Maternal post-natal GP checks: exploring the equity of care provision in England

Date of ISAC Approval: 
15/04/2019
Lay Summary: 
The National Maternity Review Better Births report (2016) highlighted the importance of the GP 'six-week check' in monitoring the health and wellbeing of both mother and baby. However, it also found that GPs do not feel engaged in maternity care and that the six-week check is being carried out inconsistently and with the focus mainly on the baby. An expert reference group on postnatal care convened by NHS England has recommended that GPs should provide an assessment for mothers at six-weeks after the birth, and that this should focus on: mental health and general wellbeing; return to physical health and identification of pelvic health issues; family planning and contraception; and pregnancy-related conditions which may need ongoing management (e.g. if women developed diabetes while pregnant). The purpose of this study is to assess the proportion of new mothers in England who received a six-week postpartum check, or appointments related to these specific issues in the first 12 weeks post-partum. We will describe whether access to these checks is affected by where mothers live, their age, ethnicity or other characteristics. We will explore the impact of attending for a six-week check on early detection of key conditions and the chances that a mother will later need additional care or treatment for key conditions (such as incontinence, depression or anxiety). The findings will be used to inform maternity care policy.
Technical Summary: 
The Better Births report (2016) highlighted the importance of the GP 'six-week postpartum check' in monitoring the health and wellbeing of both mother and baby. However, the maternal checks are being carried out inconsistently. This study aims to: i) Describe current practice, identifying women who are receiving a six-week postpartum check in England; ii) Examine the factors associated with not receiving a maternal six-week postpartum check iii) Assess the evidence that the six-week postpartum check improves outcomes for new mothers Data for women who gave birth in England between July 2015 and June 2018 will be drawn from the Pregnancy Register. Where available, a linked baby record will also be used. Descriptive analyses will assess the proportion of women who were offered a check, and how many attended. The patterns of interaction with GP (number, type and timing of consultations) will also be described over the first 12 weeks postpartum. Logistic regression will be used to assess the equity of provision, assessing whether geographic region, maternal age, ethnicity, parity and deprivation are predictors of having a six-week postpartum maternal check, while accounting for similar standards of care within practices. A cohort analysis will examine whether a six-week maternal check improves women's outcomes. Outcomes will initially be compared in women who were offered a check and those who were not: including urinary and/or faecal incontinence; perineal pain; depression or anxiety. The prevalence of adverse outcomes will be compared and adjusted Odds Ratios calculated using logistic regression. Cox proportional hazards analysis will be used, to account for differing time to follow-up, examine time to first diagnosis, treatment and/or referral. Demographic characteristics, consultations, diagnoses and treatment, including referrals to specialist care, will be informed by Primary Care data. Linked geographical data on IMD will provide necessary information on deprivation.
Health Outcomes to be Measured: 
For descriptive study (objective 1 & 2): record of being offered a six-week check, record of attending a six-week check for the mother, record of a six-week check for the baby, consultations in the first 6-8 weeks post-partum. Record of other (related) consultation(s) in the first 6-8 weeks (e.g. consultation for mental health, physical/pelvic/continence issues, contraceptive/family planning advice), number of consultations (for any reason), or other interactions (e.g. phone consultations) in the first 12 weeks. For cohort study (objective 3, hypothesis testing): key outcomes for maternal health postnatally, including diagnosis or evidence of treatment/referral for mental health issues (depression, anxiety, psychosis); urinary or faecal incontinence; perineal pain, or records of reported painful sexual intercourse; total number of appointments
Collaborators: 

Dr Claire Carson - Chief Investigator - University of Oxford
Dr Claire Carson - Corresponding Applicant - University of Oxford
Professor Jennifer Kurinczuk - Collaborator - University of Oxford
Dr Yangmei Li - Collaborator - University of Oxford

Linkages: 
Mother Baby Link;Patient IMD;Practice IMD (Standard);Pregnancy Register