A smokefree pregnancy: a perspective from NHS England Dr Jacqueline Dunkley-Bent OBE Professor of Midwifery

Dear younger older me Dear younger me Dear older me Don’t hold back from sharing the evidence Be confident that your opinion matters Don’t collude by accepting vague flippant responses Empathise don’t sympathise Reflect and learn during/after stop smoking training Support staff who feel guilty about giving stop smoking advice Seize opportunities that make a difference for the greater good Policy into practice not on a bookshelf Be courageous and speak truth to power Use strengths to role model and empower others Do not succumb to group think Have faith in human kind – most do not wish to do harm Slide 5: Why did we need a national maternity review? - Matthew Whenever we are asked to present on maternity transformation we find it helpful always to go back to the beginning, to make sure everyone understands the journey we have been on so far. The National Maternity Review was a key commitment of the Five Year Forward View. It came about at a time when there was some concern developing that UK outcomes from maternity services might not compare as well as they might with other high income countries At the same time the Morecambe Bay investigation report had uncovered some very poor care in one particular trust with disastrous consequences for some individuals. And surveys also showed that maternity services were not always good at providing what women wanted. Although progress has been made in recent decades, national and international evidence demonstrates that there is still more that we can do. Our outcomes do not reflect our potential. Our stillbirth rate in particular remains unacceptably high when compared to other similar countries – the Lancet Stillbirth Series, which was published in January 2016, ranked the UK 24th out of 49 high-income countries. This same publication showed that our annual rate of stillbirth reduction of 1.4% is much slower than many other countries –for example, the Netherlands achieve 6.8%v.

Reduce the prevalence of smoking in pregnancy from 10 Reduce the prevalence of smoking in pregnancy from 10.5% to 6% or less by the end of 2022 For services to become safer, more personalised, kinder, professional and more family friendly; where every woman has access to information to enable her to make decisions about her care; and where she and her baby can access support that is centred around their individual needs and circumstances. Maternity Safety Ambition now re-set to halve the rates of stillbirths, neonatal and maternal deaths and brain injuries occurring during or soon after birth to 2025

Guided by 7 themes of Better Births Slide 9: Guided by 7 themes of Better Births - Matthew NB The themes will appear on the screen one by one The vision is built around 7 themes: personalised care, safer care, continuity of carer, better postnatal and mental health care, working across boundaries, and multi-professional working, supported by a payment system which enable the best care to flourish. It is not a detailed blueprint for rolling out methodically, but a set of principles that can be adapted to fit the needs of local populations. Consistent principles nationally, with flexibility to implement locally

9 work streams Supporting local transformation NHS England Promoting safer care NHS Improvement Choice and personalisation NHS England Perinatal mental health NHS England SAFETY CHOICE Transforming the workforce Health Education England Data and information sharing NHS England Technology NHS Digital Payment systems NHS E & NHS I Public Health England Prevention

The Saving Babies’ Lives Care Bundle In 2015 there were 2,952 stillbirths in England Since 2010, the stillbirth rate has fallen 16% from 5.1 stillbirths per 1,000 births in 2010 to 4.3 stillbirths per 1,000 births in 2016 Despite this, England has higher neonatal mortality and stillbirth rates than many other high income countries. There is also a wide variation in stillbirth rates between different regions’ across England. NHS England has brought together a care bundle of elements intended to significantly impact on stillbirth rates through: Reducing smoking in pregnancy by carrying out Carbon Monoxide (CO) test at antenatal booking appointment to identify smokers (or those exposed to tobacco smoke) and referring to stop smoking service/specialist as appropriate 2. Detecting Fetal Growth Restriction 3. Raising Awareness Of Reduced Fetal Movement 4. Improving Effective Fetal Monitoring During Labour

Announcement by Secretary of State for Health New funding to train midwives and MSWs to have the knowledge, skills and confidence to give very brief advice to women during antenatal appointments (DH 2017) Slide 5: Why did we need a national maternity review? - Matthew Whenever we are asked to present on maternity transformation we find it helpful always to go back to the beginning, to make sure everyone understands the journey we have been on so far. The National Maternity Review was a key commitment of the Five Year Forward View. It came about at a time when there was some concern developing that UK outcomes from maternity services might not compare as well as they might with other high income countries At the same time the Morecambe Bay investigation report had uncovered some very poor care in one particular trust with disastrous consequences for some individuals. And surveys also showed that maternity services were not always good at providing what women wanted. Although progress has been made in recent decades, national and international evidence demonstrates that there is still more that we can do. Our outcomes do not reflect our potential. Our stillbirth rate in particular remains unacceptably high when compared to other similar countries – the Lancet Stillbirth Series, which was published in January 2016, ranked the UK 24th out of 49 high-income countriesiv. This same publication showed that our annual rate of stillbirth reduction of 1.4% is much slower than many other countries –for example, the Netherlands achieve 6.8%v.

Improvement and Assurance Framework December 2016 -Maternity and Women’s Health Policy Team granted £75k (£1.95m total) of additional funding to each of 26 CCGs with the highest rates of smoking at time of delivery  Aim to help CCGs implement measures to reduce smoking in pregnancy, as set out in NICE public health guideline and also Element 1 of NHS England’s Saving Babies Lives Care Bundle This includes universal carbon monoxide monitoring at booking, and opt-out referrals to stop smoking services Slide 5: Why did we need a national maternity review? - Matthew Whenever we are asked to present on maternity transformation we find it helpful always to go back to the beginning, to make sure everyone understands the journey we have been on so far. The National Maternity Review was a key commitment of the Five Year Forward View. It came about at a time when there was some concern developing that UK outcomes from maternity services might not compare as well as they might with other high income countries At the same time the Morecambe Bay investigation report had uncovered some very poor care in one particular trust with disastrous consequences for some individuals. And surveys also showed that maternity services were not always good at providing what women wanted. Although progress has been made in recent decades, national and international evidence demonstrates that there is still more that we can do. Our outcomes do not reflect our potential. Our stillbirth rate in particular remains unacceptably high when compared to other similar countries – the Lancet Stillbirth Series, which was published in January 2016, ranked the UK 24th out of 49 high-income countriesiv. This same publication showed that our annual rate of stillbirth reduction of 1.4% is much slower than many other countries –for example, the Netherlands achieve 6.8%v.

Levers & incentives? 10% reduction in their CNST maternity contribution Trusts that are able to demonstrate compliance with 10 criteria will be entitled to at least a 10% reduction in their CNST maternity contribution Slide 5: Why did we need a national maternity review? - Matthew Whenever we are asked to present on maternity transformation we find it helpful always to go back to the beginning, to make sure everyone understands the journey we have been on so far. The National Maternity Review was a key commitment of the Five Year Forward View. It came about at a time when there was some concern developing that UK outcomes from maternity services might not compare as well as they might with other high income countries At the same time the Morecambe Bay investigation report had uncovered some very poor care in one particular trust with disastrous consequences for some individuals. And surveys also showed that maternity services were not always good at providing what women wanted. Although progress has been made in recent decades, national and international evidence demonstrates that there is still more that we can do. Our outcomes do not reflect our potential. Our stillbirth rate in particular remains unacceptably high when compared to other similar countries – the Lancet Stillbirth Series, which was published in January 2016, ranked the UK 24th out of 49 high-income countriesiv. This same publication showed that our annual rate of stillbirth reduction of 1.4% is much slower than many other countries –for example, the Netherlands achieve 6.8%v.

10% reduction in their CNST maternity contribution Box 2: Criteria for the Maternity Safety Strategy CNST discount 1 Are you using the National Perinatal Mortality Review Tool to review perinatal deaths? (Y/N) 2 Are you submitting data to the Maternity Services Data Set (MSDS) to the required standard? (Y/N) 3 Can you demonstrate that you have transitional care facilities in place and operational to support the implementation of the ATAIN Programme? (Y/N) 4 Can you demonstrate an effective system of medical workforce planning? (Y/N) 5 Can you demonstrate an effective system of midwifery workforce planning? (Y/N) 6 Can you demonstrate compliance with all 4 elements of the Saving Babies' Lives care bundle? (Y/N) 7 Can you demonstrate that you have a patient feedback mechanism for maternity services, such as the Maternity Voices Partnership Forum, and that you regularly act on feedback? (Y/N) 8 Can you evidence that 90% of each maternity unit staff group have attended an 'in-house' multi-professional maternity emergencies training session within the last training year? (Y/N) 9 Can you demonstrate that the trust safety champions (obstetrician and midwife) are meeting bi-monthly with Board level champions to escalate locally identified issues? (Y/N) 10 Have you reported 100% of qualifying 2017/18 incidents under NHS Resolution's Early Notification scheme?

Maternal and Neonatal Health Safety Collaborative Improve the safety and outcomes of maternal and neonatal care by reducing unwarranted variation and provide a high quality healthcare experience for all women, babies and families across maternity care settings in England Slide 5: Why did we need a national maternity review? - Matthew Whenever we are asked to present on maternity transformation we find it helpful always to go back to the beginning, to make sure everyone understands the journey we have been on so far. The National Maternity Review was a key commitment of the Five Year Forward View. It came about at a time when there was some concern developing that UK outcomes from maternity services might not compare as well as they might with other high income countries At the same time the Morecambe Bay investigation report had uncovered some very poor care in one particular trust with disastrous consequences for some individuals. And surveys also showed that maternity services were not always good at providing what women wanted. Although progress has been made in recent decades, national and international evidence demonstrates that there is still more that we can do. Our outcomes do not reflect our potential. Our stillbirth rate in particular remains unacceptably high when compared to other similar countries – the Lancet Stillbirth Series, which was published in January 2016, ranked the UK 24th out of 49 high-income countriesiv. This same publication showed that our annual rate of stillbirth reduction of 1.4% is much slower than many other countries –for example, the Netherlands achieve 6.8%v.