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've got shared care and I think it works really well. My GP is clued up on antenatal care (as I would expect a GP to be) and the midwives I've seen know their stuff.

I suppose MW only care would also be fine, but seeing as I'll only see midwives during pregnancy, I kind of want to see my GP too so that post birth there is "continuity" in care for the baby (and me!).

But I agree that in some areas, unless you are lucky you may see a different GP everytime (and in my area, a different midwife everytime), which kind of makes it irrelevent in a low risk pregnancy as to whether it's MW or GP led - as long as the MW or GP knows their stuff then you get the care you need. Just a shame to not get the relationship/continuity as well...

GP's generally know bugger all about pregnancy and are not current in what they know, so I wouldn't be at all happy with shared care, and I don't imagine most GP's would welcome the extra workload either TBH.

Generalists are not appropriate for Obstetrics. Midwives are not doctors, but they are experts in their field, I'd take midwife care over GP any day.

I had shared care with my second pregnancy. I saw a GP once. When I next saw the midwife she rubbished everything he had said and written down. A waste of GP's time I think.

The assumption here is that, if you're pregnant, you need to see the mw, regardless of the problem. But I think that shared care would be good. If I had a pregnancy related problem, I could easily see the mw, which was good. BUT when I had a problem which was not directly caused by the pregnancy but could cause complications (strep B in urine, so needed antibiotics) I was shuttled backwards and forwards between the antenatal clinic (where it was picked up), the GP (who claimed not to have received the info from the antenatal clinic) and mw (who kept saying that I needed to see the GP).

In the end, it took a week and a half, lots of phone calls and 3 appointments for the neccessary antibiotics to be prescribed, despite signs that it might be causing my body to send me into early labour.

It certainly could do with being more joined up.

Midwives should not expect all GPs to have the same depth of knowledge as them - that makes the job of a midwife out to be something that that GPs can do on the side. Midwives roles are highly specialised, and I think like in every job some are good and up to date and some are terrible. Same with GPs of course, their job is specialised and nobody else can do it.
I think the point of the statement was that GPs have knowledge of underlying medical conditions, and these are the more high risk pregnancies. Often Obstetricians are not up to date with non-obstetric matters and it is often GPs that flag up problems. Midwives can miss red flags and not appreciate the severity of some conditions and the effect on the pregnancy. Involving the GP/midwife and the obstetrician in high risk pregnancies is best for mum and baby and utilises the specialist skills from each, it is not a one or the other situation - i.e. teamwork as another poster said.
There has been a lot of GP bashing on this post and I would be interested to know who you see when your child is sick?

'Involving the GP/midwife and the obstetrician in high risk pregnancies is best for mum and baby '

Mum and baby . . .

Typical patronising language belittling women and demoting them from human beings to incubators by pigeon-holing them into one role, mother.

Another reason why I'd hate to see antenatal care become more 'shared' with physicians.

Never hear them referring to males as father.

There's a dear now, this is best for Mum (no name, no identity, she's just one thing, not an actual person) and Baby.

A high-risk pregnancy needs a consultant.

Even in incredibly-medicalised US, despite what you see on TV shows, if a woman comes into ER with trouble in pregnancy she is immediately sent to OB, that is where she needs to be treated, by an obstetrician.

It's also been pointed out ad nauseum that pregnancy is not an illness, so this whole whom do you see when your child is ill is an entirely separate matter.

"
There has been a lot of GP bashing on this post and I would be interested to know who you see when your child is sick? "

that's a different point entirely, of course for an illness you would see your GP, but pregnancy is NOT an illness!

For my first pregnancy I had shared care with GP and hospital (midwife unit).

IME although the doctors I saw were good (I switched from one to another about half way through when one was away) I think it was not ideal, although I didn't understand that at the time.

For my second pregnancy I went to the midwife clinic in my GP's surgery and it was far better. It meant missing work to go to the clinic rather than making appointments that suited me, but it was worth it.

The community midwife is a specialist in antenatal care - she is better at palpations, knowing the way the baby was lying (very important in both my pregnancies, and caused some problems first time), finding the heartbeat, etc.

Honestly I felt more confident in her care than with the GPs. They are general doctors and antenatal care is not what they do all day.

Of course, maybe if GPs did antenatal care routinely they wouldn't be so out of practise.

'Now you just sit here, mum.'

'Do fuck off. I have a name, thank you.'

I really like our GPs, btw, but preferred seeing the midwife whilst pregnant.

For one, it was easier to get an appointment and she had more time to spend on me.

I have 3 children. I've never seen a GP either, during all three of my pregnancies.

I was/am very happy with the service. For the last 2 pregnancies, I was seen by the same midwife all the way through. The maternity service I have received by the one particular midwife - all through my 3 pregnancies - was second to none. (She did make a couple of annoying comments, but nobody's perfect.) I even named her as my choice to win an award (Midwife of the Year) through a magazine.

I would not wish my GP to be involved. The bit about GP knowing their patient is rubbish. I have never met my named GP on my NHS card. Everytime I go to the surgery to see a GP (very rarely, no more than twice a year) I'm always greeted by a different GP, although this year I did see the same GP twice, but only because I insisted on seeing the same GP, which in itself incurred a 2 week delay for the priveledge. This was for the insertion of a contraceptive implant - so not urgent. Can you imagine this sort of palaver whilst pregnant? No thanks.

The midwife led care that I have had here in the UK on the NHS, beats hands down OB led private care I had in Australia.

To be fair though I have uncomplicated pregnancies and births, but I much prefer the approach here, much much more woman/baby friendly.

My own impression of the King's Fund report was that it wasn't saying we should in any way undermine the lead role of midwives (for normal pregnancies) and obstetricians (for complex pregnancies) since they are the experts in caring for mums-to-be and the quality of the care experience has undoubtedly improved as a result for most women.

As your comments make clear, GPs need to be better trained and able to give the right level of advice and support in the early stages of pregnancy (since 80% of new mums do go and see a GP first when they find they are pregnant). I think this is particularly important if the mother has a pre-existing illness - such as diabetes or a mental health problem - or need to be told of the risks of smoking, alcohol or obesity. The mother is not just a 'bump' and the GP clearly has a role to play in their wider health needs.

In my own experience (as a father) my wife had a terrible experience with her first midwife because she was unaware of her history of anxiety and depression. She even tried to persuade her to reduce her medication despite these risks having already been discussed with the GP and a specialist. Result - she refused any further midwife-led antenatal check-ups and I had to ensure (through the GP) that she got ongoing care from an obstetrician with mental health training - which was just fantastic care and a major relief.

If any of you have the time, post some of your thoughts on the King's Fund website page at
www.kingsfund.org.uk

On a slightly different tack, I think GPs should play a greater role pre-pregnancy. I went to my GP to tell her that my DH and I had decided to try for a baby and is there anything I should do/be aware of - apart from the obvious! (first time I've ever made a GP laugh ) and she said to take Folic Acid etc, lay off alchohol.
Once I was pregnant I had the leaflet from the midwife telling me all the STI and HIV tests I would now have. WHY could these not have been done pre-pregnancy?! All of my tests were clear, as expected, BUT what if they hadn't been? Women considering conceiving should be advised to be referred for these tests pre-conception.

My DH is American, and okay their system needs work, but it is frustrating to compare the two and see the lack of preventative care in the UK.

I had shared care when preg with DS. The GP checked urine samples, took weight and pressure. I had a VBAC for that baby and he was nowhere in the picture - it was my midwife and OB.

Now I am at a different surgery and am under midwife and OB care. Currently preg with muber 3 - just into 7th month and haven't seen the GP other than the first visit to refer to antenatal. Suits me fine.

Btw, when my child is sick I wait 2/3 days and go for an antibiotic prescription. For all other things she/he is either referred somewhere or if urgent I take them to A&E or after hours doctor.

My surgery charges 1.50 per minute for a phone call in office times (even calling for an appointment or anything...) and the GP is unavailable at any other time and I need to wait at least 2 days to get an appointment.

I am approaching 29 weeks.

I have seen two midwives at Queen Charlotte's (a specialist maternity hospital), where I am having my baby. They were both hopeless and one of them was totally unprofessional to boot. (When she asked me why I looked anxious at my 16 week appointment I explained that it was because I had had 3 MCs - which of course she had read in my notes. Her response was "well, I have had one miscarriage and couldn't get pregnant again, so you are doing better than me". I personally find that grossly unprofessional - not to mention unsympathetic.)

I realise I might have been unlucky, but since then I have been seeing my GP for all appointments (as prescribed by my notes - not because I asked for it). I have seen two different Drs at my local surgery and both have been excellent. They appear to have checked everything they should and have given me all the information I have asked for.

I am personally up for Drs having more input.

zerovian I had the absolute opposite with my MW, I went into my pregnancy on citalopram, my history was thoroughly discussed with my MW and I was referred to a specialist mental health mw, I couldn't have asked for a better experience.

Expat - your experience is directly opposite to my own! I saw my GP for more antenatal appointments than the midwife - because she only worked at the surgery 3 hours a week!! It was loads easier to see my (very helpful, never rushed, always answered my questions) GP than try and see the MW. And I also liked my GP better than the MW, so I was perfectly happy with that.

That said, I had v straightforward pregnancies, so perhaps would have felt different if I needed specialist medical help?

We have shared care. Unfortunately, the way it works out in practice is that I see someone different at nearly every appointment (have seen 3 people twice each, and about 4 other people) and that there is no communication between them, no continuity, no chance to build any sort of relationship.

When I mentioned to MW that I had had a campylobacter infection (for which I had seen GP) she wrote in the notes "had bug but is better now". When I mentioned to MW that my mum and aunt had hypo-thyroidism (which runs in families) and that I probably had borderline hypo-thyroidism, she wrote "hyper-thyroidism" into the notes (which is the opposite).
So, clearly, there is some understanding of "general" medical issues that might strongly affect pregnancy that is lacking (for some MWs). But, just as clearly, the "shared care" practice in my case does nothing at all to alleviate this problem, as the GPs and MWs don't actually communicate.

I would much much prefer having seen fewer people but more often. If MW-only care would have given me that, I would have chosen that over shared care anytime.

If your tests hadn't been clear then it would have affected the plan for delivery and the neonatal period. The risk to the baby is very small if properly managed, so there's no particular advantage to having the tests pre-conception (especially as they'd just repeat them when you were actually pregnant).

I actually want to have less obstetrician care. I am "high risk" because I (probably) had undiagnosed GD when pregnant with DS leading to his being very large, and then had diagnosed GD when pregnant with DD (easily controlled with diet and she was fine), and because I had a c-section with DS (had successful VBAC with DD, though). As a result I've been referred for OB-led care rather than MW-led care. Which up to a point is fair enough BUT for the GD I'm going to be attending separate appointments with a specialist diabetes nurse and dietician anyway (so nothing for the OB to do except ask how my blood sugar is) and it's not as if anything is going to happen re a repeat VBAC until much later on -- so that takes care of all my risk factors. So what is the OB adding to the process? I've found in the past that when I see an OB they are generally rushed, generally haven't read my notes so I have to explain things from scratch, have misread things in my notes (last pregnancy OB misread the report from my growth scan) and/or make odd suggestions (with DS the consultant wanted to move his due date up by an entire month based purely on his size, even though I'd had a 6 week scan that had blatantly shown a 6 week embryo rather than a 10 week foetus).

In contrast when I see a midwife it's generally the same midwife for all my antenatal care, she remembers me from one appointment to the next, has generally read through my notes in advance (although that may be down to my Lovely Midwife from my pregnancy with DD, who at the booking interview had pulled and gone through my notes from my pregnancy and birth with DS so that she knew more about it than I did, and I'd been there -- this time the booking midwife had clearly done no such thing. But then maybe that was because she knew I'd be going to OB-led care and wouldn't be seeing her again?), and has plenty of time.

Which isn't directly relevant to the GP question, unless seeing a GP instead of an OB (given that the system has decided I must see a doctor) would be an option. If there were a GP with a special interest in maternity care then I'd probably prefer that, as a low risk "high risk" person.