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

Susan Baines

Position
Midwifery Lecturer and S.O.M.,
Organisation
University of Salford
Comment date
05 August 2010
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.

Gill

Position
Midwife,
Comment date
05 August 2010
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.

Angela

Position
Midwife,
Comment date
06 August 2010
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.

Dr Paul Thomas

Position
GP Principal,
Organisation
Gippping Valley Practice
Comment date
06 August 2010
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?

Dr Paul Thomas

Position
GP principal,
Organisation
Gippping Valley Practice
Comment date
06 August 2010
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.

Greta Beresford

Position
Midwife Teacher,
Organisation
Independent Practice
Comment date
06 August 2010
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

Cathryn

Position
Independent Prescribing Midwife,
Comment date
07 August 2010
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.

Paul Thomas

Position
GP Principal,
Organisation
Gippping Valley Practice
Comment date
07 August 2010
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.

Hillary

Comment date
07 August 2010
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?

Hillary

Comment date
07 August 2010
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 ..?