A total of 31 PCPs were approached and 29 of them agreed and participated in 4 FGDs and 11 IDIs. The participants included 5 General Practitioners (GPs) in private practice and 24 PCPs in various public primary care clinics (polyclinics). Their ages ranged from 26 to 61 years. The FGD or IDIs lasted between 53 minutes to 87 minutes, averaging 69 minutes. Their characteristics are represented in Table 1.
Table 1
Demographic Characteristics of Study Participants (N = 29)
Characteristics
|
N (%)
|
Age (years)
|
25–34
|
16 (55.2%)
|
35–44
|
7 (24.1%)
|
>=45
|
6 (20.7%)
|
Ethnicity
|
Chinese
|
24 (82.8%)
|
Malay
|
1 (3.4 %)
|
Indian
|
1 (3.4%)
|
Other
|
3 (10.4%)
|
Postgraduate training
|
MBBS
|
9 (31.0%)
|
Graduate Diploma in Family Medicine
|
4 (13.8%)
|
Master of Medicine (Family Medicine)
|
11 (37.9%)
|
Fellow of the College of Family Physicians, Singapore
|
5 (17.3%)
|
Designation
|
Medical Officera
|
4 (13.8%)
|
Resident Physicianb
|
4 (13.8%)
|
Family Physicianc
|
16 (55.2%)
|
General Practitionerd
|
5 (17.2%)
|
Site of practice
|
Public healthcare institutions
|
24 (82.8%)
|
Private GP practices
|
5 (17.2%)
|
a = Qualified physicians granted conditional or full medical registration by the Singapore Medical Council (SMC) without postgraduate qualification.
b = Qualified physicians with at least an undergraduate medical degree, granted full medical registration and with at least 3 years of clinical experience.
c = Registered medical practitioners with relevant and recognized postgraduate qualifications (Graduate Diploma in Family Medicine, or a Masters in Family Medicine) and with at least 3 years clinical experience.
d = Registered medical practitioners with relevant and recognized postgraduate qualifications (Graduate Diploma in Family Medicine or a Masters in Family Medicine) working in the private setting.
|
The results are grouped into 4 main domains based on the conceptual framework. They include the PCP’s personal attributes towards postpartum care; their information mastery on postpartum care; professional relationship with postpartum mothers; and their interaction with the healthcare system and policies. All themes and subthemes are supported with corresponding verbatim.
Role of the PCP in Postpartum Care
Early point of contact in the postpartum period
The PCPs concurred that they were often the first touchpoints for postpartum mothers. The location of their clinical practices within the estates in close proximity to the mothers’ residences and availability of same-day medical appointment make PCPs easily accessible in Singapore.
“…we are the first point of contact for most of them…if they have any problems postpartum, they will usually go to the nearest polyclinic or GP (General Practitioner) to settle some of their queries.” (PC20, Male GP)
Scope of postpartum care
PCPs indicated that the care they provide following childbirth is not limited to the immediate postpartum period but encompasses a larger scope including providing longer-term medical and mental health support for both mother and child. In the early postpartum period, medical needs such as episiotomy or caesarean wound care, gestational diabetes or pregnancy induced hypertension can be reviewed by PCPs. Screening the mental health needs of postpartum women and provision of breastfeeding support are other important postpartum assessments that can be fulfilled by PCPs.
“…we are more familiar with the mental health aspect and we are the ones that are mainly seeing them after they have delivered for a much longer time if they have issues.” (PC24, Female Family Physician in Polyclinic)
Subsequently, education and preventive care including family planning and cervical cancer screening can also be discussed with the mother.
“…giving them advice about contraception and a follow up PAP smear.” (PC11, Female Resident Physician in Polyclinic)
Coordination of care
Most PCPs viewed themselves as coordinators of care, who can identify areas of need of postpartum mothers and match them up with available resources in the community. This can be made possible if they have adequate support such as engaging nurses and midwives to help with holistic assessment of the mother and tie-ups with community resources.
“The doctor, before even seeing the patient, will already have a very clear understanding of what are the issues that were identified by the nurse for this patient, and then, will be able to conduct a streamlined type of consultation, then refer the patient on to the necessary services that may be available. They may even think about engaging some form of community services, so that the doctor can also refer out to community services.” (PC1, Male Family Physician in Polyclinic)
Involvement in antenatal care
Some PCPs strongly believed in the need for their involvement in the antenatal care of a pregnant woman. This early establishment of physician-mother interaction can contribute to rapport building and potentially improve eventual long-term care for the mother.
“I think it becomes more natural if we are actually doing antenatal care, we establish rapport and we look after the prospective mummy, and then at a certain time, we refer in for delivery. It becomes very natural for the lady to come back.” (PC14, Male Family Physician in Polyclinic)
Personal attributes towards postpartum care
Gender
The PCPs identified the gender of the physician to be a significant factor influencing the consultation agenda with a postpartum mother. As postpartum care involved examination of the more private areas, such as the genitalia and the breasts, male PCPs reflected that they were less likely to be consulted by postpartum women. The latter might not bring up the related issues even if they were attended by male PCPs.
“Some of them, they prefer a female doctor instead of a male doctor, especially if it involves a lot of checking (of) the breast and also the private part(s)” (PC6, Male Medical Officer in Polyclinic)
“My credibility is definitely less than hers. She (female colleague) breastfed four children of her own. I can’t breastfeed any of my children. I have no credential.” (PC25, Male GP)
Background knowledge and capability in postpartum care
PCPs reported a spectrum of personal knowledge on postpartum care. They attributed their variable experience and immersion in postpartum care to their prior medical training. They would readily seek advice from their peers or consult specialists in postpartum care. The PCPs either called the obstetricians whom they were acquainted by phone, or consulted them via formal referral.
“We do have a doctors’ WhatsApp chat(group) for the doctors under that clinic. So (I) do ask my peers and my colleagues for advice.” (PC23, Female GP)
“I have… three classmates who are obstetricians, whom I can (contact) …are just a text away.” (PC25, Male GP)
“well, as primary care physicians, …. many times, you can make a referral” (PC12, Male Family Physician in Polyclinic)
Personal child-caring experience
PCPs, underpinned by their own personal experience, were more confident in advising breastfeeding and parent crafting to postpartum mothers. The experience stemmed from their personal roles as mothers and fathers who were actively involved in the care of their own children. They could empathise with the difficulties faced by the postpartum mothers.
“I think there’s a difference before and after becoming a mother myself…after experiencing (it) yourself as a patient, then it gives me more confidence.” (PC4, Female Family Physician in Polyclinic)
“It depends on how hands-on I am as a father. So, as a very hands-on person, I don't feel disadvantaged, as opposed to someone who’s not had a child before” (PC13, Male Family Physician in Polyclinic)
In contrast, single and married physicians without children had less confidence in addressing these issues. They tended to engage the help of more knowledgeable people around them or were more inclined to refer the mothers to other providers.
“I don't have any personal experience myself, so if they (mothers) do have issues about latching or how to deal with engorgement, I don't really know how to advise them… If I examine them and there’s mastitis, I can treat, but with issues to prevent that from happening … I’m really not very well-equipped, so I will ask them to either call the lactation consultant.” (PC11, Female Resident Physician in Polyclinic)
Information Mastery on Postpartum Care
Medical Training on Care of Well-women and Well-child
Most PCPs claimed to know the basic clinical examination of a postpartum woman. They were aware on the assessment of lochia cessation, wound recovery, pain control, screening for post-natal depression, breastfeeding, and preventive care, such as cervical cancer screening and contraception advice.
Some PCPs reported paucity of related formal training in postpartum care. Those who self-declared to be deficient in postpartum care, indicated their intent to embark on self-learning.
“…I also agree that I don’t recall any structured teaching on postpartum care, but for me, it was also mostly likely self-learning. A bit of teaching from likely, maybe the O&G (Obstetrics and Gynaecology) and Paediatric posting, but VERY, VERY MINIMAL, but I knew that it would be something I might see in primary care, so then, you know, I had to read myself.” (PC5, Male Resident Physician in Polyclinic)
Whilst most PCPs concurred that medical undergraduate and postgraduate training in family medicine equipped them with the medical knowledge and skills in identifying abnormal and dangerous presentations in postpartum mothers, they were not trained in assessing breastfeeding and normal feeding behaviour of the baby.
“…Knowledge wise, I think most of us are not actually well trained in that aspect as in, how to advise them on, … nutrition, how to take care of their own mental, physical health. And also, not just taking care of them, , but taking care of neonates also is important, … because most of the ladies who come in at this time, they have a lot of questions about their baby as well, which also affect their own emotional, their mental health.” (PC20, Female Family Physician in Polyclinic)
Access to Resource Materials
Most PCPs highlighted the lack of local primary care postpartum care guidelines, which they attributed to their variable scope of practice. Most relied heavily on their own informal resources to update their postpartum care knowledge, assist their consult process and to teach the more junior physicians within their institutions. They suggested references to web-based education materials from a local tertiary women and children hospital, previous training courses and resource persons within their clinic practice.
“(In) the SHP (SingHealth Polyclinics) doctor guidebook, there’s a postpartum guide over there. And then, there’s some helplines you can call, like the lactation services that are available in KKH (Women’s & Children’s) Hospital. And also, there’s online learning module about breastfeeding. So for those doctors who are not so familiar, maybe it’s something that they tap on to.” (PC4, Female Family Physician in Polyclinic)
“I did consult some of the more senior doctors, who also provided me with … some resources. The online lactation services (referring to KKH), they do have their own resources that you just download and refer. Overtime, … you just learn from there. When juniors ask you, you just refer them to the similar resources.” (PC20, Female Family Physician in Polyclinic)
“…is to look at the latest update GDFM (Graduate Diploma in Family Medicine) notes. Because I’m a faculty member, I have access. Number two, will be open resource material over the internet. Number three, is paid resources, likely UpToDate. Number 4, I have informal resources, likely my co-locating obstetrician and gynaecologist.” (PC25, Male GP)
Professional relationship with postpartum mothers
Awareness and de-conflicting postpartum mothers’ confinement practices
In the early postpartum period, traditional confinement practices among the local multi-ethnic Asian mothers are prevalent, despite a majority of them receiving western education in Singapore. Such practices may not be evidence-based but can potentially interfere with the PCPs’ efforts in addressing pertinent postpartum needs such as lactation and skin ailments.
“From my experience, confinement nannies are universally wrong in their breastfeeding advice. Usually, they will supplement with the formula, which is not what we are taught, but you are supposed to clear the breast and keep latching until the supply comes, but if you introduce supplement, you just compromise the whole thing.” (PC12 Male Family Physician in Polyclinic)
“.. some of them (mothers) don’t bathe, and then on top of that, they have to wear a long-sleeved pyjamas, and then no air-con, (they) only can use fan in this current (tropical) climate, I think that they can actually get quite a fair bit of eczema.” (PC22, Male GP)
The PCPs could readily identify myths in confinement practices. However, some of them were less inclined to debunk such practices to avoid adversely affecting their relationship with the postpartum mother, her family or confinement nanny. Therefore, if the PCPs perceived that the confinement practice was harmless, they would not take further action.
“I see less of a problem now. Of course, there’s still some traditional (confinement practices) … but … as long as it’s not a hindrance to medical care, I think some of these old wives’ tale can be left alone. It doesn’t really matter!” (PC27 Female Family Physician in Polyclinic)
Language compatibility in physician-mother communication
In view of the local cosmopolitan population with a minority of foreign women marrying local men, not all postpartum mothers are proficient in English. Language incompatibility appears to affect mutual communication between the PCP and postpartum mother, even when the spouse or family are available to translate. PCPs felt that important information might be lost during the translation process.
“…the wife is telling him a lot of things, and … just a few phrases coming out from the husband’s mouth. It’s likely the husband is already filtering whatever needs to be said … I can’t, I can’t “unfilter” (decipher) it myself!” (PC24 Female Family Physician from Polyclinic)
“The moment I have an interpreter, … it’s an added barrier. It’s harder. It makes the job double hard.” (PC25, Male GP)
Alternative formal and informal healthcare provider and perceived missed opportunities
The mother-PCP relationship is not steadfast during the postpartum period. PCPs reported that mothers tended to rely on alternative healthcare providers such as their obstetricians, and other readily accessible sources of information from their family, confinement lady and friends to address their postpartum needs.
“…I think some women, for example, they don’t see the need to tell the primary care physician about the issues they are going through postpartum. Some of them feel that it’s better for them to go to a gynae (cologist) or they might feel that the polyclinic is not the right setting to do it.” (PC5, Male Resident Physician in Polyclinic)
“it’s probably due to the community whereby we have a lot of support. For example, … they get the opinion and advice from the confinement lady. Some of them, they actually get those opinion or advice from their parents as well.” (PC6, Male Resident Physician in Polyclinic)
The PCPs postulated that the postpartum mothers were unaware of the values and purpose of a routine postpartum review and were unfamiliar with the postpartum services available in primary care. This could result in their missed opportunities to optimize postpartum care.
“.. actually even if they (mothers) feel well, they can be counselled on … contraception that they tend to just gloss over, … postpartum depression when they wouldn’t reach out in the first place. So there are things to screen, but whether they think they need visits, the doctor’s visit, it’s questionable.” (PC15, Female Family Physician in Polyclinic)
Challenges relating to the Healthcare System and Policies
Limited consultation time and ineffectual counter-measure
One common recurring barrier mentioned by the PCPs was the inadequate consultation time allocated for a postpartum visit in primary care setting. Most felt that a more realistic time per consult should last from 15 to 20 minutes, compared to the current 5 to 10 minutes in real-time clinical practice. The limited time for consult often reduced the comprehensiveness and scope of postpartum issues covered within the postpartum visit. Consequently, the PCPs tended to avoid time-consuming tasks such as mental health assessment or discussing contraception options with the mothers. To overcome the short consult, some PCPs advised mothers to return for a separate visit to tie up loose ends. However, the PCPS recognised that default rate would be high, resulting in incomplete resolution of issues faced by postpartum mothers.
“It’s actually time that is given to us. If these patients turn up in general pool (referring to walk-in consultation), …, within six-minute consult, it’s very, very challenging to address (the) so many aspects of the maternal health” (PC2, Female Family Physician in Polyclinic)
Awareness of and Access to Community Postnatal Care Services
PCPs regarded breastfeeding difficulties as a common problem experienced by postpartum mothers. Some PCPs perceived deficiency in managing women with lactation issues. However, they highlighted the inadequate lactation support services in the community. While lactation consultants are available in public tertiary institution, the long wait time for referrals is a hurdle. For those who are cognizant of private lactation consultants, engaging the latter is costly, hindering its access to mothers across different socioeconomic groups in the local fee-for-service healthcare system.
“We call the lactation consultant (in KKH), but the appointment was very long. So we got the private consultant to come down to help us. And it’s only because we are resourceful enough, that we … look for all these (services), but again, people out there may not be so resourceful, they may not be able to find all these (services)…” (PC13, Male Family Physician from Polyclinic)
Similarly, PCPs perceived limited access to community psychological services for mothers who were diagnosed with postnatal depression. Many PCPs felt that increasing access to such services would enable them to better manage the emotional needs of some postpartum mothers.
“It may not be clinical psychologist, but there are counsellors outside who can actually help this lady, so what we need is to have the network of these services. Some of them are in Family Service Centres and … for us to be able to refer, and (for mothers) to reach out to them while they are at home.” (PC14, Male Family Physician in Polyclinic)
Primary-tertiary care interface: handing over of care from specialists
Poor transfer of care from the specialists to PCP impedes transition and continuity of postpartum care of the mothers after their delivery. When postpartum women are discharged after an uneventful pregnancy and short hospital stay, they are given a memo to bring to their PCP for postpartum care. However, the appointment is usually not fixed to any specific PCP. Consequently, the mothers often miss their postpartum review within the stipulated period due to competing demands of their attention. Across public and private sectors, PCPs often do not receive any memos from the obstetricians and rely on the national electronic health records (NEHR) to access information on the mothers’ antenatal and intrapartum history. Furthermore, not all PCPs register with the NEHR agency to access the medical records, leading to fragmented information for postpartum care.
“Definitely it’s fragmented. There’s actually no proper structure to it… the hospital doesn’t know if the patient comes and we don't know whether how many patients are coming to us. There’s private sector and there’re different (systems in) restructured hospitals, polyclinics, so it’s very fragmented indeed.” (PC4, Female Family Physician in Polyclinic)
“It’s definitely not adequate, because some patients (are) follow up private, some patients in government hospitals, and we have SO MANY polyclinics, private GPs, so they choose ANYONE to follow up. The only communication we have is … the memo when the patient brings in. So if the patient NEVER bring(s) in the memo, we will never follow up with them.” (PC10, Female Resident Physician in Polyclinic)
In the current model of care, a woman is immediately referred to an obstetrician upon diagnosis of pregnancy. The PCPs alluded that this early referral compromises on the rapport with the postpartum mother. This broken linkage results in failure of the PCPs to connect with these mothers after their delivery.
“Primary care physicians should be the one handling the antenatal care part until the delivery for a normal, uncomplicated delivery. Then the patient will have trust in you and (will) be willing to follow up subsequently AFTER their deliveries. Instead, once diagnosing them as pregnant, we refer them onwards. Is this really what we want in our primary care setting?” (PC16, Male Family Physician in Polyclinic)
The Way Forward: Suggestions to strengthen the enablers
Team-based Practice
PCPs proposed measures to overcome their perceived barriers. Some of them, especially those from the polyclinics, suggested team-based practice to overcome gender and variable levels of competency. The proposed team comprises a mix of different physicians, midwives and nurses. It enables senior experienced doctors to mentor the junior physicians within the practice. It also allows mothers to engage female PCPs in the team to deal with their gender-sensitive issues and private anatomical examination. Task substitution to the midwives and nurses is another suggestion. They can be trained to be lactation consultants to manage breastfeeding issues. The multidisciplinary team can potentially reduce the PCP’s consult time, without compromising on a comprehensive postpartum review of the mothers. Nonetheless such a care model is feasible in polyclinics with a larger pool of primary healthcare professionals, compared to singleton or small GP practices with limited human resources.
“It may not need a doctor to provide the care. If you look at the previous maternal-child health model in the past, where usually the midwife is the one who provide(s) the postpartum care and to identify what are the potential issue(s) that can arise from the mother. We can train our nurses to do that. If they pick up any issues, then they refer to the doctor as the second line provider.” (PC2, Family Physician in Polyclinic)
Reorganization of antenatal and postpartum services
The PCPs suggested reorganizing antenatal and postpartum services to prepare the mothers for postnatal care. Such antenatal classes in primary care setting aim to familiarise the mothers to the PCPs and induct them on the purpose and importance of postpartum reviews.
“We need to make the public more aware that such resources are available (in primary care). Antenatally, drum in advice on possible issues that can come up in the postpartum period.” (PC11, Female Medical Officer in Polyclinic)
“The people must be trained, the nurses and doctors, to be able to deliver the care when patients turn up…It may not be enough just to read the doctor’s guidebook. There may be a need for some refresher, sort of CME (Continuing Medical Education).” (PC14, Male Family Physician in Polyclinic)
Clinical practice guidelines were deemed useful by PCPs. Some of them recommended the introduction of guidelines to ensure appropriate handling over of high-risk cases from obstetricians to PCPs and guide the PCPs to manage the well women and well child.
“If there is a clinical guideline…that would be very helpful.” (PC25, Male GP)
Improve access to ancillary postnatal care services
The PCPs recommended direct access to trained personnel within the clinic or to be able to link to a network of community resources to support postpartum care. This will value add to the PCPs’ services, without the extra step of referring mothers to other postpartum providers and incurring additional cost.
“If we can have a nurse who has worked in a O&G setting, and who can run parent-craft classes or give proper advice…with regard to milk intake for, not just breastfeeding, but for women who have been giving formula (to their children) …that will be good for parents.” (PC23, Female GP)