The MOHMQuit (Midwives and Obstetricians Helping Mothers to Quit Smoking) Trial: protocol for a stepped-wedge implementation trial to improve best practice smoking cessation support in public antenatal care services
The MOHMQuit (Midwives and Obstetricians Helping Mothers to Quit Smoking) Trial: protocol for a stepped-wedge implementation trial to improve best practice smoking cessation support in public antenatal care services
Smoking during pregnancy is the most important preventable cause of adverse pregnancy outcomes, yet smoking cessation support (SCS) is inconsistently provided. The MOMHQUIT intervention was developed to address this evidence-practice gap, using the Behaviour Change Wheel method by mapping barriers to intervention strategies. MOHMQuit includes systems, leadership and clinician elements. This implementation trial will determine the effectiveness and cost-effectiveness of MOHMQuit in improving smoking cessation rates in pregnant women in public maternity care services in Australia; test the mechanisms of action of the intervention strategies; and examine implementation outcomes.
A stepped-wedge cluster-randomised design will be used. Implementation of MOHMQuit will include reinforcing leadership investment in SCS as a clinical priority, strengthening maternity care clinicians’ knowledge, skills, confidence and attitudes towards the provision of SCS, and clinicians’ documentation of guideline-recommended SCS provided during antenatal care. Approximately, 4000 women who report smoking during pregnancy will be recruited across nine sites. The intervention and its implementation will be evaluated using a mixed methods approach. The primary outcome will be 7-day point prevalence abstinence at the end of pregnancy, among pregnant smokers, verified by salivary cotinine testing. Continuous data collection from electronic medical records and telephone interviews with postpartum women will occur throughout 32 months of the trial to assess changes in cessation rates reported by women, and SCS documented by clinicians and reported by women. Data collection to assess changes in clinicians’ knowledge, skills, confidence and attitudes will occur prior to and immediately after the intervention at each site, and again 6 months later. Questionnaires at 3 months following the intervention, and semi-structured interviews at 6 months with maternity service leaders will explore leaders’ perceptions of acceptability, adoption, appropriateness, feasibility, adaptations and fidelity of delivery of the MOHMQuit intervention. Structural equation modelling will examine causal linkages between the strategies, mediators and outcomes. Cost-effectiveness analyses will also be undertaken.
This study will provide evidence of the effectiveness of a multi-level implementation intervention to support policy decisions; and evidence regarding mechanisms of action of the intervention strategies (how the strategies effected outcomes) to support further theoretical developments in implementation science.
ACTRN12622000167763, registered February 2nd 2022.
MOHMQuit, an evidence-based systems-change intervention, will be implemented at nine public maternity services using existing health care capacity.
This trial explicitly tests a theory and framework-driven approach relative to many earlier interventions which were less clearly built on implementation science frameworks and will provide further empirical evidence of the effectiveness of this approach.
A comprehensive suite of measures will examine effectiveness and cost-effectiveness; and test mechanisms of action of the intervention strategies and factors impacting implementation to advance the field of implementation science.
Smoking during pregnancy is the most important preventable cause of adverse pregnancy outcomes, maternal-foetal health complications and ongoing developmental complications in the infant [1, 2]. Smoking during pregnancy doubles or triples the risk of multiple complications including stillbirth, preterm birth and low birth weight and birth defects and sudden infant death syndrome [1, 3,4,5]. Smoking also increases the health risks to the mother, including her risk of developing cancer, coronary heart disease and stroke; all of these are significantly reduced if women stop smoking during pregnancy . Quitting smoking at any stage of pregnancy is beneficial to both mother and baby, and quitting in the first half of pregnancy reduces the risk of preterm birth and small for gestational age babies to that of non-smokers . Reducing smoking rates in pregnancy is a key priority in health systems around the world to reduce the increased morbidity and mortality in mothers and babies and optimise children’s development in the first 2000 days [6,7,8,9].
In 2019, 9.0% of pregnant women in Australia smoked in the first half of pregnancy, with most (75%) continuing to smoke in the second half . Higher smoking rates are found in pregnant women who live in remote areas of Australia, are of low socio-economic status, of Aboriginal or Torres Strait Islander identity or are teenage mothers [11,12,13]. As such, smoking in pregnancy is considered a major public health concern and supporting women to quit smoking in pregnancy can help reduce the health inequities faced by these women and their children [6, 14]. Although many pregnant women are highly motivated to quit, they face significant challenges including lack of consistent, effective support from health professionals [15, 16], despite evidence that shows that when clinicians offer consistent smoking cessation support (SCS) using psychosocial interventions it helps pregnant women to quit . Pooled data from a Cochrane systematic review also found that among women who received these interventions there was a 17% reduction of infants born with low birthweights and a 22% reduction in neonatal intensive care admissions .
Evidence-based Australian guidelines [14, 18] recommend routine SCS be delivered during antenatal care for all pregnant women using brief interventions based on the 5As (Ask, Advise, Assess, Assist and Arrange follow-up) and include providing nicotine replacement therapy (NRT) if women are otherwise unable to quit. However, provision of recommended SCS to pregnant women has remained persistently poor [19,20,21]. A state-wide survey of women’s experiences of maternity care in New South Wales (NSW) found that only 46% of women who smoked in pregnancy recalled being told about quitting programs . Midwives, obstetricians and managers all reported major gaps in care, particularly in assisting women with cessation strategies and arranging follow-up [23, 24], both of which are crucial to quitting success [25, 26]. Despite the availability of guidelines and training, maternity care services have faced considerable barriers in implementing SCS [23, 27] illustrating the persistence of an evidence to practice gap. One possible reason for the gap has been lack of comprehensive and theoretically informed interventions to support services in delivering SCS, suggesting a theoretically underpinned systems change approach to guideline implementation is needed [28, 29].
Systems change interventions in public health services have been shown to be effective in increasing identification of smokers by clinicians and documentation of smoking status in electronic medical records, improving integration of SCS into usual care, and increasing the numbers of referrals to telephone Quitline services [30,31,32]. However, to date, only one adequately powered trial has tested the effectiveness of theoretically informed implementation strategies in antenatal settings .
In addition to the need to select implementation strategies based on theory with a clear specification of the interventions , there have been recent calls for more rigorous testing of how implementation strategies work (or do not)—the mechanisms of action of the implementation strategies [35, 36]. To achieve this, implementation strategies need to be based on a sound understanding of the barriers to implementation and clearly explicate how the strategies are intended to address the identified barriers, thus generating testable hypotheses to assess if the strategy worked—or how multiple strategies may work together to achieve the desired outcome [35, 36]. This approach will assist to advance the scientific basis of implementation research.
The implementation intervention-MOHMQuit
To better support clinicians in helping women to stop smoking in pregnancy we developed a systems-change intervention (MOHMQuit: Midwives and Obstetricians Helping Mothers to Quit), using a theoretically underpinned intervention development process, the Behaviour Change Wheel . The process of developing the MOHMQuit intervention is described in depth elsewhere . Briefly, we used the Theoretical Domains Framework—a framework of psychological constructs in behaviour change theory —to identify barriers and enablers clinicians faced to providing evidence-based SCS during antenatal care. We undertook qualitative research with maternity service managers, midwives and obstetricians  and a state-wide cross-sectional anonymous survey of midwives working in antenatal care . Working closely with key stakeholders in the NSW public health system we then applied the steps of the Behaviour Change Wheel method  to develop the initial MOHMQuit intervention. This was followed by a trial at one site to determine the feasibility and acceptability of the intervention with maternity service leaders and midwives . Following further refinements, the implementation, effectiveness and cost-effectiveness of the MOHMQuit intervention is now being tested. MOHMQuit is a multi-strategy systems-change intervention designed to be sustainable, which addresses identified barriers and enablers for clinicians providing SCS and ensures ongoing support for SCS amongst service managers.
The intervention includes multiple strategies with systems, leadership and clinician elements (see Additional file 1 which maps the intervention types and behaviour change techniques to the previously identified barriers). The systems change elements include building leadership capacity, improving recording of SCS in eMaternity (the electronic health record used by maternity services in NSW), and various resources for both leaders and clinicians, as described below. All maternity service leaders, clinicians, and Aboriginal health workers will be asked to complete two NSW Health Education and Training Institute (HETI)  online modules to ensure basic knowledge of smoking cessation prior to MOHMQuit-specific training. (See Table 1 for definitions of maternity service leaders, clinicians and Aboriginal health workers used in this research.) MOHMQuit includes provision of a range of resources with a series of workshops held at each site to train and support participants in their use. All workshops use evidence-based behaviour change techniques (e.g. social comparison, modelling, behavioural practice/rehearsal, reframing smoking) [37, 40, 41]. To maximise the sustainability of the intervention, midwifery educators will be trained in providing ongoing MOHMQuit training, and sites will be supported by the development of a ‘Community of practice’ to provide additional and ongoing peer support and encouragement. Additional details of the delivery of the intervention are given below and in Additional file 2.
Maternity service leaders’ workshop
The 3-h maternity service leaders’ workshop is designed to enhance leadership in supporting clinicians to provide SCS. The workshop will be conducted by a senior midwifery trainer. Leaders will be provided with a range of resources and supported to use them to enhance service delivery. On workshop completion, leaders will be asked to: encourage and support clinical staff to attend the relevant training (see below); complete an action planning tool and review annually; identify, develop and maintain a local smoking cessation support champion; develop local care pathways for smokers; and other actions guided by their action plan. Additionally, leaders will be asked to review eMaternity reports monthly and discuss with their team as part of an audit and feedback process to improve professional practice  and help contribute to the effective implementation of the intervention .
Training for clinicians will be jointly provided by a midwifery trainer and a smoking cessation training expert. The workshops will demonstrate use of a suite of resources, with opportunity to practise their use, with the aim of building confidence and skills in supporting smoking cessation. Training for midwives and Aboriginal health workers will be provided in a 1-day workshop, while training of approximately 2 h will be provided for obstetricians and obstetric trainees. As an incentive for participation, continuing professional development points will be awarded for all clinicians.
Clinical midwifery educator training
Clinical midwifery educators will be provided training and resources to continue to deliver training following the intervention phase, to address issues of staff turnover or absence, in order to maximise sustainability of the intervention. Clinical midwifery educators will attend the 1-day training with the midwives and Aboriginal health workers, and then an additional 1 h training on how to provide the training themselves.
Development of a community of practice
Sites will be encouraged to participate in an online ‘Community of practice’ to provide additional and ongoing peer support and encouragement. Senior members of the research team will also provide ongoing support for the implementation of MOHMQuit across all sites at these monthly meetings. Each site will be added to the Community of practice meetings after training occurs at their site.
The implementation logic model, with data collection to evaluate it, is shown in Fig. 1.
The study is being undertaken as a partnership between academic researchers, policy makers within NSW State Government and non-government agencies and senior clinicians from participating sites. At each site, there is a Midwifery Partner Investigator and an Obstetric Partner Investigator supporting implementation of the trial.
The MOHMQuit trial is a pragmatic stepped-wedge cluster-randomised controlled trial of an implementation intervention in nine public maternity services in NSW. Our overarching goal is to increase smoking cessation among pregnant women to improve health outcomes. This trial will test the effectiveness and cost-effectiveness of the MOHMQuit intervention in achieving this, while also testing the mechanisms of action of the strategies based on the underpinning theoretical development of MOHMQuit. The specific aims of the trial are to compare the effectiveness of MOHMQuit versus usual care in increasing:
Smoking cessation among pregnant women attending public antenatal services in NSW;
The provision of guideline-recommended SCS as documented in eMaternity;
Participating clinicians’ self-reported provision of guideline-recommended SCS to pregnant women;
Participating clinicians’ knowledge, skills, confidence and positive attitudes regarding providing guideline-recommended SCS to pregnant women; and
Women’s reported receipt of cessation advice, resources and referral to quit smoking services.
Additional aims include the following:
Determining the cost-effectiveness of the intervention in increasing smoking cessation;
Assessing implementation of the intervention through a detailed process evaluation;
Examining the mechanisms of action of the intervention strategies and moderators of their impact.
Among pregnant smokers (women reporting current smoking at antenatal booking) there will be a 5% increase in cotinine-confirmed 7-day point prevalence abstinence from a baseline prevalence of 16%, after introduction of MOHMQuit. This conservative estimate is based on the effectiveness of antenatal psychosocial smoking cessation interventions in the latest Cochrane review (RR 1.44, 95%CI 1.19-1.73) .
The MOHMQuit trial will be implemented in nine public maternity services in NSW. The sites vary in size and are located in rural and urban contexts.
The MOHMQuit trial uses a stepped-wedge cluster-randomised controlled trial design with random allocation of services to the intervention order [48,49,50]. All services begin as part of the control condition and are randomised to transition from the baseline condition (standard care) to the intervention at specific intervals or ‘steps’ [48, 49]. Each step will occur at two monthly intervals (Fig. 2). There is a 3-month intervention period during which the intervention is provided and embedded in the service, and a 5-month ‘washout period’ to allow time for women receiving care in the baseline period to complete their pregnancies, thus eliminating contamination between baseline and follow-up periods (Fig. 2). The trial was originally planned to run over 36 months at eight sites. However, due to the impacts of COVID-19 and some redesign work being completed in eMaternity, initiation of data collection and provision of the intervention was delayed. To compensate for the reduced time available for data collection, an additional site was added (site six in Fig. 2), and the timing of providing the intervention at the final site brought forward. This ensured the study was still adequately powered.
The stepped-wedge cluster-randomised controlled trial design was chosen because the intervention is at the service level and this design is recommended as a “pragmatic randomised study design… for the evaluation of service delivery outcomes” (, p6). Additionally, a stepped-wedge design is more powerful than a parallel cluster design in situations where there are relatively small numbers of eligible services; and it allows sites to act as their own historical controls, while also allowing observation of any within site temporal trends [49, 51]. While it is possible to offer the intervention to control sites at the end of a parallel cluster design trial, there are rarely sufficient time or resources remaining to provide this effectively and ethically. Additionally, the level of evidence provided by a stepped-wedge design is considered to be robust and comparable with other cluster randomised controlled trial designs [48, 49].
To prepare the MOHMQuit study protocol paper we have followed the Consolidated Standards of Reporting Trials (CONSORT) extension for the stepped wedge cluster randomised trial  (Additional file 3) and where applicable, the TIDieR (Template for Intervention Description and Replication) Checklist  (Additional file 4).
Eligibility criteria—study sites
To be eligible for participation, maternity services were required to provide antenatal care and birthing services and to also (i) have a prevalence of smoking in the first half of pregnancy ≥ 12%; and (ii) have a minimum of 80 women smoking in the first half of pregnancy per year . These criteria ensured that the intervention will be offered in services with smoking prevalence higher than the Australian average of 9.5% in the first half of pregnancy ; and provide an adequate number of smokers at each site. All antenatal services providing care to women intending to give birth at these sites were eligible to participate, including hospital-based, community-based and outreach services. Nine eligible maternity services have confirmed participation.
Eligibility: participants—maternity service leaders and clinicians
The following clinicians working in public maternity care services at participating sites will be eligible to participate:
Maternity service leaders (leaders): all maternity service leaders who support or supervise clinicians providing antenatal care at each site, its catchment, and associated services, will be eligible (see Table 1).
Maternity care clinicians (clinicians): all clinicians providing antenatal care, including midwives, obstetricians, obstetric trainees, and Aboriginal health workers, will be eligible to participate (see Table 1).
Eligibility: participants—pregnant and postpartum women
Pregnant/postpartum women who meet all the criteria below will be eligible to participate:
Received antenatal care through participating maternity services (including community based and outreach services and the Aboriginal Maternal and Infant Health Service )
Birthed their baby at one of the participating services during the study period
Indicated that they were smokers or quit during this pregnancy at their first antenatal appointment with a health care practitioner at the participating maternity services, as recorded in eMaternity. (Smoking status is a required field in eMaternity at this initial visit).
Pregnant women receiving antenatal care at participating sites will be excluded from the study if:
They indicate they wish to opt-out from the study
They experience a perinatal death in this pregnancy or birth
Their baby is transferred to a Neonatal Intensive Care Unit
They do not speak English
They are less than 16 years of age at the time of data collection
A Research Midwife assesses that they are unable to provide informed consent
Recruitment and consent
Prior to the submission of the trial funding application, maternity services across NSW meeting these criteria were approached to explore interest in participation—9 of 15 services approached agreed to participate and contributed to the funding application.
Staff (maternity service leaders and clinicians)
Maternity service leaders
The study will be promoted by the Midwifery Partner Investigators at each site. While each site has already agreed to participate in the trial, individual maternity service leaders and clinicians will still be provided with a Participant Information Statement (PIS) and asked to provide individual consent to participate in data collection processes. They will be invited to participate by their manager and be provided with detailed information about the study. Written consent to participate will be sought at the leaders’ workshop.
Maternity care clinicians
All clinicians providing antenatal care will be informed of the trial by their manager or other service leaders, provided with detailed information and invited to participate in the trial and provide consent to the data collection processes. This process is consistent with usual practice in health services and with our pragmatic study design.
Pregnant and postpartum women
A two-stage recruitment and consent process will be used to recruit pregnant and postpartum women to the study. In an initial opt-out process, all pregnant women presenting for antenatal care at the services will receive a PIS and be given the option of opting out of the study by contacting a research midwife by text. For women who remain and meet the eligibility criteria, a research midwife will contact them by text and then a telephone call, give a verbal explanation of the study, encourage women to ask any questions, and ask women to provide verbal consent to participating in a brief telephone interview. Women who consent to the telephone interview, and who report smoking abstinence in the 7 days before the birth of their baby, and since giving birth, will also be asked to consent to giving a saliva sample for cotinine testing. Importantly, all women will receive full ante- and postpartum care regardless of whether they consent to participate in the study.
Data collection and analysis
Mixed methods evaluation of the intervention and its implementation will be undertaken. Mixed methods evaluations are recommended as being practical and suitable for implementation research [54, 55]. Using a mixed methods evaluation will enable the multiple perspectives of leaders, clinicians and pregnant women to be understood, while examining multiple types of outcomes .
Data on the intervention and health outcomes and the implementation process will be collected by the research team, independently from each site. Variables to be collected, with the method of collection and source, timepoint of measurement and methods of analysis are shown in Table 2. Information on the types of data collected from each source are also illustrated in Fig. 3. An explanation of the relationship between the identified barriers, intervention types, behaviour change techniques and measures for the mediators are shown in Additional file 1. Analysis for aim 8 (examining the mechanisms of action of the intervention strategies and moderators of their impact) which assesses the interactions between many of the variables, is provided below Table 2. More detail regarding the process evaluation and the economic evaluation will be provided in separate protocol papers.
Primary outcome (health outcome)
A 7-day point prevalence abstinence is an established abstinence outcome and can be combined with biochemical verification [56, 60]. For women who report at least 7 days of abstinence at the end of their pregnancy, and continued abstinence since, home-visiting midwives will collect saliva samples which will be tested for cotinine levels at a central pathology facility. The samples will be tested using liquid chromatography with tandem mass-spectrometry and a cut-point of 8 μg/L. A 7-day point prevalence abstinence with biochemical verification is commonly used in pregnancy smoking cessation trials, as longer timeframes (e.g. 12-month abstinence) are not relevant to benefits to the foetus [61, 62]. As biochemical verification will not always be possible, self-reported 7-day point prevalence (regardless of verification) will be used as a secondary outcome.
Analysis to examine the mechanisms of action (aim 8)
To examine the causal linkages between the strategies, mediators, moderators and implementation outcomes structural equation modelling will be undertaken using data from clinician surveys collected pre-training and 6 months post-training. The primary outcome will be the change in the composite score of self-reported provision of SCS between pre-training and 6 months post-training. We will use structural equation modelling to estimate the direct and indirect effects of each of the intervention strategies (as articulated in Additional file 1) mediated by changes in the mediator scores listed in Table 2. A detailed statistical analysis plan will be developed.
The trial aims to recruit 4320 pregnant women who smoke over the 32 months of data collection across the nine sites.
NSW Health data indicate there were over 2000 women smoking in the first half of pregnancy in the participating sites in 2018. Assuming that at each of the 9 sites on average 40 participants will consent every 2 months, the total sample size available will be 9 × 40 × 12 = 4320. Using a significance level of 5% and assuming an intra cluster correlation (ICC) of 0.02 and a cluster autocorrelation of 0.7, the primary analysis will have more than 80% power to detect an increase in 7-day point prevalence abstinence of 5% from a baseline prevalence of 16% (i.e. intervention 21% vs control 16%). This conservative estimate is based on the effectiveness of antenatal psychosocial smoking cessation interventions in the latest Cochrane review (RR 1.44, 95%CI 1.19–1.73) .
Randomisation and blinding
The nine services have been randomly allocated to each ‘step’ (Fig. 2) by an independent statistician using a computerised simple random selection without replacement regime. This ensures no service is unjustifiably favoured by receiving the intervention before another service. Randomisation occurred after all clusters agreed to participate to reduce bias arising from the randomisation process and thus increase the internal validity of the study .
Pregnant women receiving antenatal care, the research midwives interviewing the women, and staff analysing the data will be blinded to the intervention phase. It is not possible to blind maternity service leaders and clinicians at participating sites to the intervention phase. However, risk of bias for the primary aim is reduced as smoking status will be biochemically verified. The regular data extraction of SCS recorded in eMaternity combined with the data from the interviews with women of their recall of SCS received, may mitigate these potential biases.
‘Real world’ evidence and contribution to implementation science theory
By providing a robust, comprehensive examination of whether our multi-strategy intervention improves SCS in maternity care and cessation among women, the MOHMQuit trial will deliver ‘real world’ evidence of the effectiveness and cost-effectiveness of the MOHMQuit intervention. The thoroughness and theoretical underpinnings of the design [15, 37, 38], feasibility and pilot investigations , with a clearly articulated logic model, are strengths of this trial that will also enable testing the impact of the intervention on the hypothesised mediators and testing the mechanisms of action of the intervention strategies, contributing empirical evidence to the theoretical foundations of implementation science [35, 36]. The MOHMQuit trial will provide important evidence for systems change interventions that include three levels of influence (systems, leaders and clinicians) to instigate behaviour change in clinicians, improve the provision of SCS, and ultimately reduce smoking rates in pregnancy.
Data collection has been specifically designed to test whether the MOHMQuit intervention has addressed the barriers to provision of SCS identified in our previous research, and which the intervention was carefully designed to address [15, 23, 24, 63]. Use of previously validated data collection instruments will allow us to assess this . Additionally, the process evaluation (described in more detail in a separate paper) will assess implementation outcomes and adaptations, adding further understanding regarding how to implement evidence-based practice in real world settings, while adding to the empirical evidence to support further theoretical developments in implementation science.
Advantages of the pragmatic stepped wedge trial design
The MOHMQuit trial has been designed as a pragmatic trial according to the PRECIS-2 criteria . The stepped-wedge cluster-randomised design is a pragmatic study design commonly used in the evaluation of service delivery interventions . Policy makers need strong evidence of effectiveness and cost-effectiveness in ‘real world’ conditions . A strength of this design is that it focuses on carrying out ‘real-world’ research, which in this case is representative of genuine clinical practice in the provision of maternity care in public antenatal services with a range of different models of care . This trial will also provide evidence of the practicality of using the MOHMQuit intervention in the provision of ‘real world’ maternity care provided by usual antenatal care providers, with all pregnant women who smoke or quit smoking since becoming pregnant being eligible to participate .
The stepped-wedge design has several advantages for translational research, including that (a) it controls for between-service variation in baseline practice; (b) statistical power is boosted as it allows assessment of intervention effects in a pre-/post-comparison across services; and (c) assessment of sustainability can occur in services that transition earlier . The design is particularly suited to implementation trials of service delivery interventions as it ensures all sites receive the intervention, while allowing assessment of whether (a) a change in quit rates has occurred; (b) the change is likely due to the intervention; and (c) the change is significant . The 32-month timeframe of the MOHMQuit trial facilitates measurement of the success of the intervention over a long period, also enabling the sustainability of the intervention to be assessed. Finally, the stepped-wedge design also allowed for flexibility in adapting the design of the study in response to delays resulting from the impact of COVID-19 on the health care system and redesign work being completed in eMaternity.
The inclusion of both an economic evaluation and a process evaluation are further strengths of this trial, providing information on costs of implementation, cost-effectiveness, fidelity of delivery, and factors critical for effective implementation. Detailed protocols for each of these sub-studies will be published separately. As reducing smoking in pregnancy is an identified priority for NSW Health, this ‘real-world’ evidence will support decision-making by our policy partners for broader ‘at-scale’ implementation if appropriate.
Demonstrating benefits of partnership projects and collaboration
The MOHMQuit intervention has the potential to demonstrate the benefits of partnership projects involving collaboration between policy-makers, clinicians and researchers from conception through implementation to address a population health problem [65, 68, 69]. In the research design phase, collaboration between all MOHMQuit partners helped place the policy and practice relevance of the research central to the research design [65, 68]. Ongoing collaboration with the midwifery and obstetric partner investigators at each research site will help ensure that the implementation of the intervention reflects real world practice and build the research capacity of the partner investigators [65, 68, 70, 71], increasing the likelihood of the findings being used, adopted and sustained beyond the trial timeframe. Our approach also supports broader scale up and implementation across the state, due to strong engagement of policy-makers at all stages from development of MOHMQuit to the trial itself, with potential relevance nationally and internationally.
Maternity care clinicians can play a crucial role in helping women stop smoking in pregnancy by providing evidence-based guideline-recommended SCS during antenatal care [15, 17, 23, 72]. Considering that stopping smoking in pregnancy significantly reduces the risk of adverse pregnancy outcomes, maternal-foetal health complications, ongoing developmental complications in the baby [1, 73], multiple complications including stillbirth, preterm birth and low birth weight and birth defects [1, 3], the potential benefit of achieving smoking cessation amongst pregnant women through the MOHMQuit intervention is considerable. MOHMQuit, if successful, will improve maternal and infant outcomes and has the potential for scale-up across the wider public health maternity care system in Australia.
Availability of data and materials
5As of smoking cessation support: Ask, Advise, Assess, Assist and Arrange follow-up
MOHMQuit Trial registration number in the Australian New Zealand Clinical Trials Registry (ANZCTR)
CONSORT extension checklist:
Consolidated Standards of Reporting Trials (CONSORT) extension for the stepped wedge cluster randomised trials
Viral disease caused by the novel coronavirus SARS-CoV2
The NSW Health Education and Training Institute (run through the NSW health system)
The Midwives and Obstetricians Helping Mothers to Quit Smoking Trial
Nicotine replacement therapy
New South Wales
A confidential telephone information and advice service to help smokers quit smoking and remain abstinent
Participant Information Statement (may be given in paper or appear in electronic form as the first page of a questionnaire)
Template for Intervention Description and Replication Checklist
The University of Sydney’s Research Data Store
U.S. Department of Health and Human Services. The health consequences of involuntary exposure to tobacco smoke: a report of the surgeon general. Rockville: US Department of Health and Human Services; 2006.
Diamanti A, Papadakis S, Schoretsaniti S, Rovina N, Vivilaki V, Gratziou C, et al. Smoking cessation in pregnancy: an update for maternity care practitioners. Tob Induc Dis. 2019;17:57. https://doi.org/10.18332/tid/109906.
Lange S, Probst C, Rehm J, Popova S. National, regional, and global prevalence of smoking during pregnancy in the general population: a systematic review and meta-analysis. Lancet Glob Health. 2018;6(7):e769–e76. https://doi.org/10.1016/S2214-109X(18)30223-7.
Collet C, Fayon M, Francis F, Galode F, Bui S, Debelleix S. The first 1000 days: impact of prenatal tobacco smoke exposure on hospitalization due to preschool wheezing. Healthcare (Basel). 2021;9(8):1089. https://doi.org/10.3390/healthcare9081089.
Smedberg J, Lupattelli A, Mårdby A-C, Nordeng H. Characteristics of women who continue smoking during pregnancy: a cross-sectional study of pregnant women and new mothers in 15 European countries. BMC Pregnancy Childbirth. 2014;14(1):213. https://doi.org/10.1186/1471-2393-14-213.
Australian Institute of Health and Welfare. Australia’s mothers and babies 2019—in brief. Perinatal statistics series no. 34. Cat. no. PER 101. Canberra: Australian Institute of Health and Welfare; 2021.
Mittiga C, Ettridge K, Martin K, Tucker G, Dubyna R, Catcheside B, et al. Sociodemographic correlates of smoking in pregnancy and antenatal-care attendance in Indigenous and non-Indigenous women in South Australia. Aust J Prim Health. 2016;22(5):452–60. https://doi.org/10.1071/PY15081.
Passey ME, Adams C, Paul C, Atkins L, Longman JM. Improving implementation of smoking cessation guidelines in pregnancy care: development of an intervention to address system, maternity service leader and clinician factors. Implement Sci Commun. 2021;2:128. https://doi.org/10.1186/s43058-021-00235-5.
Bar Zeev Y, Bonevski B, Twyman L, Watt K, Atkins L, Palazzi K, et al. Opportunities missed: a cross-sectional survey of the provision of smoking cessation care to pregnant women by Australian General Practitioners and Obstetricians. Nicotine Tob Res. 2017;19(5):636–41.
Longman JM, Adams CM, Johnston JJ, Passey ME. Improving implementation of the smoking cessation guidelines with pregnant women: how to support clinicians? Midwifery. 2018;58:137–44. https://doi.org/10.1016/j.midw.2017.12.016.
Passey ME, Longman JM, Adams CM, Johnston JJ, Simms J, Rolfe MI. Factors associated with provision of smoking cessation support to pregnant women – a cross-sectional survey of midwives in New South Wales, Australia. BMC Pregnancy Childbirth. 2020;20:219.
Miller M, Wood L. Effectiveness of smoking cessation interventions: review of evidence and implications for best practice in Australian health care settings. Aust N Z J Public Health. 2003;27(3):300–9.
Flemming K, Graham H, McCaughan D, Angus K, Sinclair L, Bauld L. Health professionals’ perceptions of the barriers and facilitators to providing smoking cessation advice to women in pregnancy and during the post-partum period: a systematic review of qualitative research. BMC Public Health. 2016;16(1):1.
Bar-Zeev Y, Bonevski B, Lim LL, Twyman L, Skelton E, Gruppetta M, et al. Improving health providers smoking cessation care in pregnancy: a systematic review and meta-analysis. Addict Behav. 2019;93:29–38. https://doi.org/10.1016/j.addbeh.2019.01.002.
Fiore M, Adsit R, Zehner M, McCarthy D, Lundsten S, Hartlaub P, et al. An electronic health record–based interoperable eReferral system to enhance smoking Quitline treatment in primary care. J Am Med Inform Assoc. 2019;26(8-9):778–86. https://doi.org/10.1093/jamia/ocz044.
Bell R, Glinianaia SV, Waal Zvd, Close A, Moloney E, Jones S, et al. Evaluation of a complex healthcare intervention to increase smoking cessation in pregnant women: interrupted time series analysis with economic evaluation. Tob Control. 2018;27:90–8. https://doi.org/10.1136/tobaccocontrol-2016-053476.
Michie S, Fixsen D, Grimshaw JM, Eccles MP. Specifying and reporting complex behaviour change interventions: the need for a scientific method. Implement Sci. 2009;4:40.
Lewis CC, Klasnja P, Powell BJ, Lyon AR, Tuzzio L, Jones S, et al. From classification to causality: advancing understanding of mechanisms of change in implementation science. Front Public Health. 2018;6:136. https://doi.org/10.3389/fpubh.2018.00136.
Lewis CC, Boyd MR, Walsh-Bailey C, Lyon AR, Beidas R, Mittman B, et al. A systematic review of empirical studies examining mechanisms of implementation in health. Implement Sci. 2020;15(1):21. https://doi.org/10.1186/s13012-020-00983-3.
Black N, Johnston M, Michie S, Hartmann-Boyce J, West R, Viechtbauer W, et al. Behaviour change techniques associated with smoking cessation in intervention and comparator groups of randomized controlled trials: a systematic review and meta-regression. Addiction. 2020;115(11):2008–20. https://doi.org/10.1111/add.15056.
Brown TJ, Hardeman W, Bauld L, Holland R, Maskrey V, Naughton F, et al. A systematic review of behaviour change techniques within interventions to prevent return to smoking postpartum. Addict Behav. 2019;92:236–43. https://doi.org/10.1016/j.addbeh.2018.12.031.
Faithfull-Byrne A, Thompson L, Schafer KW, Elks M, Jaspers J, Welch A, et al. Clinical coaches in nursing and midwifery practice: facilitating point of care workplace learning and development. Collegian (Royal College of Nursing, Australia). 2017;24(4):403–10. https://doi.org/10.1016/j.colegn.2016.06.001.
NSW Health - Workforce Planning and Development. Definition of an Aboriginal health worker. NSW Health; 2018.
Jamtvedt G, Young JM, Kristoffersen DT, O’Brien MA, Oxman AD. Does telling people what they have been doing change what they do? A systematic review of the effects of audit and feedback. Qual Saf Health Care. 2006;15(6):433. https://doi.org/10.1136/qshc.2006.018549.
Damschroder LJ, Aron DC, Keith RE, Kirsh SR, Alexander JA, Lowery JC. Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science. Implement Sci. 2009;4(1):50. https://doi.org/10.1186/1748-5908-4-50.
Hemming K, Taljaard M, McKenzie JE, Hooper R, Copas A, Thompson JA, et al. Reporting of stepped wedge cluster randomised trials: extension of the CONSORT 2010 statement with explanation and elaboration. BMJ. 2018;363:k1614.
Hemming K, Taljaard M. Reflection on modern methods: when is a stepped-wedge cluster randomized trial a good study design choice? Int J Epidemiol. 2020;49(3):1043–52. https://doi.org/10.1093/ije/dyaa077.
Scholl I, Hahlweg P, Lindig A, Bokemeyer C, Coym A, Hanken H, et al. Evaluation of a program for routine implementation of shared decision-making in cancer care: study protocol of a stepped wedge cluster randomized trial. Implement Sci. 2018;13(1):51. https://doi.org/10.1186/s13012-018-0740-y.
Aarons GA, Ehrhart MG, Farahnak LR. The Implementation Leadership Scale (ILS): development of a brief measure of unit level implementation leadership. Implement Sci. 2014;9:45. https://doi.org/10.1186/1748-5908-9-45.
Fernandez ME, Walker TJ, Weiner BJ, Calo WA, Liang S, Risendal B, et al. Developing measures to assess constructs from the Inner Setting domain of the Consolidated Framework for Implementation Research. Implement Sci. 2018;13(1):52. https://doi.org/10.1186/s13012-018-0736-7.
Jain R, Jhanjee S, Jain V, Gupta T, Mittal S, Chauhan P, et al. Biochemical validation of self-reported smokeless tobacco abstinence among smokeless tobacco users: results from a clinical trial of varenicline in India. J Psychoactive Drugs. 2015;47(4):331–5. https://doi.org/10.1080/02791072.2015.1073412.
Heil SH, Higgins ST, Bernstein IM, Solomon LJ, Rogers RE, Thomas CS, et al. Effects of voucher-based incentives on abstinence from cigarette smoking and fetal growth among pregnant women. Addiction. 2008;103:1009–18.
Pollak KI, Lyna P, Gao X, Noonan D, Bejarano Hernandez S, Subudhi S, et al. Efficacy of a texting program to promote cessation among pregnant smokers: a randomized control trial. Nicotine Tob Res. 2020;22(7):1187–94. https://doi.org/10.1093/ntr/ntz174.
Longman J, Adams C, Paul C, McLennan J, Passey M. Improving clinicians’ implementation of guidelines to help women stop smoking in pregnancy: developing evidence-based print and video materials. Int J Environ Res Public Health. 2021;18(19):10522. https://doi.org/10.3390/ijerph181910522.
Berry J, Jacomb I, Lunn J, Sedwell A, Shakeshaft A, Kelly PJ, et al. A stepped wedge cluster randomised trial of a cognitive remediation intervention in alcohol and other drug (AOD) residential treatment services. BMC Psychiatry. 2019;19(1):70. https://doi.org/10.1186/s12888-019-2044-4.
Luckett T, Phillips J, Agar M, Lam L, Davidson PM, McCaffrey N, et al. Protocol for a phase III pragmatic stepped wedge cluster randomised controlled trial comparing the effectiveness and cost-effectiveness of screening and guidelines with, versus without, implementation strategies for improving pain in adults with cancer attending outpatient oncology and palliative care services: the Stop Cancer PAIN trial. BMC Health Serv Res. 2018;18(1):558. https://doi.org/10.1186/s12913-018-3318-0.
Mitchell P, Pirkis J, Hall J, Haas M. Partnerships for knowledge exchange in health services research, policy and practice. J Health Serv Res Policy. 2009;14(2):104–11. https://doi.org/10.1258/jhsrp.2008.008091.
Hinchcliff R, Greenfield D, Braithwaite J. Is it worth engaging in multi-stakeholder health services research collaborations? Reflections on key benefits, challenges and enabling mechanisms. Int J Qual Health Care. 2014;26(2):124–8. https://doi.org/10.1093/intqhc/mzu009.
Morris ZS, Bullock A, Atwell C. Developing engagement, linkage and exchange between health services managers and researchers: experience from the UK. J Health Serv Res Policy. 2013;18:23–9. https://doi.org/10.1177/1355819613476863.
Olaiya O, Sharma AJ, Tong VT, Dee D, Quinn C, Agaku IT, et al. Impact of the 5As brief counseling on smoking cessation among pregnant clients of Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) clinics in Ohio. Prev Med. 2015;81:438–43.
Frandsen M, Thow M, Ferguson SG. Profile of maternal smokers who quit during pregnancy: a population-based cohort study of Tasmanian women, 2011–2013. Nicotine Tob Res. 2017;19(5):532–8. https://doi.org/10.1093/ntr/ntw222.
This paper is submitted on behalf of the MOHMQuit Trial team, including all chief investigators, partner investigators and associate investigators, and co-researchers and site leads at each of the MOHMQuit sites. In addition to the named authors, the team includes Dheya Al Mashat (NSW Health), Dianne Avery (NSW Health), Elizabeth Best (NSW Ministry of Health), Alecia Brooks (Cancer Council NSW), Rashna Chinoy (NSW Health), Justine Elliot (NSW Health), Jacinta Felsch (NSW Health), Mohamed Foda (NSW Health), Sandra Forde (NSW Health), Tara Farrugia (NSW Health), Tracey Greenberg (Alcohol and Drug Service, St Vincent's Hospital Sydney), Jane Griffith (NSW Health), Madeline Hubbard (NSW Health), Damien McCaul (NSW Ministry of Health), James McLennan (Alcohol and Drug Service, St. Vincent’s Hospital Sydney), Kate Reakes (Cancer Institute NSW), Joanne Scarfe (NSW Ministry of Health and University of Sydney School of Public Health), Virginia Stulz (NSW Health and Western Sydney University) and Tracey Zakazakaarcher (NSW Health).
Data will be extracted from eMaternity quarterly. Data will be de-identified before secure transfer to the research team and stored at the University of Sydney’s Research Data Store (USYD RDS), which is a secure, enterprise-grade Network Attached Storage device located within NSW.
Data from questionnaires with women, clinicians and leaders and training logs will be collected in REDCap (Research Electronic Data Capture application) databases set up specifically for the study. REDCap is a web-based application used to capture data for clinical research and create databases, developed by Vanderbilt University . Data from the REDCap databases will also be stored securely on the USYD RDS. Data will be stored on the USYD RDS for the duration of the study as well as on a secure server with restricted access at the Hunter Medical Research Institute for data requiring access by the statistician working there.
Recordings and transcriptions of interviews with leaders will be stored in the USYD RDS for the duration of the study. Only the University of Sydney team members will have access to these data.
All data arising from the MOHMQuit study will be held in these secure data stores for 5 years following the completion of the study.
This trial is supported by a NHMRC Partnership grant (GNT1072213) with additional funding and in-kind contributions from our partner organisations–the NSW Ministry of Health, the Cancer Council NSW, the Cancer Institute NSW, Northern NSW Local Health District (LHD), Western NSW LHD, Murrumbidgee LHD, Illawarra Shoalhaven LHD and Nepean Blue Mountains LHD. MP is supported by a NHMRC Fellowship (GNT1159601). The NHMRC did not have any role in the design of the study and will not have a role in collection, analysis and interpretation of data.
Authors and Affiliations
The University of Sydney, The University Centre for Rural Health, 61 Uralba St., Lismore, NSW, 2480, Australia
Larisa Ariadne Justine Barnes, Jo Longman, Ross Bailie & Megan Passey
Northern New South Wales Local Health District, Byron Central Hospital, Ewingsdale Rd, Byron Bay, NSW, 2480, Australia
University of Newcastle, School of Medicine and Public Health, University Drive, Callaghan, NSW, 2308, Australia
Christine Paul & Daniel Barker
University College London, Centre for Behaviour Change, Gower Street, London, WC1E 6BT, UK
Flinders University, College of Medicine & Public Health, Flinders Health and Medical Research Institute, Sturt Road, Bedford Park, SA, 5042, Australia
NSW Ministry of Health, Centre for Epidemiology and Evidence, 1 Reserve Road, St Leonards, NSW, 2065, Australia
Aaron Cashmore & Andrew J. Milat
The University of Sydney, Sydney School of Public Health, Faculty of Medicine and Health, Camperdown, NSW, 2006, Australia
Aaron Cashmore & Andrew J. Milat
Tobacco Control Unit, Cancer Prevention and Advocacy Division, Cancer Council NSW, and Conjoint Fellow, School of Medicine and Public Health, University of Newcastle, 153 Dowling St., Woolloomooloo, NSW, 2011, Australia
The Daffodil Centre, The University of Sydney, a joint venture with Cancer Council NSW, and Sydney School of Public Health, The University of Sydney, Edward Ford Building, A27 Fisher Rd, Camperdown, NSW, 2006, Australia
Western NSW Local Health District, 7 Commercial Avenue, Dubbo, NSW, 2830, Australia
Clinical Excellence Commission-NSW Health and The University of Sydney Faculty of Medicine and Health, 1 Reserve Road, St. Leonards, NSW, 2065, Australia
The study was conceived and designed by MP, JL, CA, CP, BB, LA, AP, DB, RB and AM. Further refinements to the design were contributed by all authors. The first draft of the paper was written by LB with significant input from MP and JL before receiving input from CA, LA, RB, DB, BB, AC, JD, AM, MN, CP, AP and LT. All authors have read and approved the final manuscript.
Ethical approval for the research was received from the Population Health Services Research Ethics Committee (Reference Number 2021/ETH00887), on July 23rd, 2021. All potential participants will be provided with a Participant Information Statement (PIS). Consent will be obtained by site trial staff for all maternity service leaders and clinicians who participate in the trial.
Clinicians: participation of clinicians is voluntary. Participant Information Statements for clinicians will explicitly state that the decision to participate or not participate will not influence their professional standing or the care of any of their patients/clients in any way.
Maternity service leaders: the participation of maternity service leaders is voluntary. The PIS for leaders will explicitly state that the decision to participate or not participate will not influence their professional standing or the care of any of their patients/clients in any way. The PIS will also detail that information shared in interviews will be de-identified before publication or dissemination.
Pregnant and postpartum women: participation of postpartum women (telephone interviews) is voluntary. The PIS confirms that participation is entirely voluntary and will not affect the antenatal or postnatal care provided to women from the service in any way. The PIS includes an option for women to opt-out during pregnancy by texting the research midwives. For those that do not opt out, research midwives will seek verbal consent for participation from postpartum women, which will be recorded in an online database. Separate consent will also be sought for the biochemical verification of abstinence for those postpartum women who report having stopped smoking at least 7 days before the birth of their baby, and who also report remaining abstinent. Research midwives will record verbal consent in the online database.
Consent for publication
The authors declare that they have no competing interests.
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Completed TIDieR (Template for Intervention Description and Replication) Checklist.
Rights and permissions
Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.
Barnes, L.A.J., Longman, J., Adams, C. et al. The MOHMQuit (Midwives and Obstetricians Helping Mothers to Quit Smoking) Trial: protocol for a stepped-wedge implementation trial to improve best practice smoking cessation support in public antenatal care services.
Implementation Sci17, 79 (2022). https://doi.org/10.1186/s13012-022-01250-3