The harmfulness of smoking in pregnancy is well known and what a healthcare practitioner (HCP) does and says at both the pre-conception and pregnancy stage really matters for increasing the number women having a smokefree pregnancy. Smoking remains the leading modifiable risk factor for a range of poor pregnancy outcomes, including miscarriage, stillbirth, low birthweight and neonatal complications and yet around 70,000 babies are born in England each year to mothers who smoked during pregnancy and there are significant demographic and geographical variations across the country. As trusted advisors at this vital and special time HCPs have the opportunity to use evidence-based information to help future and expectant mothers to make the best choice for their child and themselves.
This blog introduces and explains new research which recommends improvements to training and a more sustainable, system-wide approach to addressing this challenge. If you work in maternity or a position to influence future mothers, are a local commissioner, manager or training and education lead, then please read and share this blog and consider what action you can take to give every child their one chance at a smoke free pregnancy.
There is a strong ambition at national and local levels to address this, with comprehensive action underway through the maternity transformation and stillbirth reduction programmes. A key component is having midwives, doctors and other healthcare professionals with the right skills to have conversations with pregnant women who smoke and help them to access the support they need to quit.
A new report published by Action on Smoking and Health (ASH) on behalf of the Smoking in Pregnancy Challenge Group provides an analysis of the training that midwives and obstetricians currently receive in this area, and what further training is needed.
Research conducted by the Smoking in Pregnancy Challenge Group found that while staff are being taught about the harms from smoking in pregnancy, training on how to communicate this to women, how to use basic equipment such as carbon monoxide monitors, and how to provide brief effective advice to women is not being provided consistently around the country.
The research identified a number of barriers to training and the report sets out a range of opportunities for different agencies to drive improvements. It found that many midwives and obstetricians do not feel they have adequate training or knowledge to address smoking in pregnancy and while some training on this issue is included in undergraduate midwifery and medical syllabuses, more practical skills around simple behaviour change techniques and very brief advice are often not being taught.
Positively, the research found a strong appetite for more training in this area amongst both midwives and obstetricians, particularly in relation to practical actions to take when working with a pregnant woman who smokes.
This is also an issue for the wider workforce and all of those involved in the care of pregnant women. This is about raising the issue of smoking in an appropriate and sensitive way, ideally through Carbon Monoxide (CO) monitoring, and, where required, referring on for specialist quitting support. It is a brief intervention that will ensure women get the more detailed interventions they need from a practitioner with dedicated time to provide this.
To address the training gap, the report recommends that:
- All midwives and obstetricians should be trained so that they:
- have the knowledge and skills to undertake practical action to address smoking, such as CO monitoring and referral for stop smoking support;
- are able to have a brief and meaningful conversation to increase the likelihood of a positive outcome.
- Training should reach all midwifery and obstetric staff so that they can provide a consistent message for women.
- Training should be embedded in both the undergraduate and postgraduate setting.
A system-wide approach – beyond the role of the midwife
Action across the system is needed to ensure these issues are addressed in a sustainable way, with clear roles identified for Royal Colleges, medical and midwifery schools and third sector organisations. The report also presents recommendations for PHE and NHS England, both nationally and locally, which must be acknowledged and reviewed in relation to the work plans associated with the Maternity Transformation Programme, stillbirth reduction ambition and development of Local Maternity Systems.
Whilst the role of the midwife is key, it is important that others involved in the care of pregnant women, those with young families and those who may become mothers in the future also have the knowledge, skills and confidence to engage effectively on these issues. This includes maternity support workers, health visitors, nursery nurses, ultrasonographers, family nurse practitioners and school nurses.
Local commissioners, managers, and training and education leads are encouraged to review the knowledge, skills and practice of their workforce. Whilst action can and will be taken at national level to review curriculum standards and content, local leaders need to ensure that regular updates are provided across the workforce, ideally as part of mandatory training programmes, and that engagement by maternity practitioners with pregnant women who smoke is encouraged, supported and monitored.
Smoking rates are declining, but there is a risk that some population groups are being left behind and we know that smoking during pregnancy perpetuates the cycle of inequalities.
Supporting the maternity workforce to give some of the most vulnerable pregnant women the advice and help they need to stop smoking is essential if we are to continue to make progress in protecting the next generation from the harm of tobacco.
Exciting news: The government has today also published it Tobacco Control Plan which includes an ambition of a smokefree pregnancy for all. It states, ‘Every child deserves the best start in life, so we aim, by the end of 2022 to: Reduce the prevalence of smoking in pregnancy from 10.7% to 6% or less.’ You can discover more from Duncan Selbie’s blog that will be available shortly and you can build you knowledge and confidence of interventions to support people with smoking cessation with our All Our Health topic.
The full report is available here:
Action on Smoking in Health (July 2017).Smokefree skills: an assessment of maternity workforce training
Viv Bennett is Chief Nurse at Public Health England
Jacqueline Dunkley-Bent is Head of Maternity, Children and Young People’s Services for NHS England
Both are members of the National Maternity Transformation Programme Board