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The waiting game

GP postnatal checks are a vital part of women's care, not a chore

Dr Stephanie De Giorgio urges colleagues to get behind the proposal to embed six-week postnatal checks in the GP contract

dr stephanie de giorgio

I usually love the Copperfield posts; they can make me chuckle or raise an eyebrow. The contribution last week was a disappointing mess of inaccuracy and stereotype – and didn’t really feel like the usual satirical post.

It has always been public knowledge, but I shall now officially out myself as one of those involved in the proposal to get a fully funded six-week maternal check into the GP contract. To do this, I have worked alongside the wonderful staff at the NCT.

As an ex- obs and gynae reg, this didn’t originally sit easily with me (for reasons we all know) but after an initially rocky start, we got on brilliantly and the organisation has been receptive, engaged and massively skilful in navigating the messy world of politics, the media and medicine.

So why did I get involved in something when I spend many hours of my life telling GPs NOT to do things and take on more? It seems counterintuitive. I got involved because postnatal care in the UK is currently failing women and their families.

For very many women this is a difficult, traumatic and confusing time during which they need dedicated care

This isn’t some incredibly rare, once-in-a-career diagnosis that a GP ‘is best placed’ to manage. This is something that affects all women who give birth in the UK and that sadly, when managed badly, has lifelong implications for women.

Far from being a ‘recurring chore’ or ‘touchy feely’ stuff, this may be the one dedicated chance for a vulnerable woman who is feeling hideously anxious or suffering from incontinence or pain having had her pelvic floor sewn back together to ask her doctor for help and advice. I would suggest that it is only a ‘pointless ritual’ if it is done badly. Done well, it is an important opportunity to uncover significant pathology, or a valuable time for reassurance and holistic care.

So, what do we know about the postnatal period for women in the UK? The MBRRACE report released just a few days ago showed that suicide is still the leading direct cause of death for women in the six to 42 weeks postnatally. Many of the women who died did not have the care they needed in the antenatal and postnatal period.

The Falling through the Gaps report by the Centre for Mental Health and the Hidden Half research both indicated that women will not disclose significant mental health problems postnatally unless asked directly, in an open non-judgemental manner, in time dedicated to them. They are fearful of the stigma and implications.

Perinatal mental health issues affect approximately one in four women. This isn’t a niche problem, this is a massive undiagnosed amount of pathology that we are missing to the detriment of women and their children. PTSD, OCD, depression and anxiety, all serious conditions that must not be missed but are being missed in half of women suffering from them.

Research soon to be published indicates that up to 30% of women will experience faecal urgency or incontinence issues in the year after birth, but again, will not divulge this information unless directly asked, mostly due to embarrassment. Urinary incontinence, domestic violence, perineal pain, body image… the list of problems that can and do exist during this period when a woman is absolutely at her most vulnerable is huge.

The NCT questions that Copperfield alludes to do not form the basis of the postnatal check. I have created a template, in conjunction with experts in the field of perinatal psychiatry, women’s health physio, obstetrics and gynaecology, psychology and general practice. It specifically guides the person doing the check to ask the difficult and important questions. Unsurprisingly, the question ‘does your perineum feel ok?’ is not in there.

The evidence for the timing of postnatal care is limited, because it has suffered from being an under- researched and poorly funded service for so long. It got ‘forgotten’ from the 2004 contract. No funding equals no audit.

The bid put together by the NCT specifies that this has to come with adequate funding. The checks can be done by a GP or another dedicated trained health professional and can be done at a practice or cluster level. It also includes money for training. Those who are doing it already will finally be paid for their hard work. Those who aren’t, will be able to set up a system of checks.

To dismiss women’s care at one of the most difficult times in their lives as a ‘chore’ is deeply insulting. Yes, some sail through it and it might mean you get to catch up writing your Pulse columns if they leave quickly. For very many women however, this is a difficult, traumatic and confusing time during which they need dedicated care.

The status quo is failing women, badly. Women are dying and suffering from significant harm as a result of not getting good postnatal care and the effects of this stay with them life-long.

Including the six-week postnatal check may be an opportunity to start the process of working together with our community midwifery and health visiting colleagues to right this wrong.

I know some GP colleagues will never agree with this, I know many others are firmly behind it. I hope all will, if the government funds this appropriately, give it their best shot to ensure postnatal women begin to get the care that the evidence shows they need.

Dr Stephanie De Giorgio is a portfolio GP and maternal and infant mental health lead for East Kent

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Readers' comments (6)

  • Okay I’m all for this but had been doing this check for decades until midwives muscled in on the service. This ‘check’ was sometimes as useful as asking the Tesco checkout person for advice and reassurance and invariably the advice was ‘see your GP’ !!
    That being said I feel that the six week check for mothers should also include the check for babies too as many issues can materialise when mother and baby are seen together. More work maybe but potential present or future problems can be dealt with before they become worse but my past obstetric experience may make me a bit biased in giving my opinion!

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  • doctordog.

    Great idea- with appropriate time and manpower.

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  • I think it's great you've highlighted the need for better postnatal care for women but I think there are more fundamental problems with maternity care that a GP appt at 6 weeks isn't going to fix. Many women are suffering from PTSD after labour due to their horrendous experiences in hospital - while it is good to pick this up it would be better to prevent it happening with better staffing, support, access to analgesia etc and better postnatal support in hospital. If there are perineal problems will it be guaranteed we can quickly refer back to an obstetrician/gynae physio otherwise there isn't much point in identifying a problem. My other issue is the NCT - I personally detest this organisation, I think they are part of the natural childbirth agenda that has dominated midwifery and maternity care leading to deliberate inadequate analgesia provision, demonisation of cesarean section and other interventions leading to the disasters at Morecambe Bay etc and to a massive group of women feeling like they have failed as they didn't manage to have a natural birth when this is completely out of their control. I think this is why postnatal care is so scanty, it's like 'well if she'd just tried harder she wouldn't have had a 60hr labour forceps and an episiotomy so on you go....'

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  • Cobblers

    Old Codger Hat on: Time was when women would come to the GP have their pregnancy test, be diagnosed pregnant and booked into the GPs antenatal clinic. Delivery could be under the GP's care but mostly not. Post natal clinic followed that and there was continuity.

    Then the Madwife took over and Obstetrics all but vanished in GP in the new Contrick in 2004.

    Now the government wants to bring part of it back. At a time when there is no spare time in the GPs day. And at a time when a lot of GPs are untrained or deskilled in Obstetric care.

    Now we have a "special interest GP" banging her drum and involved in the proposal to get a fully funded six-week maternal check into the GP contract.

    This is but half the question. By all means bring it in FULLY FUNDED, and generously so, but also consider what you would take out of the GP day to allow this to slot in.

    Failure to do the latter means, funded or not, evidence based or not, it does not enter the contract.

    Have I made your day harder Stephanie? My apologies but time to step back on your currently overfocused viewpoint.

    GP is overworked and dying. Don't kick it further.

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  • Good on you Cobblers in making the point better than I was trying to do! Some of us ‘mature’ GPs did have obstetric experience and willingly used and enjoyed it. As the midwives ‘took over’ I found that many women were disappointed that the main contact with their GP had been taken away from them against their wishes. How on earth that can be reintroduced back to the GP even postnatally with all the other demands on us would be challenging (understatement!). We can only sit back and see where it takes us.

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  • Necessity and chore do not have to be mutually exclusive. Think: appraisal, washing the car...…….etc etc.

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