Obstetricians should focus on problemsBMJ 1995; 310 doi: https://doi.org/10.1136/bmj.310.6971.37 (Published 07 January 1995) Cite this as: BMJ 1995;310:37
- David K James, professor of fetomaternal medicinea
The provision of care for pregnant women is changing enormously. Many of these changes were under way before the well publicised Winterton and Cumberlege reports.1 2 One of the changes is that women with normal pregnancies increasingly see their general practitioner and midwife for most of their care and see the obstetrician less often. In some instances women do not see an obstetrician at all. I think that this trend is to be encouraged. I believe that in the ideal world women with normal pregnancies need not see an obstetrician for four reasons—consumer, philosophical, scientific, and evolutionary.
Several studies have shown that most women with normal pregnancies do not wish to see an obstetrician.3 4 5 6 Naturally, it is difficult for such studies to be free of bias. It depends who asks the questions, how they are asked, and how they are phrased. Nevertheless, I am not aware of any survey which claimed that most women would wish to see an obstetrician if their pregnancy were normal.
Care in pregnancy has four aims (box).7 General practitioners and midwives are perfectly able to fulfil the first three aims (providing reassurance, treatment of minor problems, and undertaking screening). There is no evidence that obstetricians are any better at performing these functions in otherwise normal pregnancies. In contrast, women with problems in pregnancy require the skills of an obstetrician, and it is at these women that an obstetrician's efforts are best directed.8
Controlled studies have shown that the outcome of women with normal pregnancies seen by an obstetrician is no better than that when no obstetricians are involved.9 10 It should be stressed, however, that in such studies the normal pregnancies were managed following clearly documented guidelines for identification of risk and referral for obstetric review should problems be recognised.
Aims of care in pregnancy7
To provide advice, reassurance, education, and support for the woman and her family
To deal with the minor ailments of pregnancy
To provide an ongoing screening programme (clinical and laboratory based) to confirm that the woman continues not be at risk
To prevent, detect, and manage those problems and factors that adversely affect the health of the mother or her baby
Obstetricians should have and develop skills that are different from those of general practitioners and midwives. These skills are those which at present are regretfully seen as the province of the subspecialist. Thus obstetricians in future should be expected to have expertise in ultrasound evaluation of the fetus, care of the more routine medical problems without immediate reference to a physician, and high dependency obstetric management.
In addition, all obstetricians should take part to some degree in clinical audit and research. This is more likely to have a multicentre basis. For example, there is a pressing need for the development of new methods of screening for fetal compromise in normal pregnancies. It is hardly surprising that over half of fetal deaths are unexplained when current fetal screening comprises only monitoring of fetal activity, measurement of fundal height, and auscultation of the fetal heart.
In an ideal world women with normal pregnancies should not see an obstetrician. Most do not want to, and they do not need to. Obstetricians should be concentrating their skills on women with problems. Pregnant women should see medical professionals according to their clinical needs and individual wishes. The general practitioner, midwife, and obstetrician represent the professional team responsible for providing care for all pregnant women. Though obstetricians need not provide care for normal pregnancies they should have a role in the interdisciplinary planning and audit of such care. General practitioners and midwives should share responsibility for caring for women with normal pregnancies—not the midwife alone. Each has skills that the other does not possess. They should not duplicate each other's efforts but complement them.