This is the first study to investigate practice related factors that may affect access to routine postpartum care in general practice. A high proportion of the practices involved in the study undertook antenatal shared care and all provided community postpartum care for mothers and infants on a regular basis.
The majority of consultations were allocated 15 minutes or less with solo GP practices having significantly higher odds of longer consultations for mothers. While quality of postpartum care cannot be assessed by consultation time alone, previous studies have found that GP consultations for either the mother or infant often take longer than 15 minutes , and take longer than anticipated . It has also been found that short and rushed consultations were an impediment to women seeking care and to discussing issues of concern with the GP . This problem is accentuated if an appointment is only made for either the mother or the infant, although both mother and infant need to be seen. More broadly, there is evidence that in Australia the number of long consultations for children has decreased over recent years , although the proportion of consultations for children has remained static . This may be in response to the emphasis on chronic disease management in general practice . Similar studies have not yet been undertaken focusing on postpartum consultations in general, or for postpartum women in particular.
While routinely making double or long appointments for women and their infants, or ensuring an appointment is made for both mother and infant, has been suggested to overcome inadequate consultation times , this strategy would only be effective if the practice staff were aware of the purpose of the appointment. In this study there was no difference in consultation times with methods of identification of postpartum mothers. However, we were unable to ascertain if timely identification resulted in two appointments being made rather than one. Of the practices surveyed, 67 % relied on mothers to inform them that they had recently given birth and would thus require extra time for mother and infant. In country towns with smaller populations, practice staff were more likely to be aware of pregnant patients and proactively asked whether the birth had occurred. Not only does this allow for appropriate appointment scheduling, but also reinforces the connection with the practice that facilitates women accessing care . Strategies such as giving information to all pregnant women from the practice, regardless of the model of maternity care, about services offered postpartum and the importance of postpartum follow-up may also be advantageous when staff are less familiar with the patient population.
As noted previously, cost is a significant factor in people’s willingness to access to health care in general  and may have a negative impact on women accessing care in the postpartum period within general practice. In this study the majority (54.5 %) of practices automatically bulk-billed children, but in nearly 70 % of practices, families had some out-of-pocket expenses for either the infant or mother. In some situations this out-of-pocket expense was as high as $60 per consultation. Problems concerning payment for consultations for infants before they received a Medicare number were mentioned in the free text section of the questionnaire, and mothers may be required to pay and then claim from Medicare in these situations. While each practice can determine who it charges and how much, mothers are vulnerable at this time and should not be discouraged to seek care if needed, by financial impediments. This is especially important for mothers from a lower socio-economic background who tend to have more complex health care needs and are less likely to seek postpartum care . We were unable to correlate cost with area of practice. However, a recent study found that cost of a GP visit for an infant under 12 months was lower for families if the mother had a lower level of education and the family had a lower level of income. In contrast to a previous study that found patients from low socio-economic status areas were less likely to receive longer GP consultations  the study by Golenko et al. . found that income was not related to the number or length of consultations. These findings suggest that families from lower socio-economic settings were able to receive comparable free or low cost care to other families .
One way to improve practice efficiency and patient access to comprehensive care, especially if the appointment time with the GP is short, is to use PNs to undertake some routine or preventative consultations. In this study in approximately 80 % of GP practices a PN ‘nearly always’ or ‘sometimes’ saw a mother and/or infant within the first eight weeks postpartum. However, only 19 % of the nurses held midwifery qualifications, and only 8 % held child health qualifications. These figures are slightly better than the PN population in general where 10.9 % have midwifery qualifications . It appears that many nurses rely on personal experience or guidance from their supervising GP (who may not have the requisite knowledge) to develop the necessary skills to undertake these consultations. Most research conducted with PNs has focused on chronic disease management with the few studies reporting on PN involvement in postpartum care finding they often lack the knowledge and skills to adequately care for the women and infants they see [24, 25].
Nevertheless the Australian Primary Health Care Nurses Association’s (APNA) website indicates that the PN role includes well baby and toddler care, maternal postpartum care and parenting advice and referral for specialised service if indicated . The one randomised controlled trial where PNs were trained to deliver a motivational interviewing intervention about breastfeeding at the regular two month immunisation visit, found an improvement in exclusive breastfeeding rates before six months . PNs therefore, can play an important role in improving health outcomes for mothers and their babies as long as they have adequate education, which seems to be lacking at present.
Although the study response rate was less than 30 % this is not uncommon in studies of general practices . The fact that the practices were from metropolitan as well as regional and rural/remote areas and that a range of practice sizes were included increases the generalisabilty of the results. However, the data may be indicative of practices with an interest in maternity care as nearly all had at least one GP who conducted shared antenatal care and in 20 % of practices there was a GP obstetrician. These findings are therefore likely to be a ‘best case’ scenario. All data are self-reported and have not been verified by audit or by cross-checking with patients.