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?

soory - meant not

sorry even!

I had shared care with some consultant input last 2 times. I saw the same midwife every time in our small familiar GP surgery with lovely receptionists. It's 2 min walk from my house, and everyone was fab. The HV baby clinic followed the antenatal session which was very handy.

This time they've decanted loads of midwives into a children's centre miles away. There's no parking, I was terrified my dc with special needs would kick off, and I'll be seeing someone different each time. The midwife can't access my GP notes, has to refer me up to the horrifically overcrowded and overrunning hospital antenatal for any possible medical problems, and she doesn't know my family or social circumstances. Health visitors have vanished from the face of the earth.

So... midwives usually great? yes. GPs being excluded from maternity care? not ideal for me.

My GP practise has 8+ doctors, plus duty doctors to mop up the "need to see a doctor today" appointments. I don't go often. I usually just talk to the receptionist and ask for a GP to ring me back, which means I'll speak to a GP the same day (better than waiting 1+ hours for a 5 minute appointment later that week). And the receptionist has the sense to try and get the doctor with for example an interest in young childcare to ring back if I make it clear that that's why I'm ringing. I'd rather have a chat on the phone and for the two of us to decide if I need to actually see someone, rather than waste everyone's time.

My midwives has, well I don't know how many midwives, I'm in my second pregnancy and out of the 8 or appointments I've probably had in the two pregnancies, only two have been with the same midwife. In the home visits you get after you've given birth, I had visits from midwives from the neighbouring county as my midwives were so stretched. There isn't an free appointment with a midwife for the next 3 weeks but if you ring and leave a message they will ring back within 3 days.

The only consist thing in my care has been the health visitor, who ironically didn't visit, but instead rang me two or three times and told me to pull myself together. Thankfully the tablets I finally got enabled me to do that !

Don't get me wrong - I'm quite happy with the care I have received from both my GP practice and the midwives, but the whole arguement that getting the GP's more involved in antenatal care seems a little crazy if there isn't more GP time available. And it seems like a few more midwives wouldn't go amiss either. I just don't see how you can improve the service without more healthcare individuals being brought in..

I suppose what has happened is because GPs tend not to do antenatal stuff they've just got very, very rusty at it. I don't think the feeling on here is anti-GPs per se - just that when it comes to pregnancy and antenatal care, they just don't know as much as the midwives. That may be difficult for a former GP to take, but it's what specialism is all about - isn't it?

appropriatre training would be a good start for all concerned.

The prinicple of midwife led care was one i was very positive about prior to needing the service

While pregnant i never met the same midwife twice, i did meet one who couldn't spell my name properly (it's not that hard-), i met another who couldn't add up correctly, i met another who's response to a medical query was, oh that just happens (apparantly, we mothers loose all our intelligence, it's never good when you know more than the expert does). I met another who couldn't draw the blood (my fault, my bad veins she said) she needed and had to send me to the phlebotomy unit where my veins magically became good veins.

they did make a point of asking me on every single visit if i was in an abusive relationship and what they would be able to do to help me if i would just talk to them.

My poor DP, he had the patience of a saint!

Oh and that's not forgetting the midwife who rammed the pethedine needle in my thigh as surprise because it's better that way! Less fuss and bother she said.

I think there is a valid point that a midwifes should be better placed to support pregnant women. But that only applies when they are of a suitable standard and are a capable of more than the absolute basics.

next time around. I don't want to be anywhere near a midwife, they waste my time and refer me back to the doctors/hospital anyway for the slightest reason

I disagree with the idea that a GP should be more involved in antenatal care - I believe antenatal care should be in the hands of an obstetrician/gynocologist and a team of midwives like it is in much of Europe and where where I live in Luxembourg.

I had my ds in the UK where I had the usual GP/midwife set up. My experience of antenatal care was ok, the GP obviously had alot of medical knowledge but he was not a specialist in obstetrics and wasn't going to be at the birth anyway, I guess my labour and childbirth were satisfactory in the sense that we are both alive, although the whole childbirth seemed quite disorganised, panicy and therefore a bit scary not to mention impersonal - my GP didn't even know the baby had been born til I was home and told him, and the midwives who attended my labour (4 went on and off duty while I laboured) ranged from friendly to downright sour which I think comes down to having no personal relationship to maintain with someone "superior" to them in the room, meaning that they can feel like they have carte blanche to behave in any manner they see fit.

Here, having dd was a different story. My antenatal care involved knowing my obstetrician and being seen by the same midwives throughout my antenatal period. Once in labour, midwives led the birth, but my obstetrician made an appearance to make sure I was ok and to deliver the baby. I felt that the care was comprehensive and personal.
If I ever have another baby, I will do it here, not in the UK.

I absolutely feel that GP's should have more involvement. At 16 weeks I had a medical termination - it was obviously extremely traumatic and there were complications that led to further issues. When I left the Maternity Unit after taking the first tablets to start the termination, the nurse who was looking after me said she had called my midwife to tell her what was happening and so that, as she put it 'someone in the community know whats going on'
After finally leaving hospital (like I said with complications) I heard nothing from anybody, no follow up from the hospital and not a word from my midwife. After 6 weeks and still bleeding heavily, my husband got us a GP appointment as I needed to be sorted and we both felt that we had been abandoned - my GP was wonderful BUT they knew nothing about the termination! The hospital hadn't advised them and the midwife hadn't told them, as far as they were concerned my pregnancy was all tickety boo. It's now 2 months and although my GP has written to the hospital, they STILL have not been properly updated.
So yes, in my opinion GP's should be much more involved - I feel I was the classic case of someone who fell through the cracks and to be totally honest, I blame the Midwife for that. I feel it was her responsibility to at least make a call to the GP if she didn't want to speak to me. Because she didn't do this, I've had no follow up, no offer of counselling, in fact absolutely nothing and I feel completely and utterly abandoned.
I do not feel this would have happened if the GP had a bit more involvement.

Debs - that is shocking! And I am so sorry for your loss! That is why I really like the situation here. My obstetrician is directly responsible for my care, so the proverbial buck stops with him. The midwives that take care of the woman are all part of his "practice" and therefore they all have access to the same files and information which is shared with the hospital that the Obstetrician works from. The costs of this set up are covered by the state, so it is not "private" care - the set up is a bit different to the NHS, but the principle of free health care still applies. I believe the system is similar in some ways to that in Belgium and in France.

I saw my GP loads with DD1 and only saw a MW at hospital when having bloods and scans.

14 years later I have seen my GP twice. once to tell him I was pregnant and the 2nd 6 weeks later to tell him I was going ahead with the pregnancy, was in shock when I found out. I have had MW car throughout until 24 weeks when diagnose with GD and consultant care since.
TBH I prefer not goping to the Drs and having the nurse pick up on my weight loss. You neversee the same GP twice as it is hard to get an appointment until the day before.

I do think GP's should be involved but it isn't their place to take over the ante-natal care

In fact I'm going to argue against myself here. The medical system in this country appears to be at creaking point and my whole experience has been pretty poor.
To give some background, I have to see a GP fairly regularly as I have thyroid and blood pressure issues, both requiring medication. At one of these 'get togethers' I told the GP that we were trying to conceive - she was great, immediately arranged blood test to check my Rubella immunity and gave me prescription for folic acid, also advising that I would have to be closely monitored during pregnancy becasue of the thryoid thing and told me that she wished everyone trying to conceive came to see their GP. What she failed to tell me was the medication that I was on for high blood pressure can cause feotal abnormalities!
When I finally conceived, I went straight to the GP. He went through the thyroid issue and gave me the blood test forms so the midwife could take bloods at my first appointment - highlighting how important it was that my thyroid levels were spot on otherwise it could cause major defects. Again, until I actually asked about my blood pressure medication it wasn't mentioned. On asking him, he said it was fine, then checked his book and said 'oh no, you'd better stop taking that it can cause feotal abnormalities' I was 6 weeks pregnant so had potentially been poisoning my baby every day for 6 weeks!
After seeing the doc, I looked up what the issues were with the thyroid and it was very clear that if hormone levels were wrong, then it would cause neural tube defects. By 9 weeks pregnant I was starting to panic as my bloods had not been taken (not heard from the midwife) so in the end made my own appt. with the phlebotomy clinic and got my bloods checked - my hormone levels were too low and medication increased - by now 10 weeks in, the damage would have been done.
On seeing the midwife at 11 weeks, she referred me to a consultant as she agreed I would need to be under consultant care - at the time of losing my child at 16 weeks, I had heard nothing from the consultant!
All in all, with what happened after the termination I still agree that GP care is needed but really I think our whole medical system is failing people badly. I feel the story of my first pregnancy is a very, very sad indicator that in the majority of cases, each medical individual can be great but put the whole lot together and the system comes tumbling down!

GP's are very important. generally do a good job. but it is gettign silly now. they are becoming far too powerful. reports saying last month that more power is going to passed to gp, more control over finances, more decisions being made by them.
what about consultants, mw's and hv ?
whats the point of having them, then ?

Hi I think they should have better working knowledge of managing pregnant ladies but many don't so in practical terms I think it is better that midwives handle the majority of pregnancy care. I would be helped by more midwives being able to prescribe restricted list of items. I had problems getting my GP to prescribe ferrous sulphate despite hospital unit initiating and midwife telling me to continue. I also had 3 blood tests taken, of which only 1 result (baseline) was ever recorded in my notes. When I requested the most recent result prior to attending another hospital review, I was told the GP was not happy to release it to me!?. The appointments I did have with 2 different GPs - one told me information about Rhesus negative that I knew to be incorrect, and another that a unit was open for deliveries when I knew it was not. I know these are only trivial matters in the scheme of things, but it doesn't inspire confidence!

Oblomov - GPs will take greater responsibility for commissioning i.e. buying care from hospitals and community services. It's what Primary Care Trusts do now. Won't take any work away from other doctors or health professionals.

Not sure there are too many GPs who will be terribly keen though. I went to a medical event with GPs when I was 40 weeks - nothing was happening and I could see the hospital from the building I was in. Most of the docs blanched at the sight of me!

They were terribly worried something might happen and they'd be pressed into service with something they hadn't confronted since being junior doctors a decade or more ago. Spent most of my time reassuring them that it was fine, honest, look, if anything did happen I'd just have to jump in a cab for a five minute journey...

Was a bit tempted to start wincing and grimacing just to wind them up a bit.

Our midwives in East London were over booked and we had to hire an independent one to get a level of care we felt safe with. We moved to Wiltshire and our midwives have been worryingly bad and have made a lot of mistakes. I can only think that GPS are better in general.
The level of education for a GP is so much more than a midwife. I have never found community midwives in the NHS particularly educated. The hospital ones seem somewhat better, but I personally haven't seen any expertise from the NHS ones I've seen that couldn't be done by a GP.

Would only work if said GP was passionate about women's health in pregnancy. I have seen plenty of docs who don't take much of an interest and it's enough to put a woman off!! Lots of these GP's (espsh male ones for some reason) can be quite old-fashioned about it all, which is not very pleasant.

"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"

Yes I am aware of that but I am guessing you didn't have some sort of mind wipe where you forgot everything you had been taught about nursing when you then decided to specialise as a midwife....

I always think discussions like this are never going to go anywhere as there are shit GPs and shit midwifes. Your view will probably depend on which one you have encountered.

There was great criticism of nurses not being able to 'shake off' their nursing mindset when becoming a midwife, as it was believed that the majority could not move on from the illness concept. Hence direct entry training. I must admit that my nursing experience has been beneficial when dealing with illness in pregnancy etc.

I totally agree with your last statement LSAB.

I know I am banging on about Europe here, but my midwives in Lux (who as I stated before worked, not for a GP, but for an ob/gyn) had to qualify first as a nurse, practice nursing for 1 year and then complete a 2 year midwifery course. I don't know if this considerable training made a difference (you would think that it would have to), but, anecdotally, all of the midwives involved in my care were extremely professional and knowledgeable and good at putting a woman at ease. (Not the case for my pregnancy in the UK) So the midwives were highly trained and worked for a specialist Dr, who had overall responsibility for my antenatal care.

Why is this sort of set up so impossible to acheive in the UK?

We have had a long look at the report and a chat to the Kings fund and RCM and take the view that this is going backwards in a not helpful way.

comments here

news.bbc.co.uk/today/hi/today/newsid_8883000/8883909.stm

and here

www.nct.org.uk/press-office/press-releases/view/229

views welcome as always www.nct.org.uk/contact-us

Belinda NCT CEO

I am not opposed to antenatal care from a variety of people, mw/dr etc, as each medical professional have different trains of thought and valuable experience.

It is paramount that the health and well being of both mother and child are monitored, however the nhs appears stretched already in my opinion, therefore I can not see where the extra time and money to make this compulsory nationwide is possible.

I was advised by my mw that it was illegal to miss an appointment with her and that she could report me to social services for neglect to my unborn child if I did and suggested mothers who visit the gp are usually mothers who like attention. As I was in full time employment prior to the birth of my first child, I did not want to take more time out of work than necessary and felt if I did visit the gp in addition to the mw that this was comprimising my relationship with the mw.

Poppity, I know what you mean. I have the same view of hospital midwives.

The problem is that a lot of them think they are scientific but aren't really and you can tell that with a lot of them the last time they read research was circa 1970. I remember when DS was born in the middle of summer last year and the midwife telling me that he needed to wear a hat and gloves (it was 30 degrees outside). I couldn't help but think she was completely mad.

My experience of midwives is also that a lot of them think they know a lot more than they actually do and are happy to dole out advice on nutrition and what they think they know of medicine (which can actually be dangerous).

Really good midwives (of whom I know one) keep up to date with scientific knowledge, are on the ball about advances in their field but also know the extent of their limitations.

What I am saying is that there are times when a doctor is better than a staid, unmotivated midwife. They should stick to what they know newborns and delivering babies and leave medicine to doctors.

Let's get real here. A midwife is a nurse equivalent, albeit a specialised nurse. I had a look at the requirements to get on a midwifery course and there is NO academic minimum. For the pre-degree course, they expect 5 grade cs at GCSE. A doctor normally needs 3 As at A level to start and then trains for 7 years.

Of course some midwives are very bright and are way beyond minimally qualified. However, there is the other end of the spectrum. The one who presided over my wife's labour did not have the "specialist" additional qualification to put a drip in! In London, certainly, midwives tend to work in teams and, out of office hours, all you get is a recorded announcement telling you to phone NHS direct or go to A&E.

Midwives are trained in pregnancy and labour but that can mean they can miss other symptoms which can affect pregnancy but are not specific to pregnancy. A good GP will not miss these.

I guess the choice is personal. We have gone with a private highly qualified midwife who works as a team with an obstrician. She is unafraid to refer either to our GP or to the obstretician when she has any concerns or feels her knowledge is insufficient to address any problems. I do feel a good GP with good personal relationships has a role to play in any health issues throughout life, including pregnancy.

interesting thread. Being a GP and mum ,I can see all sides of argument.I agree with post saying there are shit midwives and shit gps! I found midwife care rushed when I had my own child and unfortunately they were very poor with breastfeeding advcie. GP's are expected to know about antenatal care and we do keep up to date-that is part of our appraisals. However we cannot know everything about it-that is the job of the midwife and obstetrican.However midwives have their role and drs have their roles-we work as teams however each person should know their strengths and limits. I would like being involved in antenatal care as I continue to see the children and their families and look after them for years.To pooh pooh the role of Gp's is just silly - having the government put access limits and our 24 hour convenience culture has limted time and access to GP's not our choice. If we had the system in most european countries, I expect you would get more continuity of care and people wouldnt come to the GP for minor illnesses and we would have more time for antenatal care, chronic care, etc.

larrygrylls Don't know what entry requirements you were looking at but midwifery education has been degree only for a couple of years as far as I'm aware. I don't know of any places still offering the diploma route and had been told that the diploma was now finished.

Entry requirements onto the degree will be 3 a-levels or equivelent.