GPs should have a bigger role in antenatal care

[LikeGarlicChicken]

Better confess straight off, I'm a retired GP. I couldn't agree more with this statement by The King's Fund. But the Gen.Sec. of the Royal College of Midwives says of GPs "....they must be able to demonstrate an up to date knowledge of the field...". Well Hello, Excuse me, who's the doctor here? I know I'm a bit reactionary and I still live in the world of "the doctor prescribes the treatment and the nurse carries it out", but really! The problem with midwives, from the beginning of time is that they have always thought of themselves as doctors in all but name. But it ain't so.
Yes I'm being a bit provocative here, but I always shared antenatal care with the midwife and I think this should always be the case. What does everyone think?

I did have a fantatsic GP with 1st preg. He really knew me and my family. The midwife care was very hit and miss and he picked up the pieces.

I think he recognised where his skills lay and got involved but no further than he should/could. It made all the difference to me because he stayed with me throughout a traumatic time. I rarely saw the same midwife more than once.

I think I'd probably say I'd like my GP to be as supportive in the future. This doesn't threaten the role of midwife however

I had shared care with DS.

Midwife was vague, woolly, and didn't seem to think she needed to answer any of my questions.

GP was helpful, provided lots of info and was far more use in discussing options for birth etc.

The midwives were useless post-birth too, I got minimal BFing support from them, just lots of sarcastic comments about how 'scrawny' and 'skinny' DS was and suggestions that DH go and buy some formula. My GP was wonderful, supported me all the way. Dealt with my slow-healing cs scar, breast thrush and a host of other niggles.

It is potentially hard to find a foetal heart before 20 weeks but ime it's more about the quality of the Doppler than anything else. We have some of the standard pg dopplers and they would never detect anything before 20 weeks. But I have one super Doppler which is very sensitive and I've never failed to find a heartbeat in an ongoing pg after 14 weeks. Of course it was tons more expensive and most hospitals will only supply mws with the standard cheap ones which probably explains their policy rather than any issues re placental position etc

I think what this thread suggests is that GPs who have an interest in providing support for women antenatally/postnatally should do that (and it looks like they do), but that adding the extra burden of providing antenatal care to the workload of a GP who has no particular interest would be a bad idea.

Particularly if GPs taking on more antenatal care meant a reduction in the provision of community midwives.

I know some GPs will say they haven't the time but it's all about priorities. Pregnant women and newborns are the focus of family medicine and as I'm hoping to be in the same practice for the next 20-25 years I am hoping to see these new babies through their childhood and maybe even to the time they become parents themselves. Also I spend a lot of time looking after my frail elderly and terminally ill patients and it is nice to be able to witness the start of life as well as the end.

I think it depends. My old GP I was happy to have heavily involved - he knew my medical condition inside out, and it seems very difficult for people to pick that sort of knowledge up and apply it to their practice without the patient having to reiterate themself many times.

I think where I live now, I would end up with 99% secondary care, which is not great for smoothing the path to post natal care.

This relates to the team aspect - most GPs around here seem to be either single-handed, or have high throughput of medical student and GPs in training with the loss of the view that patients see one GP if they have a chronic condition - neither is ideal if you have a chronic and rare condition.

I don't see pregnancy as an illness or affliction to be treated - which is what I would see a GP for. Medical staff such as midwives and obstetricians are specifically trained to deal with pregnancy, therefore, I would prefer to deal with them.

It is BECAUSE doctors got involved with the birth process that births became more medicalised. Midwives have always been the experts on childbirth,antenatal and perinatal care.
The only time doctors should be getting involved is when serious complications develop. For the rest of us - pregnancy is not an illness why should we need a doctor when it is the MW who has all the experience and knowledge we need?
Yes doctors should update their knowledge so they are aware of the extra care a pregnant women may need if they become ill or are bring treated for an existing condition, but that should be the extent of their involvement.

We have shared care here too & see GP for at least 3 of the antenatal checks. I have a brilliant GP who I am very comfortable with so this is fine by me. In fact it was probably after seeing him whilst PG & after my DD was born that I have developed such a good relationship with him & he goes out of his way to help me with other medical problems. The GPs at my surgery all have 'special' interests and my GP's is obsterics so he is the one that does every woman's antenatal appointments. So you always see the same doctor & he is very up on lastest practices. Can't praise him highly enough tbh. The MW at our surgery is assigned there from the local MLU, so you always see the same MW at antenatal appts too & if you are lucky enough to give birth at the MLU or stay there post birth chances are you will see your MW. I think it's a brilliant set up, wouldn't change a thing. But I guess it comes down to the individual practices & their set up as to whether or not it would work.

For all the midwives who are getting their knickers in a twist about being called a nurse if the OP is retired she might not be aware that now you don't have to train as a nurse before becoming a midwife, which used to be the case and which some people think is a shame you still don't have to do.

"The problem with midwives, from the beginning of time is that they have always thought of themselves as doctors in all but name. But it ain't so"

How very dare they!

Many gp's are worse than useless when it comes to antenatal and postnatal care. I have had shockingly bad advice on breastfeeding from more than one doctor.

If they specialise in obstetrics then great. Otherwise their time is better spent doing something else. GP's are hugely expensive and most have less expertise in pregnancy than midwives. You really can't justify increased gp involvement in antenatal care on either medical or economic grounds.

I agree with Suzikettles that GPs who are interested should remain involved when patients want them to be (especially where patients have pre-existing medical problems or a longstanding relationship with that particular doctor).

I am a GP and enjoy doing antenatal care but I recognise that midwives do have much more experience of 'normal' pregnancies than me. They also have more time; a 5-10 minute appointment is not long enough to do effective antenatal care. As has been said above, all doctors in all specialties should be able to recognise pre-eclampsia.

The problem with routine care being done by GPs is that we are now out of the loop (whether we like it or not) and there can then arise communication problems with the hospital/community midwives using different systems of recording results etc. GPs have inevitably becomes deskilled in dealing with routine antenatal care and I personally would choose to see a midwife rather than a GP for routine care.

As for early antenatal care, I think it is a terrible shame that GPs don't generally get involved until 6 weeks anymore as it is an excellent opportunity to get to know a family well and offer ongoing support.

I think it is to the GP's benefit to be more involved in antenatal and postnatal care. If you don't practise a skill you lose it so I certainly can see that if the were to have greater exposure to pregnant women their standard of care would improve.

I've seen shocking levels of knowledge regarding breast feeding from GP's, paeds, HV's and midwives though. It isn't just the GP's that are uninformed

I saw a GP once during pregnancy. He really hurt me when he felt "bump" ad made some really hurtful comments about age / delivery etc. Told midwife when I next saw her and she said she's heard before re him being rough with bumps. So no, I would avoid seeing a GP in another pregnancy.

I would have to say that the midwife knows best - well in theory.

When I had my 2 children, the community midwives were pretty poor but they were up to date with their skills. The GPs meanwhile didn't seem to know anything about maternity care. If I hadn't trusted in my own convictions I believe that my GP's advice could have led to the death of my first child. I managed to see a GP only once in my second pregnancy and that was for an unrelated problem.

So, by all means have them more involved but please ensure that GPs have half an idea what they are doing when providing maternity care.

Personally I see GPs as a point of referral and provider of prescriptions. They are not experts themselves.

""The problem with midwives, from the beginning of time is that they have always thought of themselves as doctors in all but name. But it ain't so"

How very dare they!"

Well I'd agree with the OP. They're not doctors and If they act as though they are or expect to be treated as though they are well then they shouldn't.

I think these sort of 'initiatives' are a poorly cloaked attempt to cut the number of midwives and increase the workload of GPs as a cost-cutting measure.

I have absolutely no desire to be treated as a doctor, in fact, the aspects of the job tha most midwives dislike are the medicalised ones tbh! Midwives are the specialists in normal pregnancy and birth and have a duty to refer any woman outside this sphere of normality to a doctor or appropriate professional. Brilliant, however, many women are presenting with more complicated medical problems and midwives find themselves little more than obstetric nurses in many situations. What a shame that the OP views doctors as the pinnacle of achievement rather than valuing fellow professionals for their own areas of expertise. It would be great if GPs became more involved in the care of women for whom it was appropriate, but it is pure fanatsy to suggest that GPs have detailed knowledge of each patient on their books. Community midwives are better placed to do this as they have smaller caseloads. Btw, please can we avoid the usual 'my midwife/GP was crap' comments as although they may have important personal meaning for the poster, they add little to the debate.

Librashavinganotherbiscuit - just to let you know that even when midwives had to be nurses first (like me), we were no longer nurses once trained as a midwife. Midwifery is a separate profession regardless which often is not understood by the public or retired GPs

I really like my GP, I think he is an excellent doctor and always listens, has time for his patients etc. However, I really don't see the point in GPs being more involved in antenatal care. I'm 37 weeks and haven't seen him once, at our surgery you go straight to the mw and see her throughout. I honestly don't see what benefit seeing the GP would bring.

Do midwives act as if they are doctors, really?

I am also an Allied Health Professional and the reason we exist is that a GP can't be 100% up to date with research on all the many, many areas they need to deal with.

I am a speech and language therapist and I can tell you now that most GP's haven't the foggiest when it comes to development in this area: I have seen adults prescribed beta blockers to cure stammering, frenulectomies (tongue tie) suggested for lisps and, more worryingly, GP's telling parents of children who have significant social communication issues (read = undiagnosed ASD) that their 9/10 year old child will "grow out of it".

I have, of course, also come across fantastic GP's, but rarely have I met a general practitioner who knows very much about my specialist area.

Does a doctor know more about medical care and treatment of a vast array of conditions than I do? Of course. Do I know more about this particular aspect of child development (a niche within a niche within the range of things they must stay up to date with?). Of course!

The same is true for pretty much everything. A Community Paediatrician and a GP are worlds apart in terms of their understanding of children's development so I an presuming the same is true for an obstetrician and a GP.

GP's are the gatekeepers: they need to screen and decide on treatment on such a huge variety of issues from physical and mental health and well-being to child development, pregnancy etc. How could they possibly be as up-to-date as someone whose life's work it is to keep abreast of developments in a particular area?

OP, your post reminds me of a joke:
What's the difference between God and a GP? God doesn't think He's a GP.

The point of a midwife is that she is a specialist and will (hopefully) have years of experience of treating pregnant women and dealing with childbirth. The only equivalent on the doctor's side would be an obstetrician or gynaecologist, not a GP. I know there are some GPs who specialise in women's health / neonatal health but it's not that common. We have shared care in my area, so I get to see a GP and midwife at alternate appointments. As it's my first pregnancy, I can't comment on whether that's a good system yet(!) but I am glad to have the choice to see both.

If I had total freedom of choice, I would opt for a German / US style healthcare system where you can see a gynaecologist / obstetrician any time, not only if you have complications. When I lived in Germany, every woman I knew had a gynaecologist she could see regularly for general check-ups. The medical system there does not really have GPs. Every doctor is a specialist in their area - respiratory illness, gastroenterology, whatever - and you can make an appointment with any specialist any time. There is no gatekeeper deciding whether or not you deserve the attentions of the mighty god-consultant, which seems to be the system here. It shouldn't be a question of cost as I would happily pay extra if I had to. I really struggled to believe that I would never see a gynaecologist or obstetrician here and they would be absent from any aspect of my pregnancy care, unless I was unlucky enough to have complications. Can't quite get my head around how that is in the interests of patients but since I don't have a choice then a GP is better than nothing at all!