“Better GP training needed to reduce maternal deaths”

Oh no it’s not. It’s all political.

The headline is from the Herald. It originates from this BMJ editorial, whose first line is “Since the first report of the Confidential Enquiry into Maternal Deaths in 1952, the maternal death rate in the United Kingdom has decreased dramatically.” They say that “many doctors are unfamiliar with the interaction between pregnancy and medical disease”.

This is odd, since GPs used to offer maternity care, within their own practices, with visiting midwives and the odd hospital visit if scans or other interventions were needed. We were a team, the midwife who looks after normal pregnancies, and the GP who looks after women before and after having a baby, who probably know the family, other children, and where the health visitor is down the corridor.

The new ‘midwife-led’  system seeks to exclude GPs from normal pregnancy care. Women were advertised to via a press campaign featuring a midwife, and posters in Glasgow and told to ‘see me first’ – book direct with a midwife. Whereas, I would normally have seen women soon after they confirmed pregnancy, could check out the woman’s general health – any medication issues or other problems? – talk about folic acid, alcohol, smoking, etc.

Now our patients book centrally, are seen centrally, and we have no personal contact with the midwives looking after them.

Sure, I don’t think you forget how to deal with rare emergencies in pregnancy easily. But the overall experience that GPs have in dealing with obstetrics has changed because of politics, not evidence. Women haven’ t been given a choice about this, despite what the ‘choice agenda’ in the NHS says. There is plenty of GP training in obstetrics; just not much chance to use it.

The bigger problems are not about GPs being able to reduce risks in pregnancy, but about the risk factors pregnant women already have: obesity, hypertension and diabetes, for example. These are all conditions which GPs will see patients about before, between and after pregnancies. Fragmented care does not serve patients well.

One Response to ““Better GP training needed to reduce maternal deaths””

  1. steve mccabe August 13, 2011 at 9:35 am #

    Margaret – in case you didn’t see it at the time, here’s a letter I wrote to the BJGP late last year on the subject of GP obstetrics, maternal deaths, etc.

    ” David Jewell’s lament for GP obstetric services is clearly heart-felt and he makes some valid points. But I am far from convinced that his sense of loss, particularly for GP intra-partum care, is shared by the majority of current practising GPs. Moreover he makes a number of assertions which are open to critical analysis.

    It has become common place to blame the 2004 change in out-of-hours care arrangements for a variety of perceived deficiencies in UK general practice. Jewell cites these changes as one of the reasons for GPs giving up intra-partum care but he provides no evidence to back up this claim. In reality, in my locality at least, GP intra-partum care disappeared long before 2004.

    Whilst it’s true to say that I miss my previous level of involvement in antenatal care, I am more than happy to accept community midwives as an integral part of the primary care team and to delegate the care of normal pregnancies and deliveries to them. This is where their field of expertise lies. GPs now need to focus their attention on higher risk pregnancies rather than carrying out routine but unnecessary monthly antenatal reviews of healthy, uncomplicated pregnancies.

    Jewell focuses on the Confidential Enquiry into Maternal and Child Health, highlighting thromboembolism, cerebral haemorrhage and mental health issues in particular. Whilst there is no place for complacency, he does not put these areas of concern into context and I think he over-emphasises the case. In reality, as the Confidential Enquiry clearly states, “maternal deaths are extremely rare in the United Kingdom, and the proportion of the very small number of mothers whose care was less than optimal has not increased for many years”. There has been no statistically significant change in the numbers since 1985 (when, presumably, GPs were more heavily involved in obstetric care) but again, as the Enquiry makes clear, that fact has to be seen in context – “The failure of the maternal mortality rate to decline has to be viewed in the light of both documented and undocumented changes in the childbearing population. Although there have been positive changes, there have also been increases in the numbers of women whose social circumstances and health put them at risk of maternal death”.

    According to the Enquiry, thromboembolism is very uncommon, occurring in approximately 13 per 100,000 maternity cases. Fatal pulmanory embolism is even rarer with an incidence of 2 per 100,000 pregnancies. In my practice we have around 50 maternity cases per annum from a practice population of 5200. This means we will see one case of fatal pulmanory embolism in a maternity case every 1000 years! Of course, that fatal case could occur today, tomorrow or next week but it is hardly grounds for panic. In reality the combination of road traffic accidents, murder and non-obstetric cancer account for about the same number of maternity deaths.

    Training is important and Jewell is right to emphasise that and to bemoan any reduction in training. But the Confidential Enquiry also has things to say about training. It makes a number of recommendations about training:

    All clinical staff must undertake regular, written, documented and audited training for:
    – the identification and management of serious medical and mental health conditions which,
    although unrelated to pregnancy, may affect pregnant women or recently delivered mothers
    – the early recognition and management of severely ill pregnant women and impending
    maternal collapse
    – the improvement of basic, immediate and advanced life support skills. A number of courses
    provide additional training for staff caring for pregnant women
    – staff also need to recognise their limitations and to know when, how and whom to call when
    assistance is required.

    Neither Jewell nor the Enquiry demonstrate the mechanisms by which such a level of training can be delivered clearly and consistently in primary care. Moreover, it is widely recognised that under-utilised skills deteriorate within weeks or months of training. Unless the training is provided on a recurring basis how can GPs hope to maintain the skills required for intra-partum care on the basis of one or two deliveries a year? And, as was recently pointed out in the British Medical Journal, a push towards home births or births in midwife-led units may not be without increased risks (particularly in terms of neonatal mortality).

    I know from the anecdotal experience of my own locality that the majority of GPs heaved a quiet sigh of relief when they were no longer faced with the prospect of intra-partum care”