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Type and Title of Submission


Title:

Smoking cessation in routine antenatal care

Description:

Smoking in pregnancy is a particular problem in Rotherham. This example outlines how we reshaped the existing service to bring the smoking cessation advice into routine antenatal care and improve outcomes without additional investment.

Category:

2010-11 Shared Learning examples

Does the submission relate to the general implementation of all NICE guidance?

No

Does the submission relate to the implementation of a specific piece of NICE guidance?

Yes

Full title of NICE guidance:

PH26 - Quitting smoking in pregnancy and following childbirth

Category(s) that most closely reflects the nature of the submission:

Is the submission industry-sponsored in any way?

No


Description of submission


Aim

The aims were: - to target vulnerable, hard to reach women by embedding smoking cessation advice into routine antenatal care. We wanted to ensure that pregnant women know it is the norm to be challenged on their smoking during pregnancy and that they recognise smoking as a greater risk than eating potentially harmful foods and drinking alcohol in pregnancy - to develop a model based upon the need to treat smoking in pregnancy in the same way as other risk factors and upon the outcome of focus groups held with women who had previously smoked or previously quit during pregnancy. They told us that they wanted to be told clearly exactly what could happen to them and the baby if they continued to smoke and to be offered immediate support.

Objectives

1: To reduce the prevalence of smoking at delivery. 2: To deliver at least one face-to-face intervention to all pregnant smokers by the stop smoking specialist midwives, outlining the high risks of the pregnancy by adopting a prescriptive medical model. 3: To ensure a robust smoking in pregnancy service was in place to deliver expected NICE guidance.

Context

- An audit of pregnant smokers over a three-month period in early 2009 indicated that the existing opt-out pathway was not working effectively. Of 164 pregnant smokers who initially opted out, 149 declined support or were unable to be contacted when further contact was made to encourage engagement with the service. - 08/09 outturn showed Rotherham as having the 10th highest smoking at delivery rate in England (25.4%) and an increasing trend (09/10 was 26.3%, 7th worst). - High infant mortality rate. - Addressing health inequalities. - Local audit in maternity unit showed smoking most common contributory factor in stillbirths, pre-term births, placental abruptions and maternal thromboembolism. - Significant under-performance on PCT and national targets for smoking at delivery. - Focus groups with women who had smoked during pregnancy indicated a need for a more prescriptive intervention. - The previous model was underperforming on some of the NICE recommendations; we were identifying pregnant smokers but potentially losing women because telephone follow-up wasn't being carried out in a timely manner. - We were not seeking to save costs through this initiative, but recognise that each successful quitter saves, on average, 400 in additional costs associated with smoking in pregnancy, and significantly more if pre-term birth and special care is avoided. - Specialist stop smoking midwives based in the hospital antenatal unit alongside the maternity team see all pregnant smokers, whether or not they have requested help to quit, at different stages of the antenatal pathway as part of routine care.

Methods

Successful quitters receive ongoing support from maternity support workers until delivery. A supply of nicotine replacement therapy has been established to administer initial doses at first assessment. We provided training for all health professionals and admin staff in the antenatal clinic so they know to consistently deliver smoking cessation messages to women seen during her pregnancy. Staff prompt cards indicate what to say to patients about their smoking, ensuring all smokers are sent to see the specialist midwife. Admin systems in the service have been improved to eliminate delays in getting appointments for motivated quitters. Clinic rooms were in short supply and the specialist midwives had a different room each day; this meant that not all women were being sent for specialist intervention. They are now based in the midwives' office, identify and call through smokers as they arrive at clinic for the stop smoking intervention. NICE guidance has helped to change some initially resistant attitudes within the maternity unit to this intensive approach resulted in greater acceptance of the specialist midwives, as we have been able to demonstrate the pathway is addressing and exceeding national requirements. There are only two specialist midwives so covering annual leave and sickness is challenging, but maternity support workers can provide brief interventions if the midwife is not available and book appointments for the women with the specialist midwife. Midwives and support workers were already in post and the service is based in the existing antenatal unit. There has been additional admin work in delivering this pathway but this has been managed within existing establishment. There has therefore been no requirement for additional financial resources as staff work in a different way to achieve the desired outcomes.

Results and evaluation

Results were monitored through the routine data collection by the Stop Smoking Service. During the first six months of 2010/2011 there has been an additional 10 successful 4-week quitters compared to the same period the previous year. The quit rate had also increased from 35.84% to 44.44% during the same period. Smoking at delivery rates have shown significant improvement on the 26.3% outturn for 09/10. In 10/11 quarter 1 the rate had dropped to 22.6%, with a further drop to 21.9% in quarter 2. We are reaching the most vulnerable and hard to reach women to deliver the vital information on the risks of smoking to enable her to make an informed choice. For these women we are breaking down the barriers that have prevented them seeking support before, therefore tackling health inequalities. We know that many of these women live chaotic lives so quit rates are not likely to be high, but any quit among this population is a significant benefit to their health and the health of their baby and will contribute towards the reduction in infant mortality. These women had already declined help and would have carried on smoking without the new pathway. The incidence of premature delivery among pregnant smokers is between 17% and 26% and the estimated cost per infant born prematurely is 100,000. Therefore the new pathway has the potential to deliver significant financial savings with no additional investment. The pathway has resulted in a significant enhancement of antenatal care the woman receives without actually changing what anybody in the pathway of care actually delivers, just the way and place in which that care is delivered. It delivers holistic antenatal care at a crucial time. These women now receive a comprehensive one-stop-shop service at the antenatal clinic; nicotine replacement therapy can be issued and follow-up visits arranged at the time. Subsequent support is offered at the woman's home to make the process of quitting as simple and effective as possible.

Key learning points

- All areas, and particularly those with difficulty reaching the most vulnerable women or with high rates of smoking at delivery could replicate the model, subject to pregnancy specialist smoking cessation advisor capacity. Most areas have pregnancy specialists in their Stop Smoking Service who could deliver the interventions in this manner. - This is a low-cost intervention for areas with an existing specialist smoking in pregnancy team to deliver, but with the potential to deliver significant health benefits for mother and baby short and long term, with associated cost savings. - Good relationships between the stop smoking service, obstetrics and the commissioner are needed.

View the supporting material

Contact Details

Name:Alison Iliff
Job Title:Public Health Specialist
Organisation:NHS Rotherham
Address:Oak House, Moorhead Way, Bramley
Town:Rotherham
County:S Yorks
Postcode:S66 1YY
Phone:01709 308870
Email:alison.iliff@rotherham.nhs.uk
Website:http://www.rotherham.nhs.uk/

 

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This page was last updated: 10 February 2011

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Copyright 2014 National Institute for Health and Care Excellence. All rights reserved.