Maternity care in general practice

Comments: 50

GP involvement in the care of pregnant women has declined significantly over the past 30 years and midwives are now the main health care providers for 'low risk' pregnancies. The role of GPs in maternity care could disappear completely, unless valid future responsibilities can be defined and clarified.

What did we explore?

To inform its work, the Inquiry panel commissioned a discussion paper to examine what good-quality maternity care looks like and the implications for general practice. The role of GPs in maternity care – what does the future hold? assesses the current state of general practice involvement in maternity care, what GPs can do to stimulate and maintain care quality, and how care quality can be measured. The paper's authors are Alex Smith, former Health Policy Researcher, The King's Fund, and Judy Shakespeare, GP.

What have we learnt about maternity care?

Key issues raised for debate include:

  • The implications for a woman's general health care, both physical and psychological, if GPs are not involved in maternity care.
  • The role of general practice in meeting the stated preferences of pregnant women for continuity of care and post-natal support.
  • The potential for GPs to provide co-ordination and advocacy for women who have complicated medical histories in addition to being pregnant.

What's your view?

During the inquiry, we asked for your opinions on this care dimension. You can read the comments submitted below. You can also read the response to this paper from the Royal College of Midwives

Comments

#763 Geoffrey Rivett
Homerton Foundation Trust

A valuable document. I am incorporating it in my NHS history www.nhshistory.net and want to reference it. At present I can hyperlink to the report but my experience is that links to KF documents often fail as the documents are sooner or later removed from the website. Do you give such reports doi numbers and ensure permanent availability?
Regards

Geoffrey Rivett

#764 Katie Mantell
Head of New Media
The King's Fund

Geoffrey, thanks for your comment, and for referencing the document. We don’t give our reports DOI numbers at the moment. However, we won’t be removing the document from the website. Do contact the web team directly at website@kingsfund.org.uk if you have problems locating previous documents and we’ll be happy to help. Regards, Katie

#765 Mark Deverill
Senior Lect. Health Economics
Newcastle University

see our recent paper that suggests women prefer antenatal care from midwives

Antenatal care for first time mothers: a discrete choice experiment of women's views on alternative packages of care , 12 April 2010
M. Deverill, E. Lancsar, V.B.A. Snaith, S.C. Robson
European Journal of Obstetrics & Gynecology and Reproductive Biology July 2010 (Vol. 151, Issue 1, Pages 33-37)

#766 Ed Wallace
Clinical Lead
GNEF teaching CHP Fife

Timely discussion. I think that we underestimate the importance of the relationship between GPs and pregnant women. e.g. Research has shown that anxiety can increase the risk of adverse outcomes in pregnancy and that a good relationship with Midwife and GP can reduce anxiety levels and reduce complications

#767 Dr. Margaret Ma...
Chief Executive Officer
Action on Pre-eclampsia

At last recognition that antenatal and postnatal care is of such importance, it is crucial that GPs are actively involved. Not only is it important tht GPs update themselves on the latest NICE guidelines and current knowledge, but also that they seek to actively connect with the midwives and obstetricans also involved. Better handover and information sharing systems would give the necessary level of care and reassurance to pregnant women - my organisation runs day seminars and workshops on community care for the most dangerous and common diseases of pregnancy - hypertensive diseases of pregnancy - and yet we struggle to get a single GP to attend. There are new NICE guidelines out this year and Action on Pre-eclampsia has a seminar on their implementation in London in December and GPs would be very welcome.

#768 Belinda Phipps
Chief Executive
NCT

This report comes at a time when maternity services are under close scrutiny and though it makes some useful suggestions, the preferred model of care would be to continue to provide choice of carer and to actively promote midwife-led care to women.

The current problems in maternity care are caused not by the principle of less GP involvement but rather by the lack of supportive systems to make the role of the lead carer, midwife or consultant obstetrician, easier and seamless. A partnership needs to emerge between the health professionals involved in the care of pregnant women, when they are well and when they are unwell.

Birth is a normal, physiological process and the majority of women who are healthy, with a straightforward pregnancy, do not require medical involvement either at general practitioner or hospital consultant level. A social model of care is therefore preferable which is why midwife-led care should be offered to all women. Some women will benefit from the involvement of a GP or require specialist help from dieticians, substance abuse services or social services and some will want to maintain their relationship with their GP. However, many women find getting to know a midwife they can trust and who will be with them thought their pregnancy and birth is vital.

Pregnant women in England currently have a choice to receive their care from their GP or a midwife. The midwife will explain this choice to them when they book their first visit.

GP knowledge on maternity issues has fallen behind current evidence and a considerable amount of retraining will be required to enable them to fulfill their role in pregnancy in relation to the health of the woman and the baby who have medical needs. Even more training would be required if GPs are expected to deal with the pregnancy and birth and the post partum period, as a midwife would.

In the current, cost conscious climate, the most effective solution would be for a pregnant woman to book in with a midwife, for the midwife to have her medical records on her first visit, and the midwife then informing the GP of the pregnancy of one of their patients. Where there are pre-existing medical problems, the woman should be referred by the midwife to the appropriate service, which may be the GP or may be other services.

#769 Rhonda Crockett
3rd yr student midwife
NHS

Pregnant women with no other "medical issue" or obstetric risks should have care provided by a midwife If shared care is then necessary then referral by the midwife to the Obstetric consultants would be all that would be appropriate. Then with the women plan the care she would like. With Children's centres in the community, women are able to have their care by the midwives, the experts in Normal childbirth, away from "sick" people in waiting rooms. I would like to see Midwife prescribers, so that women do not have to then see their GP when a low HB, or Candida infection or when other common pregnancy ailment occurs.
Should the women have other medical/ill health issues, not connected to pregnancy arise, then the GP is the right person to see. And the appropriate referrals to the Obstetric team when necessary.
I would also like to see the 6 week postnatal check for mother and baby, also within the midwife's domain.
I wonder if this issue is really about the "funding" for GP shared care. Perhaps this money should go into the provision of more midwives who can then provide a case loading model of care and continuity for all women. Have enough midwives to honor the commitment to home births and Midwifery led birth centres.
As just starting out in this career, I have hopes for the future and it isn't going backwards .

#770 Clare

As a mother of 2 boys one only 5 months, I personally prefer midwife led care - my expereince and that of friends is that not all GP are well informed and this can lead to mixed messages, confusion and stress - also extra appointments are also not welcome. That said if there are any medical issues that may impact on birth and preganacy GP's input can very useful but I think this should be exception rather than the rule

#771 Janet Patience
Midwife

The basic premise of this document as outlined in the introduction is "This paper asks whether there still is a role for GPs in maternity care." and it is therefore a flawed document.
There is no evidence to suggest that todays GP's can contribute to improved maternity care and indeed their involvement in such care can only detract from their ability to provide care for their other patients. In a time of financial contraints to suggest the reintroduction of a generalist practitioner into a specialist care model is unrealistic.
Such overt, politically motivated research is unworthy of consideration.

#772 Maureen Treadwekk
BTA Committee
BTA

This document is absolutely excellent – particularly its incisive final conclusions. “The GP should be part of an effective team in which the roles, responsibilities and lines of communication are clear. Collaboration, co-operation, communication and competence are key.” So many of the tragic cases that our organisation encounters result from poor teamwork, poor communication and lack of skills and knowledge. This is costly primarily in human terms but also because the NHS is wasting huge amounts in litigation. Childbirth is often a straightforward event but complications are extremely common; women are having bigger babies later in life, there is more IVF and more obesity. Most women might hope for an uncomplicated pregnancy birth but they also want health care professionals to be alert to potential problems including those that may be unrelated to pregnancy. Midwives are trained to deal with uncomplicated births in healthy women – indeed their focus is often described as ‘promoting normality’. Whilst this may be safe in most cases, perhaps there needs to be more caution and more focus on promoting best outcomes. Many women have an excellent relationship with their GP and, providing they have choice, should not be prevented from receiving shared care from a health care professional they trust, who may know a great deal about them and could make a valuable contribution to their care.

#773 Dr Paul Thomas
Principal
Gipping Valley Practice

I find this reading very worrying but extremely interesting. The current situation is a direct result of the privatisation of medicine with “superspecialisation” and the duty doctor and duty midwife and the consequential lowering of standards for the post-graduate training of doctors. Until 2004 and the new GP contract, which excluded GP maternity services and permits trusts to exclude GPs from their properties, I offered intrapartum care mostly on the GP ward of the local maternity department. There follows an extract of my letter to the BMJ published in 1996; "I recently received correspondence from the Clinical Director of my trust's maternity unit, who states that the trust considers any medical intervention during pregnancy to be the sole responsibility of hospital obstetricians. I was particularly concerned that this same manager also seems to believe in a planned "place of normal confinement" and considers planned home deliveries under his nominal supervision are safe with the support of paramedics alone. Surely all general practitioners are qualified in midwifery and vocational training must equip them to manage most obstetric problems more adequately than any paramedic? If standards are as low as the General Medical Services Committee supposes perhaps we should examine the educational content of current senior house officer posts in obstetrics and call for refresher courses to improve standards. Intrapartum obstetrics is one of the most rewarding and satisfying aspects of family medicine but, like all aspects of immediate care, it requires skill and practice. Obstetrics also takes time and so cannot be provided by any deputising service or co-operative. I believe the General Medical Services Committee's advice and its call for the removal of maternity care from general medical services has more to do with the drive towards corporate medical services and privatisation than with any hypothetical issues of negligence and malpractice.*" Although I continue to offer shared antenatal care, it seems to me that the current philosophy is to exclude GPs from any part of a woman’s pregnancy. GPs are often derogatorily referred to as “male midwives” and while pregnant patients are encouraged to believe midwives are the experts in “normal deliveries”, pregnancy is not without its risks. For example, the early detection of pre-eclampsia, abruption, an undiagnosed breech or other time-critical condition in a supposedly low-risk normal pregnancy by an adequately trained, practiced and experienced doctor between routine midwifery appointments in a GP’s surgery can be lifesaving. Sadly, my letters were prophetic. If nine years of vocational training no longer equips doctors to manage obstetric emergencies more adequately than any midwife or paramedic something is very wrong indeed and fear vocational training no longer equips GPs to recognise, let alone manage, obstetric problems. In addition, patients appear to be encouraged to treat a normal delivery as a consumer's right and to ignore the very real risks of pregnancy. In consequence lives are needlessly being lost.

*Thomas P D. British Medical Journal 1996; 313: 305. (3rd August), P D Thomas, British Medical Journal 1996; 313: 1148 (2 November)

#774 Manas Sikdar
GP

Frankly, the vast majority of pregnancies can be managed by midwives. Unfortunately, midwives are not doctors and so may not be able to recognise non-pregnancy related health problems.

Whe

#775 AC

GP's could be involved in pregnancy providing they have additional training. It seems to get forgotten that GP stands for General Practitioner, they are not experts. I have had three children, I WANT my pregnancy care to be completed by Midwives. I want my GP to be there for when my children and I have General health problems. Midwives are under-resourced and undermined as it stands, it would not be appropriate to push them aside in favour of GP's. That would be like history repeating itself, enough damage was done to maternity care in the 19th Century that we have barely repaired.

#776 Kat Sumner

A modern GP's role as the name General Practitioner suggests is more an initial contact point for people with health problems. They administrate the health system for patients who need referrals to specialist services and treat some minor to middling health conditions.

Pregnancy is not and illness, it does not require treatment, it requires a referral to antenatal care and it is very difficult for me to conceive what role a GP should play in any level of antenatal care since they have neither the specialist antenatal training nor the knowledge to provide the standard of care that midwives and obstetricians are already providing.

Are GPs supposed to be replacing midwife appointments? Are they supposed to see women as well as midwives? It seems an absolute waste of their time and the NHS' money for GPs to see pregnant women. The only relevant role I can imagine a GP having in pregnancy is the prescribing of creams for stretch mark rashes and anti-sickness medications for hyperemises and it is better if you can manage without these, often superfluous, medications in pregnancy.

If we are talking about increasing the quality of maternity services then we need to increase the numbers of midwives and legislate for fair pay and working conditions for them.

If we are talking about reducing the numbers of surgical or medical interventions in births (and therefore reducing the costs of births) then we need to be training midwives in more traditionally specialist deliveries, improving birth environments and de-medicalising birth. Not increasingly medicalising it by introducing GPs into antenatal services.

This is a truly strange idea.

#777 Kat Sumner

Have just read rhonda's comment about midwife prescribers. I definitely disagree with this for the reasons Manas Sikdar was writing about. If a woman needs iron prescribing (incidentally you can buy iron over the counter) or creams then they should see someone who has medical training since these are actually medical problems which should be assessed by a medical practitioner in case there are other health issues associated which need to be picked up and might be missed by someone who is not medically trained. Also I would not like to see midwives becoming medicalised. Midwives are for pregnancy, delivery and birth - not for medical problems and training them for treating medical problems would compound the problem of the medicalisation of birth

#778 Anthony
PCT

This report wastes ink and paper. GPs do not need any involvement in Maternity Services unless the healthcare professional involves direct the patient in that direction. GP training and interest is not in this area, as usual their main motivation is money and power. During our last pregnancy we had two interactions with the GP both ended in hospitalisation. Both times this was unnecessary as an expert (Midwife) would have known. Let the Midwives get on with the job and you can count your money!!!

#779 L Martin
Midwife
NHS

As an NHS hospital-based midwife working with both low and high-risk women I welcome the report, which I hope will lead to better team working and communication, and therefore to better standards of care.

I have noticed a shift away from GP involvement in maternity care, which leads to poor communication and in potentially poor care - the long-term health of woman and their children can be severely jeopardised by this.

Communication works both ways between hospital staff and GPs, and I can cite a number of examples where breakdowns in communication have undermined care standards; where high-risk women are being missed by the maternity services because GPs do not pass on relevant medical information; or when GPs are not effectively informed of maternity complications and the opportunity of good follow up care may be overlooked.

I am very concerned about the skills level of some GPs when it comes to maternity care – I have very recently been involved in the care of a woman who had all her antenatal care from her GP, who failed to recognize the risk of her increasing blood pressure and prolonged pregnancy, and who failed to refer her to the maternity services.

I find it interesting to note that one correspondent (Dr Paul Thomas) writes: “If nine years of vocational training no longer equips doctors to manage obstetric emergencies more adequately than any midwife … something is very wrong indeed.” I think that this statement highlights one of the key issues of interdisciplinary care – an idea that some members of the team are inferior or less well qualified than others.

Midwives are recognised by the NHS, the British Government, RCOG, FIGO and the WHO as experts in normal maternity care, and as such are highly trained in recognizing deviations from normal, referring appropriately and carrying out care in emergency situations. Our statutory duties include constantly updating our practice in accordance with the best and most recent research available.

Conversely, many SHOs who go on to become GPs rarely see truly ‘normal’ maternity care during their professional training, as the workload and intervention rates are so disconcertingly high in modern maternity services. This may result in a lack of confidence in the normal physiological processes of childbearing and an unwillingness in the future to provide GP-led maternity care.

In order for GPs to contribute effectively to maternity care I propose three main areas of improvement:
• Better communication at all levels and between care providers.
• Greater understanding and respect for the roles of different care providers.
• Increased training for SHOs in providing normal maternity care as well as high-risk care.

#780 Jan Phipps
Midiwfe

I can only talk about my area, but many GP's have become de-skilled inproviding routine ante natal care. This may be due to the way the training has changed, but when women are booking to see the midwife the day after seeing a GP because they did not feel confident in their findings it becomaes a wasted appointment, and women are choosing not to return to the GP.
We have also had situations where the GP has choosen to manage pregnancy complications which should have been referred to Obstetric care, so there is the question of all professions working within their limitations and a team approach.
In my practice I work from the GP surgery (we do not have a children's centre in my area- which encourages Ante natal care to be removed from GP's) where we meet up every 2 months to discuss any concerns regarding women who may be pregnant or thinking about becoming pregnant. We work together I provide the routine Ante natal care the GP, provides the holistic medical care, and the obstetric is involed when it is required. This works well, and the Gp's at the surgery do not feel the need to carry out pregnancy care, or 'look' for medical problems as we mentioned on the BBC yesterday- ante natal care is not just about looking for medical problems.
Kat Sumner above mentioned seeing a medical practitioner for creams - an example from recently was cream given my a medical practitioner for a rash, and itching. Only on returning to see a different person was any consideration given to the fact that this should be investigted further, midwives are more likely to be thinking about pregancy related issues rather than the general causes of itching and certainly would not have sent a woman in the 3rd trimester away with medication for eczema.

#781 SM

What an idealised view of general practice - GP's neither have the time or the inclination to provide the holistic care that womnen expect in relation to their preganancies, planned or real.
As stated by previous commentators they are generalists and women expect specialist care whether they are high or low risk. X

The proposal for shared care would result in decreased continuity for the low risk woman and I believe reduced staisfaction on a number of levels. Many women have had very limited contact with their GPs prior to their preganancy and with less and less small GP practices the chance of them having built up the kind of relationship described in this report is unlikely.

The key point in preventing the catastrohic outcomes mentioned in the report is communication & access to information, inadequate IT systems, poor commmunication and sadly perceptions of ownership result in these incidents.

thankfully I don't think this will happen as an earlier comment notes there's no financial incentive.

#782 Debbie Graham
Health Strategy Consultant
D.A.G. Consultancy Ltd

The title of this paper highlights a major flaw – i.e. the paper is centred on the role of the GP in the provision of maternity services rather than first placing the woman at the centre of her care and then exploring the ways in which her preferences and choices can/should be met throughout the continuum of her pregnancy and the GP's role in contributing to this.

As a practising midwife of many years experience, the last 6 of which have been dedicated to the modernisation of maternity services I have had the opportunity to work with many service users’, providers and commissioners of maternity services across England. These experiences have afforded me the following insights:

Pre-conceptual care: not all women access GP services and indeed a percentage of those who do are cared for in large practices rather than experiencing services based on the concept of a ‘family GP’. Saving Mothers Lives 2003 -05 states that ‘Black African women including asylum seekers and newly arrived refugees have a mortality rate nearly six times higher than White women’. For some women pregnancy will bring them into contact with the health care profession for the first time.

Access: Although the concept of direct access to a midwife has been around for some years now it has not been widely promoted nationally nor have the systems and processes required to successfully set-up the service been commissioned in all health economies. Indeed, many women are still unaware that this service exists. Many GP’s still remain the gatekeepers to maternity services often referring women for care on historical referral grounds rather than offering a genuine choice.

It is the responsibility of commissioners of maternity care to ensure that the available access routes to maternity services and the providers of those services meets the needs and choices of their local population. It is also their responsibility to ensure that, regardless of the profession of the health professional providing the woman’s first contact, that the contact content standards outlined in the NICE antenatal guideline 2008 are met. Many women have described their first contact with their GP when pregnant as a “form filling exercise” with information being taken from them but none of their questions answered until they met with their midwife.

The key to ensuring safe, high quality care regardless of how the woman chooses to accesses maternity services is clearly set out in Saving Mothers Lives 2003-05 namely well established, robust communication and referral pathways between G.P’s and provider trusts. In fact many providers of maternity services now have a standard antenatal referral form, however the quality of the information provided remains variable.

Antenatal care: Now more than ever, during this time of austerity for health care provision, it is imperative that service users’, commissioners and providers of maternity care have a clear understanding of the concept of ‘shared care’ between GP’s and midwives. Women, who chose to have shared care, need to understand their schedule of antenatal care and who their lead professional is if duplication of effort between midwives and GP’s is to be avoided. It is also important that a clear definition for the concept of ‘shared care’ is agreed as some GP’s offering ‘shared care’ services will provide the contact themselves whilst others interpret the service as providing a room in their surgery (not always a suitable one) for a midwife from the local provider trust to provide the contact. This latter model provides a major challenge for providers of midwifery services as economies of scale and environmental standards are not always assured. In fact I have firsthand experience of this when I recently shadowed a community midwife to review the services shared care offer. The midwife provided the antenatal clinic from a converted cupboard with no window, IT or telephone point, and where the receptionist entered at regular intervals to collect stationery during consultations! This is not to say that there are not many examples of excellent facilities available, however there is no set environmental standard by which facilities can be benchmarked. Many women have also reported difficulty in not being able to book appointments with their GP more than 48 hours in advance, getting through to their surgery via the telephone and opening times being inconvenient. Some have also reported seeing a different GP at each visit.

The underpinning principle for safe, high quality and cost effective antenatal care is that regardless of which health professional the woman chooses to deliver her care she can be assured that both the professional and the environment in which her care is delivered is fit for purpose, and that the care she receives is both compliant with NICE antenatal guidance 2008 and is underpinned by clear, robust communication and referral pathways between GP’s, midwives and obstetrician’s thus ensuring the care and support she requires is safe, timely and appropriate.

Postnatal care: I found it astonishing that the GP’s role in the care of the newborn has not been explored in this paper. With the national drive to increase the number of home births along with earlier transfer of postnatal women to community care the demand to perform newborn physical examinations in the community setting will increase and the GP’s role as the family practitioner in providing this service should be clarified.

Debbie Graham

#783 Susan Baines
Midwifery Lecturer and S.O.M.
University of Salford

I believe that GP's should be actively involved with the care of mothers and their babies. My view is based upon the following -
1. The current increase in primary based maternity care provision necessitates the GP responding directly to midwifery concerns raised within the community and so needs to "know" what is actually going on with regard to the mother's pregnancy.
2. Pregnancy is a transient rather than a perminant state and as such, the woman's GP needs to be familiar with and understand her experiences in order to provide appropriate care long after the midwife has discharged her.
3. By restricting GP involvement, the professional rapport which in many cases has taken considerable time to establish could be damaged and as many areas within the UK cannot commit to "continuity of midwife carer" due to staff shortages etc. the woman's GP is in a position to provide this much needed stability.
4. GP's need to be re-skilled regarding birth and its sequale and as such "working with midwives" ie. attending home births and parent education groups, perhaps rotating into hospital birth units and shadowing obstetricians when possible will help them manage women who have had traumatic or poor outcomes much more effectively. Practices need to identify a named GP to specialise in Maternity care and liaise with the midwifery team.
Finally, birth should not be viewed as an isolated life event, it is a continuum of normal physiology and GP's and Midwives working together in a joined up way will enhance care ultimately.

#784 Gill
Midwife

A paper proposing significant changes to the way community midwifery services are provided yet devoid of the voice of mothers; whose agenda are we meeting here? How can you possibly expect women to engage in a trusting relationship with a GP during pregnancy on the premise that "GP's no longer provide intrapartum care as it is considered too risky as they are not sufficiently skilled, they do not wish to encroach on their time off and do not feel they are paid enough to take on the responsibility" Labour and birth cannot be conveniently segregated from the pregnant woman; her primary focus during pregnancy will be birth and therefore I question the value of adding another professional providing routine antenatal care.

Although I now lead services I have considerable experience in community midwifery care and would like to address a number of issues raised in this paper.

There is an implication that although both Changing Childbirth and Maternity Matters proposed that women should self-refer to a midwife, many women still continue to access care via the GP, inferring that this is a preference. No additional resources were made available to fund the necessary public information campaign hence the failure in this initiative. Poor compliance with Maternity Matters in terms of choice of where to give birth is a further example of idealist strategy without the necessary available resources to deliver.

When I started my career as a Community Midwife in 1999, five years before the new GP contract only a very small minority of GP's were delivering any antenatal care despite recieveing £100 for each pregnant woman. I was not afforded any designated facilities to provide my services within GP surgeries, further I had to provide all my own equipment including Uristix, so that "substantial percentage of their income" was spent on what, exactly?

The paper does not reflect current practise; women are routinely screened by community midwives in early pregnancy for haeamoglobinopathies prior to the first booking appointment, therefore the critical time period is not missed.

GP's can play an important role in antenatal care, by ensuring that all relevant information about a woman's medical history is shared. We know that women will withold information from a midwife at booking, that is why we inform GP's of every new pregnancy and ask for relevant history. In my experience however, some practices have refused to provide information on the basis that if midwives are now based in Children's Centre's they will no longer engage in communication! Further I have attended a significant number of Child Protection Case Conferences over the years and on no single occassion was an invited GP present.

The paper frequently visits the idea that pregnant women will receive improved continuity of care by a GP offering antenatal care. Women often comment at booking that although they have a designated GP, they never see her/ him and see a different GP every time they visit the surgery.

There is I agree a strong argument for women with ongoing medical conditions to continue to receive care from the GP, in my experience this is and always has been the case.

The debate in my view, misses the point. The discussion should not be around the role of the GP but should instead focus on the role of normal pregnancy within a wider healthcare context. We've all heard the rhetoric, "All pregnant women need a midwife, only a few need a doctor" Like it or not, whilst health professionals understand the scope of the GP in terms of promoting health, the general population's perspective is that the doctor is someone to access when you are sick. Pregnancy is not an illness, it is a normal physiological life event and midwives are highly skilled in caring for women enjoying a healthy pregnancy and birth. Throughout the continuum of pregnancy a midwife will refer appropriately to a GP or an Obstetrian should the woman's experience deviate from normality. There is a national campaign to promote normality in pregnancy and birth; diverting well, low risk women towards medical practitioners is at odds with that philosophy and a retrograde step.

#785 Angela
Midwife

I totally agree with the staement made by Gill ...."whilst health professionals understand the scope of the GP in terms of promoting health, the general population's perspective is that the doctor is someone to access when you are sick. Pregnancy is not an illness, it is a normal physiological life event and midwives are highly skilled in caring for women enjoying a healthy pregnancy and birth. Throughout the continuum of pregnancy a midwife will refer appropriately to a GP or an Obstetrian should the woman's experience deviate from normality. There is a national campaign to promote normality in pregnancy and birth; diverting well, low risk women towards medical practitioners is at odds with that philosophy and a retrograde step."

A midwife is an expert in normal maternity care and is highly trained in recognising any deviations from the norm, referring and carrying out care in emergency situations.

Pregnancy is not an illness. It is a nornal physiological process and the majority of women who are healthy and low risk do not require medical involvement from a GP or obsetrician.

At the present time GP's training and interests are not in this area and therfore GP knowledge on maternity issues has fallen behind current evidence. This would therefore require a considerable amount of retraining to enable GP's to deal with antenatal, intrapartum and post natal care as a midwife can.

I agree with the statemant made by L.Martin, that the comment made by a GP infers that some members of the team "midwives" are inferior and less qualified than others. This is a sad opinion as we all have different but vital skills to offer women, but I was unfortunately not surprised to see it.

#786 Dr Paul Thomas
GP Principal
Gippping Valley Practice

While I agree with Gill and Angela and others that we should not re-medicalise pregnancy I do not entirely agree with the concept that pregnancy is not an illness. While pregnancy is indeed a normal physiological process it is a process that is not entirely free of medical problems. Surely, the whole purpose of antenatal care is the early detection and correction of those medical problems by a suitable qualified doctor? In the case of intrapartum care, I therefore believe the preferred place of delivery for a low risk pregnancy is on a quiet midwifery unit of a hospital where there is rapid access to specialist medical help should things go wrong, as they most certainly do, even in so-called low risk pregnancies.

Angela also states, “At the present time GP's training and interests are not in this area and therefore GP knowledge on maternity issues has fallen behind current evidence. This would therefore require a considerable amount of retraining to enable GP's to deal with antenatal, intrapartum and post natal care as a midwife can.” Sadly, while I have seen no non-anecdotal evidence to support this staement, I couldn’t agree more, at least with regard to intrapartum care and speaks volumes. Much has changed in the fourteen years since I wrote my letter to the BMJ and I do not see any motivation to turn the clock back. I have been a GP since 1990 but have not provided any intrapatrum care for the last six years although I try of offer antenatal and postnatal care . In the case of antenatal care, despite negotiations as long ago as 2004, when an agreed schedule for shared antenatal care was determined, few patients are offered any real choice since my patients are given a schedule appointments for the attached midwife who attends weekly. Nevertheless, when that midwife is on leave I am expected to act as her deputy. I must emphasise that I do have a good working relationship with that midiwife.

I find it interesting that those woman who do attend appointments with me for shared antenatal care tend to be multips and those patients with whom I have already developed a close professional relationship, and know more about what I can and cannot offer and what pregnancy involves, than for a woman in her first pregnancy.

I understand that my trust’s community midwives do not provide intrapartum care since this is provided by duty midwives on the labour ward. My patients are seldom, if ever, delivered by the midwife she has come to know. Is it therefore an appropriate use of the expensive resource of a qualified midwife to provide antenatal and postnatal care alone since a suitably qualified and experienced GP can offer and equally safe and efficient service within normal surgery at times that may be more agreeable to the patient?

#787 Dr Paul Thomas
GP principal
Gippping Valley Practice

L Martin (a midwife) writes “I find it interesting to note that one correspondent (Dr Paul Thomas) writes: “If nine years of vocational training no longer equips doctors to manage obstetric emergencies more adequately than any midwife … something is very wrong indeed.” I think that this statement highlights one of the key issues of interdisciplinary care – an idea that some members of the team are inferior or less well qualified than others.

Midwife Martin has taken this old item of correspondence out of context. I will restate that this letter to the British Medical Journal was written fourteen years ago at a time when most GP registrars could undertake at least six months training on an obstetric unit as an SHO where we were taught to manage obstetric emergencies and could enter the GP obstetrics list in recognition of that additional expertise. This was an expertise held by no midwife. I was not and I am not suggesting that midwives were or are inferior or any less qualified than doctors but we have different roles. However,I would suggest that an appropriately qualified and experienced GP still has a role to play in the provision of maternity services for his or her patients if such a doctor were actually accepted as an integral part of a multidisciplinary team. I think that is the crux of the current problem. If nothing more, that doctor would considerable reduce the ever increasing number of the obligatory and very costly referrals by midwives to an obstetrician for even the simplest of problems.

I fear this is very unlikely to happen.

#788 Greta Beresford
Midwife Teacher
Independent Practice

I welcome this report, and the recommendations that GPs, who wish to do so, should be actively involved in the care of women during pregnancy and in the postpartum period. GPs are concerned with the health of the woman and her family before pregnancy and long after the midwife has withdrawn her services and most will have established a trusting relationship with them. Continuity of antenatal care is important for women, and in areas where there is a shortage of midwives and care from a known midwife cannot be guaranteed, GPs will be able to modify the concerns of women who value seeing a trusted health care professional when they need to do so. It must also be acknowledged that some women praefer to see the GP fo much of their antenatal care.
GPs have exclusive knowledge of the woman's family and social circumstances, which may have an impact on the pregnancy, during which they are expected to provide medical care for illnesses and long term conditions, as well as advice on social problems. To exclude them during a critical period in the life of the woman may deprive her of essential help and support. Although it is recommended that the contribution from the GP should be confined to antenatal and postnatal care, attendance during labour and birth should not be excluded, if the woman and the GP want this, especially if the midwife is not previously known to the mother, which happens more often than is acknowledged.
Because of the length of time that many GPs have not been involved in maternithy care, they will need to update specific knowledge and skills required to provide safe care. Workshops and seminars for GPs, midwives, obstetricians and neonatologists aimed at increasing knowledge and awareness of the contribution that different disciplines can provide, will improve the level of care for women and the newborn, and attendance should be mandatory for all those concerned with pregnanct women and their babies. Information sharing syhstems and referral pathways can be drawn up and updated regularly during workshops and seminars. Closer communication between GPs, midwives and obstetricians will reduce the incidence of complicaitons, currently unrecognised.
A model of care, which will include the GPs conribution, will depend on local circumstances and should be drawn up by all those concerned with the provision of antenatal and postnatal care. Information sharing between professionals is crucial.

Greta Beresford
Midwife Teacher

#789 Cathryn
Independent Prescribing Midwife

As other respondents have stated above, I take issue with the fragmentation that will occur if GPs become involved in routine care for low risk women. Locally, women are allocated to a "team" of 2 Midwives. This ensures continuity together with such practical measures that they are provided with that include access to us on our work mobiles at any time. If we are attending another women they have the option of discussing their concern with a midwife 24/7 at our birth centre or obstetric unit. Would GP's be prepared to offer this service in a time when you can not see your own GP let alone one from your practice out of hours locally?

In terms of practice issues, I have also experienced GP's failing to recognise the significance of proteinuria and raised BP, together with passing off itching as pregnancy related rather than initiating investigations to rule out obstetric cholestasis. This would suggest that GP's would have a significant learning curve to get up to speed with current research/practice.

However, the research offers some important suggestions that GP's have an important role in pre-conceptual matters such a obesity management and advice to women in respect of hyper-emesis and bleeding in early pregnancy. Introduction of a service that addresses these issues would be most welcome, In our locality we already see and book the women before 10 weeks including routine blood taking, risk assessments and checking for haemoglobinopathies.

With respect to cmace comments, I have certainly experienced a one way flow of information from myself and our maternity services to the GP. Very rarely (3 times) in 4 years of community practice have I received feedback from GP's on very relevant issues such as ongoing domestic violence issues/ changes in medication or initiation of new medication. This is despite the fact that GP's receive a printed summary of the booking history taken by the Midwife requesting the GP to update us with any relevant medical or contradicting history that they are aware of. This lack of multi-disciplinary co-operation has serious implications for me as in Independant Prescribing Midwife, (I always inform the relevant GP in writing when I prescribe a new medication)

In conclusion, I would suggest the notion of GP's providing routine care for low risk women is an attempt to mend a model of care that isn't broken and that women appreciate currently. In this age of patient choice should we not ascertain from women what they would like, rather than what meets GP's professional development requirements.

#790 Paul Thomas
GP Principal
Gippping Valley Practice

Catherine states, “In conclusion, I would suggest the notion of GP's providing routine care for low risk women is an attempt to mend a model of care that isn't broken and that women appreciate currently. In this age of patient choice should we not ascertain from women what they would like, rather than what meets GP's professional development requirements.”

In an ideal world I am sure most women would like to have an entirely normal pregnancy and an uncomplicated pain-free delivery performed by a midwife she knows, likes and trusts but this is seldom possible, if ever. In practice even in an entirely normal pregnancy the woman has little choice other than to accept care from a duty midwife. Perhaps, given the choice, woman might even like to have their maternity services provided by their own GP?

I am not at all surprised that most of the comments posted here are from trust midwives and none are from other GPs since so many obstacles have been put in our way that few currently even attempt to offer any form of maternity services and have no wish to do so. The anecdotal derogatory comments posted by a few contributors illustrate only one aspect of this.

Catherine further states, “If we are attending another women they have the option of discussing their concern with a midwife 24/7 at our birth centre or obstetric unit. Would GP's be prepared to offer this service in a time when you can not see your own GP let alone one from your practice out of hours locally?” Well, I for one still am, as I believe this is fundamental to the practice of medicine and the vitally important doctor-patient relationship, which has been all but destroyed by the 2004 GP contract. This is not to say that I can do much more than offer appropriate advice out of hours, but considering that my patient knows me and I know them, advice is usually all that is required.

I am sorry that I have allowed myself to rise to these comments but I feel that we have lost our way and the model of care is broken, which the report appears to confirm. However, while Greta Beresford and others have shown that it is possible for individuals to rise above issues of ownership and professional protectionism I fear our corporate NHS is dominated by trust’s blinkered self-interest so little will change.

#791 Hillary

With all respect to midwives. I am more confident with the more 'open-minded' and less 'defensive' professional approach of views posted here, by Dr Paul Thomas - GP principal, Gipping Valley Practice.

Midwives are PART of a multi-disciplinary team for any GP's female patient undergoing pregnancy and hopefully full-term delivery of a healthy infant?

A woman's GP should always remain in the 'loop', of his or her, patient during pregnancy and after delivery. Is that not logical? The involvement of the GP of their patient throughout pregnancy and after delivery is not a 'medical model' imposed by the GP on midwives, but simply part of the 'continuity of care ' by a medical professional who knows their patient before pregnancy and long after?

#792 Hillary

Post script. It would be helpful if The Midwifery Council reviewed their own training practices?

Midwifery is increasingly practicing less 'holistically', and, marginally, in isolation? What I mean by that is: some, not all, midwifery teams are just that - midwifery teams who can 'do it all'? A woman is pregnant - increasingly, that's all they see?

Most certainly expect some vociferous comments on that? Ah well ..?

#793 Elizabeth El-Abed
RN & Antenatal Student
NHS & NCT

I do believe that there would be some merit in GP's being involved, somehow in the care of pregnant women. However, in the current climate of cut backs and service change,they are already streched. And as others have mentioned would need additional training to be updated in maternity issues. SO where would that care fit in?

Pregnancy is not a state of illness - so why see a Dr? But for those that have complex medical and social needs the shared care option would optimise their care and hopefully the outcomes. Would a one stop shop be useful- perhaps at booking? At this time the midwife and GP could exchange notes and devise a plan of care collaberatively. An expensive option I know. But wouldn't this demonstrate team work and cohesiveness and respect for one anothers expertise? A time for learning and reflection.

Midwifery training fully equips the midwife to recognise when things stray from the norm and have routes to refer when appropriate.

However, I struggle with the thought of adding another professional into the care pathway of a pregnant woman.. it should be one woman, one midwife. And the evidence strongly supports this notion with better outcomes for baby and mum.

The other side of this discussion is unscheduled care. Having been involved in this for the last 15 years, in various Emergency Departments and latterly for an Ambulance Service, which also runs the GP Out Of Hours. This is a massive area which severly lets pregnant women down. There should and must be better access to midwifery/obstetric care Out OF Hours. When a women is facing a miscarriage do they really need to spend 4 hrs plus in ED and still not get access to Early Pregnancy Assessment Clinic? But that I know digresses slightly from the topic.

So essentially I'm suggesting investing more in Midwifery services across the board. More midwives - one to one care. More specialist clinics. And the ever supportive GP on the sidelines for when they are needed.

#794 Elizabeth El-Abed
NHS & NCT

PS. Sorry, not sure what happened to that.. I certainly didn't type it as one paragraph!!.

#795 Paul Thomas
Family Doctor
Gipping Valley Practice

I had intended to post no more comments but I have to agree with Elizabeth El-Abed in her very valid criticism of the so-called GP out-of-hours service the quality of which, most agree, is appalling. This is not a family doctor service by any stretch of the imagination (Nor is NHS direct). These are services provided by jobbing "locums" or nurses with no knowledge of the patient even if patient records are available. For example, three doctors are employed to cover the whole of Suffolk, where I practice.

In fact, GPs can also refer their patients directly to an obstetric unit for early assessment, either immediately or for the following day, thus by-passing the hospital's emergency department but patients have come to learn that the out-of-hours service does not offer maternity care so vote with their feet by attending A&E.

To all Student midwife contributors could I ask you to think about what doctors, midwives and nurses should strive to achieve in their professional lives? Surely, it is the best outcome for the pregnant woman and her baby? As I have tried to explain, it was not so long ago that it was accepted that family doctors had much to offer their registered patients during the transitory period of their patients' lives known as pregnancy. Is there any evidence to support the apparently widely held belief that doctors cannot be taught to provide the (antenatal and postnatal) services currently provided by midwives? If nothing else this gives the mother the opportunity to develop a lasting relationship with the doctor who will be caring for her as-yet unborn child.

As far as availability is concerned, I am sure, like me, most GPs would prefer to be seeing and treating "people who are ill or believe themselves to be ill" as was formerly required, rather than dealing with the mountains of useless paperwork currently imposed upon us.

In the case of maternity care I consider we see people at increased risk of illness although most are not ill and save lives by seeing people who are ill but do not know they are ill.

#796 Hillary

The 'costs and/or cost-effective' care or 'cut-backs' should never be directed at pregnancy, maternity services, GP involvement of their patient during pregnancy, or midwifery.

The integrated and shared care of pregnant women involves two lives - all professionals and political dogma should never, ever forget that?

#797 Eva Longley
Junior Midwife

I have been following the recent reaction to the Kings fund report with great interest as a young midwife, a daughter of a G.P and a 10/40 pregnant woman. I can only welcome such a report as it will hopefully bring back a seamless rapport between two very different but equally important professions. Working as I do in an antenatal clinic I have no issues with sharing my care with a G.P. Any medical issues I know I cannot deal with I feel happy to pass on to a medical professional i.e the G.P. Likewise I am happy to provide the expertise of our profession such as detailed palpations, making realistic birth plans and being a listening ear to every woman who comes through our doors.
So many midwives are eager to remind the world the are the experts in normal pregnancy whilst trying to solve complex medical issues that are beyond their training. I became a midwife as a truely wanted to care for women and deliver their babies, not to be a mini G.P.

#798 Sheila Kennedy

I have been a midwife for 40 years and well remember the time when GPs were the gatekeepers of maternity services, and were fully 'involved'. However, the majority had no up-to-date training and merely referred women to midwives or obstetricians whilst being paid for work they didn't do! This led to duplication, twice as many visits for women, and twice the cost to the NHS. We lost a local midwives unit due to lack of interest or commitment by GPs who were supposed to be our first line of support if a problem arose in those days. Currently midwives spend a lot of time 'mopping up' after GPs who, because of lack of training in midwifery, give innappropriate advice and information. Please don't let's go back to that. It will add nothing to the care of women and much to the cost of maternity care.

#799 Michelle
Midwife

To expect "ALL" GP's to have up-to-date understanding of current maternity issues, is unrealistic. It will never happen, there is already dysfunction between woman-centred care and target driven medicalized childbirth. The less conflicting views a pregnant woman is exposed to the better,
However, A GP, and the woman should have access to in-depth written information about a woman's personal obstetric history, so that he/she can access it and pass information over if needed. Communication between maternity staff is often poor, and midwives, management and and obstetric doctors often have different agendas, each working separately, and this is something that needs working on first, once we get that right, then we can try and communicate better with the GP's and PCT's!!!

#800 Michelle Salem
Midwife

oh and furthermore.
The reality of our world today is that the only way you may be able to entice the majority of already busy general practitioners to further study and involvement is by offering a financial incentive!
there may be the odd GP who is keen as mustard and regularly reads the RCOG guidelines and latest maternity issues for no extra pay, however, they are going to be in the minority.
I believe there is no money, why run the risk of further mucking up an already messy emotive area, where litigation costs far exceed any other speciality. The less people a woman has involved in her care the better!

#802 Georgina

It is interesting that this paper was put together with no input from midwives or indeed women.

As a midwife with 20 years experience I do feel that women need a degree of protection from some maverick GP's, who assume that a spell working in a maternity unit during their GP training, which in some cases is many years ago, prepares them to provide safe maternity care. I have had the misfortune of working with such GP's and of dealing with the aftermath of their substandard care.

It is also my experience that women who do try to access their GP whilst pregnant are invariably seen by the Nurse Practitioner who is either not a midwife or is not eligible to practice as a midwife.

Women who are healthy and pregnant should be looked after by the "expert" in normal pregnancy - that is the midwife. If they have a medical problem which is likely to impact or be exacerbated by their pregnancy then they should be looked after by the obstetrician. The issue of GP involvement in any specialist care area is difficult, as they are not the expert in any particular field and as such should always refer patients on to the specialist - be it a midwife or an obstetrician. I would also agree with several other comments that unless a substantial financial incentive is offered to GP's they are unlikely to want any involvement in maternity care. In my area they were quick to give up the newborn baby examination when the fee was withdrawn for that service. Luckily we had excellent midwives who were trained to do the newborn examination.

#804 Nick Preston

When oh When oh When... will people stop talking territorially - the NHS is about the PATIENT - not the GP or the Midwife... There are plenty of maverick midwives (See Daily Telegraph today - p12 re: Julia Duthie - baby died after midwife ignored advice), as there are GPs, Lawyers and everyone else... We need to start connecting up healthcare for patients, stop thinking of separate "pots" of money, and start thinking what is cheaper and has a greater health benefit for the NHS and the patient. We are all specialists in our own right - be it midwives, GPs etc we ALL need to be involved and to suggest otherwise is - in my opinion fundamentally flawed.

COI: NHS Anaesthetist, Father and Patient!

#805 Astrid Cullen
Consultant Midwife
NHS [UCLH]

I agree with the senitments of many of the respondents, particularly Nick who points out how important it is to reduce territorial warfare and concentrate on the people for whom we are providing the service. Incidentally Nick, most mw's will call pregnant women, just that rather than patients. I guess this points out the way in which mw's see their role. As the partner in care for women, who should have made a realistic choice about where she will access her maternity care. Maternity Matters [2007] may have been under resourced but there are good examples of very equitable services where women can choose and duplication should not exist.
I have been a midwife for 35yrs and my daughter is a GP, I see all sides of this issue.
My message is: It has taken many years to see mw's holding a possition that is not subservient to Doctors. We must continue to promote realistic and fair choice for women [at the centre of care] while considering the whole health ecconomy. We must work as a team, some GPs will want to be and are equiped to be part of that team,
others will not.
Never forget that the majority of women will not need to see a Doctor for pregnancy care, but may need a Doctor during pregnancy for a host of other things. It down to all of us to communicate effectively across the healthcare spectrum.
To answer the question about GPs leading maternity care for all women - in my view this is not an equitable or ecconomical option and would turn the clock back to the 1970s. Care was not as good then as now, we have all moved on, let's not go back!

#806 Rajat Srivastava
GP

If it ain't broke, don't fix it...

#809 Martin McCrone
Clinical Lead
South Aberdeenshire CHP

An interesting and timely document especially as we see the draft publication of A REFRESHED FRAMEWORK FOR MATERNITY SERVICES IN SCOTLAND. It is my experience that effective Primary Care teams produce the most comprehensive and effective care for communities. Midwifery as an intergral part of these teams makes eminient sense. Primary care teams esp General Practitioners follow people through their life. Clearly midwifes have an important specialist role within an child bearing episode. Continuity of care however is crucial, especially where there are complications either prior to conception (infertility, health co-mrbidity etc), or complication for mother or baby resulting from the pregnancy (birth defect, birth trauma etc).
No one person or professional can singularly provide the most effective care in pregnancy. We need systems that recognise the worth of all professionals working to the best interest of the populations we serve. Integration and common aims appears the logical way ahead.I note the comments raised that midwifes need to be in charge and not subservient to doctors. Surely it is not acceptable to artificially design a service to protect midwifes or for that, any professional group.

#810 Mercedes
Midwife
ELHT

I agree that continuity of care is essential, especially for women with pre-existing conditions and GPs are the best placed profesional to offer that continuity. However, to offer that continuity doesn't necessarily mean that they have to physically see these women and offer direct care. A good three partite communication between obstetrician-midwife-GP should be all is needed: the GP can pass on the medical and family history to the main professionals caring to the woman during the pregnancy (obstetrician and / or midiwfe) and these in return keep the GP informed of any events occurring during the pregnancy. In the context of their current practice and experience they have in looking after pregnant women, it seems unlikely that their input in direct care to pregnant women would offer any benefits other than the familiarity of the practitioner.

#811 Jean Richards
Public Health Physician

My involvement with planning of obstetric services and coordinating a regional perinatal mortality unit, makes me very concerned with the gradual exclusion of GPs from antenatal care. I find that midwives do not seem to value the historic knowledge of the patient and her family which is often crucial in ensuring a healthy outcome of the pregnancy.
This is particularly important where the GP has knowledge of domestic violence, mild mental health or problems involving other members of the family. Of course the role of the GP in intrapartum care has evolved over the years and should be appropriate to the geographical and other circumstances, but the Patient will still consult the GP for medical problems throughout pregnancy and full cooperation between midwife and GP is crucial for optimal care of the mother.

#813 Jayne Cozens
Community Midwife
NHS Trust

I have read all comments with much interest. I have been a midwife for almost 19 years and have worked with many GP's during that time. Although I consider myself an expert in caring for women during pregnancy etc I am not an expert in medical problems, although I have alot of knowledge I am not a doctor. I work very closely with GP's and we have a very professional relationship with respect for each others knowledge. I have access to the medical records when giving care to women from the outset and can see for myself whether there are medical complications. I always refer my women to the GP for review early in the pregnancy (if there are medical probs) and would then refer to an obstetrician. All is recorded in the the hand held notes and on the GP records so the GP is always in the loop. If I have any worries about a woman, I will discuss with the GP, the management, so he knows and I do not have a problem with it! I do it out of professional curtious, we are both caring for the woman, however, I am caring for the pregnancy etc. I am a midwife prescriber now and most of my women do not see a GP during the pregnancy, however, should they need to see one, all is there for the GP to see. I think that health professionals need to work together for the health of the woman, I would welcome Gp's to be involved with women with medical complications, but in my experience, most GP's would rather the obstetrician care for the woman, with the midwife sharing the care, even though they are excellent GP's, they do not have the time or would require some extensive updating and with so much they are now expected to do in the surgeries, I do not think they would have the time. I do think that midwives should keep GP's informed what is going on, afterall, they are going to be caring for the woman after the midwife has finished visiting. Midwives are experts in midwifery, but will always require medical services in certain situations (midwives rules) and its very important that the medical person is up to date, as well as the midwives giving care, like I said, we all need to work together for the good of the woman and her baby/family.

#818 Sally Theodoreson

'As a Breastfeeding Strategy Steering Group we were disappointed to note that there is no mention of the GP's role in relation to breastfeeding information, education, promotion or support in this document. This is particularly disappointing considering the following:
* There is evidence to demonstrate the important role of the health professional in informing, educating, promoting and supporting women to initiate and continue breastfeeding (Dyson et al, 2006)
* Research indicates that breastfeeding can significantly contribute to an infant’s short and long term health and development and is also associated with better health outcomes for the mother. A lack of breastfeeding is associated with an increased risk of a range of disorders and illnesses in childhood and through adult life (Ip et al., 2007; Horta et al., 2007; León-Cava et al., 2002)
* In particular, breastfeeding has been shown to provide a protective effect against obesity in children and early bottle-feeding increases childhood obesity which is predictive of obesity in later life (Arenz, 2004; Bergmann et al., 2003; von Kries et al., 1999).
* The Department of Health fully supports the UNICEF Baby Friendly Initiative and, alongside the World Health Organisation (WHO), recommends that all babies are exclusively breastfed for the first six months with breastfeeding continuing into the second year.
* Breastfeeding is central to the Department of Health's Healthy Child Programme and is recognised as 'a priority for improving children's health' and playing 'an important role in reducing health inequalities'.

As breastfeeding promotion and support is fundamental to best practice in both antenatal and postnatal care, surely it should be an integral part of a GP's role in maternity care?

Refs:
Arenz, S., Ruckerl, R., Koletzko, B. & von Kries, R. (2004). Breast-feeding and childhood obestity – a systematic review. International Journal of Obesity 2004 Oct;28(10), pp.1247-56.
Bergmann K.E., Bergmann, R.L., von Kries, R., Bohm, O., Richter, R., Dudenhausen, J.W., Wahn, U. (2003). Early determinants of childhood overweight and adiposity in a birth cohort study: Role of breastfeeding. International Journal of Obesity 2003,27, pp.162-172
Dyson, L., Renfrew, M., McFadden, A., McCormick, F., Herbert, G. & Thomas J. (2006). Promotion of breastfeeding initiation and duration. HDA/NICE.
Horta BL, Bahl R, Martines J, Victora C. (2007). Evidence on the long-term effects of breastfeeding: systematic reviews and meta-analyses. Geneva: World Health Organization.
Ip S, Chung M, Raman G, Chew P, Magula N, DeVine D, et al. (2007). Breastfeeding and maternal and infant health outcomes in developed countries. Evidence Report/Technology Assessment No. 153. Rockville, MD: Agency for Healthcare Research and Quality.
Von Kries, R., Koletzko, B., Sauerwald, T., von Mutius, E., Barnert, D., Grunert, V. & von Voss, H. (1999). Breast feeding and obesity: cross sectional study. BMJ. 1999 July 17; 319(7203): 147–150
León-Cava N, Lutter C, Ross J, Martin L. (2002). Quantifying the benefits of breastfeeding: a summary of the evidence. Washington DC: Pan American Health Organization

S.Theodoreson, Chair - local Breastfeeding Strategy Steering Group

#828 Gordon
GP

Pregnant women have disparate needs not always pregnancy related; midwives and obstetricians have a very specific remit and training, with midwives having no general nursing training. Initially midwives waved the banner of choice in maternity care and we are now seeing in Scotland the midwifery dogma that says women MUST book with the midwife regardless of preference, not the GP; This reveals the extent of power basing that goes on within ALL professional groups, not necessarily to the benefit of patients. The pendulum has swung too far and we need to work together for the good of patients and address the imbalance. GPs should be involved in the health needs of all their registered patients where appropriate, pregnant or not. My not inconsiderable experience of hospital midwives was a lack of understanding of the psychological, emotional and social needs of the women they cared for and as a GP felt that I could complement that. Community midwives are more understanding of these wider social and family issues and the best of them engage with the primary care team, which is to the advantage of the most vulnerable and deprived, who need the most help.

Many of the midwifery responses show that most dangerous of conditions, an unawareness of their own limitations. Thankfully this is a treatable state in the main and we should be working together to develop care pathways that suit our local settings, just as this excellent report suggests. The idea that GPs cannot contribute is nearly as ridiculous as saying that midwives can manage without medical support.

#831 Jayne
midwife

Gordon, although I agree with much of your comments, not all midwives are direct entry. I myself am an RGN as well as a registered Midwife and have worked in many areas of nursing as have many other of my colleagues. I also continue to learn and develop, which in the culture that we live and work is expected. At the grand age of 49, I am doing my degree as time allows now. I think it is crucial for all healthcare givers to continue with updating and learning, and so outdated midwives and Gp's is no excuse or defence when it comes to providing care for women/babies and families. Everyone, who may be involved with pregnant women needs to be in the loop, both midwives and Gp's should stop being territorial and I agree that women have other issues that Gp's have to deal with, it just so happens that they are pregnant as well and vice versa. As I said earlier, I have good relations with all the Gp's I work with, its all about being polite, mutual respect and ultimately providing good safe care for the women/babies and families in ALL aspects of health, surely?

#900 Grace
Midwife

I have been a Midwife for many years and cannot understand why the goverment continue to pay GP's for every Antenatal women they see. For years I have begged the question, Where does this money go ?.
Gp's are not specialists in pregnancy care and hospital services provide excellent Day Assessment Units where women can be seen 24 hours a day. In my experinice women are often sent in by GP's for the slightest Antenatal problem. This to me wastes time and money, why pay a GP when the hospital deals with the problem.
Midwife's have the skill, knowledge and authority to refer women directly into hospital themselves and can refer patients to see Consultants/Antenatal clinics. Midwife's are independent practioners in their own right. Why do GP's persist in seeing women Antenatally, is it just for the Money ? Why not pay a Midwife for a every Antenaal woman they see, I am sure Women Services could do with the extra money.
I am sure money can be saved or better utiltised for Women's Health care if we just stop paying GP's for their involvement in Antental Care.