This is the fourth article in a monthly series from members of the GPs Down Under (GPDU) Facebook group, a not-for-profit GP community-led group that is based on GP-led learning, peer support and GP advocacy.
THE practice of medicine is constantly changing and evolving in ways that would astound, impress and dismay our predecessors. Best practice care depends on constantly changing evidence, location, training, workforce, available resources and a multitude of other factors, some of which most definitely include the point of view, perspective or political persuasion of the beholder.
The broad scope of practice that is both the essence and strength of the generalist is also a weakness, as staying across the minutiae of each topic is, quite frankly, impossible.
My passion is maternity care, and it is my observation that team care is absolutely critical if we are to provide best practice care to women and their families. Unfortunately, this is a very tribal space and one which GPs have progressively been pushed out of. GPs Down Under is helping us find our common ground, hear our collective voice and build a resolve to push back and reclaim the GP role in maternity care.
Working in our silos, a number of us have been creating tools and pathways to improve the knowledge base among the maternity team and the journey for women. Clinical discussions on GPDU frequently cover a multitude of maternity care topics; for example, pre-conception work-ups, genetic testing, pre-eclampsia, non-invasive prenatal tests, mental health, domestic violence resources, the value of holding a Royal Australian and New Zealand College of Obstetricians and Gynaecologists diploma, and the November 2017 changes to Medicare item numbers 16590 and 16591 and what that means in practical terms across the nation.
Those of us in the capital cities have access to specialist colleagues, allied health and the luxury of referring women with high needs to relatively well resourced services. Our regional, rural and remote colleagues are often the only clinician within a mind-blowingly large geographic area, and telehealth will only get you so far.
The context of care in the community and, in particular, in remote and isolated rural areas is too often not understood by medical staff receiving calls for assistance or transfer, which can result in a reluctance to seek assistance in future and compromised care. Too often, GPs around the nation feel judged on the basis of the visible errors or omissions, with little or no appreciation of the unseen tsunami of poor outcomes we prevent. The lack of understanding some in the health professions have for the difficult space GPs occupy in the medical world is a frequent topic of conversation.
Models of GP obstetric care
We live in an era where evidence must be produced and where the Cochrane review is held up as the gold standard. Unfortunately, there is a lack of high quality, systematic literature looking at the outcomes of GP-based antenatal care, be it GP shared care or continuity of care models with a GP obstetrician (GPO). Most of the evidence that is cited examines the perinatal period only, whereas the strength of GP care lies in the long term relationships and continuity of care measured over years, not months.
There are many aspects of maternity care that defy randomisation or statistical interpretation, and caution is needed when considering the evidence base for change, as we are already seeing reports of significant unintended consequences. GPs are concerned about a movement towards models of care that diminish, or completely remove, the GP in providing maternity care. Action is needed, as losing the GP or GPO models of care may have a profound impact.
The Cochrane review of 2016 is frequently cited as evidence for moving towards midwifery-led models of care. It concluded that “women who received midwife-led continuity models of care were less likely to experience intervention and more likely to be satisfied with their care with at least comparable adverse outcomes for women or their infants than women who received other models of care”. However, there were a couple of major problems with their analysis. Of the studies conducted, half of which were from Australia, all other forms of care except for midwifery-led care were lumped together; therefore, the review does not make it clear if GP shared care is inferior to midwife-led care. The other significant shortfall is in the short term outcome measures. There is a vague narrative about “satisfaction”, but a complex intervention such as changing pathways of care requires a much more in-depth review of impacts.
What about deskilling? What about care of the growing child? Immunisation rates? Longer term outcomes for post-natal depression? None of these topics were assessed by the Cochrane review. Before a wholesale exclusion of GP shared care or GPO care, these impacts need to be considered.
Threats to GPO skill sets and the collaborative solution
Pre-conception, maternity, neonatal and early childhood care are critical foundation blocks in the health of our country, and having a well informed, well connected and skilled GP workforce is an essential component of the maternity team. Fifty-one per cent of pregnancies are unplanned. Eighty-nine per cent of Australian women visited a GP in the past 12 months. Maternity care falls naturally into the community GP sector; it is very much a core component of what general practice does. Clinical resources and ongoing education need to be a priority for all working in maternity care as well as improving communication pathways and interprofessional relationships.
It is important as GPs that our skill set is maintained, and that we do not become deskilled as a flow on effect of reduced exposure to routine maternity care. To this end, GPDU is one source of information, providing regular clinical case discussions and resource-sharing, and a file-sharing section that contains information on antenatal testing, recently updated flowcharts and antenatal checklists from 2015 and 2018.
Great work has been done in health departments across Australia, but if the resources created are not known about or not accessible by GPs, they will fall well short of the mark in improving outcomes for women and their families.
Informal asynchronous GPO meetings and longitudinal GP care
One of the most important parts of knowledge-sharing in the GP community is that it connects us with other GPs who are doing great work and who have been passionately advocating for the ongoing role of GPs in the maternity workforce, while holding the fort across the nation. I am humbled by the great work done in difficult situations by our GPOs.
Personal stories remind me that continuity of care in the GP sector is measured in decades and generations. Regular cries of frustration come from across the nation, common experiences are that hospitals have changed the models of care, typically increasing the midwifery models, but with little or no consultation with local GPs. The availability of regular training updates for GPs in general but GPOs in particular is too variable, when it should be an established process embedded within a state health system.
Some consultants are broadly supportive and engaging while others push GPs aside, limiting their role to the point of collapse of a GP-based service. Concerns are also raised about the long term outlook, especially outside the major centres, as a deskilled GPO or GP workforce can’t simply step into the gap at short notice should there cease to be sufficient work for a specialist obstetrician.
A side but critically important issue is the longstanding culture wars. There is intergenerational seeding of distrust and disrespectful attitudes which harm each other and also harm women and their families. Breaking down the isolation and allowing the sharing of stories is both devastating and motivating. The culture wars of obstetric care have to change.
Solutions for GP obstetric care: opportunities for integrating longitudinal holistic care
There are many opportunities to engage in creative discussions, focusing on improving the access of women to appropriately skilled health professionals, which simply are not happening. GPs are well aware of the importance of continuity of care, and in this, we are natural allies with our midwifery colleagues. Hospital-centric models of care or models that fail to acknowledge the fundamental role GPs play in the longitudinal and intergenerational care of families miss the opportunity for cross-sector collaboration and women and family-centred handover of care. Appropriately skilled GPs can organise thorough and timely antenatal screening, identifying and referring women at high risk early in the pregnancy, reducing the risk to women. GPs have or can acquire the skill set to better manage pre-conception consultations and refer, when appropriate, common medical conditions that affect pregnancy outcomes, such as asthma, diabetes and hypertension – conditions they will be managing before and after the pregnancy. So many opportunities, so many of them wasted, to the detriment of health outcomes.
New Zealand GP obstetric warnings
The experience of our New Zealand colleagues was known, but through GPDU the first-person voice of GPs who have lived through the changes in funding, which effectively removed GPs as providers of maternity care in that country, weaves a narrative that has much more impact than raw data or simple awareness.
Our New Zealand colleagues caution us, pointing out that the move to midwifery-led models of care has effectively removed GPs and GPOs from maternity care. In 2015, in New Zealand, only 0.3% of women were registered with a GP as the lead maternity carer. The New Zealand GP obstetrics workforce with its immensely valuable skill set has been decimated (page 29). There is interest within New Zealand GP registrars to return to obstetric care, but there needs to be political will and funding if that is to happen.
It is the view of most GPs who engage in the discussions around maternity on GPDU that it is imperative GPs remain a core component of maternity care in Australia. GPDU discussions reflect alarm at moves to limit the extent to which GPs will remain involved in maternity care. There is a passionate GP workforce out there, keen to continue to use their existing skills or, if required, to upskill and, most importantly, wanting to remain involved with providing care to patients before, during and after pregnancy.
Now is the time to harness and strengthen our GP maternity workforce, not to dismantle it.
Dr Wendy Burton is a Brisbane GP, whose specific interests are maternity and paediatric care, but she provides personalised care to all ages and genders.
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