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

Elizabeth El-Abed

Position
RN & Antenatal Student,
Organisation
NHS & NCT
Comment date
08 August 2010
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.

Elizabeth El-Abed

Organisation
NHS & NCT
Comment date
08 August 2010
PS. Sorry, not sure what happened to that.. I certainly didn't type it as one paragraph!!.

Paul Thomas

Position
Family Doctor,
Organisation
Gipping Valley Practice
Comment date
08 August 2010
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.

Hillary

Comment date
08 August 2010
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?

Eva Longley

Position
Junior Midwife,
Comment date
12 August 2010
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.

Sheila Kennedy

Comment date
13 August 2010
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.

Michelle

Position
Midwife,
Comment date
15 August 2010
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!!!

Michelle Salem

Position
Midwife,
Comment date
15 August 2010
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!

Georgina

Comment date
16 August 2010
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.

Nick Preston

Comment date
19 August 2010
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!