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.
Related document: The role of GPs in maternity care - what does the future hold?
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?
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)
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.
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 .
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.
*Thomas P D. British Medical Journal 1996; 313: 305. (3rd August), P D Thomas, British Medical Journal 1996; 313: 1148 (2 November)
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.
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.
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.
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.
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.
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.
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.
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.
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?
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.
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.
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.
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.
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?
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 ..?
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.
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.
The integrated and shared care of pregnant women involves two lives - all professionals and political dogma should never, ever forget that?
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.
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!!!
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!
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.
COI: NHS Anaesthetist, Father and Patient!
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!
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.
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.
* 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?
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
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.
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.