APPENDIX 21
Memorandum by the Royal College of General
Practitioners
RECOMMENDATIONS
1.1 Women should be empowered to make a
full range of pregnancy and labour choices which are compatible
with their medical, social and obstetric history.
1.2 Where possible their choices should
be based on high quality research evidence and where evidence
is lacking this must be made clear to women.
1.3 Appropriately trained and committed
GPs should be enabled to provide the range of maternity care which
they are competent to provide, and which women wish them to do
so.
1.4 There should be further research into
the contribution that GPs make to enhancing women's choices, continuity
of care and control of their pregnancy care.
SUMMARY
2.1 The provision of pregnancy care is,
and should remain, an essential component of British general practice.
2.2 GPs can, and do, assist women to make
informed choices about their pregnancy and labour care.
2.3 Published research shows that most women
wish their GP to be involved in their pregnancy care.
2.4 Pregnancy care (antenatal, labour and
postnatal) should be seen as part of a larger continuum of care
related to successful pregnancy outcome such as, for example contraceptive,
infertility and miscarriage services.
2.5 There is a clear trend for GP s to be
less involved in pregnancy care but to be more involved in such
pregnancy related care.
2.6 Nearly all GPs undertake junior hospital
obstetric posts as well as being a GP registrar and are therefore
trained to provide antenatal and postnatal care.
2.7 GP involvement in labour care is now
uncommon. But there are still some hospitals (13% in a recent
survey), especially small stand alone units without resident obstetric
staff, where GPs formally or informally provide labour support
to women and midwives. This facilitates such units remaining open
and maximises women's choices near such units. Women and their
families invariably strongly oppose the closure of such units.
2.8 A well functioning primary care maternity
team (GPs and community midwives, based at a GP practice) can
promote women's choices. Evidence demonstrates that this can lead
to home birth rates of over 13% and give excellent choices and
also continuity of care for women.
2.9 In the future, some GPs may offer a
service at primary care trust level (GPwSI) to pregnant women
to facilitate their choices; this is likely to be especially important
for pregnancy related care.
2.10 Future research should investigate
further the value to pregnant women of a well functioning primary
care maternity team.
2.11 Maximising pregnant women's choices
will be facilitated by ensuring that interested and competent
GPs are enabled to continue to provide pregnancy care, in partnership
with midwives and hospital doctors.
AIM OF
MATERNITY CARE
2.12 This should be to enable women to deliver
a healthy baby whilst maintaining their own health and maximising
their choices around and throughout pregnancy.
BACKGROUND
3.1 High quality maternity care can only
be provided when competent professionals listen to an individual
woman's wishes and assist her (and her partner) in making informed
choices based on research evidence, where this is available.
3.2 Women need time to reflect upon information
provided and may, in addition, ask for professionals to advise
them. Ultimately it is the woman's decision as to the type of
care and choices that she makes. The duty of professionals is
to support her (and her partner) in their decision-making and
in their subsequent choices (or refer them to someone who will
where the professional disagrees).
3.3 Several factors can help to achieve
high quality maternity care. These include: good communication
between professionals, patient held records, clear lines of responsibility,
locally agreed guidelines, shared governance and audit, closer
interaction and training of professionals.
3.4 Maternity care can be seen in the narrow
definition of that provided when the woman is pregnant and wishing
to continue her pregnancy.
3.5 Much care is also provided within general
practice both before and after pregnancy that should not be seen
in isolation from the pregnancy per se. Such related care includes
contraception, infertility management, pre-conception counselling,
miscarriage care, termination of pregnancy, the promotion of breast
feeding, detection of postnatal depression, and child heath promotion.
3.6 Hence choice in maternity care, and
its related concept of continuity, should be seen in a wider context
when considering who should be enabled to provide it, and where
it should be provided.
3.7 Most women wish to have greater choice
of maternity care; some also wish for greater continuity of care
as part of that choice.
3.8 Present Government policy is to promote
such choice & continuity as set out in the document "Changing
Childbirth" but little systematic data are available about
whether such choice really exists. There are many inaccuracies
and much missing data in routinely collected data.
3.9 Such choice should include the options
of delivering at home, in birth centres or in stand alone hospitals;
there is no evidence that appropriately selected low risk women
have worse labour outcomes if they choose to deliver outside of
a consultant obstetric hospital.
3.10 There is much debate about the future
configuration of maternity services especially in terms of stand
alone maternity units and small consultant units.
3.11 It is generally accepted that continuity
of care improves pregnancy & labour outcomes, and reduces
intervention.
3.12 All GPs can promote choice and some
may choose to provide continuity of care whereas hospital doctors
are unlikely to do so and continuity of midwifery care is variable.
3.13 It is crucial that those providing
pregnancy care work as a team, to agreed guidelines to which patients'
representatives have contributed.
THE ROLE
OF THE
GP IN PREGNANCY
RELATED CARE
4.1 Ideally women should be able to choose
when they wish to become pregnant ie to plan their pregnancies.
To do so they need contraceptive advice. Most GPs provide contraception
care and the majority of contraceptive services are provided by
GPs.
4.2 To assist them in such planning GPs
are well placed to provide pre-conception care. This should include:
advice on taking folic acid, checking rubella immunity, optimising
the care of ongoing health problems, taking an adequate family
history, providing or referring for genetic counselling, general
health promotion advice, & screening for sexually transmitted
infections.
4.3 Unfortunately a significant minority
of couples will have problems conceiving. GPs are well placed
to provide infertility care. This may include: taking an adequate
history and examination, pre-conception care, investigation and/or
referral, treatment, follow-up & counselling, ongoing care
and guideline development.
4.4 10-15% of pregnancies end in miscarriage;
the GP is often consulted by a woman in early pregnancy with bleeding
and or pain. They can arrange appropriate investigation if they
are permitted appropriate access to lab testing and imaging; if
the miscarriage is confirmed they can advise on management options
and then arrange the follow-up that some women need.
4.5 Some women become pregnant by mistake
and wish a termination. GPs are usually consulted and have an
important role in counselling, referral (both NHS and private)
and subsequent follow-up especially for contraception and emotional
problems.
4.6 Breast feeding has clear health benefits
for both mother and child. Despite the majority of women commencing
breast feeding only a minority do so beyond six weeks postpartum.
The GP, midwife and health visitor together must provide supportive
evidence based care for breast feeding mothers who are having
problems to maximise breast feeding rates. In particular the GP
may be consulted over possible infection causing mastitis.
4.7 Postnatal depression is increasingly
recognised as a major illness affecting not only the mother but
also her baby and perhaps existing children. The GP and health
visitor must be sensitive to such a possibility and respond appropriately
to cues that the new mother may give. Systematic primary care
screening may be effective to detecting more women with this distressing
condition.
4.8 Child health surveillance services are
provided by most GPs. This starts with the first baby check, which
in future may be the province of the midwife rather than the doctor.
However, the GP and HV subsequently provide such care starting
with the formal six week GP check and finishing with the 4 yr
old pre-school medical. An integrated programme is essential.
THE ROLE
OF THE
GP IN PROMOTING
WOMEN'S
CHOICES IN
PREGNANCY CARE
5.1 Most GPs continue to promote choice
for women by either (a) actually providing some aspect of maternity
care themselves, and/or (b) ensuring choices exist for women especially
in terms of place of birth.
5.2 Most GPs provide antenatal and postnatal
care, although the degree of their involvement is not clear. In
some practices it may be in name only to enable them to claim
the relevant item of service fee; in others they may fully share
such care with midwives and hospital doctors.
5.3 In a survey in the South West region
of England in 1992 98% of GPs were providing antenatal and postnatal
care, 45% were providing intrapartum care and 27% booked women
for home deliveries. But fewer than 5% of GPs now provide intrapartum
care. However, the majority of GPs either wish to, or do still
continue to provide, antenatal and postnatal care. Pregnancy care
must be seen as a core part of family practice in the UK.
5.4 GPs continue to provide hospital intrapartum
care in less than 10% of UK maternity units, but this does include
a number of stand alone maternity units for whom they provide
valuable formal and informal support. This provides valuable backup
to the midwives working in those units and enhances their viability
and therefore promotes women's choices in terms of place of delivery.
5.5 Some GPs also continue to attend selected
home births to provide continuity, support and midwifery back
up.
5.6 Many women wish their GPs to be involved
in their pregnancy care. A postal survey in the Bath and Wiltshire
area in 1994 of women who delivered in the preceding two years
found that women generally wished their GPs to be involved in
their maternity care. 68% agreed that GPs play an important role
in routine antenatal care and 53% that they have an important
role in normal labour. 73% of women stated they were cared for
throughout their pregnancy by one GPs whom they knew well; such
continuity was desired by nearly all women in this study. Over
90% of women had their final six week postnatal check with their
GP.
5.7 There is some evidence that the majority
of women prefer to see both their GP and their midwife in early
pregnancy, whereas those that only see one professional tend to
be dissatisfied with such arrangements.
5.8 A National Childbirth Trust investigation
in 1994 concluded that women want their GPs to provide: up to
date information about choices in clinical matters, continuity
of care as part of a motivated, interested, successful and harmonious
maternity care team, pre-pregnancy care, appropriate referral
and sharing of care with adequate time to discuss anxieties; home
birth medical cover if desired; a visit early after their return
home from their GP; contraceptive advice, and neo-natal and feeding
advice if necessary.
EVIDENCE OF
GPS ENABLING
WOMEN'S
CHOICES
6.1 Data from two rural practices demonstrate
what can be achieved by a committed primary maternity health care
team. Such a team is based at a GP practice and comprises the
GPs and attached community midwives. In the following two examples
these primary care professionals (ie both GPs and midwives) all
promoted choice for low risk mothers in terms of place of birth
and in choice of lead professional.
6.2 In these two practices women routinely
saw the GP before the midwife, because of the interests of the
GPs in maternity care. The resultant home birth rate was over
10%. In neighbouring practices where women routinely saw the midwives
first the home birth rate remained at 1-2%. I would argue that
the major reason it was so high in these two practices was because
the GPs offered home birth as a realistic choice to women very
early on when they first contacted them in their pregnancy and
before they were formally booked by a midwife, who also supported
home births strongly.
6.3 Rural general practice 1; nine years'
data from 1988 to 1996
6.2.1 500 consecutive bookings; of these
only 22.4% were consultant booked because classed as "high
risk" at the start of pregnancy.
6.2.2 Home birth rate rose from 1.5% for
the first 200 births to 9.0% for the last 300 births; the GP was
present for 90% of these 30 home births.
6.2.3 In addition the GPs provided choice
as 68.6% of these 500 women were booked to deliver under the care
of their GP in hospital. The GPs also provided continuity of care
by being present in labour for 86.3% of the 233 women who started
labour under their GP (as well as midwives).
6.2.4 GPs provided both antenatal and postnatal
care for all women, whether consultant or non-consultant booked
as part of either the larger maternity care team or the primary
maternity care team respectively
6.4 Rural general practice 2; three years'
data from 2000 to 2003; list size average 3000 patients
6.4.1 73 consecutive deliveries; of these
22 consultant booked, 51 (69.9% ) GP or midwife booked as lead
professional.
6.4.2 10 home deliveries (13.7%); equivalent
to 19.6% of low risk women.
6.4.3 GPs provided continuity of carer in
labour by attending 39 (76.5% ) of women booked under their care.
6.4.4 GPs provided both antenatal and postnatal
care for all women, whether consultant or non-consultant booked
as part of either the larger maternity care team or the primary
maternity care team respectively.
6.5 Previously there were many GPs providing
intrapartum care in the UK. This percentage has steadily fallen
from about 15% of all births being under the care of the GP in
1975 to about 6% in 1988. There are no recent national figures
since that time. Similarly the number of units within which GPs
provide intrapartum care has fallen. In 1988 there were 65 isolated,
29 alongside and 134 integrated general practitioner maternity
units. GPs have now withdrawn from nearly all of these.
6.6 In view of the debate about the future
configuration of maternity services especially in terms of stand
alone maternity units and small consultant units, a UK survey
was undertaken to establish the present provision of, and variation
in, maternity units in terms of their number, type, booking options,
training & governance.
6.6.1 In 2001 all UK maternity units were
sent the main survey questionnaire, and then a supplementary one
in 2002. Data on delivery numbers by type, transfers to consultant
care, and change in unit type were sought over the last four years.
Intrapartum procedures which were permitted by midwives and GPs
were ascertained, as were the level of unit training, access to
evidence-based sources, and governance meetings.
6.6.2 Completed questionnaires were received
in 2001 from 258 (83.5%) of 309 maternity units, of which 156
permitted sole MW booking and 34 GP booking.
6.6.3 There were 55 stand alone (isolated)
units without resident obstetric cover, situated an average of
20.0 miles (+/- 10.3) from the nearest consultant unit with an
average driving time of 27.9 minutes (+/- 10.8) to it.
6.6.4 The median percentage of home births
was 28 (1.84%), with more occurring near units where midwives
were allowed to autonomously book women, especially near stand
alone units. In large units where midwives could book women autonomously
they were also more likely to be permitted to undertake other
intrapartum tasks autonomously eg in 10% of stand alone units
they could undertake ventouse deliveries.
6.6.5 GPs generally undertook little intrapartum
care, although in 40% of stand alone units they were permitted
to undertake forceps deliveries. In one third of midiwife stand
alone units GPs were still providing "unofficial" care
for intrapartum problems.
6.6.6 The survey concluded that there has
been a reduction over the last 14 years in the number of stand
alone units in the UK, and also in the involvement of GPs in intrapartum
care. This has reduced women's choices.
THE FUTURE
ROLE OF
THE GP
7.1 GPs will continue to provide pregnancy
related care, and this is likely to increase in areas such as
pre-conception care, genetic counselling, contraception and infertility
management.
7.2 GPs are best placed to provide efficacious
and cost-effective care for inter-current and chronic illness
in women who also happen to be pregnant
7.3 GPs are best placed to provide an overview
of the needs of the pregnant woman in terms of her health before,
during and after the pregnancy and in terms of her medical, social
& psychological care and finally in terms of her family and
social circumstances.
7.4 The participation of GPs in the provision
of maternity care will continue to evolve, especially if the proposed
new GP contract is accepted by the profession. Many practices
will wish to continue to provide antenatal and postnatal care,
jointly with midwives and hospital doctors.
7.5 A group of GPs with a special interest
in pregnancy care are likely to develop in line with joint RCGP/DOH
guidance ("GPs with a special interest"(GPwSI)); these
GPs will provide a service to the whole primary care trust in
a specific area eg contraception, infertility, antenatal monitoring
7.6 Some GPs will wish to provide a range
of pregnancy care to their own patients; they should be enabled
to do so where they are adequately trained, competent, undertake
appropriate CPD and where their patients wish them to do so.
7.7 A small cohort of GPs will wish to provide
intrapartum care for their own patients; it is crucial that they
do so within an appropriate governance and risk management framework
(see Appendix).
FURTHER RESEARCH
8.1 Research in a wide range of topics is
likely to assist women in making informed choices and thus improve
the quality of their care and also of their patient experiences
8.2 Topics which are of major importance
are:
8.2.1 The development of questionnaires to
measure women's experiences.
8.2.2 The value, or otherwise, of continuity
of different types of carer, not just of midwife care.
8.2.3 The inter-relationship of continuity
of carer, continuity of care, and patient expectations; their
interaction with place of care including place of birth.
8.2.4 Symptom control in "minor"
pregnancy related problems such as heartburn, nausea, backache,
oedema, etc.
8.2.5 Shared core competencies of various
professional groups and how best to teach shared knowledge and
competencies to enhance present and future teamwork.
8.2.6 Whether evidence based guidelines can
actually improve pregnancy outcomes outside of research settings.
8.3 How best to implement best practice.
8.4 How can women (and their partners) most
cost-effectively contribute to improving the quality of both core
and related pregnancy care.
REFERENCES
1. The Role of General Practice in Maternity
Care. Occasional Paper 72, November 1995. Royal College of General
Practitioners.
2. General Practitioners and Intrapartum
Care: Draft Interim guidance England and Wales only. GMSC March
1997. British Medical Association and Royal College of General
Practitioners.
3. L F P Smith. Should general practitioners
have any role in maternity care in the future? British Journal
of General Practice, 1996; 46: 243-247.
4. L F P Smith. Views of pregnant women
on the involvement of general practitioners in maternity care.
British Journal of General Practice, 1996; 46: 101-104.
5. L F P Smith, D Jewell. Contribution of
general practitioners to hospital intrapartum care in maternity
units in England and Wales in 1988. BMJ 1991; 302: 13-16.
6. L F P Smith. Provision of obstetric care
by general practitioners in the south western region of England.
British Journal of General Practice, 1994; 44: 255-257.
7. Community-based maternity care. Oxford
General Practice Series. Edited by G Marsh and M Renfrew. 1999.
8. The case for Community-Based Maternity
Care. 1996, 3rd Edition. Association for Community-Based Maternity
Care.
9. L F P Smith, D Jewell. Roles of midwives
and general practitioners in hospital intrapartum care, England
and Wales, 1988. BMJ 1991; 303: 1443-1444
10. L F P Smith. Role of primary care in
infertility management. Human Fertility (in press)
11. J Trinder, L F P Smith et al. Management
of miscarriage: expectant, medical or surgical? Results of a randomised
controlled trial (the MIST trial) (unpublished findings).
12. L F P Smith et al. Women's experiences
of three early miscarriage management options. (unpublished findings)
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