Maternal Smoking Is a Key Determinant of Poor Outcomes for Mothers, Babies and Children

4th December 2014. V1 FINAL

Models for Access to Maternal Smoking cessation Support (MAMSS)
Interim Report
Author: Siobhan Jones, Consultant in Public Health, Dr Shantini Paranjothy, Senior Clinical Lecturer, Rachel Lewis, Senior Practitioner Public Health, Dr Aimee Grant, Research Fellow, Ceriann Tunnah, Senior Health Promotion Practitioner, on behalf of the MAMSS steering group (see appendix 1, page 15)
Date: 11.03.2014 / Version: v1 FINAL
Publication/ Distribution:
Early Years Steering Group
MAMSS Steering Group
Relevant local stakeholders, groups and partnerships
Purpose and Summary of Document:
To update on the progress of the Models for Access to Maternal Smoking Cessation Support (MAMSS) Project.
Work Plan reference: Early Years Programme
Date of Board meeting:
This paper is for:
Discussion / ü
Decision / ü
Information / ü

1  Background

Maternal smoking is a key determinant of poor outcomes for mothers, babies and children. Smoking in pregnancy is associated with increased risk of miscarriage, perinatal death, prematurity, low birth weight and congenital anomalies in the baby in particular of the heart, face and limbs[1]. In developed nations, the single most important determinant of low birth weight is cigarette smoking during pregnancy[2].

Wales has a higher rate of smoking during pregnancy than any other UK country. Around a quarter (26%) of mothers in the UK smoked directly before or during their pregnancy[3]. The prevalence of cigarette smoking before or during pregnancy was highest in Wales (33%) and lowest in England (26%). This equates to approximately 11,500 pregnant smokers in Wales per year. Data obtained from local maternity services indicates that the prevalence of maternal smoking at the time of the ‘antenatal booking’ (around 12 weeks gestation) ranges between 20 – 25%.

Supporting women to stop smoking during pregnancy is a challenging area of public health. In 2012, Public Health Wales estimated that the uptake of NHS smoking cessation support in Wales was below 5% in some areas[4]. A recent briefing paper on smoking in pregnancy in Wales highlighted that whilst high quality evidence exists for interventions to promote smoking cessation in pregnancy, this is not currently implemented in a robust, coordinated or systematic way within the NHS in Wales[5].

2  Aim and Objectives

The overall aim is to implement and evaluate the extent to which different service delivery models for smoking cessation services for pregnant women can increase the proportion of pregnant smokers who engage with stop smoking services and reduce the number of women smoking during pregnancy.

The objectives are to:

• Fully implement NICE guidance for smoking services for pregnant women in selected project and usual care sites

• Design and deliver different models of service delivery for smoking cessation services for pregnant women

• Compare the effectiveness and cost effectiveness of new models of service delivery with usual care

3  Method

3.1  Summary

The Models for Access to Maternal Smoking Cessation Support (MAMSS) project has been developed to (i) implement current NICE guidance on smoking cessation for pregnant women and (ii) compare the effectiveness of new models for providing specialist smoking cessation services to pregnant women with existing services delivered by Stop Smoking Wales.

The MAMSS projects are being implemented over a 9-12 month period in selected sites across four health boards in Wales using an integrated approach between maternity services, local public health teams and Stop Smoking Wales. Core recommendations from NICE were implemented across project and usual care sites within the participating Health Boards[6]. In usual care sites, stop smoking support for pregnant women was delivered by the existing Stop Smoking Wales service. In project sites, support was provided by a specialist stop smoking advisor (Maternity Support Worker, Midwife or dedicated Stop Smoking Wales advisor) and was delivered more flexibly than in usual care sites.

NHS research and development permission was granted to the overarching MAMSS research project, which compares the three models of delivery, by Public Health Wales’ Research Risk Review Committee (reference: 2013PHW0004). Of the four project sites, three were classed as service evaluation and thus did not require ethical approval. In the fourth site, the intervention was classed as research and has received approval from their local Research Ethics Committee (13/WA/0087) and Public Health Wales’ research and development Committee (reference: 2013PHW0003).

The geographical area, or community midwifery teams selected by the participating health boards are shown in Table 1. Areas that fall outside the project and usual care areas continued to provide services according to existing arrangements, to identify and refer pregnant smokers to Stop Smoking Wales. Data from these areas have not been included in this interim report and will not be included in the final evaluation.

A full breakdown of the methodology for this project can be found in the study protocol: Public Health Wales. 12th April 2013. Models for Access to Maternal Smoking Cessation Support: An evaluation of the effectiveness of service delivery to increase engagement of pregnant smokers in stop smoking services.

Table 1: Pilot and usual care sites.

Health Board Area / Project Sites / Usual Care Sites / Project commencement date:
Aneurin Bevan University Health Board / County Hospital, Pontypool / Ysbyty Ystrad Fawr, Ystrad Mynach / 12th June 2013
Abertawe Bro Morgannwg University Health Board / Princess of Wales Hospital, Bridgend / Singleton Hospital, Swansea
Neath Port Talbot Hospital / 20th May 2013
Betsi Cadwaladr University Health Board / Denbigh Community Midwifery team
Rhyl Community Midwifery team / Wrexham 1 Community Midwifery team
Wrexham 3 Community Midwifery team / 15th July 2013
Cwm Taf Health Board / Rhondda Community Midwifery Team / Prince Charles Hospital, Merthyr Tydfil / 5th June 2013

Core elements of the evidence base were implemented in all project and usual care areas, including:

·  Strict adherence to NICE opt out smoking cessation pathway for pregnant women, including CO monitoring

·  Smoking cessation services being more closely aligned to maternity services (being provided as part of the package of maternity care)

·  Referral from midwife to smoking cessation support within 48 hours

In addition to these core elements, project areas within each health board developed and implemented a new service delivery model, based on a woman centrered approach with flexibility in how the service is provided as summarised below:

·  Aneurin Bevan University Health Board: A newly appointed SSW advisor working in a more flexible way than current services. The advisor was based within the Midwifery Unit and received referrals directly from midwifery colleagues at the time of booking and offered intensive interventions at times/settings of women’s choice including home visits.

·  Abertawe Bro Morgannwg University Health Board: Two qualified midwives, each working part-time, received referrals directly from their midwifery colleagues and provided intensive interventions at times/ settings of women’s choice, including home visits.

·  Betsi Cadwaladr University Health Board: Two Maternity Support Workers, each working part-time, received referrals directly from their midwifery colleagues and provided intensive interventions at times/ settings of women’s choice, including home visits.

·  Cwm Taf Health Board: One Maternity Support Worker, working full-time, received referrals directly from midwifery colleagues and provided intensive interventions at times/ settings of women’s choice, including home visits.

4  Progress Report

The MAMSS project steering group was set up and has met monthly since September 2012. Considerable effort was made to ensure governance arrangements were in place to meet the needs of all partners, develop protocols, referral pathways and data sharing agreements across all four health boards. Following this set-up period, the first pregnant smokers were referred to the ABMUHB project site in May 2013 (see table 1 for commencement dates).

Specialist project stop smoking advisors (n=6) were recruited and trained to deliver smoking cessation interventions and follow the project protocol to ensure consistency across all four project areas. Midwifery teams (n=13) across the project and usual care sites were trained to offer brief interventions and provided with a Carbon Monoxide monitor in order to routinely assess all pregnant women at their ‘booking appointment’ and follow the NICE referral pathway.

4.1  Early findings

The data in this interim report covers referrals of pregnant smokers in project and usual care sites from the start of the project in each Health Board to the 30th of September 2013, wth follow up until the 30th of November 2013. This period was chosen to allow sufficient time to follow pregnant smokers through their treatment pathway.

4.1.1  Engagement and effectiveness

We have not yet received data from maternity services on the number of pregnant women who were smokers in all sites for this period of analysis. We have estimated this for each area based upon the number of women booking in for antenatal care (2011-12 data) and smoking prevalence (2012-13 data). However, as table 2 shows, the number of referrals received exceeds the estimated number of smokers in intervention sites. This suggests that previous data were underestimates, particularly as the use of CO monitoring was not implemented as it has been within this project. In the full analysis we will be using data from maternity systems and will therefore have a more accurate estimate of smoking prevalence in each project and usual care site.

All four project sites had a higher number of referrals of pregnant smokers than their usual care comparators (Table 2). The number of maternity referrals received by each project site ranged from 78- 108 pregnant smokers, with a small number of self re-referrals. The percentage of service users attending an assessment session ranged from 58%-69%. Around half of the pregnant women who were referred or self re-referred became treated smokers as defined by the Russell Standards[7], that is they attended an assessment session and at least one treatment session and set a quit date. This ranged from 27% in ABHB to 60% in ABMU. Among all smokers who were referred or re-referred themselves, the four week quit rate in these sites ranged from 13% - 15%. In total, 49 women quit in project sites. Within project sites, between 13% (ABMU, Cwm Taf) and 6% (ABHB) of referred and re-referred pregnant smokers successfully quit at four weeks and were CO validated, a total of 40 pregnant smokers.

By comparison there were very few referrals to usual care, although this varied between Health Boards from four to 86 (see table 3). In total there were 112 referrals, of whom 14 were treated smokers and there was one four week quitter (CO validated).

Effectiveness in project and usual care sites was also assessed against Welsh Government Tier 1 targets in table 4. Tier 1 targets refer to the number of treated smokers, the percentage of those treated smokers who quit smoking at 4 weeks and the percentage of treated smokers who had their self-reported 4 week quit CO validated. Across the four project sites, 150 pregnant women became treated smokers and 40 of those were CO validated (27%). In some project sites, there was an initial issue with self-reported four week quits being CO validated within the necessary time frame, identifying a training need. Additional training has been provided. Numbers of treated smokers in usual care areas were too small to draw meaningful conclusions.

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4th December 2014. V1 FINAL

Table 2: Referrals, engagement and successful quit attempts in project sites.

Area (referrals between) / ABHB (12th June – 30 Sept 2013) / ABMU (20th May – 30 Sept 2013) / BCU HB (15th July – 30 Sept 2013) / Cwm Taf (5th June – 30 Sept 2013)
Estimated number of pregnant smokers[8] / 65 / 131 / 42 / 79
Maternity pathway Referrals received by site / 78 / 108 / 85 / 89
Self re-referrals / 1 / 0 / 2 / 1
Total referrals received / 79 / 108 / 87 / 90
Contact made
% of maternity referrals / 65 / 85 / 78 / 88
83% / 79% / 92% / 99%
Number of maternity referrals accepting an appointment
% of maternity referrals / 45 / 75 / 68 / 62
58% / 69% / 80% / 69%
All referrals (including re-referrals) who attended an assessment session
% of all referrals / 45 / 72 / 54 / 62
57% / 67% / 62% / 69%
Number of Treated smokers
% of all referrals / 21 / 65 / 26 / 38
27% / 60% / 30% / 42%
4 week quit smoking
% of all referrals / 10 / 14 / 13 / 12
13% / 13% / 15% / 13%
CO validated 4 week quit
% of all referrals / 5 / 14 / 9 / 12
6% / 13% / 10% / 13%

Table 3: Referrals, engagement and successful quit attempts in usual care sites.

Area (referrals between) / ABHB (12th June – 30 Sept 2013) / ABMU (20th May – 30 Sept 2013) / BCU HB (15th July – 30 Sept 2013) / Cwm Taf (5th June – 30 Sept 2013)
Estimated number of pregnant smokers[9] / 107 / 323 / 42 / 85
Referrals received by site / 6 / 86 / 16 / 4
Assessment session appointment accepted / 4 / 35 / 8 / 3
Attended assessment session / 2 / 11 / 4 / 2
Treated smokers / 2 / 8 / 2 / 2
4 week quit smoking / 0 / 1 / 1 / 1
CO validated 4 week quit / 0 / 0 / 0 / 1

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