TrueCare

Hospitals and clinics throughout the U.S. have been offering collaborative models of multi-discipline maternity care for years. While this approach has been successfully implemented in many areas, organizations that manage maternity care in the U.S. continue to face difficult challenges, including a shortage of obstetricians and limited access to quality perinatal care for some populations.

Of greater concern has been the failure of many efforts to implement collaborative maternity care that is truly collaborative. Fortunately, the tide is turning as more maternity care providers understand what it takes to successfully combine multiple disciplines to provide better patient care.

As a board-certified Obstetrician and Gynecologist (OB/GYN), I have worked alongside midwives in a collaborative setting throughout my career. This includes 10 years at TrueCare, a Federally Qualified Health Center (FQHC) with the mission to serve the underserved and make an impact on social determinants of health. I’m fortunate to have been mentored by two outstanding Certified Nurse Midwives (CNMs) at TrueCare – Katherine Kelly, currently serving as Interim Clinical Director, and Marie Mateo, former Clinical Director.

One of the primary challenges of operating a collaborative maternity care team is that each specialty brings its own experience and perspective to the table. Midwives see birth as a normal event and respectively build relationships with patients from that specific expertise. OB/GYNs not only see birth as a normal event but they are trained to look for pathology – what can go wrong and how can I fix it?

At times, these divergent viewpoints can create a challenging work environment. However, it is only when a collaborative team creates a culture of mutual respect, trust, and regard for each profession’s expertise and skill set, will a truly successful labor and delivery (L&D) team with bench-setting outcomes be born.

The results we’ve had at TrueCare include recognition from the American College of Nurse-Midwives (ACNM) for two national best practices – one for our low rate of postpartum hemorrhage (PPH) and another for our high rate of intact perineum.

Go With What Works

Organizing a collaborative maternity care team is a complex and demanding process. What I have learned is that some best practices contribute to building and sustaining a close-knit team that functions at a high level. When these processes are in sync, patients experience their maximum benefits. This collaborative workforce was jointly affirmed by both the American College of Obstetrics and Gynecology (ACOG) and ACNM in 2018.

“A flat hierarchy – where everyone is equal – is essential for developing a common language that team members use when speaking to each other in patient case conferences.”

Here are eight learnings from my experience:

Build from the trenches

It is essential to have people who have experienced life  on labor and delivery at the table when creating such a team. Their input on issues such as medical staffing including OB/GYNs and anesthesiologist patient volume, nursing support, and available ancillary support (e.g., nursery, neonatology, lab, and radiology personnel) will help ensure the L&D unit will have the necessary people and resources to provide quality care.

Create a flat hierarchy

The collaborative model involves a team of highly trained medical professionals, each with different credentials and experience. A flat hierarchy – where everyone is equal – is essential for developing a common language that team members use when speaking to each other in patient case conferences. It also ensures everyone shares and listens with respect and an open heart to what others have to say.

Use outside resources when needed.

On a collaborative team, everyone’s voice and perspective on how to take care of a patient’s needs are heard and respected. At times and in particular clinical settings, this can present challenges for doctors and midwives with different mindsets of approach to care. Engaging conflict resolution, communication, and teambuilding coaches or consultants can help imprint these skills into the culture.

Create a foundational checklist of competencies

The team should have a comprehensive list of competencies and a minimal number of delivery observations that providers are required to meet with specific attention to the management of obstetric emergencies. Individuals joining the team must meet these strict requirements in their respective specialties.

Establish clear patient management guidelines

The L&D unit should have clear guidelines for which patients are candidates for midwifery care and which should be cared for by OB/GYNs. These guidelines provide the boundary of safety and ensure that team members are not stretched beyond their scope of training.

Conduct weekly team meetings and daily round huddles

Team meetings are vital for discussing high-risk patients. Everyone on the team contributes to identifying high-risk factors and painting a holistic clinical picture to identify the best approach for safe delivery.

Provide stress management resources.

The care of the couplet through the L&D process is inherently challenging and creates a level of stress that, often, becomes a silent source of burnout for maternity care providers. Hospital systems with a high birth rate volume, should consider a wellness team with an understanding of this level of stress and therefore provide appropriate support for workforce stability and provider wellness.

Learn from the pioneers

In 2005, the Boston Medical Center created a set of guiding principles that led to the development of a collaborative maternity care model based on trust, accountability, and communication rather than discord and divisiveness. I strongly recommend anyone working in maternity care review Boston Medical Center’s article, The Birth of a Collaborative Model, and the 10 Collaborative Model Principles it contains.

In conclusion, when a collaborative maternity care team with a clearly defined practice structure and sustainable systems that promote a culture of safety are in place, the success of interdisciplinary education and skill integration results in excellent patient care and improved job satisfaction. As an OB/GYN, I find it extremely rewarding to work in such an environment and to be part of a care team during a woman’s most vulnerable life event.