General practice

Opinions of general practioners in Nottinghamshire about provision of intrapartum care

Department of Public Health Medicine, Nottingham University Medical School, Nottingham NG7 2UH Correspondence to: 226 Radford Boulevard, Nottingham NH7 5QG.

Abstract

Objective : To examine the beliefs of general practioners concerning intrapartum care.
Design : Postal questionnaire survey.
Subjects : All general practioners with patients in Nottinghamshire Family Health Services Authority in September 1993.
Main outcome measures : General practioners' current involvement in maternity care, and beliefs on intrapartum care.
Results : Of 694 general practioners sent questionnaires, 550 (79.2%) replied. 529 of these were on20the obstetric list; 437 had not attended a delivery in the past 12 months; 36 had attended two or more; 358 general practioners did not wish to provide more intrapartum care; 349 did not feel competent to do so. Reasons for not wanting to provide intrapartum care included current workload (453), disruption to personal life (407), and the fear of litigation (377). General practioners who already booked women for home delivery were more likely to20wish to do more deliveries (62/42 v 61/316, X²=85.3; P<0.0001) and to have more positive attitudes towards increasing women's choice in maternity care (90/22 v 195/151, X²=227; P<0.0001).
Conclusions : The involvement of general practioners20in intrapartum care in Nottinghamshire is20low, and most general practioners are unwilling to increase their role. However, general practioners who already book for home delivery are keen to do more.

Introduction

Until the middle of this century intrapartum care was considered a fundamental part of general practice.¹ The situation has changed greatly, however, over the past 50 years, most women in Britain now giving birth in hospital. The move to hospital has occurred because of arguments that the safety of mother and child is better assured under specialist care, *RF 1-4* but there is opposition from groups of women and members of the medical profession who argue that general practitioner obstetrics is as safe, if not safer, for women with low risk pregnancies.*RF 5-9*

The Winterton report of 1992¹⁰ and the Cumberlege report of 1993¹¹ advocated an emphasis on community based maternity care and increased choice for women concerning maternity care. These reports have suggested there may be an increased role for general practitioners in providing intrapartum care, particularly at home and in general practitioner units. I conducted a study to discover the maternity services provided by general practitioners around Nottinghamshire and their views on the new initiatives from government.

Subjects and methods

I obtained the names and addresses of all general practitioners who had patients in the Nottinghamshire Family Health Services Authority and sent them a confidential questionnaire in the autumn of 1993. The questions covered their age, sex, number of children, medical experience and qualifications, membership of the obstetric list, whether they provided antenatal or postnatal care, whether they booked for home delivery, and how many deliveries they had attended in the past 12 months. General practitioners' views on 24 statements concerning intrapartum care were assessed by using a seven point Likert scale with a central "no opinion" box. Eleven of these statements were derived directly from the recommendations of the Winterton report and three from the recommendations of the Cumberlege report.

The returned questionnaires were analysed with the SPSS-PC statistical analysis package. Analysis of subgroups was done with a standard X² test. Because of the number of comparisons being made significance was set at 1%, and only subgroups with more than seven significant comparisons are reported here.

Results

Of the 694 general practitioners in the sample, 550 (79.2%) responded. Table I shows the characteristics of these responders. Table II shows the responses to the 24 statements relating to provision of intrapartum care. Opinions did not differ significantly between men and women nor with degree of obstetric experience.

TABLE I - Characteristics of general practitioners responding to
questionnaire on intrapartum care
-------------------------------------------------------------------------------
                                                   No of responders (n=550)
-------------------------------------------------------------------------------
Male/female                                                 406/140
On obstetric list                                           529
Provide antenatal care                                      528
Provide postnatal care                                      528
Book for home delivery                                      128
Postgraduate qualification:
 DRCOG                                                      218
 MRCOG                                                        8
 MRCGP                                                      237
Hospital obstetric or gynaecology experience at senior house officer grade
 or above:
 None                                                        69
 6 Months                                                   225
 12 Months                                                  169
 >=13 Months                                                 40
No of deliveries attended in past 12 months:
 None                                                       437
 1-2                                                         70
 3-9                                                         18
 >=10                                                        18
------------------------------------------------------------------------------
Not all respondents answered every question.

TABLE II - Responses of 550 general practitioners to 24 statements
concerning provision of intrapartum care
-------------------------------------------------------------------------------
                                             No (%) of general practitioners
                                          -------------------------------------
                                                           No
Statement                                   Agree        opinion     Disagree
-------------------------------------------------------------------------------
Ideally, I would like to be able to offer
 more intrapartum care to my patients      124 (23)      61 (11)      358 (66)
I believe that I am sufficiently competent
 in obstetrics to be able to offer
 intrapartum care to my patients           153 (28)      42 (8)       349 (64)
I am discouraged from offering
 intrapartum care by:
 My lack of confidence                     267 (49)      62 (11)      217 (40)
 Lack of hospital based general
  practitioner obstetric facilities        182 (33)     115 (21)      247 (45)
 Fear of litigation                        377 (69)      61 (11)      107 (20)
 Rate of remuneration for intrapartum
  care                                     210 (39)     157 (29)      178 (33)
 Disruption of my personal life            407 (75)      46 (8)        93 (17)
 Attitudes of my fellow partners           203 (37)     109 (20)      178 (33)
 My current workload                       453 (83)      34 (6)        59 (11)
Women with uncomplicated pregnancy
 should be able to book with a midwife
 as the lead professional for all their
 maternity care                            248 (46)      62 (11)      234 (43)
Obstetricians should be used primarily
 to provide expertise for those women
 who have complicated pregnancies          423 (78)      33 (6)        89 (16)
Vocational training for general
 practitioners in obstetrics needs
 to be radically altered                   197 (36)     197 (36)      150 (28)
Women should be able to choose
 where they would like their baby
 to be born                                286 (52)      86 (16)      173 (32)
The policy of encouraging all women
 to give birth in hospital cannot be
 justified on the grounds of safety        189 (35)      48 (9)       307 (56)
There is widespread demand among
 women for greater choice in the type
 of maternity care they receive            315 (58)      80 (15)      152 (28)
There is potential for a damaging
 demarcation dispute between the
 professional groups over how
 labour should be supervised               377 (69)     109 (20)       60 (11)
Midwives should carry out the routine
 examination of apparently healthy
 newborn infants, provided they are
 well trained in the detection of
 congenital abnormalities and the
 subtle signs of impending illness         221 (41)      68 (12)      256 (47)
The item of service payments to
 general practitioners for maternity
 care, as presently operated, should
 be abandoned and redesigned               182 (33)     185 (34)      177 (33)
A new system of remuneration for
 general practitioners for maternity
 care should be heavily weighted
 towards rewarding those who
 provide intrapartum care                  150 (27)     100 (18)      297 (54)
It is wrong to remove a woman from
 a general practitioner list solely
 because she wishes to have a home
 confinement or midwifery only care        384 (71)      67 (12)       92 (17)
A duty should be placed on general
 practitioners to have in place
 arrangements for women to have a
 home confinement                           92 (17)      46 (9)       398 (74)
Most maternity care should be
 community based and near to the
 women's home                              385 (71)      58 (11)       97 (18)
Those general practitioners who wish
 to provide care throughout
 pregnancy, labour, and the
 puerperium should be enabled
 to do so                                  501 (92)      34 (6)        12 (2)
Vocational obstetric training at senior
 house officer level should
 concentrate on the normal and
 those aspects of abnormality that
 can be dealt with by general
 practitioners                             418 (76)      62 (11)       67 (12)

The 128 general practitioners who reported booking women for home delivery showed a difference of opinion from the other general practitioners on over half the statements. General practitioners who booked home deliveries were over three times more likely to agree that they would like to offer more intrapartum care to their patients (62/42 v 61/316, X²=85.3, df=2; P<0.0001), were more likely to feel competent (80/38 v 73/311, X²=101.2, df=2; P<0.0001), and were less likely to report lack of confidence (32/84 v 235/133, X²=48.1, df=2; P<0.0001), fear of litigation (72/42 v 304/65, X²=18.7, df=2; P<0.0001), disruption to their personal life (74/38 v 332/55, X²=25.1, df=2; P<0.0001), attitudes of their fellow partners (35/55 v 168/122, X²=19.42, df=2; P<0.001), or their current workload (93/28 v 359/31, X²=21.2, df=2; P<0.0001) as discouraging them from offering more intrapartum care compared with other general practitioners. They were more likely to agree that women should be able to choose the place of birth (90/22 v 195/151, X²=22.7, df=2; P<0.0001), to believe that a widespread demand for choice exists among women (87/23 v 227/129, X²=9.1, df=2; P=0.01), and to agree that the policy of increasing hospitalisation cannot be justified on the grounds of safety (68/52 v 121/255, X²=24.8, df=2; P<0.0001).

Discussion

The degree to which the population of general practitioners studied in this survey are representative of general practitioners nationally cannot easily be determined. However, the descriptive statistics show broad agreement with figures produced for the BMA in 1993 on the number of general practitioners providing antenatal and postnatal care, the proportion of men and women, and the size of partnerships.¹² In the BMA survey, the proportion of general practitioners wishing to provide intrapartum care was 27.3%, which is in keeping with the 22.8% in this survey. However, the proportion of doctors providing intrapartum care was much lower than the 25% reported by Marsh et al in the Northern region in 1983.¹³

Reasons for not providing intrapartum care

The most important reasons given for being discouraged from providing intrapartum care were current workload, disruption to personal life, and fear of litigation. The workload of general practitioners has increased since the introduction of the new general practitioner contract.^14,15 Disruption to personal life has also been cited as justification for not continuing with obstetric work in America.¹⁶ Although obstetric work in Britain does not necessarily take more hours, it does affect lifestyle. It could be difficult to persuade doctors who have given up obstetrics to take it up again if their lives are now less stressful.¹⁷

Litigation has been rising in all areas of medicine in recent years. Younger general practitioners seem to fear litigation the most. This may be because they are better informed of the risks, or because, as some commentators have suggested,*RF 18-20* they have been in a hospital obstetric environment more recently and are more likely to have been "reared on a diet of abnormality and fear."²⁰

Surprisingly, general practitioners did not find lack of remuneration an important deterrent. Increasing payments in line with the disruption caused by provision of intrapartum care has been suggested to be the best way of increasing general practitioners' participation,*RF 21-23* but my results indicate that this may not be effective.

Training, too, was not considered particularly important. Smith's survey of general practice trainees found that though an obstetric senior house officer job increased perceived competence to perform obstetric procedures, it did not encourage trainees to use their skills.²⁴ It has been suggested that hospital obstetric training should be given only to those trainees who wish to provide intrapartum care.^23,24 General practitioners in this survey agreed that training should concentrate on normal deliveries and that obstetricians should primarily be used for the care of women with complications. Such an arrangement might therefore be welcomed.

Meeting demand for choice

The Winterton report concluded that most women have no choice about their maternity care. The Cumberlege report recommended that maternity services should be woman centred. Since most general practitioners in this survey did not want to offer intrapartum care it may be difficult to meet the increasing demand for more choice.

A minority of general practitioners did wish to provide more intrapartum care and had positive attitudes towards community obstetrics, and these general practitioners were likely to book for home delivery already. Establishing local forums for enthusiastic general practitioners similar to those already run by the Association for Community Based Maternity Care would enable these general practitioners to identify ways of providing intrapartum care without unduly disrupting their personal life or their surgery time while at the same time reducing the likelihood of litigation.

Subspecialisation within general practice has become more common, larger partnerships using the skills of individuals in certain areas such as dermatology, cardiology, and ophthalmology for all patients.²⁵ Such arrangements could be applied to the provision of intrapartum care. Indeed, in some practices this is already happening. The experience in the Netherlands shows that the success of such an arrangement depends on the support of other professional groups, most importantly the obstetricians and midwives who currently provide most intrapartum care.²⁶

I thank all those general practitioners who completed the questionnaire and the staff of the department of general practice and the department of public health medicine and epidemiology at the University of Nottingham Medical School for their support and help.

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