Targeted and personal support for pregnant women to stop smoking as early as possible in pregnancy is an important intervention to optimise the health of both unborn babies and their mothers, and for a number of pregnancies, prevent stillbirth. It is well-known that smoking during pregnancy is one of the most important risk factors to fetal growth and development (Mund et al, 2013). Recent UK figures show some success with national smoking rates in pregnant women dropping from just under 16% in 2006/2007 to just under 11% 10 years later (see Figure 1). The Department of Health (2017) has set a new target to reduce the prevalence of smoking in pregnancy to 6% by late 2022. This paper describes one strand of measures to reduce stillbirth in Poole Hospital NHS Foundation Trust, namely smoking cessation, as well as innovative approaches to achieving this target in a group of NHS in England. It demonstrates measures of success and how innovation and research are tackling the wider determinants of maternity services users' smoking behaviours. A single new project in one trust is also described.
In 2014, Public Health Dorset funded three whole-time posts to train and employ specialist smoking cessation midwives in three neighbouring NHS trusts. Across Dorset, the three trusts providing maternity care use the ‘BabyClear’ (National Institute for Health Research [NIHR], 2017) package which is a complex intervention designed using existing knowledge of what works to help pregnant women stop smoking. It includes training midwives to monitor carbon monoxide levels in all pregnant women, an opt-out referral system for all smokers, and improved referral pathways and communications between midwives and smoking in pregnancy (SiP) midwives. All women smoking at time of the ‘booking’ appointment (8–10 weeks' gestation) are referred to SiP midwives. In line with national guidance, all pregnant women are offered carbon monoxide screening at every routine contact with a healthcare professional.
The target length of time from referral to contact by the local SiP midwife is 48 hours. In Poole, the woman is then offered a home visit. Subsequent support visits are based in a setting of women's choice (at home, children's centres, cafés). Text support is supplied between visits. Women who choose not to engage in treatment after contact from the team are offered support and information, and an opportunity for re-referral at every contact with a healthcare professional.
The ‘plan, study, do, act’ (PDSA) (Deming, 1950) model is the basis for the quality improvement approach used in Figure 2. This system-wide, evidence-based approach has the following aims (a) increase the uptake of smoking cessation services among pregnant women (b) using a personalised approach, visit pregnant women weekly in their homes (c) supply nicotine replacement therapy (NRT) directly (‘vaping’ is not discouraged as a substitute but not directly supplied) and eventually (d) support household members to quit by direct supply of pharmacotherapy including the smoking cessation aid ‘Varenicline’ (for smokers over 18 years). Since late 2019, younger smokers (at least 12 years old) can also be offered support to quit through behavioural support and NRT supplied by the SiP midwife.
This service improvement is run on the expectation that all hospital staff are part of the drive for smoking cessation. To this end, every member of staff was included in a training package delivered by the first author. Staff have their own roles to play, for example a porter may gently remind anyone smoking on the hospital premises to remove themselves from the grounds, explaining as they do, the rationale. Staff on wards reiterate the effects of smoking on an unborn baby eg if a woman intends to leave the antenatal ward to smoke. This is done with the knowledge and sensitivity they have gained from training. Community midwives are the most likely to make the first referral and will play an important part in starting the discussion around benefits to quitting and the known efficacy of seeking support. The community midwife team provides the continuity of message and support, and make repeat referrals to the SiP service. Medical practitioners are also encouraged to play a part.
Positive early results
Between 2015–2016, there was a reduction in smoking at time of delivery from 14%–10%. This exceeded the target of 11%. In Poole, the quit was validated by carbon monoxide measurements and matched the three-year target set by Public Health England. In 2016, the national quality improvement project ‘Saving babies' lives’ was launched. This project used a multi-element approach to reducing stillbirth at Poole Hospital NHS Foundation Trust.
Element one: reducing smoking
The whole package of ‘Saving babies lives’ interventions as rolled out by Poole Hospital NHS Foundation Trust was associated with in a 50% reduction in stillbirth, again reaching the target (this time for 2030) within the first three years. The support for SiP midwives' activities may be a factor in reaching the target early as they are able to offer the following:
Static results
By 2016–2017, the smoking rate had reduced to 8.4% at time of birth in Poole Hospital NHS Foundation Trust and remained at around this level for the next three years. Meanwhile, in 2017, the tobacco control plan ‘smoke free generation’ (Department of Health, 2017) set a new target of 6% of pregnant women still smoking at the time of their babies' births by 2022. Quarter one of 2019 showed a disappointing rate of 8.2% in the first author's trust. This compared unfavourably with Dorset county which was 10.5% and the whole Wessex region which was achieving an overall decline of rate of 11.2%.
The response in Poole Hospital NHS Foundation Trust in 2019
The reiteration of ‘Saving babies' lives’ which is the main subject of this paper was launched in 2019. The Trust started with a scoping exercise which included mapping existing UK smoking cessation services and their approaches. The smoking cessation midwife discovered a range of useful smoking cessation interventions. The second layer of networking was done locally and regionally to ensure that all stakeholders were on board. More recently, in 2019, the regional Wessex maternity and neonatal learning system was introduced. This offers an opportunity to share ideas and support across the south of England. Our success meant that the first author also became the regional Smoke Free Pregnancy Champion for the national Smoking and Pregnancy Challenge Group. Importantly, good support from midwifery management and obstetricians made a difference to status of the service.
Looking at those who are not engaging, we knew that infants from the most deprived quintile are most likely to be exposed to smoking in their homes. Women living in disadvantaged circumstances are often described as ‘hard to reach’ and their disadvantage also increases the chances of them living with a partner who smokes (Flemming et al, 2015). Looking at our routinely gathered maternity data, we were aware that 31% of all pregnant smokers had a partner who also smoked. In addition, women who live in households containing smokers are less likely to quit (Koshy, 2010). From local data, we know that 83% of women still smoking at the time of their babies' births have been identified as ‘vulnerable’ in terms of having complex needs (including issues around socio-economic deprivation, mental health and domestic violence).
Anderson et al (2007) identified that service users want services that are reliable, accessible, sensitive to individual needs and well-coordinated. The key factors seem to be whether a trusting relationship is built with service providers and the degree to which they feel they are in control of the help they are receiving. These are factors which need to be taken into consideration when creating personal care plans in collaboration with women. Previous research shows that health education for pregnant women who smoke can be tailored toward their motivational stage.
Women who are not ready to think about quitting need information on the consequences of smoking and of quitting for themselves and their babies to create a positive attitude. So called ‘contemplators’ and ‘relapsers’ need information on coping with barriers that prevent them from quitting in order to increase self-efficacy (Devries and Backbier, 1994). The SiP midwives are trained in motivational interviewing and work using this communication tool to enhance self-efficacy in their contacts. Self-efficacy is at the heart of motivational interviewing and is defined by Bandura (1982) as ‘how well one can execute courses of action required to deal with prospective situations’.
Motivational interviewing has its roots in the field of substance use and is now being successfully used in a multitude of settings. Its aim is to promote self-efficacy in the person wishing to change their health behaviour. Miller and Rollnick (2013) describe motivational interviewing as ‘arranging conversations so that people talk themselves into change based on their own values and interests’. The motivational interviewing approach uses three key concepts (Bandura, 1982):
In addition to the initial phase of all staff training around smoking cessation, there has been a drive to provide all levels of staff with training in motivational interviewing (initially via ‘et al training’) and more recently, using the NHS education package, ‘Making every contact count’ (Health Education England, 2020). Both authors are trainers. The SiP midwives provide high intensity intervention, all other staff provide brief or very brief interventions.
The continual process of reflection embedded in the PDSA model showed that focusing solely on pregnant women proved to be a limiting factor to success. Hemsing and colleagues (2013) conducted a systematic review which shows that partners or others smoking in the household is a contributing factor to the woman continuing to smoke. From October 2019, Public Health Dorset funded a whole family approach with funding for a pilot study. This was a trial of the direct supply of pharmacotherapy as well as behavioural therapy.
We have no results yet for the newest phase of quality improvement in Poole Hospital NHS Foundation Trust. However, the drive towards, and momentum of, ongoing success so far has ensured that smoking cessation efforts are supported by funding for additional two SiP midwives and two maternity support workers. To optimise the chance of success in reducing rates of smoking in pregnancy, we recommend the following transferable characteristics of services, adhering to quality improvement principles:
In the light of static cessation results, we have taken stock and collaborated with others, and, with the support of the trust research team, will be rolling out a further step in our PDSA quality improvement plans. Commitment to frequent PDSA cycles is key to running smoking cessation services. Celebrating successes is important as is re-doubling efforts when results are less than hoped for. The most recent innovation in the practice of the SiP service has the potential to increase smoking cessation by helping partners and other family members to quit. By having the unusual facility to offer help to over 12 year olds in the household, this project may prevent future unborn babies being affected by smoking.