Statement of significance
Problem or issues
What is already known
What this paper adds
Introduction
Methods
Study design
Conceptual framework
Site
Period of study
Researcher characteristics
Study population
Recruitment
Interviews and transcribing
Coding
Results
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%) |
Role of the PCP in postpartum care
Early point of contact in the postpartum period
“…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
“…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)
“…giving them advice about contraception and a follow up PAP smear.” (PC11, Female Resident Physician in Polyclinic)
Coordination of care
“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
“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
“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
“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
“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)
“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
“…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)
“…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
“(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
“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)
“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
“…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
“…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)
“.. 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
“It’s actually time that is given to us. If these patients turn up in general pool (referring to walk-in consultation), …, within 6-min 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
“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)
“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
“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)
“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
“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
“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)
“If there is a clinical guideline…that would be very helpful.” (PC25, Male GP)
Improve access to ancillary postnatal care services
“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)