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					Gloucestershire PCT

Gloucestershire
Primary Care Trust

Policies, Protocols, Guidelines and Procedures

PATIENT CARE PATHWAY & SERVICE PROTOCOL FOR ANTENATAL SMOKING CESSATION ADVICE and SUPPORT

This document may be made available to the public and persons outside of the Trust as part of the Trust’s compliance with the Freedom of Information Act 2000.

The most up to date policy will always be available under Policies and Procedures on the PCT’s Intranet. If you require this document in a different language or format please contact Michelle Poole, Head of Midwifery, Gloucestershire Primary Care Trust.

Last Reviewed: New Review Date: January 2012 Policy: Community : Antenatal Smoking Cessation Advice Author: Michael Richardson

Issue date: Page 1 of 11

Gloucestershire PCT POLICY AUTHORISATION FORM
NAME OF POLICY:

ANTENATAL SMOKING CESSATION ADVICE and SUPPORT
Michael Richardson: Service Co-ordinator (GSAS)

1
JOB TITLE OF AUTHOR:

DIRECTOR:

Shona Arora

NAME OF GROUP: (if applicable)

PCT Clinical Policy Group

EQUALITY AND DIVERSITY An Equality & Diversity assessment has been completed (Please contact the Equality & Diversity Manager 01452 389496

Date Completed:

2

CONSULTATION NAME OF GROUP (S) (complete where relevant) Name of Local Committee or Specialist Group? Name of Countywide Committee or Specialist Group? County Wide Policy YES / NO Other relevant Forum/Individual? Head of Midwifery for Gloucestershire PCT Assistant directors for Women and children‟s services GHNHSFT

DATE CONSIDERED

November 2008

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APPROVED BY BOARD/AUTHORISED GROUP/DIRECTOR NAME i.e. Trust Board DATE APPROVED PCT Clinical Policy Group TO BE REVIEWED BY: (Author) DATE TO BE REVIEWED: Michael Richardson January 2012 TO BE COMPLETED BY CO-ORDINATOR HARD COPY ISSUED POLICY NUMBER: DATE PLACED ON INTRANET: CMC12 To be confirmed

4

Last Reviewed: New Review Date: January 2012 Policy: Community : Antenatal Smoking Cessation Advice Author: Michael Richardson

Issue date: Page 2 of 11

Gloucestershire PCT
POLICY UPDATES/CHANGES
(AFTER BOARD/DESIGNATED GROUP APPROVAL)

Date

Summary of Changes

Author/Editor

Approved by

Version No.

CONTENTS
Section 1 2 3 3.1 3.2 3.3 4 4.1 5 5.1 5.2 6 7 8 9 9.1 9.2 10 10.1 11.0 12 Appendix 1 Appendix 2 Appendix 3 AIMS OBJECTIVES BACKGROUND Health risks to unborn babies Health risks for children Further Information TARGET AUDIENCE Structures in Place SCOPE OF SERVICE Who will be included? Who will not be included? PROTOCOL DETAILS COMMUNICATION OF POLICY MONITORING and EVALUATION RISKS and BENEFITS Key risks Key benefits COST IMPLICATIONS Resource Needs TRAINING REFERENCES Pathway for Antenatal Women Prompt cards for Midwives Referral form Section Heading Page Number 4 4 4 5 5 5 6 6 6 6 7 7 7-8

8 8 8 8 8 9 10 11

Last Reviewed: New Review Date: January 2012 Policy: Community : Antenatal Smoking Cessation Advice Author: Michael Richardson

Issue date: Page 3 of 11

Gloucestershire PCT ANTENATAL SMOKING CESSATION ADVICE and SUPPORT 1.0 Aims: To reduce smoking prevalence in pregnant smokers within Gloucestershire by utilising a midwifery led “opt-out” referral processes to a specialist smoking service. 1.1 The aim is for Gloucestershire Stop Smoking Service (GSAS) to see all pregnant smokers who opt in to the pathway, who otherwise would not have taken up an offer of stop smoking support on their own volition. GSAS will provide them with an opportunity to discuss their smoking, have help and support to quit and ensure they have information on keeping children safe from second hand smoke. The ultimate aim is to improve maternal, foetal and family health. 2.0 Objectives: a. To refer all pregnant smokers, unless they decline, to GSAS by midwives where they will be offered greater opportunities for stop smoking support. b. To give pregnant smokers the opportunity to opt out of the referral process. c. To provide additional data to accurately assess the rate of smoking during pregnancy countywide. d. To enable midwives to have professional responsibility and accountability for stop smoking support. e. GSAS to offer improved opportunities for all pregnant smokers to receive advice on reducing the harm to their families from second hand smoke. f. To reduce inequalities in health by targeting pregnant smokers who are in deprived socioeconomic groups. g. To develop carbon monoxide reading as a routine antenatal test. h. To reduce the rate of smoking in pregnancy by 1% per year. 3.0 Background: Smoking during pregnancy is the greatest cause of foetal ill health and death. It can cause serious problems including complications during labour, increased risk of miscarriage, premature birth and stillbirth. Smoking is harmful throughout pregnancy and stopping at any stage will be good for the baby. The most damaging effects of smoking happen in the gestational months, four to nine. This means that, if a mother stops smoking within the first three months of her pregnancy, the baby is still likely to be of a healthy weight with minimal damaging effects. When a person smokes, over 4,000 chemicals go into the body. One of these is the gas carbon monoxide which enters the mother‟s bloodstream and cuts down the oxygen reaching the baby. For every cigarette smoked, the oxygen supplied to the baby is disrupted for 15 seconds and the baby experiences reduced blood oxygen flow for 15 minutes.

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Gloucestershire PCT 3.1 Health risks to unborn babies of smoking pregnant women include:
     

Lower birth weight. Slower growth of the baby. Higher risk of cot death. Damage to airways which could cause breathing problems or asthma. Increased risk of perinatal death – up to one third higher Higher risk of premature birth

The peri-natal death rate in 2005 in Gloucestershire was 7.2/1000 births. We aspire to see a reduction in this statistic if we increase significantly the smoking quit rate of pregnant women.

3.2 Health risks for Children Health risks to children if they are growing up in a home where one or more parents smoke include:
    

High incidence of upper respiratory infections. Asthma attacks or lower respiratory infections. Higher risk of lung cancer in adulthood. Meningitis. 'Glue ear' and partial deafness.

3.3 Further Information 3.3.1 Hospital data on maternal smoking behaviour at booking or delivery is incomplete (more than 5% are unknown in England). Smoking rates during pregnancy are likely to be closer to the female prevalence overall (22%) than self report data tell us. An internet survey by Usher et al, (2000) identified a range of barriers to women accessing stop smoking services during pregnancy, including, fear of failure, unwillingness to seek help and lack of access to services. Other identified barriers were fear of weight gain, denial of risk addiction and wider social context. We need to invite more women to use effective treatment, ideally before, or failing that during pregnancy. 3.3.2 We need better and consistent:  Data accuracy on the prevalence of smoking in this client group,  Referral to specialist stop smoking services,  Engagement of pregnant women through brief interventions by midwives to increase client confidence in being able to quit,  Treatment/retention,  Supportive relapse prevention.
Last Reviewed: New Review Date: January 2012 Policy: Community : Antenatal Smoking Cessation Advice Author: Michael Richardson 11 Issue date: Page 5 of

Gloucestershire PCT 3.3.3 Bauld (2008) suggests that routine screening of all pregnant women for tobacco use via CO monitoring combined with an “opt-out” referral process will help the above. This has been shown in pilot studies in Glasgow and South Birmingham and now has been incorporated into their routine practice. It will also provide an opportunity for the midwife to have a discussion with the client regarding the need to reduce harm from second harm smoke. South Birmingham PCT has had a successful opt out referral scheme enhanced with midwives using carbon monoxide monitors for over a year and a half. 4.0 Target Audience: This protocol is for midwifery staff and smoke free family advisors within Gloucestershire PCT. 4.1 Structures in place for this service: 4.1.1 Midwifery service: Midwives in Gloucestershire provide high quality midwifery antenatal care in various locations in Gloucestershire. These include:  Stroud Maternity Unit  The Gloucestershire Birth Unit, at Gloucester Royal Hospital  St Paul‟s Wing – Delivery Unit Cheltenham Royal Hospital (combined midwifery and consultant led)  Community Hospitals in the Forest of Dean  General practices/health centres 4.1.2 Gloucestershire Stop Smoking Service (GSAS) is based at Park Road in Gloucester. It is made up of a team of specialist stop smoking advisers that provide support in helping smokers to give up. These advisers have various expertise and provide services in various locations throughout the county. They accept referrals from a variety of sources, including GPs, Practice Nurses and self referral by the client. The service has two “stop-smoking-in-pregnancy” advisers who will manage the referrals from the midwifery service. In most cases these advisers will provide the stop smoking support to clients unless this is geographically prohibited. GSAS has an administration team that provides the necessary support needed to provide a specialist stop smoking service. 5.0 Scope of Service 5.1 The service will be open to all women who undertake a CO monitoring and score greater than 5 will be offered the „opt out‟ referral pathway. 5.2 What will not be included in the scope of the “opt-out” referral service? Partners who smoke or other smokers in the household of pregnant women who are not present at booking cannot be referred via this opt out scheme. However information on how to access Gloucestershire Stop Smoking Service can be given to the women for these third parties. If the women have household
Last Reviewed: New Review Date: January 2012 Policy: Community : Antenatal Smoking Cessation Advice Author: Michael Richardson 11 Issue date: Page 6 of

Gloucestershire PCT members present at booking who smoke, then they can be referred together if all parties consent. 6.0 Protocol details. 6.1 Patient Pathway: - see flow chart in Appendix 1 6.1.1 During the antenatal booking the patient is routinely asked if they smoke as part of the „booking‟ assessment. 6.1.2 A carbon monoxide (CO) monitoring test is also offered routinely in the way other tests such as urine testing, BP and weight monitoring are performed at booking contact. 6.1.3 If CO monitoring is refused it is recorded in their maternity records. 6.1.4 If the client indicates they smoke, and/or their CO level reading is >5ppm, and they have given verbal consent, an automatic referral using an agreed form (appendix 2) is made into the specialist stop smoking service. A stop-smoking-in-pregnancy specialist will then contact the patient. The midwives can use the prompt cards (Appendix 3) for the phrasing of the result. 6.1.5 If the client declines to be referred they will not be automatically referred. The discussion as regards smoking issues will be noted and raised appropriately at another opportunity. 6.1.6 The stop smoking support specialist will offer the patient support in a mutually convenient setting of the patient‟s choice i.e. group setting, one-toone in various locations e.g. antenatal clinic or other location including the home if only option available. 6.1.7 If the patient accepts the support they will ideally be seen on a weekly basis for the first 4-6 weeks and then fortnightly up to 12 weeks and beyond as required. 6.1.8 Longer term contact will be maintained by GSAS in order to prevent relapse through pregnancy and in the postnatal period. 6.1.9 Attempts to contact the patient will be made by GSAS in the event of DNA/loss to follow ups, and appropriate relapse support given if possible. 7.0 Communication of Policy.
7.1 The Head of Service will send a memorandum to individual staff members to inform them of the reviewed guidance. 7.2 A newsletter will also inform staff of this new protocol. 7.3 GSAS will share with their staff.

8.0 Monitoring & Evaluation: 8.1 An audit will be undertaken at least once in 3 years reviewing heath records (including electronic and specialist‟s notes) to identify documentation relating to the protocol. 8.2 GSAS monitors all smoking quit attempts according to DOH guidelines and reports are submitted quarterly to DOH, SHA and PCT. Data is also analysed by
Last Reviewed: New Review Date: January 2012 Policy: Community : Antenatal Smoking Cessation Advice Author: Michael Richardson 11 Issue date: Page 7 of

Gloucestershire PCT postcode in order to ascertain our level of success of helping people to quit in areas of inequalities. 8.3 The PCT has Vital Signs monitoring to be reported to SHA in relation to the numbers of women who smoke at the time of birth. 9.0 Risks and benefits. 9.1 Key risks 9.1.1 Sensitivity, tact, experience and training is required when addressing smoking in pregnancy with clients. Women report guilt, anxiety, and added stress from victim blaming messages. 9.1.2 Women often feel pressured into stopping smoking, feel guilty, and are less likely to admit to continue smoking. It is important therefore that midwives receive appropriate brief intervention training in order to boost patients‟ confidence in stopping smoking. 9.2 Key benefits 9.2.1 A reduction in smoking prevalence in pregnant women in Gloucestershire leading to maternal/fetal health gain. 9.2.2 Supports midwives to provide a holistic care package to pregnant women.

10. Cost Implications. 10.1 Identified resource needs:  Referral pads  Carbon monoxide foetal monitors for midwives with attachments.  Prompt cards  Health promotion literature and information on GSAS. Funding is available through GSAS for these resources. 11.0 Training: 11.1 Stop-Smoking-Support Brief Intervention training to midwives (including the principles of health behaviour change). 11.2 Training in the use of carbon monoxide foetal monitors This will be provided by GSAS.

12.0 References. Bauld et al (2008)xxxx Usher et al, (2000) xxxxx

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Gloucestershire PCT
Pathway for Antenatal care Smoking cessation Advice and Support Appendix 1

Pregnant woman presents to MW at booking

MW assesses smoking status and measures CO level to help identify whether patient is a smoker, non-smoker or passive smoker CO reading <5 CO reading >5

Most likely non-Smoker (unless identified by history)

Smoker/Passive Smoker

Midwife continues normal antenatal booking process

MW advises patient using appropriate prompt cards (see later) and requests permission to refer to stop smoking service

Patient declines and exercises their “optout” choice MW offers patient appropriate stop smoking support literature and how to access support/effects of second hand smoke, & continues normal antenatal booking process

Patient agrees. MW fills in referral form and sends it to stop smoking service Stop Smoking Service contacts patient by phone and if patient agrees to receiving support, appointment letter is sent to patient.

Patient receives stop smoking support from specialist stop smoking service in addition to appropriate routine antenatal support from MW

Last Reviewed: New Review Date: January 2012 Policy: Community : Antenatal Smoking Cessation Advice Author: Michael Richardson 11

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Gloucestershire PCT Referral form to GSAS for midwifery staff. Appendix 2

Last Reviewed: New Review Date: January 2012 Policy: Community : Antenatal Smoking Cessation Advice Author: Michael Richardson of 11

Issue date: Page 10

Gloucestershire PCT

Prompt cards for Midwifery staff.

Appendix 3

As part of the midwifery training the midwives will be supplied with a prompt card to guide them in what to say. Prompt Card for people who report as non-smokers but have CO >5 “As your carbon monoxides reading is over 5, you may be inhaling second hand smoke and it is now part of our routine antenatal care to pass your details on to the stop smoking service unless you object to this. They will give you information on how to keep yourself and baby safe from second hand smoke. Is that OK?” Prompt Card for people who report as smokers and/or have CO >5 “As you are a smoker, it is now part of our routine antenatal care to pass your details on to the stop smoking service unless you object to this. Is that OK?”

Last Reviewed: New Review Date: January 2012 Policy: Community : Antenatal Smoking Cessation Advice Author: Michael Richardson of 11

Issue date: Page 11


				
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