Safe Births are a Team Effort

On today’s podcast, we welcome two innovators in obstetrical care and how they’re using team communication methods to improve the chance for a good labor and delivery outcome. April Henry is Director of the Family Center, Center of Reproductive Care and Maternal Fetal Medicine at Exeter Hospital in Exeter, New Hampshire.

We are also joined by Dr. Kathleen Farrell, an OB/Gyn who serves as Medical Director of the Family Center at Exeter Hospital.

Both will be talking about their experience implementing a team-based model to improve communications—throughout labor and delivery, between providers and patients, and among providers themselves. Leading today’s discussion is Julie Higden. Ms. Higden is a nurse and Senior Program Director of Patient Safety at CRICO, the medmal insurance program for the Harvard Medical Community.

Julie, it’s great to have you with us today; thanks for leading our discussion with April and Kathleen. Welcome.

Julie Higden: Thanks Tom. A top risk area we see in our medical malpractice data is in obstetrics, in which most cases are not only of high financial costs, but the majority are also high clinical severity, meaning there could be permanent or grave harm caused to the laboring patient or baby.

Many of the factors that contribute to these cases stem from clinical judgment issues, the clinical environment, and also communication, a contributing factor that is seen in over one-third of OB-related claims.

Today we’ll be diving into one care team’s experience with implementing a model to address risks and communication amongst the team and with the patient and family to improve safety and the patient experience during labor and delivery. That model is called Team Birth.

April and Dr. Farrell, thank you so much for joining me today, and I’m delighted to have you both here.

April Henry: Hi, Julie, thank you for having us.

Kathleen Farrell: Yeah, it’s great to be here.

Julie Higden:  So let’s get started. April. I’ll begin with you. For those who may not be familiar, can you just sort of set the stage for us and introduce us to the Team Birth model? What is it, and what led Exeter Hospital to adopt this approach?

April Henry: Yes, of course. Thank you again, Julie, for having us and allowing us to speak to our experience, because it’s been an excellent one here at Exeter Hospital. So Team Birth is a care model designed to improve communication, collaboration and shared decision making between patients and the care team.

So at its very core, Team Birth is very simple in nature, and it centers around the birthing person as the active participant in their care supported by the team, the nurses, the midwife, and of course, their support people which are paramount to success. So that would include their significant other, doulas, or any other support people that they are choosing to have in their birthing experience.

So one of the key tools in Team Birth, and really the basis for all we do, is a shared planning board. It’s a very powerful visual aid that we keep in the room, and it outlines the patient’s preferences, their care plan, who is part of their care team, and it’s updated in real time.

It ensures that everybody in the room is literally on the same page, and as many people in healthcare know, like there’s always white boards, usually in a patient’s room. They’re just not always used in a systematic way, in a way that promotes communication, teamwork, and best outcomes. So that’s really what the Team Birth model centers around. 

And, you may ask, why is this so important? And the state of the state in the country over the past generation giving birth in America has become less trustworthy, and this is all based on research provided to Katie, myself and the team through Team Birth. US women have the highest rate of maternal mortality among high income countries, and it’s continuing to rise, unfortunately.

We also know that two-thirds of pregnancy related deaths are preventable, and a third of the women in the US who give birth in a hospital reported experiencing one or more types of mistreatment, such as loss of autonomy, or receiving no response to requests for help. So again, these statistics are staggering, but this is all research put forth by Ariadne labs. And we also know that 80 to 90% of reported sentinel events, and this is from the Joint Commission, are due to failures in teamwork and communication. So again, that emphasizes why the Team Birth model and the communication is so important. 

And part of what we do in the model is eliciting preferences. So we’re literally asking the patient, how do you want your birth to be, and what can we do to ensure that your needs are met? It flattens the hierarchy in the room, which also in turn promotes safety. So again, I mean, I could talk about Team Birth for hours. But it’s a very simple concept. But when used consistently in every birth, for every patient every time, it can really improve outcomes, patient satisfaction, and even staff morale.

So I believe that every experience, even the difficult ones, can be a catalyst for growth and reflection and improvement, constant quality improvement on the unit. And a few years ago, our unit experienced a deeply impactful event. We had a uterine rupture during labor. Thankfully it was identified quickly, and after a thorough review it was determined that our team followed all the appropriate protocols and provided excellent care. 

But that wasn’t the end of the story for us, any continuous quality improvement, we talked with staff, we talked with providers, we talked with the family involved, and we did recognize that we could have done better with communication in the real time. Communication during any critical event—communication on a good day is difficult—but communication during a difficult event, is really paramount to providing the best outcomes. 

Julie Higden: Dr. Farrell. I’d like to turn to you. Can you tell me—I know you were the co-lead for the implementation—can you tell me who are the key stakeholders involved in the decision to implement Team Birth. And what do you think helped with buy-in among all the team members?

Kathleen Farrell: Sure. Thank you. So truthfully, a lot of the credit for bringing the initiative Team Birth to Exeter Hospital needs to go to my predecessor in the role of medical director, Dr. Trina Turer, and she and April were really the catalysts and champions for bringing this initiative to Exeter hospital, partly in response to that situation that April was just describing. And as part of that they approached a variety of leaders in the institution. They had buy-in from the Medical Executive Committee, which includes medical directors across multiple specialties. The chief physician officer at that time, a doctor called Neil Meehan, who was also spearheading quality practice. Obviously our pediatrics colleagues were also extensively involved, and then the risk management team and the current president of course, Deb Cresta, all of those individuals, among many others, were approached and brought on board with the model before it was implemented and rolled out to our actual labor and delivery units. 

I think the benefits of a program like this are self evident. So, when it then came to introducing it to our actual staff across groups. I think some of our own cases of adverse outcomes we could reflect upon those and identify where communication did not occur adequately. So I think it’s a relatable goal and initiative, no matter what specialty you practice, but even amongst the practitioners on our own labor and delivery unit.

And as the model was rolled out to staff, I think that the Team Birth program provides a really good and compelling educational material set that includes firsthand accounts from patients and care team members about how Team Birth has enhanced their experience from higher satisfaction to reduced work burden.

I also think our institutional team champions were very good at emphasizing the patient safety focus of the project, which is a hard goal to disagree with if you’re someone who’s being asked to implement this because working to improve outcomes and experiences is just the right thing to do.

I recently came across the email April sent out announcing the implementation of Team Birth, and I think these sentences she included capture what the messaging was really well. She wrote, the purpose of Team Birth is to promote best outcomes for our patients and keep them safe. You all do amazing work at this, and this will help us to better communicate with our team and provide the best experience we can for our patients.  

Julie Higden: I am curious, it sounds like it’s going well now, and there were a lot of key stakeholders that were on board with the education and the implementation. But as with anything, resources are constrained. Staff are dealing with production pressures. This question could be to either one of you. I’m just curious. What are some of the challenges you experienced or faced during, or even post, implementation. And how did you work through them as a team?

April Henry: I can start with that, Katie. So you know, I think one of the biggest challenges is definitely buy in. Right? Buy-in from the top buy-in from providers, buy in from staff. And again making sure that what we’re doing is meaningful and not just another QI measure, so that that definitely was a challenge. 

And we really wanted to change the culture on the unit. And I’m sure a lot of you know, changing culture doesn’t happen in a minute. It takes time, again, it takes trust. So that was definitely one of the challenges. 

And then in the beginning anytime you want to bring a new program in, it’s cost right? So there’s always a cost to this program. So in today’s healthcare climate, where you know, every penny is accounted for, that was a challenge for us as a team, a leadership team to try to come up with that money. And so we got creative with stuff. We really looked to philanthropy to assist us with this, and really brought the community in, and we also went to our local rotary club and we talked to them a little bit about maternal child health and the current state of the state, and what we’re trying to do to improve it, and why they should help us. And so their response was incredible. And they’re all still really invested in everything that we’re doing here. So it’s been nice, because that was a nice connection to the community.

But yeah I really do think like, just buy-in at the beginning is probably one of the biggest challenges in getting the program up and running.

Julie Higden: That’s amazing. I love your outreach to the community, and how they supported you in this initiative. And it sounds like, really, with your education found the value in this program and what it could bring to laboring patients and moms in the area. So that’s amazing.

I think one of the hardest parts of implementing an initiative, as you all well know, is tracking progress and measuring the impact. So, Dr. Farrell, maybe you can speak to how are you measuring the impact of Team Birth? Are you looking at the patient experience, staff feedback, safety outcomes,  all of the above?

Kathleen Farrell: Sure we’re looking at all of those in some fashion. 

So by the time we reached the last round of monthly survey data at 6 months post implementation, we were up to 90% of patients who identified that they participated in huddles during their birth up from 40% at the start of the implementation.

And just briefly for patients who identified that a huddle had had occurred they were much more likely to report feeling included in their care and supported in their birth. 

Similarly to a question of how involved did you feel in decisions about your body and your baby?, 78% of patients who did not identify they had a huddle, still said that all of the time they felt that they were involved in those decisions, compared to 97%, once a huddle was identified as having been part of their birth care. So I think it was a really, the data is fairly positive at baseline, but it really moves the bar even further when patients can say a huddle happened, and that changed how I perceived my participation in this care.

They also provide direct patient quotes from the surveys that they share during those implementation meetings. And those are especially nice to read, because while they’re qualitative data, they really do specifically call out care by different members of our team in ways that are reinforcing, I think, and motivating. So I do have a couple of those that I pulled out if it’s okay, if I share as well.

Julie Higden: Please. Yeah.

Kathleen Farrell: So the two that I pulled were, one patient commented that staff were incredibly thorough, thoughtful, and professional. We felt our needs and care were the number one priority, very positive birth experience. And the second one was from a patient who had actually had a previous birth, I believe, prior to the Team Birth model being implemented, and they commented that they thought huddles were a good icebreaker. In comparison to our last experience, dialogues were much improved. We did not feel as pressured when it came to certain decisions. So I think that’s a really strong message, too, of just a true comparative before and after, from the patient experience, perspective.

Julie Higden: That’s great. Thank you for sharing that. Clearly the data supports the program, as you said, and the quantitative measures are there. But I am always in favor of hearing directly, as I know you are, from the patients, and those quotes are incredibly powerful. And I do particularly like that pre/post comment. But clearly you can see the impact from the patient’s perspective, which is really what it’s all about. So that’s wonderful. Congratulations. 

Kathleen Farrell: So I think one other thing that bears mentioning, while it’s really hard to establish a causal relationship, is that one of the metrics we track super closely on our unit, as is done across the US, is our primary C-section rate, or our Ntsv (nulliparous term singleton vertex, C-section rate). Because safe reduction of the primary C-section is obviously an important goal and metric. As a unit in 2024, the year during which Team Birth was rolled out midway through the year, we had a 30% Ntsv rate for our unit.  Team Birth was implemented in July of 2024, and the year-to-date January to July of 2025, we’re down to an 18% primary C-section rate. And so, again, it’s not possible, obviously to say that this is a direct result of Team Birth, but I think it’s a really interesting correlation, and obviously something that we as a unit, are really proud of that, I do think, speaks to improved communication among our team members as we safely try to get laboring patients to delivery.

April Henry: Yeah, agreed Katie. And I think you know another topic worth mentioning is the shared planning board is definitely the focus of Team Birth, but they also provide us with a lot of other evidence-based resources, such as our admission decision guide. You know they provided us with some nice tools for our clinicians to be able to have a discussion with the patient and really involve them in the decision making. And I think again, that just really builds trust, transparency,  and promotes the patient experience for sure. And I know I’ve seen Katie do it in action, and she is really good.

Kathleen Farrell: Thank you April.

Julie Higden: I have no doubt, very skilled. That’s great. Thank you both for sharing that really amazing outcome, as you said, and correlation at this point, but certainly metrics that you know other hospitals are tracking and very important for patient outcomes. So that’s incredible work. Thank you again, April and Dr. Farrell, for your time today. Congratulations on all of your wonderful work.  

Kathleen Farrell: Thank you.

April Henry: Thank you.

Julie Higden: Back over to you, Tom.

Tom Augello: Well thank you, Julie. That was a great discussion. Julie Higden is a nurse and Senior Program Director of Patient Safety at CRICO. We thank our special guests. April Henry is Director of the Family Center, Center of Reproductive Care and Maternal Fetal Medicine at Exeter Hospital. And Dr. Kathleen Farrell, who serves as Medical Director of the Family Center at Exeter Hospital.

I’m Tom Augello for Safety Net.