Midwives' views on referring pregnant women to Quitline and their participation and engagement with smoking cessation services (Quitline)

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In Australia, about 70% of women who smoke before 20 weeks of pregnancy continue after 20 weeks, with little change over the last decade. Women are more likely to quit when attending cessation programs, but Quitline referral rates remain low. The aim of this study is to examine the Quitline (a telephone-based smoking cessation service) referral process for pregnant women and to identify the barriers and facilitators that influence appointment attendance. Methods Semi-structured interviews across Queensland maternity services with midwives who refer pregnant women to Quitline. Midwives were recruited through information sessions, posters and QR code registration. Deductive analysis using the Theoretical Domains Framework, followed by inductive thematic analysis, was employed to identify factors affecting the Quitline referral process and barriers and facilitators that may influence women’s attendance at telephone appointments. Results Eighteen midwives were interviewed between December 2023 and June 2024. Five themes were identified and linked to two Theoretical Domains Framework domains. Midwives had a limited understanding of the Quitline referral process and available Quitline services. Barriers included a lack of education, limited appointment time, and resource unavailability. Midwives suggest that offering Quitline calls following antenatal appointments may reduce the time between referral and appointment, thereby increasing Quitline appointment uptake. Conclusions Some midwives said that they were unaware of how to refer pregnant women who smoke to Quitline or what services Quitline offers. They also mentioned limited access to Quitline resources and insufficient time during appointments to make referrals. Enabling women to speak directly with Quitline counsellors following antenatal appointments could increase referral and attendance rates. Developing a Quitline education program for midwives and establishing a national referral system could increase referral and appointment attendance rates among pregnant women who smoke. Smoking Cessation Tobacco Pregnancy Referral and Consultation Quitline Stillbirth Background Smoking during pregnancy significantly increases health risks and adverse birth outcomes ( 1 ), such as low birth weight, preterm birth, and stillbirth ( 2 ). Women who are heavy smokers face a two to three times greater risk of stillbirth ( 3 ), with intrauterine death and neonatal infection also associated with maternal smoking of more than 20 cigarettes per day ( 4 ). There is no safe level of smoking during pregnancy, and quitting, even in the second or third trimester, can greatly reduce the risk of neonatal mortality ( 5 ). Around 8% of women reported smoking in Australia in 2023, which has decreased from 13% in 2011 ( 6 ). However, the percentage of pregnant women who continue to smoke after 20 weeks in Australia has remained largely unchanged over the past decade, with rates of 71% in 2011 and 69% in 2023 ( 7 ). Pregnancy is an ideal time to educate women about the dangers of tobacco ( 8 – 10 ), as women consult health professionals for their care, yet about half of all pregnant women who smoke report not receiving cessation advice from health professionals ( 11 ). Women participating in a smoking cessation program generally achieve higher abstinence rates than those attempting to quit on their own ( 12 ). Women have various support options to quit smoking during pregnancy, with Quitline being the most common referral service in Australia, offered to the majority of pregnant women in routine maternity care ( 13 ). Since 1997, Quitline, a telephone-based support service, has been nationally available nationally in Australia ( 14 ). It is funded and managed by individual states rather than the Federal Government ( 15 ), leading to differences in services offered across jurisdictions ( 16 , 17 ). Despite its existence, the Quitline referral rate remains low, with approximately half of the women referred not attending any telephone appointments ( 17 ). Currently, there appears to be no clear understanding of the most effective ways to address the low referral rate and increase women’s attendance at telephone appointments. In 2010, the National Institute for Health and Care Excellence (NICE) recommended that UK maternity care providers include carbon monoxide testing and an opt-out referral to Quitline or local smoking cessation services as part of routine antenatal care ( 18 ). This was later adopted by the 2016 UK 'Saving Babies Lives' bundle ( 19 ), and Australia's Safer Baby Bundle (SBB) ( 2 , 20 ), both aimed at reducing the risk of stillbirth and adverse pregnancy outcomes. A core component of the SBB involves referring pregnant women who smoke to Quitline as part of routine maternity care ( 2 ), using a standardised and equitable approach to ensure all women receive consistent support regardless of background or circumstances. Given the limited evidence on the effectiveness of the Quitline referral process during pregnancy, it is essential to examine how the referral pathway functions, its overall effectiveness, and the entire process involved. The study aims to understand midwives' perspectives on the Quitline referral process, focusing on the barriers they recognise and their suggestions for increasing women’s engagement with the service. The scope of this study is part of a broader piece of work, including Quitline appointment uptake, reasons for not continuing Quitline programs, and service level barriers at Quitline that impact women’s continued appointment attendance ( 17 ). The Theoretical Domains Framework (TDF) ( 21 ) was used, as it identifies key factors such as knowledge, skills, and beliefs that underpin evidence-based interventions. Mapping midwives' interviews to the TDF domains will help develop theory-based strategies to overcome barriers and leverage facilitators that can drive behavioural change ( 22 ). Methods 1.1 Study design and setting This qualitative study employs a phenomenological framework to understand individuals' experiences in the context of their everyday lives ( 23 ). The TDF offers a comprehensive list of theory-based explanations of behaviour, which can be employed to analyse factors that might hinder performance behaviours ( 21 ). Semi-structured interviews were held with midwives from Gold Coast University Hospital (GCUH), Ipswich Hospital (IH) and Mater Mothers Hospital (MMH) between December 2023 and June 2024. 1.2 Recruitment and Participants Midwives were informed about the study during in-person educational sessions and through promotional posters, providing them with the opportunity to express their interest either by scanning a QR code or by contacting the researcher directly via email. Each midwife was contacted directly and informed about the aim of the interviews and provided with an information letter. Verbal consent was obtained, and interviews were scheduled, either immediately at the antenatal clinic or later via Zoom or phone. Midwives’ contact details were collected for participation, with reassurances that the interviews were for research purposes only and that the published results would be de-identified. Participation was voluntary, and midwives could withdraw from the study at any time. 1.3 Data collection Midwives were interviewed using a guide developed by the research team to understand the Quitline referral process and identify any barriers and facilitators that may influence women’s attendance at Quitline appointments. The main topics discussed included midwives' understanding of the referral process to Quitline, their knowledge of the service, reasons for referring or not referring women, and potential improvements to increase women's engagement with Quitline appointments. After each interview, the researcher CB documented the field notes. No new questions were added to the interview guide throughout the study. The interviews lasted on average between 20 and 30 minutes. The interviews were audio-recorded with the midwives’ permission. 1.4 Data Analysis Recorded interviews were transcribed verbatim. CB performed the transcription, coding each line with an inductive thematic approach ( 24 ). CB read all transcripts multiple times to become familiar with the data and compared them to the original audio recordings. The TDF provided the initial structure to organise the data. Responses from the transcribed interviews were assigned to the 14 TDF domains using deductive analysis of these colour-coded domains. The next step was inductive thematic analysis to identify themes related to barriers and facilitators for increasing Quitline appointment uptake. A subset of four interviews were coded independently by both CB and PM according to the TDF to minimise bias and enhance the validity of the coding. A high level of agreement was reached during the coding process. All authors approved the study methods. During meetings, all authors reflected on and refined the themes iteratively until a consensus was reached. Results Eighteen registered midwives were interviewed, ten from Gold Coast University Hospital (GCUH), four from Ipswich Hospital (IH), and four from Mater Mothers Hospital (MMH), Brisbane. 2.1 Characteristics The 18 midwives included in this study had varying levels of experience in their role: (n = 3) 1–5 years, (n = 10) had 6–10 years, (n = 2) had 11–15 years, and (n = 3) had more than 16 years of experience. All midwives worked in antenatal care as registered midwives, clinical midwives, or midwives working in a continuity model (see Supplementary 1). 2.2 Domains and Themes Only two domains, Knowledge and Environmental Context and Resources, were reflected in the data (see Table 1 ). These domains are central to this study, reflecting awareness, social influences, and external factors that can shape behaviour. Table 1 Themes and sub-themes aligned to the Theoretical Domain’s Framework Theme Number Theoretical Domain’s Framework Domains Theme Theme 1 Knowledge The limited knowledge of the Quitline service Theme 2 Knowledge The limited understanding of the Quitline referral process Theme 3 Environmental context and resources The limited access to Quitline resources Theme 4 Environmental context and resources The limited time in appointments to complete Quitline referrals Theme 5 Environmental context and resources Initiating Quitline calls after antenatal appointments 2.2.1 Domain one: Knowledge The Knowledge domain involves midwives' understanding of the Quitline referral process and the services it offers. Limited or inconsistent knowledge among midwives was identified as a barrier to making referrals and reducing the quality of information shared with women. 2.2.1.1 Theme One: The limited knowledge of the Quitline service, Around half of the midwives interviewed reported having limited knowledge of Quitline services and the support available to women. This lack of understanding may affect their confidence in making referrals, some midwives said “To be honest, I actually don't know what the Quit people go through with the women ” (MW4). “I'm not too sure of what actually occurs once they are in contact with each other” (MW7) Some midwives knew they should refer women to the Quitline service, but they lacked sufficient knowledge to advise them on what they might receive. “I usually sell it but to be honest I actually don't know what the quit people go through with the women” (MW6) One midwife thought that the program did not include counselling, stating “ I don't really know what they mean by ongoing support, I think it's not like a counsellor but like some sort of support programme for them ” (MW5) Midwives also had a limited understanding of nicotine replacement therapy at Quitline, including what is offered and how it is received, saying “ They contact them, they offer them this nicotine replacement therapy, and then they kind of get counselling, is that kind of what they get?” (MW12) “ I thought that they were able to mail out NRT directly to their house. I don’t know if that's correct or not, but that's really as much as I know ” (MW16) 2.2.1.2 Theme Two: The limited understanding of the Quitline referral process Some midwives were hesitant to refer women to Quitline, while others mentioned they had little or no experience making referrals, they said "We don't refer ourselves unless they specifically ask for that, because I'm actually unsure of that process" (MW18) " I've not really done any referrals to Quitline just yet" (MW10) "I've only ever had one woman say, 'Yes, I would like a referral " (MW6). Some midwives were aware of the hospital Quitline referral pathways, but there seemed to be some uncertainty about the process, with some midwives saying. “I think it's a great service it's just we don't know how to access it and we don't know how to refer to it” (MW7) "I think there is an online portal that my team leader showed me last time, where we can make the referral online" (MW12) Education on the Quitline referral pathway was needed in some hospitals. One midwife said “Maybe have some more training around you know the process of referrals, what’s needed” (MW5) A midwife mentioned that at a previous hospital, midwives could complete and fax Quitline referrals, unlike the current hospital, saying “I used to work in [another health service] and we had Quitline referral forms that we would complete and we would fax them off to Quitline….. it was a document, two-page document that we would fax to the Quitline people. Yep, there's nothing here” (MW2) 2.2.2 Domain two: Environmental context and resources The Environmental context and resources domain includes the physical, social, and resource-related factors that influence both the referral process to Quitline and women's capacity to attend appointments. A major theme within this domain is the limited time and resources midwives face as barriers to providing Quitline support. 2.2.2.1 Theme three: Limited access to Quitline resources Midwives are well-placed to provide women with Quitline information during maternity care, but limited access to Quitline brochures and resources often prevents this. One midwife explained “ At the moment, we don’t have any access to any Quitline packs in the clinic in which I work” (MW2) Another midwife working within a continuity model observed a similar issue during outreach clinics, stating “ We're a satellite clinic, we don't have all of the resources ” (MW6) One midwife explained that their health services now use QR codes as an alternative way to educate women about Quitline smoking, “ We have no printout education available to handout anymore, it is all QR codes, . …. I think there needs to be some form of, a brochure or flyer or pamphlet or something that we can pass them” (MW5) However, not all midwives encountered this obstacle, as one midwife observed that resources were accessible within their healthcare setting. “ We do have like a handout in our office ” (MW10) 2.2.2.2 Theme four: Limited time in appointments to complete Quitline referrals Some midwives felt they lacked time in appointments to discuss smoking and provide Quitline referrals and information about Quitline, saying “ We don't get a lot of time dedicated to this in our appointments, we don't really have enough time” (MW11) “The time allocated to our appointments are not that long so for a completion of booking it's usually about an hour ” (MW12) One midwife felt that dedicating more time during appointments might result in more Quitline referrals, “ More antenatal time with midwives will support referrals ” (MW7) 2.2.2.3 Theme five: Initiating Quitline calls after antenatal appointments Some midwives believed aligning telephone Quitline appointments with antenatal visits could increase engagement, saying “ If they were incorporated into their appointments with us, like even if it was like a telehealth sort of thing, if there was a dedicated space and time to have that discussion, it might be just easier for them to actually speak with the Quitline people ” (MW6) “ Why don't we have something in antenatal clinic so if they come to the antenatal appointments, they can attend that Quitline appointment as well” (MW10) Another midwife wanted to be more involved with Quitline, rather than just referring women to an external service, saying “ If we could be a bit more involved and talk to someone and call them and start that process” (MW12) Discussion The study aimed to explore the Quitline referral process and identify the factors that influence whether midwives refer pregnant women who smoke to Quitline. Referral to this government-funded service remains an overlooked and underexplored aspect among pregnant women who smoke. Although other smoking cessation and substance use support services are available during pregnancy, this study focuses explicitly on referrals to Quitline as recommended by the SBB ( 25 ) and the Australian pregnancy care guidelines ( 26 ). We acknowledge that substances like vaping also pose risks during pregnancy ( 27 ), however, our emphasis remains on the referral pathway and Quitline service only. Two TDF domains (Knowledge and Environmental context and resources) identified barriers to implementing the Quitline referral pathway, while one domain (Knowledge) identified facilitators. Our five main themes highlight: 1) midwives’ limited knowledge of the Quitline service, 2) midwives’ limited understanding of the Quitline referral process, 3) limited access to Quitline resources, 4) limited time in appointments to complete Quitline referrals and 5) initiating Quitline calls after antenatal appointments. In 2023, Queensland recorded 58,549 births ( 29 ). With a 9% smoking rate, this would be approximately 5,269 pregnant women who said they smoked. However, only 487 women were referred to Quitline in 2023 ( 17 ). Midwives in this study lacked understanding of the referral process and reported inconsistent procedures across the three maternity services involved, even though all were situated in Southeast Queensland and were part of the SBB initiative ( 28 ). Variations in Quitline referral pathways are likely more apparent across Australia, as each Quitline operates independently within its respective jurisdiction ( 29 ) and referrals must be made to the relevant Quitline in the jurisdiction where the woman resides. Implementing a standardised national Quitline referral process is crucial to minimising variability and simplifying the referral process for all midwives, helping to prevent missed opportunities. Giving women the option to opt out of a Quitline referral rather than opt in should also be incorporated into maternity care. This was a recommendation by SBB, implemented across Australia ( 28 ). Midwives highlighted the need for improved access to Quitline resources. Pregnant women who smoke often have different experiences compared to other smokers, as many women do not consider quitting before pregnancy ( 30 ). A common barrier for cessation is women is living with a partner or family members who smoke ( 31 ). Nicotine is highly addictive, and women are more likely to continue smoking if they have a partner or someone in their home who smokes ( 32 ). Offering resources that women can share with their families may support informed decision-making by emphasising key details from Quitline that help women and their families quit smoking. In this study, one midwife indicated that resources were available at their hospital, while another disagreed, and a third midwife mentioned that all information is now accessible via QR codes. This illustrates the variation in the care women might receive when accessing maternity care at different hospital sites. Quitline resources should be accessible in all maternity units to promote equality and for both midwives, women and their families. Women referred to Quitline often experience delays between accepting the referral and their initial phone appointment, which may result in low engagement. More effective strategies are needed to reduce this delay. Accelerated intake after referrals for people with substance use has shown improvements in appointment attendance ( 33 ), as motivation can decline over time. Reducing the time spent waiting for appointments after referral may also reduce anticipatory anxiety ( 34 ), as this has been shown to increase during waiting times. In this study, midwives believed that offering women the opportunity to speak with a Quitline counsellor at a convenient time after their antenatal appointment would be beneficial. This approach could reduce the delay between Quitline referral and first contact, potentially increasing Quitline appointment attendance. Initiating a call to Quitline in a private room after the woman’s antenatal appointment could also help prevent adding to the midwife's workload. Integrating smoking cessation support into regular antenatal visits could increase engagement through ongoing women-centred care. Alternative strategies, like assigning specialist midwives to deliver smoking cessation support during antenatal visits, should also be explored. Having dedicated, experienced smoking cessation midwives in antenatal clinics can enhance the consistency and quality of support provided to women ( 35 ). The BUBsQuit approach exemplifies this model with specialist midwives providing counselling and mobile apps to assist women in quitting smoking ( 36 ). This approach also aligns with the MOHMQuit implementation trial, which emphasises training midwives and integrating evidence-based practices in smoking cessation care ( 37 ). 3.1 Strengths and Limitations A strength of this study is that the interviews offer practical insights from midwives working in various roles across three health services, providing a diverse perspective on Quitline referral barriers and facilitators in different settings. Having a midwife lead the study greatly contributed to its development, especially in crafting the interview guide and analysing data, due to their valuable field experience. Nevertheless, it is important to recognise limitations, as three maternity services might not fully represent the prevalence of smokers. All midwives were from southeast Queensland, which might not represent the Quitline referral processes across the entire state or be broadly applicable to other healthcare settings or countries. Another limitation is that most midwives were from the Gold Coast, where smoking rates are very low. Therefore, education on Quitline might not be a high priority for them. It is also unclear whether health services in areas with higher smoking prevalence employ different approaches. Although focusing solely on midwives' perspectives is a limitation, this study provides valuable insights into current practices and challenges within the Quitline referral system. Exploring the perspectives of women and Quitline counsellors is planned and is an essential but underexplored area that can guide the development of strategies to improve the Quitline referral process and the services offered. Conclusion This study shows that some midwives are unaware of how to refer pregnant women who smoke to Quitline or what services Quitline provides to women. To improve this, midwives need a clearer understanding of the Quitline service and what Quitline offers women. Integrating these strategies into the SBB e-learning for health professionals and establishing a nationwide Quitline referral process could increase referrals and attendance at appointments. Midwives also noted limited access to Quitline resources and not enough time during antenatal appointments to make referrals. Providing women with the opportunity to speak with a Quitline counsellor by telephone after antenatal appointments could increase referrals and attendance. This research confirms the importance of establishing a national referral system and of providing education on Quitline services. The emerging role of specialist midwives in offering smoking cessation support offers a valuable opportunity for further study, especially in understanding how their expertise can improve engagement and outcomes for pregnant women who smoke, compared to referring women to external smoking cessation services such as Quitline. Declarations Ethics approval and consent to participate Verbal consent was obtained from all participants. The study adhered to the Declaration of Helsinki. Approval was obtained from the Gold Coast University Hospital HREC reference number HREC/2022/QGC/88538 on 7 March 2023. SSAs were obtained and approved from Gold Coast University Hospital SSA/2023/QGC/88538 (Jun ver 2) on 07/06/2023. Mater Health MSSA/MRGO/88538 (V5) on 26/10/2023. West Morton Health Service SSA/2023/QWMS/88538 (Aug ver 6) on 24/08/2023. Consent for publication Not applicable Competing interests The authors declare that the research was conducted without any commercial or financial relationships that could be construed as a potential conflict of interest. Funding This study falls within the work program of the Stillbirth Centre of Research Excellence, which is funded by the NHMRC (AP1116640). The Safer Baby Bundle study is further supported by an NHMRC Partnerships Project Grant (APP1169829) and MRFF Accelerated Research Grant. Author Contribution CB, DE, PM, VF and CA contributed substantially to the study’s conceptualisation, and all authors contributed substantially to the interpretation of findings and article writing. CB was responsible for data collection, and CB and PM analysed the data. All authors read and approved the final manuscript for submission. Acknowledgement We would like to thank the midwives for taking the time to participate in the interviews. References World Health Organization. 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WMA Declaration of Helsinki – Ethical Principles for Medical Research Involving Human Participants: World Medical Association. 2024 [Available from: https://www.wma.net/policies-post/wma-declaration-of-helsinki/ Additional Declarations No competing interests reported. Supplementary Files Supplementary1Midwives2026BMCPregnancyandChildbirth.docx Cite Share Download PDF Status: Under Review Version 1 posted Reviewers agreed at journal 13 Mar, 2026 Reviewers agreed at journal 08 Mar, 2026 Reviewers invited by journal 05 Mar, 2026 Editor assigned by journal 04 Mar, 2026 Editor invited by journal 10 Feb, 2026 Submission checks completed at journal 06 Feb, 2026 First submitted to journal 06 Feb, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8759036","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":602627073,"identity":"f0655ec4-d20a-47ee-8ece-5f6ad919e19f","order_by":0,"name":"Cheryl BAILEY","email":"data:image/png;base64,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","orcid":"","institution":"The University of Queensland","correspondingAuthor":true,"prefix":"","firstName":"Cheryl","middleName":"","lastName":"BAILEY","suffix":""},{"id":602627074,"identity":"d50de70e-292e-41bf-9604-b7dd03744821","order_by":1,"name":"Philippa MIDDLETON","email":"","orcid":"","institution":"Centre of Research Excellence in Stillbirth","correspondingAuthor":false,"prefix":"","firstName":"Philippa","middleName":"","lastName":"MIDDLETON","suffix":""},{"id":602627075,"identity":"24da2192-c080-4207-9e4a-ac0ecde28930","order_by":2,"name":"Vicki FLENADY","email":"","orcid":"","institution":"Centre of Research Excellence in Stillbirth","correspondingAuthor":false,"prefix":"","firstName":"Vicki","middleName":"","lastName":"FLENADY","suffix":""},{"id":602627076,"identity":"67c367f0-11f3-48aa-8694-932cf3339917","order_by":3,"name":"David ELLWOOD","email":"","orcid":"","institution":"Centre of Research Excellence in Stillbirth","correspondingAuthor":false,"prefix":"","firstName":"David","middleName":"","lastName":"ELLWOOD","suffix":""},{"id":602627077,"identity":"a6e3a512-450a-4395-a308-9c06c093d087","order_by":4,"name":"Christine ANDREWS","email":"","orcid":"","institution":"Centre of Research Excellence in Stillbirth","correspondingAuthor":false,"prefix":"","firstName":"Christine","middleName":"","lastName":"ANDREWS","suffix":""}],"badges":[],"createdAt":"2026-02-01 22:38:29","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8759036/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8759036/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":104406190,"identity":"a9fb005e-7cf2-4b88-9dfc-162a3c42ebac","added_by":"auto","created_at":"2026-03-11 12:25:00","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":726889,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8759036/v1/6909afff-ce78-4755-8f8b-4e02fd736369.pdf"},{"id":104364620,"identity":"68a263f8-7360-4d9f-956c-7a3dbcd9a944","added_by":"auto","created_at":"2026-03-11 02:50:22","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":16983,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementary1Midwives2026BMCPregnancyandChildbirth.docx","url":"https://assets-eu.researchsquare.com/files/rs-8759036/v1/485b6432f383056ba04f3dde.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Midwives' views on referring pregnant women to Quitline and their participation and engagement with smoking cessation services (Quitline)","fulltext":[{"header":"Background","content":"\u003cp\u003eSmoking during pregnancy significantly increases health risks and adverse birth outcomes (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e), such as low birth weight, preterm birth, and stillbirth (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Women who are heavy smokers face a two to three times greater risk of stillbirth (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e), with intrauterine death and neonatal infection also associated with maternal smoking of more than 20 cigarettes per day (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). There is no safe level of smoking during pregnancy, and quitting, even in the second or third trimester, can greatly reduce the risk of neonatal mortality (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Around 8% of women reported smoking in Australia in 2023, which has decreased from 13% in 2011 (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). However, the percentage of pregnant women who continue to smoke after 20 weeks in Australia has remained largely unchanged over the past decade, with rates of 71% in 2011 and 69% in 2023 (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e \u003cp\u003ePregnancy is an ideal time to educate women about the dangers of tobacco (\u003cspan additionalcitationids=\"CR9\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e), as women consult health professionals for their care, yet about half of all pregnant women who smoke report not receiving cessation advice from health professionals (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). Women participating in a smoking cessation program generally achieve higher abstinence rates than those attempting to quit on their own (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). Women have various support options to quit smoking during pregnancy, with Quitline being the most common referral service in Australia, offered to the majority of pregnant women in routine maternity care (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). Since 1997, Quitline, a telephone-based support service, has been nationally available nationally in Australia (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). It is funded and managed by individual states rather than the Federal Government (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e), leading to differences in services offered across jurisdictions (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Despite its existence, the Quitline referral rate remains low, with approximately half of the women referred not attending any telephone appointments (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Currently, there appears to be no clear understanding of the most effective ways to address the low referral rate and increase women\u0026rsquo;s attendance at telephone appointments.\u003c/p\u003e \u003cp\u003eIn 2010, the National Institute for Health and Care Excellence (NICE) recommended that UK maternity care providers include carbon monoxide testing and an opt-out referral to Quitline or local smoking cessation services as part of routine antenatal care (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). This was later adopted by the 2016 UK 'Saving Babies Lives' bundle (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e), and Australia's Safer Baby Bundle (SBB) (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e), both aimed at reducing the risk of stillbirth and adverse pregnancy outcomes. A core component of the SBB involves referring pregnant women who smoke to Quitline as part of routine maternity care (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e), using a standardised and equitable approach to ensure all women receive consistent support regardless of background or circumstances. Given the limited evidence on the effectiveness of the Quitline referral process during pregnancy, it is essential to examine how the referral pathway functions, its overall effectiveness, and the entire process involved.\u003c/p\u003e \u003cp\u003eThe study aims to understand midwives' perspectives on the Quitline referral process, focusing on the barriers they recognise and their suggestions for increasing women\u0026rsquo;s engagement with the service. The scope of this study is part of a broader piece of work, including Quitline appointment uptake, reasons for not continuing Quitline programs, and service level barriers at Quitline that impact women\u0026rsquo;s continued appointment attendance (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). The Theoretical Domains Framework (TDF) (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e) was used, as it identifies key factors such as knowledge, skills, and beliefs that underpin evidence-based interventions. Mapping midwives' interviews to the TDF domains will help develop theory-based strategies to overcome barriers and leverage facilitators that can drive behavioural change (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e).\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003e1.1 Study design and setting\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis qualitative study employs a phenomenological framework to understand individuals' experiences in the context of their everyday lives (\u003cspan class=\"CitationRef\"\u003e23\u003c/span\u003e). The TDF offers a comprehensive list of theory-based explanations of behaviour, which can be employed to analyse factors that might hinder performance behaviours (\u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e). Semi-structured interviews were held with midwives from Gold Coast University Hospital (GCUH), Ipswich Hospital (IH) and Mater Mothers Hospital (MMH) between December 2023 and June 2024.\u003c/p\u003e\n\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\n\u003ch2\u003e1.2 Recruitment and Participants\u003c/h2\u003e\n\u003cp\u003eMidwives were informed about the study during in-person educational sessions and through promotional posters, providing them with the opportunity to express their interest either by scanning a QR code or by contacting the researcher directly via email. Each midwife was contacted directly and informed about the aim of the interviews and provided with an information letter. Verbal consent was obtained, and interviews were scheduled, either immediately at the antenatal clinic or later via Zoom or phone. Midwives\u0026rsquo; contact details were collected for participation, with reassurances that the interviews were for research purposes only and that the published results would be de-identified. Participation was voluntary, and midwives could withdraw from the study at any time.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\n\u003ch2\u003e1.3 Data collection\u003c/h2\u003e\n\u003cp\u003eMidwives were interviewed using a guide developed by the research team to understand the Quitline referral process and identify any barriers and facilitators that may influence women\u0026rsquo;s attendance at Quitline appointments. The main topics discussed included midwives' understanding of the referral process to Quitline, their knowledge of the service, reasons for referring or not referring women, and potential improvements to increase women's engagement with Quitline appointments. After each interview, the researcher CB documented the field notes. No new questions were added to the interview guide throughout the study. The interviews lasted on average between 20 and 30 minutes. The interviews were audio-recorded with the midwives\u0026rsquo; permission.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\n\u003ch2\u003e1.4 Data Analysis\u003c/h2\u003e\n\u003cp\u003eRecorded interviews were transcribed verbatim. CB performed the transcription, coding each line with an inductive thematic approach (\u003cspan class=\"CitationRef\"\u003e24\u003c/span\u003e). CB read all transcripts multiple times to become familiar with the data and compared them to the original audio recordings. The TDF provided the initial structure to organise the data. Responses from the transcribed interviews were assigned to the 14 TDF domains using deductive analysis of these colour-coded domains. The next step was inductive thematic analysis to identify themes related to barriers and facilitators for increasing Quitline appointment uptake. A subset of four interviews were coded independently by both CB and PM according to the TDF to minimise bias and enhance the validity of the coding. A high level of agreement was reached during the coding process. All authors approved the study methods. During meetings, all authors reflected on and refined the themes iteratively until a consensus was reached.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eEighteen registered midwives were interviewed, ten from Gold Coast University Hospital (GCUH), four from Ipswich Hospital (IH), and four from Mater Mothers Hospital (MMH), Brisbane.\u003c/p\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e2.1 Characteristics\u003c/h2\u003e \u003cp\u003eThe 18 midwives included in this study had varying levels of experience in their role: (n\u0026thinsp;=\u0026thinsp;3) 1\u0026ndash;5 years, (n\u0026thinsp;=\u0026thinsp;10) \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003ehad\u003c/span\u003e 6\u0026ndash;10 years, (n\u0026thinsp;=\u0026thinsp;2) \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003ehad\u003c/span\u003e 11\u0026ndash;15 years, and (n\u0026thinsp;=\u0026thinsp;3) had more than 16 years of experience. All midwives worked in antenatal care as registered midwives, clinical midwives, or midwives working in a continuity model (see Supplementary 1).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003e2.2 Domains and Themes\u003c/h2\u003e \u003cp\u003eOnly two domains, Knowledge and Environmental Context and Resources, were reflected in the data (see Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). These domains are central to this study, reflecting awareness, social influences, and external factors that can shape behaviour.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThemes and sub-themes aligned to the Theoretical Domain\u0026rsquo;s Framework\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTheme Number\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTheoretical Domain\u0026rsquo;s Framework Domains\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTheme\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTheme 1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eKnowledge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eThe limited knowledge of the Quitline service\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTheme 2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eKnowledge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eThe limited understanding of the Quitline referral process\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTheme 3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEnvironmental context and resources\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eThe limited access to Quitline resources\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTheme 4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEnvironmental context and resources\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eThe limited time in appointments to complete Quitline referrals\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTheme 5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEnvironmental context and resources\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eInitiating Quitline calls after antenatal appointments\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec9\" class=\"Section3\"\u003e \u003ch2\u003e2.2.1 Domain one: Knowledge\u003c/h2\u003e \u003cp\u003eThe Knowledge domain involves midwives' understanding of the Quitline referral process and the services it offers. Limited or inconsistent knowledge among midwives was identified as a barrier to making referrals and reducing the quality of information shared with women.\u003c/p\u003e \u003cdiv id=\"Sec10\" class=\"Section4\"\u003e \u003ch2\u003e2.2.1.1 Theme One: The limited knowledge of the Quitline service,\u003c/h2\u003e \u003cp\u003eAround half of the midwives interviewed reported having limited knowledge of Quitline services and the support available to women. This lack of understanding may affect their confidence in making referrals, some midwives said\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;To be honest, I actually don't know what the Quit people go through with the women\u003c/em\u003e\u0026rdquo; (MW4).\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;I'm not too sure of what actually occurs once they are in contact with each other\u0026rdquo;\u003c/em\u003e (MW7)\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eSome midwives knew they should refer women to the Quitline service, but they lacked sufficient knowledge to advise them on what they might receive.\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;I usually sell it but to be honest I actually don't know what the quit people go through with the women\u0026rdquo;\u003c/em\u003e (MW6)\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eOne midwife thought that the program did not include counselling, stating\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003e\u0026ldquo;\u003cem\u003eI don't really know what they mean by ongoing support, I think it's not like a counsellor but like some sort of support programme for them\u003c/em\u003e\u0026rdquo; (MW5)\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eMidwives also had a limited understanding of nicotine replacement therapy at Quitline, including what is offered and how it is received, saying\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003e\u0026ldquo;\u003cem\u003eThey contact them, they offer them this nicotine replacement therapy, and then they kind of get counselling, is that kind of what they get?\u0026rdquo;\u003c/em\u003e (MW12)\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e\u0026ldquo;\u003cem\u003eI thought that they were able to mail out NRT directly to their house. I don\u0026rsquo;t know if that's correct or not, but that's really as much as I know\u003c/em\u003e\u0026rdquo; (MW16)\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section4\"\u003e \u003ch2\u003e2.2.1.2 Theme Two: The limited understanding of the Quitline referral process\u003c/h2\u003e \u003cp\u003eSome midwives were hesitant to refer women to Quitline, while others mentioned they had little or no experience making referrals, they said\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003e \u003cem\u003e\"We don't refer ourselves unless they specifically ask for that, because I'm actually unsure of that process\"\u003c/em\u003e (MW18)\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e\"\u003cem\u003eI've not really done any referrals to Quitline just yet\"\u003c/em\u003e (MW10)\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cem\u003e\"I've only ever had one woman say, 'Yes, I would like a referral\u003c/em\u003e\" (MW6).\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eSome midwives were aware of the hospital Quitline referral pathways, but there seemed to be some uncertainty about the process, with some midwives saying.\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;I think it's a great service it's just we don't know how to access it and we don't know how to refer to it\u0026rdquo;\u003c/em\u003e (MW7)\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cem\u003e\"I think there is an online portal that my team leader showed me last time, where we can make the referral online\"\u003c/em\u003e (MW12)\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eEducation on the Quitline referral pathway was needed in some hospitals. One midwife said\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Maybe have some more training around you know the process of referrals, what\u0026rsquo;s needed\u0026rdquo;\u003c/em\u003e (MW5)\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eA midwife mentioned that at a previous hospital, midwives could complete and fax Quitline referrals, unlike the current hospital, saying\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;I used to work in [another health service] and we had Quitline referral forms that we would complete and we would fax them off to Quitline\u0026hellip;.. it was a document, two-page document that we would fax to the Quitline people. Yep, there's nothing here\u0026rdquo;\u003c/em\u003e (MW2)\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section3\"\u003e \u003ch2\u003e2.2.2 Domain two: Environmental context and resources\u003c/h2\u003e \u003cp\u003eThe Environmental context and resources domain includes the physical, social, and resource-related factors that influence both the referral process to Quitline and women's capacity to attend appointments. A major theme within this domain is the limited time and resources midwives face as barriers to providing Quitline support.\u003c/p\u003e \u003cdiv id=\"Sec13\" class=\"Section4\"\u003e \u003ch2\u003e2.2.2.1 Theme three: Limited access to Quitline resources\u003c/h2\u003e \u003cp\u003eMidwives are well-placed to provide women with Quitline information during maternity care, but limited access to Quitline brochures and resources often prevents this. One midwife explained\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003e\u0026ldquo;\u003cem\u003eAt the moment, we don\u0026rsquo;t have any access to any Quitline packs in the clinic in which I work\u0026rdquo;\u003c/em\u003e (MW2)\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eAnother midwife working within a continuity model observed a similar issue during outreach clinics, stating\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003e\u0026ldquo;\u003cem\u003eWe're a satellite clinic, we don't have all of the resources\u003c/em\u003e\u0026rdquo; (MW6)\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eOne midwife explained that their health services now use QR codes as an alternative way to educate women about Quitline smoking,\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003e\u0026ldquo;\u003cem\u003eWe have no printout education available to handout anymore, it is all QR codes, .\u003c/em\u003e\u0026hellip;.\u003cem\u003eI think there needs to be some form of, a brochure or flyer or pamphlet or something that we can pass them\u0026rdquo;\u003c/em\u003e (MW5)\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eHowever, not all midwives encountered this obstacle, as one midwife observed that resources\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003ewere accessible within their healthcare setting.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e\u0026ldquo;\u003cem\u003eWe do have like a handout in our office\u003c/em\u003e\u0026rdquo; (MW10)\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section4\"\u003e \u003ch2\u003e2.2.2.2 Theme four: Limited time in appointments to complete Quitline referrals\u003c/h2\u003e \u003cp\u003eSome midwives felt they lacked time in appointments to discuss smoking and provide Quitline referrals and information about Quitline, saying\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003e\u0026ldquo;\u003cem\u003eWe don't get a lot of time dedicated to this in our appointments, we don't really have enough time\u0026rdquo;\u003c/em\u003e (MW11)\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;The time allocated to our appointments are not that long so for a completion of booking it's usually about an hour\u003c/em\u003e\u0026rdquo; (MW12)\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eOne midwife felt that dedicating more time during appointments might result in more Quitline referrals,\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003e\u0026ldquo;\u003cem\u003eMore antenatal time with midwives will support referrals\u003c/em\u003e\u0026rdquo; (MW7)\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section4\"\u003e \u003ch2\u003e2.2.2.3 Theme five: Initiating Quitline calls after antenatal appointments\u003c/h2\u003e \u003cp\u003eSome midwives believed aligning telephone Quitline appointments with antenatal visits could increase engagement, saying\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003e\u0026ldquo;\u003cem\u003eIf they were incorporated into their appointments with us, like even if it was like a telehealth sort of thing, if there was a dedicated space and time to have that discussion, it might be just easier for them to actually speak with the Quitline people\u003c/em\u003e\u0026rdquo; (MW6)\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e\u0026ldquo;\u003cem\u003eWhy don't we have something in antenatal clinic so if they come to the antenatal appointments, they can attend that Quitline appointment as well\u0026rdquo;\u003c/em\u003e (MW10)\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eAnother midwife wanted to be more involved with Quitline, rather than just referring women to an external service, saying\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003e\u0026ldquo;\u003cem\u003eIf we could be a bit more involved and talk to someone and call them and start that process\u0026rdquo;\u003c/em\u003e (MW12)\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe study aimed to explore the Quitline referral process and identify the factors that influence whether midwives refer pregnant women who smoke to Quitline. Referral to this government-funded service remains an overlooked and underexplored aspect among pregnant women who smoke. Although other smoking cessation and substance use support services are available during pregnancy, this study focuses explicitly on referrals to Quitline as recommended by the SBB (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e) and the Australian pregnancy care guidelines (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). We acknowledge that substances like vaping also pose risks during pregnancy (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e), however, our emphasis remains on the referral pathway and Quitline service only. Two TDF domains (Knowledge and Environmental context and resources) identified barriers to implementing the Quitline referral pathway, while one domain (Knowledge) identified facilitators. Our five main themes highlight: 1) midwives\u0026rsquo; limited knowledge of the Quitline service, 2) midwives\u0026rsquo; limited understanding of the Quitline referral process, 3) limited access to Quitline resources, 4) limited time in appointments to complete Quitline referrals and 5) initiating Quitline calls after antenatal appointments.\u003c/p\u003e \u003cp\u003eIn 2023, Queensland recorded 58,549 births (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). With a 9% smoking rate, this would be approximately 5,269 pregnant women who said they smoked. However, only 487 women were referred to Quitline in 2023 (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Midwives in this study lacked understanding of the referral process and reported inconsistent procedures across the three maternity services involved, even though all were situated in Southeast Queensland and were part of the SBB initiative (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). Variations in Quitline referral pathways are likely more apparent across Australia, as each Quitline operates independently within its respective jurisdiction (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e) and referrals must be made to the relevant Quitline in the jurisdiction where the woman resides. Implementing a standardised national Quitline referral process is crucial to minimising variability and simplifying the referral process for all midwives, helping to prevent missed opportunities. Giving women the option to opt out of a Quitline referral rather than opt in should also be incorporated into maternity care. This was a recommendation by SBB, implemented across Australia (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eMidwives highlighted the need for improved access to Quitline resources. Pregnant women who smoke often have different experiences compared to other smokers, as many women do not consider quitting before pregnancy (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). A common barrier for cessation is women is living with a partner or family members who smoke (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). Nicotine is highly addictive, and women are more likely to continue smoking if they have a partner or someone in their home who smokes (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). Offering resources that women can share with their families may support informed decision-making by emphasising key details from Quitline that help women and their families quit smoking. In this study, one midwife indicated that resources were available at their hospital, while another disagreed, and a third midwife mentioned that all information is now accessible via QR codes. This illustrates the variation in the care women might receive when accessing maternity care at different hospital sites. Quitline resources should be accessible in all maternity units to promote equality and for both midwives, women and their families.\u003c/p\u003e \u003cp\u003eWomen referred to Quitline often experience delays between accepting the referral and their initial phone appointment, which may result in low engagement. More effective strategies are needed to reduce this delay. Accelerated intake after referrals for people with substance use has shown improvements in appointment attendance (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e), as motivation can decline over time. Reducing the time spent waiting for appointments after referral may also reduce anticipatory anxiety (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e), as this has been shown to increase during waiting times. In this study, midwives believed that offering women the opportunity to speak with a Quitline counsellor at a convenient time after their antenatal appointment would be beneficial. This approach could reduce the delay between Quitline referral and first contact, potentially increasing Quitline appointment attendance. Initiating a call to Quitline in a private room after the woman\u0026rsquo;s antenatal appointment could also help prevent adding to the midwife's workload. Integrating smoking cessation support into regular antenatal visits could increase engagement through ongoing women-centred care.\u003c/p\u003e \u003cp\u003eAlternative strategies, like assigning specialist midwives to deliver smoking cessation support during antenatal visits, should also be explored. Having dedicated, experienced smoking cessation midwives in antenatal clinics can enhance the consistency and quality of support provided to women (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e). The BUBsQuit approach exemplifies this model with specialist midwives providing counselling and mobile apps to assist women in quitting smoking (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e). This approach also aligns with the MOHMQuit implementation trial, which emphasises training midwives and integrating evidence-based practices in smoking cessation care (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e).\u003c/p\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003e3.1 Strengths and Limitations\u003c/h2\u003e \u003cp\u003eA strength of this study is that the interviews offer practical insights from midwives working in various roles across three health services, providing a diverse perspective on Quitline referral barriers and facilitators in different settings. Having a midwife lead the study greatly contributed to its development, especially in crafting the interview guide and analysing data, due to their valuable field experience.\u003c/p\u003e \u003cp\u003eNevertheless, it is important to recognise limitations, as three maternity services might not fully represent the prevalence of smokers. All midwives were from southeast Queensland, which might not represent the Quitline referral processes across the entire state or be broadly applicable to other healthcare settings or countries. Another limitation is that most midwives were from the Gold Coast, where smoking rates are very low. Therefore, education on Quitline might not be a high priority for them. It is also unclear whether health services in areas with higher smoking prevalence employ different approaches. Although focusing solely on midwives' perspectives is a limitation, this study provides valuable insights into current practices and challenges within the Quitline referral system. Exploring the perspectives of women and Quitline counsellors is planned and is an essential but underexplored area that can guide the development of strategies to improve the Quitline referral process and the services offered.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study shows that some midwives are unaware of how to refer pregnant women who smoke to Quitline or what services Quitline provides to women. To improve this, midwives need a clearer understanding of the Quitline service and what Quitline offers women. Integrating these strategies into the SBB e-learning for health professionals and establishing a nationwide Quitline referral process could increase referrals and attendance at appointments. Midwives also noted limited access to Quitline resources and not enough time during antenatal appointments to make referrals. Providing women with the opportunity to speak with a Quitline counsellor by telephone after antenatal appointments could increase referrals and attendance. This research confirms the importance of establishing a national referral system and of providing education on Quitline services. The emerging role of specialist midwives in offering smoking cessation support offers a valuable opportunity for further study, especially in understanding how their expertise can improve engagement and outcomes for pregnant women who smoke, compared to referring women to external smoking cessation services such as Quitline.\u003c/p\u003e"},{"header":"Declarations","content":" \u003cp\u003e \u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e \u003cp\u003e Verbal consent was obtained from all participants. The study adhered to the Declaration of Helsinki. Approval was obtained from the Gold Coast University Hospital HREC reference number HREC/2022/QGC/88538 on 7 March 2023. SSAs were obtained and approved from Gold Coast University Hospital SSA/2023/QGC/88538 (Jun ver 2) on 07/06/2023. Mater Health MSSA/MRGO/88538 (V5) on 26/10/2023. West Morton Health Service SSA/2023/QWMS/88538 (Aug ver 6) on 24/08/2023.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent for publication\u003c/strong\u003e \u003cp\u003eNot applicable\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eCompeting interests\u003c/strong\u003e \u003cp\u003eThe authors declare that the research was conducted without any commercial or financial relationships that could be construed as a potential conflict of interest.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eThis study falls within the work program of the Stillbirth Centre of Research Excellence, which is funded by the NHMRC (AP1116640). The Safer Baby Bundle study is further supported by an NHMRC Partnerships Project Grant (APP1169829) and MRFF Accelerated Research Grant.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eCB, DE, PM, VF and CA contributed substantially to the study\u0026rsquo;s conceptualisation, and all authors contributed substantially to the interpretation of findings and article writing. CB was responsible for data collection, and CB and PM analysed the data. All authors read and approved the final manuscript for submission.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eWe would like to thank the midwives for taking the time to participate in the interviews.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eWorld Health Organization. World Health Organization recommendations for the prevention and management of tobacco use and second-hand smoke exposure in pregnancy 2013 [Cited 18/01/2025]. 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Barriers to and facilitators of smoking cessation in pregnancy and following childbirth: literature review and qualitative study. Health Technol Assess. 2017;21(36):1\u0026ndash;158.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eScheffers-van Schayck T, Tuithof M, Otten R, Engels R, Kleinjan M. Smoking Behavior of Women Before, During, and after Pregnancy: Indicators of Smoking, Quitting, and Relapse. Eur Addict Res. 2019;25(3):132\u0026ndash;44.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSchauman O, Aschan LE, Arias N, Beards S, Clement S. Interventions to Increase Initial Appointment Attendance in Mental Health Services: A Systematic Review. Psychiatric Serv. 2013;64(12):1249\u0026ndash;58.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGrupe DW, Nitschke JB. Uncertainty and anticipation in anxiety: an integrated neurobiological and psychological perspective. Nat Rev Neurosci. 2013;14(7):488\u0026ndash;501.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHartz D, Crilley MM, Richmond R. O36 - BUBs Quit study: Clinical Midwife Specialist as change agent assisting pregnant women to quit smoking using counselling and embedded technology. Women Birth. 2023;36:S15.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCatling C, Salisbury J. Development of the BUBs Quit study training manuals: Enhancing midwifery scope of practice in smoking cessation. Women Birth. 2024;37:1\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBarnes LAJ, Longman J, Adams C, Paul C, Atkins L, Bonevski B, 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. Implement Sci. 2022;17(1):79.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWorld Medical Association. WMA Declaration of Helsinki \u0026ndash; Ethical Principles for Medical Research Involving Human Participants: World Medical Association. 2024 [Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.wma.net/policies-post/wma-declaration-of-helsinki/\u003c/span\u003e\u003cspan address=\"https://www.wma.net/policies-post/wma-declaration-of-helsinki/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Smoking Cessation, Tobacco, Pregnancy, Referral and Consultation, Quitline, Stillbirth","lastPublishedDoi":"10.21203/rs.3.rs-8759036/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8759036/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eSmoking during pregnancy is a major risk for stillbirth and adverse outcomes. In Australia, about 70% of women who smoke before 20 weeks of pregnancy continue after 20 weeks, with little change over the last decade. Women are more likely to quit when attending cessation programs, but Quitline referral rates remain low. The aim of this study is to examine the Quitline (a telephone-based smoking cessation service) referral process for pregnant women and to identify the barriers and facilitators that influence appointment attendance.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eSemi-structured interviews across Queensland maternity services with midwives who refer pregnant women to Quitline. Midwives were recruited through information sessions, posters and QR code registration. Deductive analysis using the Theoretical Domains Framework, followed by inductive thematic analysis, was employed to identify factors affecting the Quitline referral process and barriers and facilitators that may influence women\u0026rsquo;s attendance at telephone appointments.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eEighteen midwives were interviewed between December 2023 and June 2024. Five themes were identified and linked to two Theoretical Domains Framework domains. Midwives had a limited understanding of the Quitline referral process and available Quitline services. Barriers included a lack of education, limited appointment time, and resource unavailability. Midwives suggest that offering Quitline calls following antenatal appointments may reduce the time between referral and appointment, thereby increasing Quitline appointment uptake.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eSome midwives said that they were unaware of how to refer pregnant women who smoke to Quitline or what services Quitline offers. They also mentioned limited access to Quitline resources and insufficient time during appointments to make referrals. Enabling women to speak directly with Quitline counsellors following antenatal appointments could increase referral and attendance rates. Developing a Quitline education program for midwives and establishing a national referral system could increase referral and appointment attendance rates among pregnant women who smoke.\u003c/p\u003e","manuscriptTitle":"Midwives' views on referring pregnant women to Quitline and their participation and engagement with smoking cessation services (Quitline)","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-11 02:50:17","doi":"10.21203/rs.3.rs-8759036/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"240466039999144795222676337846216757415","date":"2026-03-13T21:17:17+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"178703303029776411494123406591776323654","date":"2026-03-08T12:42:24+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-03-06T03:39:46+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-03-04T09:26:58+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-02-10T10:25:47+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-02-07T04:44:38+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Pregnancy and Childbirth","date":"2026-02-07T04:39:18+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"12af2967-0340-4333-8a82-636e98b49280","owner":[],"postedDate":"March 11th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-03-11T02:50:17+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-11 02:50:17","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8759036","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8759036","identity":"rs-8759036","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}