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

Astrid Cullen

Position
Consultant Midwife,
Organisation
NHS [UCLH]
Comment date
20 August 2010
I agree with the senitments of many of the respondents, particularly Nick who points out how important it is to reduce territorial warfare and concentrate on the people for whom we are providing the service. Incidentally Nick, most mw's will call pregnant women, just that rather than patients. I guess this points out the way in which mw's see their role. As the partner in care for women, who should have made a realistic choice about where she will access her maternity care. Maternity Matters [2007] may have been under resourced but there are good examples of very equitable services where women can choose and duplication should not exist.
I have been a midwife for 35yrs and my daughter is a GP, I see all sides of this issue.
My message is: It has taken many years to see mw's holding a possition that is not subservient to Doctors. We must continue to promote realistic and fair choice for women [at the centre of care] while considering the whole health ecconomy. We must work as a team, some GPs will want to be and are equiped to be part of that team,
others will not.
Never forget that the majority of women will not need to see a Doctor for pregnancy care, but may need a Doctor during pregnancy for a host of other things. It down to all of us to communicate effectively across the healthcare spectrum.
To answer the question about GPs leading maternity care for all women - in my view this is not an equitable or ecconomical option and would turn the clock back to the 1970s. Care was not as good then as now, we have all moved on, let's not go back!

Rajat Srivastava

Position
GP,
Comment date
22 August 2010
If it ain't broke, don't fix it...

Martin McCrone

Position
Clinical Lead,
Organisation
South Aberdeenshire CHP
Comment date
25 August 2010
An interesting and timely document especially as we see the draft publication of A REFRESHED FRAMEWORK FOR MATERNITY SERVICES IN SCOTLAND. It is my experience that effective Primary Care teams produce the most comprehensive and effective care for communities. Midwifery as an intergral part of these teams makes eminient sense. Primary care teams esp General Practitioners follow people through their life. Clearly midwifes have an important specialist role within an child bearing episode. Continuity of care however is crucial, especially where there are complications either prior to conception (infertility, health co-mrbidity etc), or complication for mother or baby resulting from the pregnancy (birth defect, birth trauma etc).
No one person or professional can singularly provide the most effective care in pregnancy. We need systems that recognise the worth of all professionals working to the best interest of the populations we serve. Integration and common aims appears the logical way ahead.I note the comments raised that midwifes need to be in charge and not subservient to doctors. Surely it is not acceptable to artificially design a service to protect midwifes or for that, any professional group.

Mercedes

Position
Midwife,
Organisation
ELHT
Comment date
25 August 2010
I agree that continuity of care is essential, especially for women with pre-existing conditions and GPs are the best placed profesional to offer that continuity. However, to offer that continuity doesn't necessarily mean that they have to physically see these women and offer direct care. A good three partite communication between obstetrician-midwife-GP should be all is needed: the GP can pass on the medical and family history to the main professionals caring to the woman during the pregnancy (obstetrician and / or midiwfe) and these in return keep the GP informed of any events occurring during the pregnancy. In the context of their current practice and experience they have in looking after pregnant women, it seems unlikely that their input in direct care to pregnant women would offer any benefits other than the familiarity of the practitioner.

Jean Richards

Position
Public Health Physician,
Comment date
26 August 2010
My involvement with planning of obstetric services and coordinating a regional perinatal mortality unit, makes me very concerned with the gradual exclusion of GPs from antenatal care. I find that midwives do not seem to value the historic knowledge of the patient and her family which is often crucial in ensuring a healthy outcome of the pregnancy.
This is particularly important where the GP has knowledge of domestic violence, mild mental health or problems involving other members of the family. Of course the role of the GP in intrapartum care has evolved over the years and should be appropriate to the geographical and other circumstances, but the Patient will still consult the GP for medical problems throughout pregnancy and full cooperation between midwife and GP is crucial for optimal care of the mother.

Jayne Cozens

Position
Community Midwife,
Organisation
NHS Trust
Comment date
31 August 2010
I have read all comments with much interest. I have been a midwife for almost 19 years and have worked with many GP's during that time. Although I consider myself an expert in caring for women during pregnancy etc I am not an expert in medical problems, although I have alot of knowledge I am not a doctor. I work very closely with GP's and we have a very professional relationship with respect for each others knowledge. I have access to the medical records when giving care to women from the outset and can see for myself whether there are medical complications. I always refer my women to the GP for review early in the pregnancy (if there are medical probs) and would then refer to an obstetrician. All is recorded in the the hand held notes and on the GP records so the GP is always in the loop. If I have any worries about a woman, I will discuss with the GP, the management, so he knows and I do not have a problem with it! I do it out of professional curtious, we are both caring for the woman, however, I am caring for the pregnancy etc. I am a midwife prescriber now and most of my women do not see a GP during the pregnancy, however, should they need to see one, all is there for the GP to see. I think that health professionals need to work together for the health of the woman, I would welcome Gp's to be involved with women with medical complications, but in my experience, most GP's would rather the obstetrician care for the woman, with the midwife sharing the care, even though they are excellent GP's, they do not have the time or would require some extensive updating and with so much they are now expected to do in the surgeries, I do not think they would have the time. I do think that midwives should keep GP's informed what is going on, afterall, they are going to be caring for the woman after the midwife has finished visiting. Midwives are experts in midwifery, but will always require medical services in certain situations (midwives rules) and its very important that the medical person is up to date, as well as the midwives giving care, like I said, we all need to work together for the good of the woman and her baby/family.

Sally Theodoreson

Comment date
14 September 2010
'As a Breastfeeding Strategy Steering Group we were disappointed to note that there is no mention of the GP's role in relation to breastfeeding information, education, promotion or support in this document. This is particularly disappointing considering the following:
* There is evidence to demonstrate the important role of the health professional in informing, educating, promoting and supporting women to initiate and continue breastfeeding (Dyson et al, 2006)
* Research indicates that breastfeeding can significantly contribute to an infant’s short and long term health and development and is also associated with better health outcomes for the mother. A lack of breastfeeding is associated with an increased risk of a range of disorders and illnesses in childhood and through adult life (Ip et al., 2007; Horta et al., 2007; León-Cava et al., 2002)
* In particular, breastfeeding has been shown to provide a protective effect against obesity in children and early bottle-feeding increases childhood obesity which is predictive of obesity in later life (Arenz, 2004; Bergmann et al., 2003; von Kries et al., 1999).
* The Department of Health fully supports the UNICEF Baby Friendly Initiative and, alongside the World Health Organisation (WHO), recommends that all babies are exclusively breastfed for the first six months with breastfeeding continuing into the second year.
* Breastfeeding is central to the Department of Health's Healthy Child Programme and is recognised as 'a priority for improving children's health' and playing 'an important role in reducing health inequalities'.

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

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

S.Theodoreson, Chair - local Breastfeeding Strategy Steering Group

Gordon

Position
GP,
Comment date
12 October 2010
Pregnant women have disparate needs not always pregnancy related; midwives and obstetricians have a very specific remit and training, with midwives having no general nursing training. Initially midwives waved the banner of choice in maternity care and we are now seeing in Scotland the midwifery dogma that says women MUST book with the midwife regardless of preference, not the GP; This reveals the extent of power basing that goes on within ALL professional groups, not necessarily to the benefit of patients. The pendulum has swung too far and we need to work together for the good of patients and address the imbalance. GPs should be involved in the health needs of all their registered patients where appropriate, pregnant or not. My not inconsiderable experience of hospital midwives was a lack of understanding of the psychological, emotional and social needs of the women they cared for and as a GP felt that I could complement that. Community midwives are more understanding of these wider social and family issues and the best of them engage with the primary care team, which is to the advantage of the most vulnerable and deprived, who need the most help.

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

Jayne

Position
midwife,
Comment date
19 October 2010
Gordon, although I agree with much of your comments, not all midwives are direct entry. I myself am an RGN as well as a registered Midwife and have worked in many areas of nursing as have many other of my colleagues. I also continue to learn and develop, which in the culture that we live and work is expected. At the grand age of 49, I am doing my degree as time allows now. I think it is crucial for all healthcare givers to continue with updating and learning, and so outdated midwives and Gp's is no excuse or defence when it comes to providing care for women/babies and families. Everyone, who may be involved with pregnant women needs to be in the loop, both midwives and Gp's should stop being territorial and I agree that women have other issues that Gp's have to deal with, it just so happens that they are pregnant as well and vice versa. As I said earlier, I have good relations with all the Gp's I work with, its all about being polite, mutual respect and ultimately providing good safe care for the women/babies and families in ALL aspects of health, surely?

Grace

Position
Midwife,
Comment date
07 August 2011
I have been a Midwife for many years and cannot understand why the goverment continue to pay GP's for every Antenatal women they see. For years I have begged the question, Where does this money go ?.
Gp's are not specialists in pregnancy care and hospital services provide excellent Day Assessment Units where women can be seen 24 hours a day. In my experinice women are often sent in by GP's for the slightest Antenatal problem. This to me wastes time and money, why pay a GP when the hospital deals with the problem.
Midwife's have the skill, knowledge and authority to refer women directly into hospital themselves and can refer patients to see Consultants/Antenatal clinics. Midwife's are independent practioners in their own right. Why do GP's persist in seeing women Antenatally, is it just for the Money ? Why not pay a Midwife for a every Antenaal woman they see, I am sure Women Services could do with the extra money.
I am sure money can be saved or better utiltised for Women's Health care if we just stop paying GP's for their involvement in Antental Care.