David Jewell’s lament for GP obstetric services is clearly heart-felt and he makes some valid points.1 But I am far from convinced that his sense of loss, particularly for GP intrapartum care, is shared by the majority of current practising GPs. Moreover, he makes a number of assertions that 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 intrapartum care but he provides no evidence to back up this claim. In reality, in my locality at least, GP intrapartum care disappeared long before 2004.
While 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,2 highlighting thromboembolism, cerebral haemorrhage, and mental health issues in particular. While 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 Enquiry clearly states, ‘maternal deaths are extremely rare in the UK, 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 significant statistical 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’.2
According to the Enquiry, thromboembolism is very uncommon, occurring in approximately 13 per 100 000 maternity cases. Fatal pulmonary 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 pulmonary 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:
All clinical staff must undertake regular written, documented, and audited training for:
the identification and management of serious medical and mental health conditions that, 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; and
staff also need to recognise their limitations and to know when, how, and whom to call when assistance is required.2
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 intrapartum care with only one or two deliveries a year? Also, as was recently pointed out in the BMJ,3 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 intrapartum care.
Notes
Conflict of interest
A remote, rural GP formally involved with community intrapartum care.
- © British Journal of General Practice, 2010.