CORRESPONDENCE * All letters must be typed with double spacing and signed by all authors. * No letter should be more than 400 words. * For letters on scientific subjects we normally reserve our correspondence columns for those relating to issues discussed recently (within six weeks) in the BMJ'.
* We do not routinely acknowledge letters. Please send a stamped addressed envelope if-you would like an acknowledgment. * Because we receive many more letters than we can publish we may shorten those we do print, particularly when we receive several on the same subject.
General practice obstetrics in Bradford SIR,-Although we share the concern of our consultant colleagues about the high perinatal mortality in 1988 in Bradford,' too many conclusions should not be drawn from the figures of one year. In 1986 the perinatal mortality was even higher, at 16/1000, preceded by 11 4/1000 in 1985 and followed by 11 3/1000 in 1987, showing that there have been wide variations even in the space of four years. We find it illogical to single out the figures of one year and then attach the whole blame for the rise in perinatal mortality in that year to general practice obstetrics. Indeed, if that were the case the much better figures of 1985 and 1987 must have also been due to the supposedly high standard of general practice obstetrics, something which is equally difficult to substantiate. Repeated national, regional, and local surveys indicated the safety of general practice obstetrics,'7 and it would be contrary to all published evidence to argue against it. Furthermore, even with the use of the best predictors of risk in pregnancy (and there are a few) there is no guaranteed way of knowing that a low risk pregnancy will remain low risk and that a potentially high risk pregnancy will not follow a normal course.8 Pregnancy is a dynamic process that can change rapidly without anv warning and therefore requires careful monitoring with a constant readiness to modify the management plans whenever necessary. The authors report that there were four deaths in the group that was transferred antenatally and nine in the group transferred in labour. Without knowing the details of each case it is impossible to comment on whether the outcome would have been different had the patient been transferred earlier or, indeed, booked under a consultant. Balarajan and Botting recently reported that the perinatal mortality nationally was 85% higher among women born in Pakistan than among women born in the United Kingdom, a finding with obvious relevance to Bradford.9 Some of the women transferred antenatally had not had a scan to establish the exact gestation of the pregnancy. Even allowing for the vagaries of ultrasonic examination, general practitioners were until recently actively discouraged from arranging routine scanning of their patients during pregnancy because of shortages of staff and equipment. It seems unfair to castigate general practitioners for insufficient use of a service that was never available to them. The other disturbing assertion is that as some patients who were transferred from general practice to consultant care were delivered normally the transfers were inappropriate. The reasons for transfer of patients in any specialty are complex and may include factors such as patient choice, external pressures from relatives and staff, and the BMJ
VOLUME 300
31 MARCH 1990
general practitioner's own sense of anxiety. The fact that many transfers end up without any need for intervention does not negate the original reason for the transfer unless these other factors have been considered. As far as epidural anaesthesia is concerned most patients booked under general practitioners request this form of analgesia in the light of their progress in labour. Many general practitioners would be quite happy to continue to supervise the intrapartum care of these patients were it not for the policy of the department of anaesthesia that the patients must be transferred to consultant care. It is a matter of regret that 11 patients (out of 259) were seen by the deputising service. This is contrary to the guidelines, but every deputising doctor must have completed vocational training and be on the obstetric list, so a deputising doctor should be no less safe than the patient's own general practitioner. Moreover, we concur fully with the view of the Royal College of Midwives that the midwife has a central role in the conduct of normal delivery. It could be argued that the presence of a general practitioner or, indeed, a consultant at delivery is rarely necessary so long as the midwife has ready access to the doctor in case of complication. Finally, we appreciate that the desire of our consultant colleagues, like that of every general practitioner in Bradford, is to improve the perinatal mortality figures. But it is important to remember the following principles. Firstly, the essence of obstetric care is to provide our patients with a high and safe standard of care that is as sensitive to their needs and wishes as possible. The Consumers Association recently recommended that there should be more incentives for general practitioners to be concerned in maternity care of their patients.'0 Secondly, obstetric care should be regarded as teamwork with members of the team, free from interprofessional rivalry, working and communicating with each other to the benefit of their patients. Thirdly, there have to be regular opportunities for auditing our obstetric performance through constructive discussion. As a response to these anxieties and our desire to improve the standards of obstetric care in Bradford we propose to set up a general practitioner maternity morntoring group with the overall aim of monitoring, coordinating, and evaluating general practitioner obstetrics in Bradford. J BAHRAMI K HAYWOOD R j GIVANS
Bradford Local Medical Committee, Harrogate, North Yorkshire HGl lBP I Bryce FC, Clayton JK, Rand RJ, Beck l, Farquharson DIM, Jones SE. General practitioner obstetrics in Bradford.
RrMedJ7 1990;300:725-7. (17 Mlarch.)
2 Taylor GW, Edgar W, Taylor BA, Neal DE. How safe is general practitioner obstetrics? Lancet 1989;ii: 1287-9. 3 Tew M. Facts not assertions of belief. Health and Social Services journal October 1981:1194-7. 4 Tew M. Effects of scientific obstetrics on perinatal mortality. Health and Social Servicesjournal April 1981: 444-6. 5 Klein M. Booking for maternity care: a comparison of two systems. London: Royal College of General Practitioners, 1985. (Occasional paper 31.) 6 Bull MJV, Ten years' experience in general practice obstetric unit. JR Coll Gen Pract 1980;30:208-15. 7 Richmond GA. An analysis of 3199 patients booked for delivery in general practitioner obstetric units. J R Coll Gen Pract 1977;27:406-13. 8 Reynolds JL, Yudkin PL, Bull MJV. General practitioner obstetrics: does risk prediction work? J R Coll Gen Pract 1988;38:307-10. 9 Balarajan R, Botting B. Perinatal mortality in England and Wales-variations by mother's country of birth. Health Trends 1989;21:79-84. 10 Anonymous. Which way to health. London: Consumers Association, 1989:13-9.
SIR,-In fairness to colleagues practising obstetrics in integrated general practitioner units elsewhere I think that I should respond to the article by Dr F C Bryce and colleagues on general practitioner obstetrics in Bradford.' Regrettably, our unit in Oxford is not the paragon without flaw that seems to be implied. We may have our strengths, but we also have some problems that it may be constructive to discuss. Firstly, it is not true that in Oxford only a few general practitioner obstetricians can admit patients to the delivery ward. In fact, in 1989, 72 general practitioners held contracts with the district health authority to use our integrated maternity unit and-6Siof them admitted patients. This nrumrber represents about 85°0 all general practitioners who practise within the catchment r must area. To retain a contract the practit be on the family practitioner committ e o stetric list (criterion vi is not permitted) and must ttend a minimum of five deliveries each year. Actually, the average caseload is 10-just about in line with the recommendations of the joint working party on training for general practitioners in obstetrics,2 but still arguably too low to maintain practical skills and familiarity with the new technology. We have shown that the transfer rate is inversely proportional to caseload, and 10 cases each year doe seem to be the minimum number r¢quired to maintain reasonable confidence (M Bull, unpublished work). The inference is, then, that it would be more efficient if fewer general practitioners booked more cases, but this is a political issue locally and, in any event, such a course could reduce choice for patients and also diminish continuity of care-the raison d'etre of our unit. It is also true that we have encouraged general practitioners to attend their patients during labour, and we have a recording system to monitor this. In recent years, more than 80% of women were seen by their general practitioner (or his or her nominated deputy) during labour, and a general practitioner was present at the delivery in 67% of
873
* We do not routinely acknowledge letters. Please send a stamped addressed envelope if-you would like an acknowledgment. * Because we receive many more letters than we can publish we may shorten those we do print, particularly when we receive several on the same subject.
General practice obstetrics in Bradford SIR,-Although we share the concern of our consultant colleagues about the high perinatal mortality in 1988 in Bradford,' too many conclusions should not be drawn from the figures of one year. In 1986 the perinatal mortality was even higher, at 16/1000, preceded by 11 4/1000 in 1985 and followed by 11 3/1000 in 1987, showing that there have been wide variations even in the space of four years. We find it illogical to single out the figures of one year and then attach the whole blame for the rise in perinatal mortality in that year to general practice obstetrics. Indeed, if that were the case the much better figures of 1985 and 1987 must have also been due to the supposedly high standard of general practice obstetrics, something which is equally difficult to substantiate. Repeated national, regional, and local surveys indicated the safety of general practice obstetrics,'7 and it would be contrary to all published evidence to argue against it. Furthermore, even with the use of the best predictors of risk in pregnancy (and there are a few) there is no guaranteed way of knowing that a low risk pregnancy will remain low risk and that a potentially high risk pregnancy will not follow a normal course.8 Pregnancy is a dynamic process that can change rapidly without anv warning and therefore requires careful monitoring with a constant readiness to modify the management plans whenever necessary. The authors report that there were four deaths in the group that was transferred antenatally and nine in the group transferred in labour. Without knowing the details of each case it is impossible to comment on whether the outcome would have been different had the patient been transferred earlier or, indeed, booked under a consultant. Balarajan and Botting recently reported that the perinatal mortality nationally was 85% higher among women born in Pakistan than among women born in the United Kingdom, a finding with obvious relevance to Bradford.9 Some of the women transferred antenatally had not had a scan to establish the exact gestation of the pregnancy. Even allowing for the vagaries of ultrasonic examination, general practitioners were until recently actively discouraged from arranging routine scanning of their patients during pregnancy because of shortages of staff and equipment. It seems unfair to castigate general practitioners for insufficient use of a service that was never available to them. The other disturbing assertion is that as some patients who were transferred from general practice to consultant care were delivered normally the transfers were inappropriate. The reasons for transfer of patients in any specialty are complex and may include factors such as patient choice, external pressures from relatives and staff, and the BMJ
VOLUME 300
31 MARCH 1990
general practitioner's own sense of anxiety. The fact that many transfers end up without any need for intervention does not negate the original reason for the transfer unless these other factors have been considered. As far as epidural anaesthesia is concerned most patients booked under general practitioners request this form of analgesia in the light of their progress in labour. Many general practitioners would be quite happy to continue to supervise the intrapartum care of these patients were it not for the policy of the department of anaesthesia that the patients must be transferred to consultant care. It is a matter of regret that 11 patients (out of 259) were seen by the deputising service. This is contrary to the guidelines, but every deputising doctor must have completed vocational training and be on the obstetric list, so a deputising doctor should be no less safe than the patient's own general practitioner. Moreover, we concur fully with the view of the Royal College of Midwives that the midwife has a central role in the conduct of normal delivery. It could be argued that the presence of a general practitioner or, indeed, a consultant at delivery is rarely necessary so long as the midwife has ready access to the doctor in case of complication. Finally, we appreciate that the desire of our consultant colleagues, like that of every general practitioner in Bradford, is to improve the perinatal mortality figures. But it is important to remember the following principles. Firstly, the essence of obstetric care is to provide our patients with a high and safe standard of care that is as sensitive to their needs and wishes as possible. The Consumers Association recently recommended that there should be more incentives for general practitioners to be concerned in maternity care of their patients.'0 Secondly, obstetric care should be regarded as teamwork with members of the team, free from interprofessional rivalry, working and communicating with each other to the benefit of their patients. Thirdly, there have to be regular opportunities for auditing our obstetric performance through constructive discussion. As a response to these anxieties and our desire to improve the standards of obstetric care in Bradford we propose to set up a general practitioner maternity morntoring group with the overall aim of monitoring, coordinating, and evaluating general practitioner obstetrics in Bradford. J BAHRAMI K HAYWOOD R j GIVANS
Bradford Local Medical Committee, Harrogate, North Yorkshire HGl lBP I Bryce FC, Clayton JK, Rand RJ, Beck l, Farquharson DIM, Jones SE. General practitioner obstetrics in Bradford.
RrMedJ7 1990;300:725-7. (17 Mlarch.)
2 Taylor GW, Edgar W, Taylor BA, Neal DE. How safe is general practitioner obstetrics? Lancet 1989;ii: 1287-9. 3 Tew M. Facts not assertions of belief. Health and Social Services journal October 1981:1194-7. 4 Tew M. Effects of scientific obstetrics on perinatal mortality. Health and Social Servicesjournal April 1981: 444-6. 5 Klein M. Booking for maternity care: a comparison of two systems. London: Royal College of General Practitioners, 1985. (Occasional paper 31.) 6 Bull MJV, Ten years' experience in general practice obstetric unit. JR Coll Gen Pract 1980;30:208-15. 7 Richmond GA. An analysis of 3199 patients booked for delivery in general practitioner obstetric units. J R Coll Gen Pract 1977;27:406-13. 8 Reynolds JL, Yudkin PL, Bull MJV. General practitioner obstetrics: does risk prediction work? J R Coll Gen Pract 1988;38:307-10. 9 Balarajan R, Botting B. Perinatal mortality in England and Wales-variations by mother's country of birth. Health Trends 1989;21:79-84. 10 Anonymous. Which way to health. London: Consumers Association, 1989:13-9.
SIR,-In fairness to colleagues practising obstetrics in integrated general practitioner units elsewhere I think that I should respond to the article by Dr F C Bryce and colleagues on general practitioner obstetrics in Bradford.' Regrettably, our unit in Oxford is not the paragon without flaw that seems to be implied. We may have our strengths, but we also have some problems that it may be constructive to discuss. Firstly, it is not true that in Oxford only a few general practitioner obstetricians can admit patients to the delivery ward. In fact, in 1989, 72 general practitioners held contracts with the district health authority to use our integrated maternity unit and-6Siof them admitted patients. This nrumrber represents about 85°0 all general practitioners who practise within the catchment r must area. To retain a contract the practit be on the family practitioner committ e o stetric list (criterion vi is not permitted) and must ttend a minimum of five deliveries each year. Actually, the average caseload is 10-just about in line with the recommendations of the joint working party on training for general practitioners in obstetrics,2 but still arguably too low to maintain practical skills and familiarity with the new technology. We have shown that the transfer rate is inversely proportional to caseload, and 10 cases each year doe seem to be the minimum number r¢quired to maintain reasonable confidence (M Bull, unpublished work). The inference is, then, that it would be more efficient if fewer general practitioners booked more cases, but this is a political issue locally and, in any event, such a course could reduce choice for patients and also diminish continuity of care-the raison d'etre of our unit. It is also true that we have encouraged general practitioners to attend their patients during labour, and we have a recording system to monitor this. In recent years, more than 80% of women were seen by their general practitioner (or his or her nominated deputy) during labour, and a general practitioner was present at the delivery in 67% of
873
