Teamwork and Communication for Patient-centered Childbirth

For this month’s newsletter issue, the Rx Foundation is honored to be in conversation with Dr. Amber Weiseth , DNP, MSN, RNC-OB. Dr. Weiseth is the Director of the Delivery Decisions Initiative at Ariadne Labs .?Below, Dr. Weiseth offers insights on Ariadne Labs’?TeamBirth?program – what it?looks like in clinical spaces, how teams function together, and how this approach may function outside of the labor and delivery unit. At its heart, TeamBirth is?giving every person a chance at a safe, dignified childbirth experience.

Background

The U.S. has the highest rates of maternal mortality and reported mistreatment among high-income countries. Black and Indigenous patients experience significantly worse outcomes relative to white patients. But these outcomes are indeed?preventable. The?Delivery Decisions Initiative?at?Ariadne Labs, a joint center for health systems innovation at Brigham and Women's Hospital and the Harvard T.H. Chan School of Public Health , has spent the last 11 years focusing on transforming childbirth care around the world so that every person can start or grow their family with dignity.

In Conversation with Ariadne Labs

(Rx): We know people giving birth in the U.S. are more likely to face mistreatment, serious complications, and even death than people in any other high-income country. The risks are even greater for Black or Indigenous people. But importantly, TeamBirth notes that many of these cases are indeed preventable. Can you share more about what you learned about these preventable complications from your work? What are some of the contributing factors causing these preventable complications or deaths?

(Dr. Weiseth, TeamBirth):?Let’s start with where these statistics come from. Preventable deaths data comes directly from maternal mortality review committees.?Most states have these. Clinicians and public health workers come together to review individual mortality cases and determine if they’re related to the pregnancy or not. That includes whether they were preventable.?

On the national level,?at least four out of five maternal deaths are preventable, meaning that there was an opportunity for the clinical team to intervene earlier, but they did not or failed to do so. We call these sentinel events. The Joint Commission reports that 80 to 90 percent of sentinel events have a root cause failure in human factors – in how teams work together, how they’re communicating together, etc. There is a failure in communication and teamwork among the clinical team.

TeamBirth creates a solution where teams can function better together, where all the voices are heard, and every single clinical decision is centered around the patient. It’s a process by which we improve communication, teamwork, and shared decision-making throughout the birthing process.

I’ll give an example of how that looks in the clinical space: I remember there was a time when I was working as a labor and delivery nurse, and I had concerns that a patient was bleeding. I called the provider, and the provider at the time didn’t think there was enough evidence to intervene. So, it went on and it went on. I kept calling with more concerns, but we never really got the team all together to talk it through. What ended up happening is there was a delay in when that patient could have been treated because we weren’t all watching the same scene. We had different narratives from our different vantage points.

TeamBirth is different because instead of waiting and waiting, or playing a game of telephone, we bring everyone together – patient, clinicians at all levels, and family – in a huddle to discuss everyone’s lived experience and expertise, and then we collectively make a plan together. We discuss progress, make changes to care plans, and schedule check-ins collectively. Every person on the team has an opportunity to share their experiences. Using a Shared Planning Tool, displayed on the wall, the team takes notes during each huddle that become a visual reminder of the care plan and preferences of the mother and baby.

(Rx): How are team huddles different from the typical experience that we have in the hospital as a patient?

(Dr. Weiseth, TeamBirth):?A lot of hospitals will say, “Well, we already do the basic standards of best practices.” However, we know that care isn’t delivered equally to every patient, or every time; so, TeamBirth is really trying to standardize how we communicate as a team. Every patient, no matter what’s unique about them, gets that high quality communication with huddles.?

What we know from literature is that Black women report not being heard, not being listened to when they express concerns or have pain. People of different races, ethnicities, or insurance backgrounds – they all receive subpar communication or subpar interventions or decision making.?

Patient-centered communications should be standard. And we want it to be done for every single person every single time.

Most people can relate to being a patient themselves or having a loved one that needed health care and watching a sort of a game of telephone. The nurses are at the bedside most of the time, supporting the patient in labor, and if there’s a concern or something is going wrong, what typically happens is the nurse leaves the room to go call the provider, the physician or the midwife, and then only they talk about it. The clinical team is meeting to talk about what they are seeing, what’s going on. But the patient is not involved in that discussion. Then the nurse will typically receive orders or interventions from the physician or a midwife, and come back into the room and basically deliver that information to the patient.

As a patient, you’re seeing clinicians play this whole game of telephone, having multiple conversations about the same thing. And we’re cutting the patient out of all that clinical conversation that’s happening among providers. It’s a more paternalistic style of health care.? In contrast, TeamBirth recognizes that all patients have every right to all of their information and all of the decision-making conversations about their care.

(Rx): What I think is unique in your example is that not only does it give more autonomy to you as a labor and delivery nurse, to be heard on the team and have a say in decision-making about whether to intervene or not, but it also gives more autonomy to the patients themselves to make clinical decisions. Can you speak more to how a team huddle approach is giving both autonomy and dignity to patients?

(Dr. Weiseth, TeamBirth):?TeamBirth really creates a space where we elevate what’s most important to you as a patient, which gives you autonomy. Patients have awareness as to what’s happening with their care, and more control in what the decisions are being made regarding their care.

Autonomy is one of the things we measure in TeamBirth, and the way patients describe it is that they feel as though they are a vocal part in the decision-making team. Patients report being more frequently updated; the care plan is transparent and known to all; and, most importantly, patients feel as though their opinions matter.

(Rx): How does TeamBirth also account for people who may want to have midwives or doulas play a part in their birth plan? How does the team huddle approach incorporate and adapt to people’s cultures or circumstances?

(Dr. Weiseth, TeamBirth):?TeamBirth is trying to flatten a paternalistic hierarchy that exists, a top-down, from clinician to patient model. In our model, however, everybody has a role in knowledge and decision-making. Midwives love TeamBirth. They often say, “Oh my gosh, this is the midwifery model of care, now you’re just making obstetricians and nurses and everybody do it!”

What we’ve been finding more recently is that doulas love TeamBirth too because it gives them a concrete way to be integrated into the birthing team. By creating this huddle structure, the doulas are named as a core member of the team – their names are written on the Shared Planning Tool as an active role of the patient’s decision-making team. It flattens out a hierarchy that we’re trying to move away from.

(Rx): What other applications could you see the TeamBirth model be applied to?

(Dr. Weiseth, TeamBirth):?This is one of the more fun parts of my job! We see more and more relevance for TeamBirth outside of the labor and delivery unit.

In the very beginning, TeamBirth was designed exclusively for labor and delivery. But patients loved it so much that when they arrived at the postpartum care phase, they often complained like, “But where’s my team? How come I don’t know what’s happening? Where is everyone?” So we naturally spread to postpartum through patient demand.? Well, the same thing happened with our perinatal patients and clinicians, who were saying, “We need to do this earlier on.” Then after that, we had hospitals coming to us and saying, “Can we do this in the NICU?” It’s kind of snowballed since then. More and more of our hospitals are seeing the benefit to their patients and to their health system and have come to us in the past year to ask, “Can you design TeamBirth, but for the whole hospital?” We can’t call it TeamBirth per se, but the principles and tenets behind it aren’t particularly unique to birth. It really cuts across all of health care. Hospitals are starting to do it now in medical units and other spaces like the Emergency Room, so I do think over the next couple of years, we will have a more standardized designed model for things outside of the OB unit.

(Rx): From your vantage point, as someone who’s worked as an L&D nurse, where do you see continued needs for improvement both inside and outside of hospital walls?

(Dr. Weiseth, TeamBirth):?One of the larger challenges that we brush up against all the time is the current structure of health care has misaligned incentives.

I work with physicians. I don’t know a single doctor that is happy and thriving. They’re miserable and the system just squeezes them and squeezes them. It’s demanding being at the clinic or being at the hospital and going back and forth. It’s not sustainable. It’s also not the best model to give the most safe and respectful care. So we put people into these positions that are then impossible for them to flourish and be the best provider they can be.

TeamBirth doctors have said to us, “TeamBirth brings me back to the bedside. This is why I went into health care to help people and connect with them!” TeamBirth does that. It’s a really powerful statement. Most of health care, all the electronic records, everything is being pulled away from clinicians’ hands. TeamBirth actually brings them back to why they went into this. It brings them back to the patient’s bedside.

Until we really are willing to change some of those structures and where payment goes, change is going to be difficult. We need changes on a policy level.

(Rx): What is your North Star?

(Dr. Weiseth, TeamBirth):?Oh gosh, I’m just so passionate about improving safety and dignity in childbirth! It’s the thread that I see throughout my whole life, whether it be at the bedside or whether it be in quality improvement or in research or in policy.

I really do believe that how women or how birthing people experience their health care is critical. Those birthing experiences – whether you feel respected or whether you consented before you were examined – influences your trust or your relationship with the health care system throughout your whole life. We have such an opportunity to build more trust with patients! It’s interesting to think that that is such a formative experience, and it often happens at such a young age – it can shift the whole trajectory of how you interact with the healthcare field. It affects people’s lives for a very long, long time. You know, I interact with people who find out I work in childbirth, like when I’m traveling, and people always tell me their birth stories all the time. They impact people through their whole life, not only how they feel about themselves or their birth, but how they view health care, which is unfortunate if it went wrong. But there’s also an opportunity there to make it right.

I think that’s my North Star, as well as all those patients I’ve taken care of in the past.

Connect with TeamBirth

Today, TeamBirth is now in over 130 hospitals across the U.S., providing the tools, hands-on training, and implementation support needed to empower patients and clinicians to achieve better childbirth experiences.?If you are a provider who would like to learn more about bringing TeamBirth to your hospital or birthing center, you can contact the team or access the tools and resources by joining?TeamBirth’s Community of Practice.