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Why ‘Smoking during pregnancy’ health promotion messages don’t always work: Lessons learned from a teenager and why we need to ‘change it up’

Following on from Ben O/Mara’s reflection on his role as a QuitMan comes another piece which questions the relevance and effectiveness of ‘traditional’ health promotion strategies.

In the Croakey longread below, Professor Kerry Arabena describes how a pregnant 15 year old in a small rural town caused her to re-think her approach to health promotion and public health policies

It is a powerful and arresting reminder of the need for health policies and programs to be based in consumer experience if they are to be effective.

This piece was first published on the First 1000 Days blog* and is re-posted here in full with permission.

Kerry Arabena writes:

This week, I had the opportunity to work with a group of students when teaching into the First 1000 Days Australia short course and Master of Public Health subject at the University of Melbourne. I am always delighted to be in the company of students, as I learn so much.

During this course, I had the opportunity to share a story that I learned from a teenage girl in a regional town in the west of New South Wales about 10 years ago. I always refer to this girl as a profound teacher of mine – despite her age. For when I met her, she was just 15 years old, standing up in front of me, pregnant and smoking. I only met her for 20 minutes, but learned more from her in that short space of time than I would have ever thought possible.

On the road

Our meeting took place when I was the Executive Director of Sexual Health and Family Planning ACT. Kim Davison, the Executive Director of Gugan Gulwan Aboriginal Youth Corporation, and I were driving all over New South Wales talking to young people about their knowledge and experiences of sexual and reproductive health so we could write a strategy document; turned out we learned so much more than we bargained for.

The first thing I learned was that Kim did not fly in planes, that she loved country music and thought that I drove too fast. She learned that I liked doof doof music, that I look at things off the road about as much as I look at the road, and when I say this work will be ‘money for jam’, what I actually mean is that we will be working 16 hour days for five days straight, with a lot of hours in cars driving between workshops across the State. It was a long trip for both of us, made better for having met my perfect, 15-year-old pregnant teacher.

The trip coincided with the terrible Millennium drought, which pushed farmers to the edge and led them to be the only other community in Australia to experience the same terrible suicide rates as our young men. Families that had been putting food on our tables were fighting the banks, getting moved off farms and having to put their stock down due to lack of water and feed. Despite campaigns to buy water and feed for farmers, family stressors saw an exacerbation of violence, our regional economy dry up, families move into towns, teenagers become restless, and it was endlessly hot and grim with red dust coating everything.

Taking a break

Kim and I drove in to one such town and started to set up for our sexual health workshop, to which about 16 young people showed up. We worked with a series of comic strips I had developed with ACT-based cartoonist Neville O’Neale to draw out some of the issues young people had about their sexual and reproductive health, and to hear from them what was happening in their own lives – and then devise a strategy that could support them. During one of the breaks, I went outside with those young ones having a smoke, one of them being this 15-year-old girl.

Now, being a responsible adult, I first judged her and then chose to enlighten her with my deep knowledge of health messaging about smoking in pregnancy. Being non-confronting, I thought I would use my social work skills to invite her into the conversation… ‘So, smoking while pregnant, are we?’ She took a serious drag and said, ‘Well, at least I’m not doing heroin any more’, to which I stupidly replied ‘Alright then!’. I think it was because I was too shocked to open my mouth to fill that uncomfortable silence after she shut me down that I listened to what she had to say.

Listening and learning

She told me that she was having this baby because her boyfriend’s car had blown its head gasket and it was going to cost a couple of thousand to fix up. Both of them were too young for a loan, and her boyfriend had a black mark on his credit rating for unpaid mobile phone bills. So she decided to get pregnant because then they could get the baby bonus money and that would pay for the car as well as his phone bill with enough left over to get some things for the baby.

She also said her mum was about to lose her family allowance support money because she, as the youngest child, was about to turn 16. This would mean that her mum would be without that payment for the first time in years; so, if she had this baby, she could give the baby to mum who could then continue to get the family allowance support.

She had also worked out that she would be eligible for a two-bedroom flat rather than a bedsit on the public housing list, and could get a supporting parent’s benefit rather than the Newstart allowance. Furthermore, because she had only finished Year 10, and no one else she knew was going onto Years 11 and 12 so neither was she, she knew she wasn’t going to get a job. So she was having a baby to have someone to love and to have something to do in a town that had few options for someone like her.

Lessons learned

She very clearly showed me three things: the first was the power of perverse incentives in policy. While her immediate needs were met, she was deeply entrenched in the experience of welfare, as were others in her family. Secondly, she showed me how important it was for her to have this baby so that she and her family could continue to leverage benefits from our welfare system.

Welfare benefits, the health card, standing in lines, being desperate, being kept on the phone to Centrelink for hours watching your phone credit disappear, and lashing out at social security officers was a daily experience for many people during that drought, across all walks of life. This baby, and many others across Australia, also allowed that young girl to use her pregnancy, and the welfare system, to care for and to be responsible for other members of her family – her mum and her boyfriend in the first instance.

Thirdly, she told me a little gem that has stayed with me ever since I first heard it. She told me that she and her girlfriends were smoking during pregnancy because they didn’t want big babies. She said this was because she was worried her boyfriend would leave her if her ‘hole was too big’ after having her baby. She and her girlfriends were purposefully smoking to have small babies so their V-Jay Jays could remain tight for their boyfriends, who got their ideas about a perfect vagina from… where? Pornography.

The influence of pornography

I was gobsmacked.

I had never thought to provide young women who smoked during pregnancy with the opportunity to talk about what they thought the impact of having a vaginal birth might be on their relationship, or of whether they were smoking to increase the chances of having a small baby to ‘keep their vaginas tight for their partners’.

I had knowledge that women who survived sexual assault could find pregnancy, birth and early parenthood particularly challenging, but I had never heard of young women, in consultation with their peers, making a purposeful decision to smoke so as to have small babies. From a cursory look through tobacco-related research projects and health promotion material offered to young pregnant Aboriginal and Torres Strait Islander women, neither is anyone else.

A great majority of the Quit literature focuses on recognising that smoking is being used to counter stress, and that there is generally poor knowledge about the impact of smoking on the health of the baby, and the likely complications that the baby and mother will experience because of smoking. There is also literature that points to the need for consistent messaging and family-focused smoking cessation strategies, along with a realisation that professionals need correct information to women who have more stress and less knowledge about the impact of smoking on their health and wellbeing.

But no one has made specific programs or resources available that explicitly link access to pornography and ideals about ‘body perfection’ with young women smoking so they will have small babies because they want to keep their partner’s ideals of pornography-informed body perfection alive.

Pornography as sex education

Over the years, young people have typically come across or sought out sexually explicit material in the form of photographs, films, books and magazines. However, contemporary ‘electronic’ society means sexually explicit material is now even more available, easily accessible and cheap. Unfortunately, many young people are exposed to a culture and environment saturated with sexualised images that are not easily controlled by parents or schools, and they can readily view pornography without age-related barriers.

While it is one thing to read about the impact that pornography has on perceptions about sexuality and promiscuity, and on the link between objectification and the rise of sexual violence, it is another to realise that instead of being able to discuss porn in sex education classes our young people are now viewing porn as a way of educating themselves about sex.

Porn as sex education influences our relationship ideals, creates myths about body perfection and, in some cases, compromises the health and wellbeing of babies and the mothers who smoke so they will have small babies and their men won’t need to run off with someone else ‘tighter’ than them.

First 1000 Days

First 1000 Days Australia work recognises that young people’s context for sexual relationships is ever changing – particularly when organising sex dates on a smart phone is developing into a cultural norm and increased representations are being made to our legal services for the inappropriate sharing of sexually suggestive images sent via smart phones.

Part of the strategy for introducing First 1000 Days Australia into regions, particularly for those focusing on pre-conception work, will be to provide sexual and reproductive health information to mitigate the impact of this toxic version of gender inequality.

We will try to set the record straight – for young people whose ideals of body perfection have been influenced by pornographic representations that are neither real nor safe. We will assist professionals and family members to talk about sexual and reproductive health and wellbeing, body pride, cultural parenting, cultural respect in relationships and the role and place of porn and sexting as part of sex education – rather than as THE sex education for our children.

We will assist those working with young women who smoke during their pregnancy to find out if they are purposefully smoking to have small babies because they are worried their partners will leave them. At the same time, we will work to turn around some of the ideas that are not only compromising our relationships, but also our children’s future health and wellbeing.

This allows for a safe place for parents-to-be to understand the power of intimate relationships, the gift of the child being born to them and to change those worrying attitudes – such as ‘I am not good enough to please him’, or ‘She will never be the same after having this baby’ – into culturally safe and secure parenting strategies that align with our First 1000 Days Australia Charter of Rights and secure family wellbeing from the outset.

The pornography industry does not get to set the quality of our relationships, the shape of our bodies or the health and wellbeing of our children during our pregnancies. We do. Time for a few more hard but good yarns we think. If we don’t, who will?

*First 1000 Days Australia – the Australian Model of the international 1,000 Days movement – aims to provide a coordinated, comprehensive strategy to strengthen Aboriginal and Torres Strait Islander families so they can address their children’s needs from pre‐conception to two years of age, thereby laying the best foundation for their future health and wellbeing.

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