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Good things take time: postnatal care


Deborah Carrington


9/02/2022 2:56:38 PM

We need better Medicare funding for postnatal care in general practice, writes Dr Deborah Carrington.

Mother with baby talking to GP
A comprehensive breastfeeding consultation usually takes between 45 minutes and an hour.

Your next patient is a first-time mother who walks slowly into your consulting room with a crying newborn in her pram.
 
She is still in pain from her C-section a week ago. Her nipples are cracked and bleeding. She is worried she doesn’t have enough milk. Her baby never stops crying.
 
The patient bursts into tears as she rocks the pram back and forth. She is worried about reflux or tongue tie.
 
Her online mother’s group has bombarded her with conflicting advice and her mother-in-law is pressuring her to give formula. Meanwhile, her husband wants to help but the baby just never stops crying.
 
For many GPs this would be a true heartsink consultation. For me, these consultations are where I am in my element.
 
Breastfeeding medicine and unsettled babies are my areas of special interest. I have trained with the International Board of Lactation Consultant Examiners and am also an NDC-accredited practitioner with Possums.
 
If social media is any indication, postnatal care is now increasingly emerging as an area of special interest for many GPs across Australia, often fueled by our own struggles adjusting as new parents and the desire to help others avoid the same problems.
 
The path has been laid by pioneers such as Dr Lisa Amir, Dr Pamela Douglas, Dr Wendy Brobdrig, Dr Marnie Rowan, Dr Anita Bearzatto and many others.
 
General practice is the ideal place to provide this help.
 
I am not aware of any official health department initiatives that include general practice at the centre of postnatal care, but from what I am seeing every day in practice this model of care has outstanding outcomes and high levels of patient satisfaction.
 
However, postnatal care in Australia can be very fragmented.
 
Mums are seen by the hospital midwives, community maternal health nurses, private lactation consultants or hospital breastfeeding clinics. As good as this care may be, it can involve multiple appointments in different locations and sometimes the confusion of working through conflicting opinions from healthcare workers.
 
In contrast, the scope of practice of a GP working in this area is astoundingly wide, preventing the need to see multiple providers for different aspects of care.
 
We can not only help with their complex breastfeeding issues, we can also assess and examine the baby, manage low-weight gain or jaundice, diagnose rashes and other common newborn concerns, review mum’s postnatal recovery, assess her wounds, advise on pelvic floor concerns, sort out their contraception and organise a cervical screening test.
 
We can check in on mum and dad’s mental health and initiate support early for those struggling. Best of all, we can follow up with these families over time and help navigate the next stages of parenting.
 
I am passionate about this area of medicine and the importance of providing high-quality, evidence-based care for families. I know there is a quiet army of like-minded GPs emerging across the country, who are responding to the well-established need of new parents sometimes desperate for help.
 
This area of general practice, however, is also a perfect example of how Medicare funding does not adequately support long, complex consultations and is letting patients down.
 
A comprehensive breastfeeding consultation usually takes between 45 minutes and an hour, sometimes even longer. This includes a detailed history of both mother and baby, examination of both, weighing the baby and then observing and providing help with a full breastfeed.
 
Whilst mum is feeding, we will cover multiple issues and concerns. Often mum or baby or both will be in tears.
 
This is hard stuff. It cannot and should not be rushed.
 
Helping a mum to be able to complete a pain-free feed and leave with a smile, feeling more confident to face the coming days, is my reason for going to work. But it can never be done in a short consultation.
 
As it stands, the Medicare rebate for a level D consultation is currently $111.50.
 
Compare this to $533 on average for a non-admitted emergency department presentation for the first-time parents whose baby won’t feed and is crying all night. Compare this again to the thousands of dollars for a hospital admission for a failure-to-thrive infant or a mother with severe postnatal depression.
 
Then there are the long-term benefits that are harder to measure.
 
We all know the lifelong impact attachment disorders and abuse has on mental health – imagine the difference it can make to change the course of a family’s trajectory at this critically sensitive period.
 
It is the perfect example of where we desperately need proper funding of long, complex consultations in primary care.
 
We also need to be able to provide this service without constant fear of attracting a Medicare audit.
Anyone working in this special interest area of general practice knows that this increases the risk of being identified as an outlier for billing more long consultations.
 
I can honestly say that I have always been absolutely scrupulous with billing appropriately for time, and I spend a long time documenting detailed notes to be able to justify this.
 
However, it seems fundamentally wrong to punish doctors for doing long consultations, as if a level 23 should be the ideal aim for all GPs. I bill very few care plans and overall, my billings are much lower than they would be if I did a higher volume of short consultations.
 
Most GP lactation consultants need to charge a gap to make up this difference, but it would be wonderful if the rebate could enable us to make this service available to all families regardless of income level.
 
Perinatal care in general practice has the potential to radically improve health outcomes for families, but we need better funding to make this financially viable and accessible to everyone.
 
Properly funded long consultations and specialised item numbers for lactation support would make an enormous difference.
 
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Dr Gwendoline Ruth Burton   10/02/2022 8:59:26 AM

General Practitioners are the only craft group who can look after the entire family unit - mum, dad, baby and our continuity can be measured in decades and generations. Yet as articulated above, we are too often not even considered an option by healthcare planners and we are not funded adequately to do this vital work. This needs to change.


Dr Heather Dawn Chalmers   10/02/2022 3:33:29 PM

I wholeheartedly agree with Deborah Carrington. Postnatal care, including managing lactation difficulties, can improve outcomes for the entire family but is time consuming. As with many things we do as GPs the work is under-appreciated and under-valued.