Intended for healthcare professionals

Rapid response to:


Maternal mortality in the UK and the need for obstetric physicians

BMJ 2011; 343 doi: (Published 09 August 2011) Cite this as: BMJ 2011;343:d4993

Rapid Response:

Frustrating lack of analysis


Leaving aside the grating juxtaposition of "general practitioners" and "doctors" (as if we GPs were no real doctors), the article jumps to a conclusion without any real analysis and contributes therefore little to the future welfare of pregnant mothers with chronic health problems.

Given the utter horror and devastation caused by each maternal death, this is very frustrating.

So, to offer some suggestions for further debate, I recommend a short look at what actually has changed in the way antenatal care is done in the UK between - say - 2000 and now? What could possibly contribute a rise in deaths of chronically ill mums?

In the year 2000 it was routine for most mums-to-be to be seen in an antenatal clinic in their doctors' (GPs) surgeries. Midwives attended and jointly or sequentially saw with the GP every mum, rather frequently.

We GPs had much exposure to normal pregnancies and were - hopefully - able to spot the "not normal" pregnancy from afar. We (GPs and midwives) complemented each other and learned from each other. We had much exchange, both formal and informal. Patients clearly profited from this.

Fast forward to today - GPs are essentially squeezed out of the antenatal care. Midwives have acquired a near-monopoly over all antenatal care and have largely dispensed of sharing information and requesting medical advice from GPs. Often we GPs are nowadays unaware who of our patients is pregnant or who has developed medical problems in pregnancy.

In early 2011 the Scottish Government sent out a letter to GPs advising them of a current poster campaign in community pharmacies telling mums-to-be, that it is not any more necessary to see their GP when pregnant, but they could directly go to see midwives. Midwives in turn would, if mothers wished so, share info back to the GP.

Now, who would think such an arrangement up, removing the one person with good and direct knowledge of the patient and their health and keeping them routinely in the dark?

This is just one example of a vast systemic change which has had likely severe impact. Dr Hogg points at another, when relating his experiences in GP obstetric training.

Maybe Professor Nelson-Piercy should have looked first at the complete picture before making a plea for more recognition (and presumably funding) for her sub-speciality. And maybe Doctors Falconer and Cardigan could have directed her in that direction, instead of jostling which specialist should get the lead in antenatal care

The bulk of mothers-to-be with chronic health problems will benefit from their own GP being closely involved, contributing directly and confidently to a shared care model. Only a small minority will hopefully ever need sub-speciality services. And even those would likely benefit from their GPs having direct input into their care.

Competing interests: No competing interests

10 August 2011
Peter von Kaehne
General Practitioner
Argyll, Scotland