Smoking in Pregnancy Addressing the Pregnancy Challenge Systematically at Local Level Stewart Brock, Public Health Specialist

Our problem was… Stubbornly high SATOD (18.9%) No improving trend Outlier with our statistical nearest neighbour local authorities Identified as a priority issue to address by the Health & Wellbeing Board and CCG

M2Bs v SATOD Pilot commenced in Yeovil in late 2009 Referrals lower than anticipated, but v good outcomes for those engaging No reduction seen in SATOD data - puzzling

Local audit & survey data 2012 100% of women reported being asked smoking status at booking “Professionals need to know these things in case of complications and to advise, so it's perfectly expected.” 56% and 77% of respondents who subsequently delivered at Taunton and Yeovil respectively said they were not offered a CO test. Of those who were, 94% took up the offer. ACTION: Need identified to ensure all women offered CO screening

Smoking at Time of Delivery Audit

SATOD 31% of respondents said they stopped smoking by the time of delivery, compared to 14% recorded on maternity databases. We estimated that the true SATOD rate was 14.8%, compared to the official reported SATOD rate of 17.9%. ACTIONS: Ensure staff obtain and report accurately smoking status at delivery. Ensure software captures SATOB and SATOD.

Results – Mums 2 Be pilot area 266g difference

SATOD* Working Group *smoking at time of delivery In 2013 we set up a multi-agency group comprising Heads of Midwifery, Stop Smoking Service Manager, CCG Quality Improvement Manager, SCC Public Health Specialist. Strategic oversight as we were working towards the CCG Quality Premium Indicator and Health and Wellbeing Board Smoking in Pregnancy Key Priority. *smoking at time of delivery

Pregnancy Challenge Group Reports

Action Plan

Action Plan & Impact Based on Challenge Group report and local intelligence, audits etc. Data collection and recording accuracy vastly improved at both booking and delivery by midwives. Specialist midwives (part time, CCG funded) act as champions for this agenda, providing training and support to colleagues and monitoring progress. Mandatory training for all Somerset midwives annually on smoking identification and referral.

Mums2B specialist smoking in pregnancy service rolled out countywide in 2014 (SCC funded) and incorporated into new contract with Solutions 4 Health in 2015 (Smokefreelife Somerset) All midwives now have access to carbon monoxide (CO) monitors (CCG funded initially, on-going by the Trusts), with an expectation that all women have their breath tested at first booking. Women with a positive CO reading are referred to the Mums2B stop smoking service, on an opt out basis.

These women are contacted promptly and those who respond are offered an intensive support programme with shopping vouchers provided throughout pregnancy and beyond, up to £200 total, contingent on CO breath tests showing continued abstinence from smoking. Women who are still smoking at the time of the 12 week scan are referred to a specialist midwife to discuss the impact of smoking on the woman and her baby, and again offered opt out referral.

Quality improvement The specialist midwives have a quality improvement role. For example: Following up booking forms with missing CO screen Training includes an emphasis on CO checks and data accuracy Training and supervising care assistants in CO screening at 12 week scan Record forms changed and stickers used on handheld notes to reinforce Auditing official SATOD recorded status versus Mums2B records

SATOD rates

Numbers SATOD

Taunton 2014/15

Towards Vision Zero The Mums2B Working Group and Somerset Maternity Services Forum to work to address remaining barriers to effective working, overseen by MSLC. Need to ensure that the identification of pregnant women who are smoking and the offer of support to quit is systematic and routine practice at both first booking and 12 week scan (Stillbirth Bundle). Maintain focus on correct ascertainment and recording of smoking status at booking and delivery/36 weeks.

Towards Vision Zero Providing brief intervention training to “upstream” professionals e.g. fertility, sexual health service, children's centre staff. Continuous improvement towards standard midwifery practice Improve resilience of risk perception clinics and midwife specialist role Closed Facebook group for mutual support Partner and household smoking – need for research into how best to achieve household cessation around pregnancy.

Conclusions Using the pregnancy challenge group reports as a template for action planning across all partners is effective Cultural change takes time and commitment, and requires clear and consistent leadership and challenge SATOD performance change is achievable within the CCG quality premium timeframe. Data accuracy is still an issue

Acknowledgements Tracey Hellyar and the M2Bs team, now at Smokefreelife Somerset. Dr Katherine Holgate, Emily van der Venter and Simon See for audit work. Heads of Midwifery and their teams at Musgrove Park and Yeovil District Hospitals.