Smoking in pregnancy is a significant 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.
This example was updated with new content in February 2016.
Aims and objectives
The aims were:
- To reduce the prevalence of smoking at delivery
- To increase the number of pregnant smokers who receive an intervention from the stop smoking specialist midwives
- To increase the number of women who quit smoking during pregnancy with NHS support
Reasons for implementing your project
- 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.
- 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 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.
- Saving costs was not the aim of 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.
How did you implement the project
We provided training for all health professionals and admin staff in the antenatal clinic so they deliver consistent stop smoking messages to women 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 have been improved to eliminate delays in getting appointments for motivated quitters. Clinic rooms were initially 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 helped to change some initially resistant attitudes within the maternity unit to this intensive approach and has resulted in greater acceptance of the specialist midwives, as we have been able to demonstrate the pathway is addressing and exceeding national requirements.
Since introducing the pathway further changes have taken place; the stop smoking in pregnancy service is now commissioned separately to the generic stop smoking service. Two specialist stop smoking midwives and one stop smoking in pregnancy advisor are now based within the community midwifery team. There has therefore been no requirement for additional financial resources as staff work in a different way to achieve the desired outcomes.
Results were monitored through the routine data collection by the Stop Smoking Service. The quit rate for pregnant smokers has also increased from 35.84% at the time the pathway was introduced to to 50.04% during 14/15. Smoking at delivery rates have shown significant improvement on the 26.3% outturn for 09/10 and stand at 18.3% in 14/15.
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.