According to Bettering the Evaluation and Care of Health (BEACH) data, pregnancy and family planning consultations accounted for 2.3% of general practice consultations in 2014–15.1 Australian women are having fewer babies at later ages than they were decades ago.2 In 2014, the median age of all mothers was 30.9 years and the fertility rate was 1.8 babies per woman.2
Considering that 51% of women have experienced an unplanned pregnancy in their lifetime,3 32% of first pregnancies are unplanned and 29% are unwanted,4 the provision of opportunistic prenatal counselling to woman in the child- bearing years as well as contraceptive advice if pregnancy is not planned is extremely important.
Particularly vulnerable are Aboriginal and Torres Strait Islander women who have higher fertility at younger ages than non-indigenous women, with the teenage pregnancy rate (maternal age less than 20 years) in 2006 being five times higher than in non-indigenous women. Newly arrived immigrant women and women of refugee-like background form another vulnerable group, and are likely to lack adequate information on contraceptive options, which increases their risk of unplanned pregnancy.5 (Refer to contextual units AH16 and RA16 for more information.)
General practitioners (GPs) carry out a number of important roles in regard to pregnancy irrespective of whether a GP has received specialised training in obstetric care. The importance of prenatal counselling to optimise outcomes, as well as antenatal, intrapartum and postnatal care, cannot be underestimated. A broad range of knowledge and skills is required to deliver quality care to pregnant women, and the degree to which a GP needs to attain these skills is largely dependant on their clinic context. As an example, the skills required for an inner-urban GP interested in providing shared care will be very different to those required by a remote rural GP who has completed advanced training in managing complex deliveries and complications.
Regardless of the context in which they practice, all Australian GPs should have skills in prenatal counselling, identification of risks before and during pregnancy and provision of care in the postnatal period.
The risks of smoking and consumption of alcohol during pregnancy on the developing fetus and ongoing risks to the growing child are well recognised but, despite this, in 2009 one in seven women smoked and in 2010 approximately half drank alcohol during pregnancy.6
Effective prenatal counselling should include ensuring that health is optimised prior to conception, particularly that vaccinations are up to date (especially rubella, varicella and influenza), enquiring into infectious disease risk (eg hepatitis B or C, human immunodeficiency virus [HIV], syphilis, varicella antibody status, herpes) and family history to assess risk of genetic conditions such as thalassaemia, sickle cell anaemia and Down syndrome to determine whether pre-conception testing and specialised genetic counselling should be considered for couples who are found to be carriers. Assessment of psychosocial risk factors, diet (particularly regarding folate supplementation), exercise, substance use, chronic disease (eg epilepsy, diabetes, inflammatory bowel disease) and medication risks, particularly in regards to category C, D and X medications (eg isotretinoin, sodium valproate, warfarin). Risks for future exposure to TORCH infections (toxoplasmosis; other infections, including listeria and parvovirus [particularly for healthcare and childcare workers]; rubella; CMV; and herpes) should also be assessed to ensure that women and their partners are well informed.7
GPs in Australia can provide a broad spectrum of care in the antenatal, intrapartum and postnatal periods, depending on the context in which they work. In 2011, the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) in conjunction with The Royal Australian College of General Practitioners (RACGP) and the Australian College of Rural and Remote Medicine (ACRRM) revised the suite of women’s health qualifications available to cater for these different contexts.8–10 These qualifications include:
- Certificate in Women’s Health (CWH) to facilitate the provision of high-quality office-based obstetric and gynaecological care
- Diploma of the Royal Australian and New Zealand College of Obstetrics and Gynaecologists (DRANZCOG), which includes management of uncomplicated labour and basic gynaecological procedures (such as termination of pregnancy)
- Advanced DRANZCOG – a more complex, procedure-based qualification that includes management of complicated labour including caesarean section, gynaecological procedures such as basic laparotomy and hysteroscopy, and training in first trimester and late pregnancy ultrasound.
Refer to the RANZCOG website for a detailed outline of knowledge and skills required for attainment of these qualifications.
GPs often play an important role in providing antenatal care. There are a variety of models in which GPs can provide this care, depending on the skills and qualifications that they have. Diagnosis and appropriate management of early pregnancy and its complications is an important role for all GPs. Developing skills to enable stratification of risk, offer effective counselling and organise appropriate testing and referral are essential components of this.11,12 Provision of shared care or being the primary care provider to pregnant women obviously incorporate different sets of knowledge and skills. As is the case with all aspects of general practice, having a clear awareness of limitations of skills and knowledge and understanding when referral onto an obstetrician or neonatal paediatrician is required is an essential part of this skill set. Some of the skills and knowledge expected for the different levels of antenatal and intrapartum care appropriate to the clinical context of the GP can be found in the RANZCOG links provided in the ‘Useful pregnancy care resources and tools’ section below.
Regardless of the level of training a GP has in antenatal care, all GPs should have the ability to recognise red flags in pregnancy that highlight the need for further investigation, review and/or management, such as pregnancy-induced hypertension, gestational diabetes, vaginal bleeding (with the need for consideration of anti-D in rhesus-negative women to optimise the health of the woman and her unborn baby), babies small for gestational age, ultrasound- detected abnormalities and premature labour.
The postnatal period can be a very vulnerable time for women and their families as they adjust to the changes that a newborn baby brings. Regular review during this time as well as working in effective collaboration with other health providers such as maternal and child health nurses, lactation consultants, paediatricians and obstetricians optimises outcomes. Provision of screening for depression, and support to assist with continuation of breastfeeding where possible, are two important aspects of this care. In Australia, exclusive breastfeeding rates are approximately 90% at birth, but only two in five women exclusively breastfeed at four months.1 Confidence in detecting and managing postnatal complications and conditions (eg mastitis, DVT, postnatal depression and psychosis) and in examining and managing new babies (as examples particularly identifying an unwell baby, hip dysplasia, tongue tie, nappy and other newborn skin rashes, and sleep difficulties) is also important to develop.
Identification of women who may be vulnerable to complications in pregnancy and in the postpartum period need to be identified early. Important groups of women who may have vulnerabilities that put them at risk during pregnancy include Aboriginal and Torres Strait Islander women, adolescents, individuals with chronic diseases (where control may need to be optimised prenatally and reviewed closely during and after pregnancy), women with disabilities (who may face prejudice about their capacity to parent), women with limited social supports and increasing numbers of women in same-sex relationships who are choosing to have families need focused advice and care.13
Women of refugee-like backgrounds have recognised issues with accessing services and may be at risk of having had female genital mutilation/cutting (FGM/C). The sense of loss experienced by women of refugee-like backgrounds can be significantly enhanced during pregnancy. Many women are distressed at not being able to follow their traditional cultural practices at this time because they often come from cultures where supporting a new mother and raising children is a shared responsibility. Women often feel the absence of their relatives acutely at this time and are at higher risk of postnatal depression.14
It is important to identify whether a woman has had FGM/C and to assess the type and to refer appropriately to ascertain whether de-infibulation is required.15 Many women from refugee-like backgrounds come from countries where there are high fertility rates and poor access to antenatal and prenatal care. Consequently, pregnancy complications and fetal loss are not uncommon.16
For all women and their families, pregnancy is a time of significant physical and psychological change, and usually of great joy. But when complications arise, it can be a time of extreme sadness and trauma. Provision of high-quality general practice care and support during this time, with health promotion and education to help women make informed choices that will contribute to improved outcomes, is essential.
Useful pregnancy care resources and tools
- Better Health, pregnancy and diet information and recommendations (including folate, listeria, fish intake and avoidance of mercury, stages of pregnancy, unplanned pregnancy resources, immunisation, pelvic floor)
- The Royal Australian College of General Practitioners, Guidelines for preventive activities in general practice, Chapters 1 and 2: Medication in pregnancy and breastfeeding,
- The Royal Australian College of General Practitioners, National guide to a preventive health assessment for Aboriginal and Torres Strait Islander people, Chapter 9: Antenatal care
- Royal Australian and New Zealand College of Obstetricians and Gynaecologists, Pre-pregnancy counselling college statement
- Royal Australian and New Zealand College of Obstetricians and Gynaecologists, Prenatal screening and diagnosis of chromosomal and genetic abnormalities in the fetus in pregnancy
- Royal Australian and New Zealand College of Obstetricians and Gynaecologists, certificate and diploma training information