Training - A view from the Royal College of Obstetricians and Gynaecologists JANICE RYMER MD FRCOG FRANZCOG FHEA Vice-President for Education, RCOG Dean of Student Affairs, Professor of O and G, Kings College London

Smokefree Skills: An assessment of maternity workforce training Janice to give College’s reaction to Smokefree Skills report

Women known to be smokers at time of delivery Data on this slide from latest NHS Digital Statistics on Women’s Smoking Status at Time of Delivery, England - Quarter 1, 2017-18 Nationally, 10.8% of pregnant women were known to be smokers at the time of delivery. There is huge variation by locality in the rates of smoking at the time of delivery. Whilst the government met its previous ambition of 11%, this was only done by aggregating all of the local CCGs data. Some localities are a lot further behind. For the most recent data, the CCGs with the lowest proportion of women known to be smokers at the time of delivery were NHS Merton (1.2%), NHS Central London (Westminster) (1.3%) and NHS Richmond (2.4%). This compares with CCGs with the highest proportions, NHS Blackpool (24.9%), NHS Durham Dales, Easington and Sedgefield (24.2%) and NHS Mansfield and Ashfield (23.8%). Only 36 out of 207 CCGs currently meet the new national ambition of 6% or less. There is a lot of work to be done! By CCG By CCG and compared with the National Ambition of 6%

Smoking in pregnancy is a major health inequality The Marmot Review 2010, Fair Society, Healthy Lives People living in the poorest areas on average die seven years earlier It is estimated that the annual cost of health inequalities is between £36bn to £40bn Action on health inequalities requires action across all aspects of health Smoking during pregnancy is a major health inequality, with prevalence varying significantly across communities and social groups. Smoking prevalence among pregnant women in more disadvantaged and excluded groups, and those aged under 20, is higher than that in older and more affluent groups Mothers in routine and manual occupations are five times more likely to have smoked throughout pregnancy compared to women in managerial and professional occupations. This means that those from lower socio-economic groups are at a much greater risk of complications during and after pregnancy The Marmot Review into health inequalities in England was published in February 2010. It found that people living in the poorest neighbourhoods in England will on average die seven years earlier than people living in the richest neighbourhoods. In general, the lower one’s social and economic status, the poorer one’s health is likely to be. It estimated that the annual cost of health inequalities is between £36 billion to £40 billion through lost taxes, welfare payments and costs to the NHS The review found that health inequalities arise from an intricate interaction of a number of factors, but that on the whole they are largely preventable. Action on health inequalities requires action across all the social determinants of health, including occupation, income and education.

Why it is important to the College Supporting women to stop smoking should be a core part of a doctor’s care As obstetricians we see the devastating impact of smoking in pregnancy first hand A coordinated approach with other Royal Colleges can help achieve the new 6% ambition Pregnancy is the perfect opportunity to change habit for life Supporting women to stop smoking before, during and after pregnancy should be a core part of a doctor’s care to enable women to have a safe and healthy pregnancies and births. Smoking in pregnancy is the single biggest modifiable risk factor for poor birth outcomes. The RCOG welcomes the Government’s Tobacco Control Plan updated earlier this year and support its ambitious target to almost halve smoking rates in pregnancy by 2022, from 10.7% to 6% or under. We hope that this can be achieved by a coordinated approach with other royal colleges and health services. The Secretary of State for Health announced his new Maternity Safety Strategy in November, stating that the Government would provide funding for midwives to train them to have the knowledge skills and confidence to discuss smoking in pregnancy with women and given advice. But too often we defer to our midwifery colleagues on this issue, if we are to help government reach its ambition, we all need to take action. As obstetricians, we see first-hand the devastating impact smoking has in pregnancy, including miscarriage, stillbirth and premature birth. Quitting smoking is one of most important things a pregnant woman can do to ensure her baby develops healthily and to reduce unnecessary pregnancy complications. We know that the decline in the number of pregnant women smoking is slowing down, and that there is a huge variation in rates across England. It is essential that pregnant women are informed of the risks of smoking during pregnancy, and receive the advice and support they need to quit. There must be an equitable distribution of smoking cessation services so that all women have access. Pregnancy is the perfect opportunity to encourage women to stop smoking for good and we as doctors need to make a lot more of this opportunity and empower women to make healthier choices.

RCOG Training Smoking in Pregnancy is currently covered within our core curriculum

RCOG Training Module 19: Developing Professionalism - ‘Health Promotion and Disease Prevention’ Trainees are expected throughout their training to understand the skills and qualities required In practice however our trainees don’t know enough about smoking in pregnancy They need the skills and confidence to raise it Smoking in pregnancy is currently covered in Module 19: Developing Professionalism under the subheading health promotion and disease prevention Students are expected throughout their training to understand the skills and qualities required to be become a consultant, this includes the communication and leadership skills necessary. Our curriculum reflects this and asks that trainees recognise important issues in preventative healthcare and take opportunities to raise these issues in health promotion. Smoking in pregnancy is specifically mentioned as an example of this in explaining to parents the risks to their children, including the effects of smoking in utero. However, despite this we know that our trainees don’t know anywhere near enough about it and don’t necessarily have the skills or feel confident to raise it.

What more needs to be done? All professionals who engage with a woman before, during and after pregnancy need to be able to understand and articulate the risks. We need to do more to embed it within our training, to develop doctors’ skills in discussing it with women. All professions who engage with women before, during and after their pregnancy need to understand and be able to articulate the risks that smoking in pregnancy can have on the mother and baby, as well as the rest of her family. Obstetricians are no exception to this rule. We are therefore doing more to embed it within our training and develop their skills to enable them to have discussions with women to make them aware of the risks and help them access support.

Currently revising our core curriculum New Part 3 MRCOG exam covered smoking in pregnancy and used lay assessors Currently revising our core curriculum There will be a new Professional Identity ‘Champion for Women’s Health’ Smoking in pregnancy will be covered under ‘Social Wellbeing’ and ‘Health promotion’ This November the College’s new Part 3 MCROG exam had questions around smoking in pregnancy. The Part 3 exam assesses doctors on key skills of patient safety, communication with patients and their relatives, communication with colleagues, information gathering and applied clinical knowledge. It meant that for the first time, lay examiners assessed the trainee doctors on their skills of communication, patient safety and information gathering from the perspective of the patient on smoking in pregnancy. We are currently revising our core curriculum extensively. One of the Professional Identities in the new curriculum will be ‘Champion for Women’s Health’, smoking in pregnancy will be covered under the sections ‘Social Wellbeing’ and ‘Health Promotion’. The aim of the Social Wellbeing section is for doctors to be competent in assessing the impact of different social determinants on women’s health and to be able to champion the health care needs of women from all groups of society. Under the Health Promotion sections, doctors should be familiar with public health priorities for women and be capable of working within local, national and international structures to promote health and a healthy lifestyle and prevent disease. Every encounter with a women should be seen as an opportunity to prevent future disease and promote health.

RCOG