Worcestershire’s smoking at time of delivery rate has historically been higher than the national average (12.2 per cent in 19/20). Worcestershire has had low rates of carbon monoxide screening in pregnancy, average quit rates that struggled to rise above 40 per cent and no service for women after they had given birth- meaning many would be likely to relapse and enter their next pregnancy as a smoker.
The challenge and approach
Over the last few years Public Health have co-ordinated a partnership approach, working with maternity and wider partners to review the whole pathway of support from booking to post birth to bring the smoking at delivery rates down. Public Health led key system partners to utilise an evidence based, self-assessment approach to identify action areas within the local maternity and postnatal system.
Using a national, evidence-based SIP Deep Dive Self-Assessment Tool', partners worked together to identify areas of strength and those requiring development and action. Key aims of this work were to increase identification of smokers, enhance the quality of frontline conversations with pregnant families, increase access to and outcomes for smoking cessation support, and ensure support was in place postnatally to reduce relapse post birth.
Public Health coordinated a partnership approach to develop an action plan to address identified gaps and weaknesses within antenatal and postnatal pathways.
In addition to the further development of a maternity-based stop smoking service (started 2019), key actions that were implemented as part of the systemwide SIP Action Plan include:
- A new SIP specific dashboard was created to closely monitor outputs and outcomes throughout the antenatal pathway from booking through to the postnatal period.
- In depth audits and scrutiny of carbon monoxide (CO) screening were completed for booking and 36 weeks appointments
- Scrutiny and development of the referral pathway to increase engagement with cessation services
- An equity review was completed to review current service access and actions to increase engagement
- Development of a new postnatal smoking service within health visiting teams, and referral pathway to expand postnatal relapse support
- Neonatal focus- identification of smoking champion and increased promotion of smoking support to NICU families
- Increased feedback and communication between smoking advisors and named midwife to prevent service disengagement
- Smoking cessation service development to expand reach and coverage
- Increased local comms and media coverage to enhance awareness of local service and outcomes
- Implementation of the provision of vapes
- Development and delivery of ‘Challenging Conversations’ training to increase the confidence of maternity staff to engage in conversations around SIP
Impact
Key outputs and outcomes that were achieved in Worcestershire following the implementation of actions, that have contributed to the biggest LMNS wide drop in women smoking at time of delivery in seven years (PHOF). National PHOF data recently published, indicates the smoking in pregnancy rate across the LMNS has now reduced, from 12.2 per cent in 19/20 to 8.3 per cent in 23/24.
- Emerging local data is also showing encouraging smoking at time of delivery rates for 24/25.
- Increase in percentage of pregnant women successfully quitting at four weeks (37 per cent in 21/22, 37 per cent in 22/23, 52 per cent in 23/24)
- Increase of women being CO screened at their booking appointment (63.6 per cent in 20/21 to 88.1 per cent for 23/24; 91 per cent for Q1-3 24/25
- Increase of women being CO screened at their 36-week appointment (33.1 per cent in 20/21 to 82.8 per cent in 23/24) 45 midwifery staff accessed ‘Challenging Conversations training’. 100 per cent attendance of those invited. A train the trainer model is currently being rolled out to ensure future sustainability.
Feedback from service users include:
‘Without the stop smoking advisor’s help I would still be having the occasional cigarette but my stop smoking advisor has provided the information, support and aids to assist in me being smoke free for four+ weeks so far. My family are extremely proud that I have been able to remain smoke free and my 10year old smiles every time we talk about not smoking because it's prolonging my life and helping keep his new brother/sister growth healthy in mommy's tummy. The stop smoking advisor is kind, caring, supportive and compassionate in her work. May long it continue.’
Lessons learnt
Recruitment of public health midwives has been a vital driving force to the success of the workstream. The public health midwives have had a huge impact implementing and embedding processes, pathways and developments, enabling change. Smoking training sessions have been booked previously prior to the recruitment of public health midwives and sign up and attendance was poor in comparison to the recent challenging conversations training. CO screening has increased by almost 30 per cent at booking and almost 50 per cent at 36 weeks since the recruitment.
Looking forward
The systemwide perinatal smoking action plan is refreshed annually and over the next 12 months focus areas will include:
- Increasing capacity within the Smoking in Pregnancy service following the recruitment of additional Tobacco Dependency Advisors, this will include supporting smokers until six weeks postpartum; focussing on deprived and vulnerable communities and working closely with NICU.
- Strengthening the pathway between the smoking in pregnancy service and the smoke-free homes postnatal service to reduce the risk of relapse following birth
- Implementing a specialist Risk Perception Intervention at additional sites across the county
- A deep dive into data exploring demographics, IMD and additional risk factors as well as barriers and motivations to quit.
- Exploring stop smoking support groups for pregnancy women alongside one to one appointments
- Exploring offering incentives to pregnant women and partners to increase quit rates and abstinence from smoking