Maternity care in general practice

This content relates to the following topics:

Part of Inquiry into the quality of general practice in England

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?

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

Related content

Comments

Dr Paul Thomas

Position
Principal,
Organisation
Gipping Valley Practice
Comment date
04 August 2010
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)

Manas Sikdar

Position
GP,
Comment date
05 August 2010
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

AC

Comment date
05 August 2010
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.

Kat Sumner

Comment date
05 August 2010
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.

Kat Sumner

Comment date
05 August 2010
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

Anthony

Position
PCT,
Comment date
05 August 2010
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!!!

L Martin

Position
Midwife,
Organisation
NHS
Comment date
05 August 2010
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.

Jan Phipps

Position
Midiwfe,
Comment date
05 August 2010
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.

SM

Comment date
05 August 2010
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.

Debbie Graham

Position
Health Strategy Consultant,
Organisation
D.A.G. Consultancy Ltd
Comment date
05 August 2010
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