Let the little children come unto me

Øyvind Stople Sivertsen About the author
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General practitioners should retain their key role in the follow-up of pregnancies.

Photo: Sturlason

Each year, approximately 55 000 children are born in Norway (1). In a normal pregnancy, the mother is offered eight regular check-ups, and she can choose whether she wants to see a doctor or a midwife. Given the current pressure on the GP scheme, it is perhaps a faux pas to mention all the tasks we wish to keep. This could particularly apply to these more than 440 000 potential appointments.

Good pregnancy and antenatal care is a finely tuned interplay between doctors, midwives and public health nurses. As a result, things most often turn out well for pregnant Norwegian women and their children. Norway has among the lowest rates of maternal mortality during pregnancy in the world (2), as well as the lowest rates of complications and mortality among both prematurely born infants and infants born at full term (3, 4). Figures from the Medical Birth Registry of Norway show that more than two-thirds of all births among primiparous women occur without any major interventions or complications, and for multiparous women the rate is as high as nine in ten births (5).

However, each pregnancy, each child encompasses so much more than figures and national averages. The new families face anticipation, concern, fear, anxiety, relief and sometimes grief. Their feelings vary from the deepest despair to unbounded joy. There are endless ways to get lost in well-intended advice during pregnancy, and at least as much advice post partum. The vast majority want the best for their children. But what is the best, and to whom should they turn? Is the doctor or the midwife the right person to consult?

In many municipalities, doctors and midwives have established good and effective collaboration. The follow-up of pregnancies is comprehensive, and both professions can apply their respective strengths. This summer, however, the follow-up of pregnant women turned into a kind of competition. In August, the Norwegian Midwives Association posted a video on its Facebook page, claiming that both the mother and the child fare better if they are followed up by a midwife during pregnancy. This naturally caused an outcry (6). The message was that all pregnant women should see a midwife, who was claimed to be the expert on women’s health. Unfortunately, the message was not only unsubtle, it was incorrect.

Pregnancy care is too important to be turned into a tug-of-war between different professions

The evidence base that was used, a Cochrane report from 2015, has later been updated and its conclusions have been changed (7). The groups that were compared included women who were monitored by a midwife from the first check-up throughout the pregnancy and until delivery, i.e. by one and the same midwife – so-called midwife-led care. This is not comparable with Norwegian conditions, where most women meet a completely different midwife in the hospital than the one who followed them through their pregnancy. The success criterion is therefore presumably not the midwife per se, but rather continuity in the provision of care and follow-up.

In June, the leaders of the Norwegian Nurses Association and the Norwegian Midwives Association published an op-ed where they all but claimed that the GPs’ interest in pregnant women is mainly based on financial concerns (8). They also wished to obtain the right to certify sickness and make referrals. Whereas it might be easy to find arguments in favour of the latter, the wish to be authorised to certify sickness appears less well-considered. Assessment of the degree of sickness requires knowledge of opportunities for workplace adaptation, social insurance medicine, the work of issuing medical certificates, and diseases other than those induced by pregnancy. I believe that I have many GPs with me when I postulate ‘forgive them, for they know not what they do’ about this wish to be authorised to certify sickness.

An increasing number of pregnant women suffer from chronic diseases such as diabetes, asthma/allergy, metabolic syndrome, cardiovascular disease, hereditary conditions, mental disorders or issues of substance abuse (9). Such conditions require medical assessment during and after pregnancy. This is an important task for GPs, and it provides the woman with reassurance and continuity.

Trust and continuity are among the key factors for a good doctor-patient relationship (10, 11). If we remove pregnancy and the postnatal period from this relationship, patients and doctors both stand to lose more than might seem the case at first glance. Pregnancy is a special and vulnerable period in a woman’s life. It should be self-evident that the doctor remains interested, updated and engaged throughout this period.

Pregnancy care is too important to be turned into a tug-of-war between different professions. It is most likely best undertaken by doctors and midwives working in collaboration, with proper guidelines regarding who does what – and when. Not about who should do everything.

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