Shared antenatal care--where has it been and where is it heading?

Each year approximately 250 000 babies are born in Australia. For us, as general practitioners, this means approximately 1.3 in every 100 encounters is with a woman who is about to, or has recently, given birth. Building a thriving obstetric practice was once the cornerstone of a successful general practice; yet in 1998 only 17.7% of Victorian GPs provided intrapartum care. This figure is likely to be much lower now, due to changes in indemnity insurance and a move by GPs to have a more satisfying personal life. Even though we are in the unique position of being able to provide care from womb to tomb, few of us continue this practice. Instead, shared care provides us with a modified (and some would say, less rewarding) form of general practice obstetrics. In this edition of our Australian Family Physician, we are presented with a variety of articles relevant to shared antenatal care. Lombardo and Golding report on the development of shared antenatal care in regional Geelong, McElduff provides an update on gestational diabetes, and Austin discusses the complexity of psychosocial risk assessment in pregnancy and the management of antenatal depression. Nel and Pashen describe some of the challenges of providing culturally responsive antenatal care to Indigenous people in one of the remotest parts of Australia, and highlight the importance of good antenatal care in reducing a totally unacceptable perinatal mortality rate. Shared antenatal care was largely introduced to reduce the burden on overcrowded antenatal clinics. In Victoria in 1990, 2% of women giving birth participated in a shared antenatal care program; in 2002 this figure is approximately 50%. These changes occurred rapidly and without rigorous evaluation. In 1994, the Survey of Recent Mothers conducted by the Centre for the Study of Mothers’ and Children’s Health reported a very low level of satisfaction with shared care arrangements. Only 33% of women receiving shared care rated their antenatal care as ‘very good’ compared with 46% of women attending a public clinic, 72% of those attending a private obstetrician, and 80% receiving team midwifery care in a birth centre. These results shocked many hospital staff, GPs and researchers. In response, the Victorian State Government funded a review in which I was involved. We surveyed Victorian public hospitals to map the shared care models available, interviewed 32 key informants at four case study sites and reviewed Medicare data. Fourteen different models of shared care were described and strengths and weaknesses elucidated. While shared care models were providing women with choice and decreasing pressure on public hospital clinics there were a number of weaknesses: fragmented care, duplication of visits and investigations, variability in the quality of care, poor coordination, and costs incurred by public hospital patients for GP visits. These weaknesses, identified in the most densely populated state of Australia, are not dissimilar from those described by Nel and Pashen in the remoteness of the Gulf country. The outcome of the review was 17 recommendations aimed at putting the concept of sharing care into practice. We called for: • formalised frameworks for consultation and review of shared care procedures • development of written guidelines in consultation with GPs and divisions of general practice • a communication strategy to engage GPs and provide the opportunity for raising concerns and contributing ideas • increased resources committed to GP liaison positions • written information about the models of care for women and GPs • patient held records to assist with communication between care providers and the woman • ongoing review and monitoring of patient outcomes within shared care programs • written guidelines regarding accreditation of shared care providers (ideally a Shared antenatal care – where has it been and where is it heading?