Reflections on team-based maternity care
In my second year of medical school, I had the opportunity to take part in a project aimed at midwifery students, medical students and nursing students interested in maternity care. A group of twelve of us met weekly to learn about labour and birth, and also to receive some basic labour support training. It was a very positive experience, and an introduction into inter-disciplinary health care quite early in my career.
Upon graduating from the St. Paul’s Family Medicine residency program in Vancouver this past summer, I joined the South Community Birth Program, a unique maternity care program dedicated to integrated, inter-disciplinary maternity care. The program was established in 2003 and has provided care for over 2000 women and families, with an emphasis on immigrant and under-served populations. In this practice, I work closely with other physicians and midwives, as well as nurses, doulas and administrators.
A recent article published in the CMAJ described some of the benefits that are being achieved with this model of care. The researchers conducted a retrospective cohort study and compared over 1000 women who participated in the program to a matched cohort receiving standard care in the community from a midwife, family physician or obstetrician. They found that those in the program had a significantly lower chance of having a cesarean delivery, had shorter hospital stays and were more likely to exclusively breastfeed.
The design of the study didn’t enable the researchers to tease out the specifics of which aspects of the program were helping to create these effects. However: “… clinicians working in the program believe that their close working relationship, including their ability to discuss patient care facilitated by immediate and remote access to electronic medical records, fosters an environment in which they can continually support and learn from each other.”
There have of course been many articles written on inter-professional health care teams, and they seem more and more to be the thrust of best practice. What I think is so interesting about our team is that we bring together groups of professionals that have not always been known for working well together. What follows are some of my experiences working with this team, which I hope may be helpful to other groups exploring this kind of care.
Working together on patient care
As I mentioned, the team is integrated – which is key, I believe. Integration has become something of a buzzword, but I have definitely seen so-called integrated teams that share the same roof or clinic space, but have little collaboration of care or meaningful interaction with each other.
Our midwives and family doctors share prenatal care, and prenatal visits could just as easily be booked with a midwife as with a GP. We share 12 hour call among us, so when our call shift ends, we are often handing over to a member of another profession. Although our training and scopes of practice are different, we share a practice style and a strong commitment to supporting families, regardless of whether their birth is vaginal, assisted or cesarean. Our goal is to have handover feeling seamless for the woman in labour.
Our nurses both co-facilitate the group care prenatal visits along with a midwife or family doctor, and provide intensive breast feeding and postpartum support. There are frequent consultations moving in both directions – if there is a perineum with questionable healing, a family doc or midwife will be called into the postpartum visit. And just the other day I had a patient come in with a lesion on her nipple – it looked like a hypertrophied gland but I couldn’t be sure. I had the privilege of being able to walk to another room and ask my colleague, a nurse/lactation consultant to take a look. This kind of informal consultation fosters mutual respect, and provides opportunities to learn from each other.
Every family is assigned one of the team’s doulas in the last month of their pregnancy. Doulas are trained specifically in non-clinical labour support and multiple studies, including a recently updated Cochrane Review, have shown their positive effect on laboring women. Our team includes over 40 doulas who among them speak more than 20 different languages. The doula brings all her accumulated knowledge and experience to each birth, as well as the specific knowledge that comes from being present with the laboring woman throughout her labour, usually beginning in the woman’s home. The doula’s familiarity with the woman and birth “plan” is very helpful to the midwife or GP attending the birth, especially when coming on call and assuming care when labour is already underway. As mentioned above, doulas and doctors have not always worked well together, and our integration of doulas as respected team members allows the family to more fully benefit from their labour support.
Different scopes of practice – depth and span
There is something particular that I’ve noticed about working as a family doctor with a team of midwives, and that is the powerful ways in which our different training and backgrounds complement and enhance each other in the practice.
Family doctors having their background in general practice, bring an impressive span to the table – that is, more than almost any other health professional, their experience is wide and varied. They have seen and done a lot of medicine outside the realm of maternity care, so when something challenging comes up, whether it’s managing a patient on multiple anti-depressants or interpreting an echocardiogram, they can bring the broad scope of their experience to the table.
Midwives, in contrast, do exclusively maternity care. As a result they know low risk pregnancy, labour, birth and postpartum care very, very well. The depth of their experience, which follows from this degree of specialization in low risk maternity care, is very valuable to the team. As a new grad, I have benefited a lot from working with midwives (not to discount the mentorship and training I’ve received from family doctors and obstetricians, who are of course experts in labour and birth in their own right).
A key factor that makes the team work well is that we are communicating all the time. This was alluded to in the CMAJ article, and we certainly benefit from technology in this regard. We use OSCAR for our EMR, which can be accessed anywhere – one of our midwives was recently running the team and trouble shooting while doing a training in Africa! On most days, the majority of team members are checking the messages in Oscar. The weekly messages number well into the hundreds. While this can pose a challenge in avoiding, let’s say, an over-indulgence in work, it is a very effective communication tool for patient care and valuable for cohesion of the team. There are also monthly team meetings, which are opportunities to review specific practices, discuss difficult cases, and do the basic logistical work of making a team function.
This seems a rather trite heading in many ways, but is of course the foundation of any healthy inter-disciplinary team. The team works because the unique and important contributions of each professional are recognized by all, and patient care is prioritized over the all too tempting pitfalls of competition, unhealthy hierarchy and power struggle.
So the question remains, how does all this translate into the good outcomes seen in the study? I don’t know exactly, and I think it’s a difficult question to answer. It may be an accumulation of very small and subtle effects. Perhaps the ability to draw from the expertise of other professionals in a team allows us to manage labour in a certain way. It may be that the relationship between the doula and midwife or doctor allows a woman to be more open to her support, thereby relaxing her and increasing the chances that her labour will progress normally. This is just speculation. But I do know that there’s something about an effective inter-disciplinary team that just seems to work well for providing quality health care.
There will always be challenges when working in teams. A recent report from the Conference Board of Canada identifies potential barriers to inter-disciplinary primary health care teams at the individual, practice and systemic level. It’s not hard to imagine how these might play out, and the full report goes into quite a lot of detail.
I hope we can continue to find ways to overcome these barriers, since I find myself very excited about the possibilities of inter-disciplinary health care teams. We’ll see what my nascent career has in store for me, but for now, I couldn’t imagine practicing any other way.
Sarah Olson is a family doctor practicing at the South Community Birth Program in Vancouver, British Columbia.