less cost than interventions
requiring health professional involvement. Assuming that
the AWHI study proves to be effective, it could be rolled out
nationwide relatively quickly and cheaply.
Limitations and Strengths
The current study has some limitations. First of all, the
number of respondents is low: 25 aunties participated in the
hui. Second, the aunties were recruited using snowball
sampling and were recruited from only three geographic
locations within New Zealand. The differences between
Maori groups who live in different regions might restrict
transferability to other iwi (tribes). Finally, it has to be
taken into account that the participants’ responses may
have been subject to social desirability bias. One of the
strengths of this study was the participatory approach
which provided for us to learn from the aunties about their
knowledge, experience and their training needs. Addition-
ally, the aunties could learn more about the latest research
findings, information about the harmful effects of smoking
during pregnancy and about NRT. The qualitative and
exploratory character provided the opportunity to discuss
the topics in depth. The hui were not restricted to specific
questions which provided the opportunity to find out sub-
tleties and complexities about the aunties views on how
they could help.
Conclusion
As demonstrated by other research studies on public health
interventions [49–51] this study supports that researchers
can work in partnership with community members. The
results of this developmental phase of the AWHI study
have shown support for the concept. The next phase will
test whether the aunties will be able to find smoking Maori
women early in pregnancy; if they can overcome the
challenges that pregnancy is not visible during first tri-
mester and that women might not tell their family they are
pregnant in case they miscarry; and if the additional sup-
port provided by aunties helps the pregnant women to quit.
Novel interventions like AWHI are desperately needed as
the latest New Zealand Health Survey (2011/2012) showed
that smoking rates for Maori have not changed since
2006/2007 with 41 % of Maori adults still current smokers
[48]. Reducing smoking prevalence among Maori may not
be necessary to reaching the goal of a smokefree New
Zealand because of the small proportion of Maori in the
population, but it is socially and politically desirable to
bring about equitable health gains for all including Maori.
Acknowledgments The data reported in this paper was collected as
part a larger project (AWHI) funded by the NZ Lottery Grant Board.
We would like to acknowledge Ces Smith of Ringa Atawhai, Makere
Herbert of Rotorua MWWL and Te Pora Thompson-Evans for
recruitment of aunties. We are also grateful to Te Pora Thompson-
Evans for facilitating the Hamilton hui.
Conflict of interest No conflict of interest has been declared.
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