Maternal Smoking Cessation: Evaluation Report

The initial section presents baseline data on the health status of service users enrolled in the One You Leeds maternal smoking cessation program. The majority of participants reported physical health problems below the national average and smoked fewer than 10 cigarettes daily, indicating a degree of readiness to quit. However, a concerning one-third reported experiencing mental health problems, a rate exceeding the national average. This warrants further investigation into the nature and extent of these mental health issues, especially considering the potential exacerbation of mental health during pregnancy. The report also acknowledges the broader context of decreasing smoking prevalence during pregnancy in high-income countries like the UK, citing a decrease in smoking rates among pregnant women in the UK, while highlighting persistent geographical variations linked to social deprivation. This underscores the significance of addressing smoking cessation as a major health inequality in the UK, impacting disparities in access to healthcare and resources. The data included statistics such as the 10.8% of pregnant women smoking at delivery time (NHS, 2018), showing a minor decrease from the previous quarter (11%), emphasizing the persistent need for intervention programs to effectively support pregnant women in quitting smoking.

This section details the aims and objectives of the evaluation, focusing on exploring the impact, reach, and acceptability of the One You Leeds maternal smoking cessation pathway. The pathway involved training healthcare professionals—midwives, children's center staff, health visitors, and sonographers—in using the Baby Clear module to engage pregnant and postnatal women about their smoking status and refer smokers to dedicated stop smoking services. Both quantitative and qualitative methods were employed. Quantitative data stemmed from service monitoring, and qualitative data was gathered using surveys and semi-structured interviews with stakeholders to gain insights into the project's progress, service delivery, and perceived user outcomes. The survey, offering a £10 incentive, yielded only 5 usable responses from service users who had used a stop smoking service. Ten semi-structured interviews were conducted with key stakeholders—seven stakeholders, two coaches, and one midwife—involved in the project, providing varied perspectives. This methodology highlights a mixed approach to data collection, striving to capture both broad trends and nuanced qualitative perspectives, yet acknowledges the significant limitation posed by the small sample size of service user data.

This section presents both quantitative and qualitative data from service users and key stakeholders. Quantitative data shows that the average year of birth of participants was approximately 1989, with a standard deviation of 6, suggesting a relatively homogenous age group. However, an outlier birth year (1957) is flagged as potentially erroneous. Qualitative data includes a case study of Melissa, a 38-year-old woman who successfully quit smoking with One You Leeds support. Her experience highlights the positive impact of convenient home visits, non-judgmental support, and a flexible approach to nicotine replacement therapy. This success story contrasts with other service user feedback suggesting varying levels of satisfaction with the different service delivery methods. Stakeholder interviews revealed barriers to service user engagement, including social deprivation, challenging upbringings, unsupportive social contexts, lack of personal motivation (more successful when self-referred), and judgemental attitudes from some midwives. Conversely, stakeholders praised the holistic approach of One You Leeds and highlighted the importance of one-on-one support, addressing triggers, and offering multiple treatment options to improve the efficacy of smoking cessation during pregnancy.

Stakeholder perspectives highlighted several crucial factors influencing the success of smoking cessation among pregnant women. Personal motivation emerged as a primary driver, with stakeholders noting that individuals who self-referred, rather than those referred by midwives, often demonstrated greater commitment and higher success rates. The role of social and family support was also emphasized, underscoring the importance of a supportive environment in facilitating quitting. Effective communication from healthcare professionals was deemed critical, with a focus on non-judgmental attitudes and the ability to convey essential information clearly and empathetically. This aligns with research emphasizing the positive impact of a woman-centered approach (Reardon and Grogan, 2016), where trust and open communication are pivotal to successful smoking cessation. The consistent provision of support, addressing individual triggers for relapse, and offering diverse treatment options, including nicotine replacement therapy and psychological support, were identified as key elements contributing to successful outcomes. This holistic approach acknowledged the complex interplay of psychological, social, and physiological factors influencing smoking behavior.

Stakeholders identified several significant challenges and barriers hindering successful smoking cessation. Social deprivation and difficult upbringings were recognized as major obstacles, suggesting that broader socioeconomic factors significantly impact the ability of pregnant women to quit smoking. The communication and referral processes between midwives and coaches also presented challenges; delays and miscommunications between these groups negatively affected service user experiences. This emphasized the need for improved inter-professional collaboration and clarity in referral procedures. Additionally, the lack of consistent training for midwives in delivering effective smoking cessation messages and interventions was identified as a major gap. Stakeholders also highlighted the inconsistency between the belief that at least half of participants would successfully quit and the actual observed success rate of only 25%. This discrepancy underscores the need for more effective strategies to improve success rates and align them with national targets. The issue of cannabis use among some pregnant women was also raised as an area that requires further consideration and potentially integrated support within the intervention.

Based on their insights, stakeholders offered several recommendations to improve the program's effectiveness. Enhanced training for midwives, incorporating face-to-face sessions and role-playing alongside e-learning, was suggested to improve their ability to engage women in conversations about smoking and offer effective support. Improving communication and collaboration between midwives and coaches, particularly regarding referrals and the sharing of information, was also recommended to prevent delays and ensure consistent support. Expanding the intervention to involve the entire household, recognizing the influence of partners and family members on smoking habits, was highlighted as a potential strategy to improve success rates. Furthermore, addressing the identified gap in multidisciplinary training to support various healthcare professionals in providing effective public health messaging on smoking cessation was crucial. The stakeholders also suggested gathering more service user feedback to gain a deeper understanding of their experiences and tailor future interventions accordingly. Finally, extending the scope of the intervention to include education about the health risks of smoking and cannabis use during pregnancy was considered an important aspect for future improvements.

The discussion section begins by synthesizing the evaluation's findings with existing research on smoking cessation during pregnancy. The observed 25% success rate among the 212 participants who engaged with the One You Leeds pathway is contextualized within the broader literature. The section cites Cnattingius (2004), who argues that pregnancy presents an opportune time for smoking cessation due to women's increased concern for fetal well-being. Furthermore, the discussion highlights the alignment of One You Leeds with Department of Health (2017) guidelines by utilizing CO screening and opt-out referrals, a strategy shown to improve service outcomes (Vaz et al., 2017). The importance of facilitators such as personal motivation and social/family support is emphasized, echoing findings from Koshy et al. (2010) and Kia et al. (2018), which demonstrate a strong link between active encouragement and successful quitting and the impact of partner smoking on relapse. The positive impact of non-judgmental communication and the creation of trusting relationships are also discussed, aligning with Reardon and Grogan (2016) and Flemming et al. (2016) research on effective midwife-led interventions.

The discussion section acknowledges the limitations of the evaluation, particularly the low participation rate from service users, which hampered the ability to draw definitive conclusions. This is contrasted with stakeholder perspectives suggesting a higher success rate than what was empirically observed (25%). The significant variations in smoking rates among pregnant women across England (NHS, 2018) and the differences in success rates across various smoking cessation services (Brose et al., 2011) are discussed. The section notes the importance of factors like clear policies, strong inter-agency links, and community-based services to improve success rates, drawing on evidence from Flemming et al. (2016). This leads to a discussion of the overall conclusion that a considerable portion of the participants (25%) achieved successful smoking cessation, but this falls short of the national targets. The service user characteristics associated with lower success are linked to the socioeconomic factors highlighted in the literature, emphasizing the disproportionate impact on those from deprived areas, leading to a recommendation for further research and refinement of strategies to better address these complex factors and improve the intervention’s effectiveness.

The concluding section summarizes the key findings: about a quarter (25%) of the 212 women participating in the One You Leeds program achieved smoking cessation. The study highlighted a link between service user characteristics and lower success rates, with many participants coming from deprived areas of Leeds and facing unemployment or underemployment. The overall conclusion is that while the program showed some level of success, it falls short of national targets, reflecting the complexities of addressing smoking cessation amongst pregnant women. The need for further improvements and modifications is emphasized, focusing on areas like enhanced training for healthcare professionals, improved communication and collaboration between different stakeholders (midwives, coaches), and the involvement of the wider household to improve support systems. The importance of gathering more comprehensive service user feedback is also highlighted, advocating for a more user-centered approach that accounts for diverse experiences and needs, particularly within socioeconomically disadvantaged communities. The discussion closes by acknowledging that despite progress, there remains a need for further work to fully address the health inequalities related to smoking during pregnancy.