‘Multidisciplinary collaboration’ and ‘team work’: misnomers for subjugation?

Abstract

Rhetoric in the maternity services is easy to sign up to when meaning and application remain open to individual interpretation. Who would argue against a general principle of 'choice' or 'a woman-centred service' underpinning provision? But then apply that to the woman with two previous caesarean sections who now wants a vaginal birth and the rhetoric's limitations are plain to see. It is all about how the rhetoric is understood and applied at the service delivery level. So it is with 'multidisciplinary collaboration' and 'team work'. Denis Walsh (DW) worked as a team leader midwife in a UK maternity hospital in the 1990s when 'team' was the buzzword. The midwives understood it as having an egalitarian dimension. We were equal but with different skills/experience which we bought to the table to create a synergy. Not so our 'linked obstetrician' who saw himself as in charge of the team, in effect his 'team of midwives'. From there his application degenerated into a benign paternalism at best and an intransigent despot at worst. Team for him was intrinsically hierarchical. For the rest of us it was fundamentally a democratic, consensual model. In a similar way, many a midwifery-led initiative has faltered on the altar of 'multi-disciplinary collaboration' where essentially an obstetric veto has operated. The rhetoric in 'Re-Birthing': Report of the Review of Maternity Services in Queensland is specific about carers working together and communicating. It suggests this will be fostered by joint training programs and the encouragement of open communication channels. It acknowledges that two contrasting paradigms represent obstetric interests (mechanical model) and midwifery interests (organic model), believing these can be reconciled on the ground. Getting down to the nitty-gritty of multi-disciplinary dynamics reminded us of an experience one of us (DW) had last year in the UK at a multidisciplinary forum. It is described here in full to illustrate some of the dysfunctional dynamics that can operate at this level. DW was asked to be a keynote speaker at the forum examining different models of maternity care. The topic was about the emerging evidence base for free-standing birth centres and midwifery-led services and the benefits of small scale facilities as opposed to the mega-unit. Other invited speakers gave their perspectives on the birth centre model. The session was then thrown open to general questions and discussions. There appeared to be a predominantly lay audience of maternity service users and a lively discussion ensued. Towards the end of the session, a question was taken from one of the few mate members of the audience. He stood up, introduced himself by professional group and spoke fluently and assertively on his particular perspective. In fact, he was not asking a question at all. Rather he was stating his view on the issue of birth centres. Some of what he said was critical of DW's earlier address. It was clear that he had used tried and tested strategies to further his agenda and undermine alternative views. They are detailed here: • If you want to be heard in a group, stand up rather than sit. This tiny gesture projects your voice, makes you visible to all present and enables you to scan the room as you address the group. • If you have a position of authority within your profession and work place, state it at the outset. In this particular case, it was a consultant neonatologist. This immediately establishes an authoritative impression. • Speak in absolutes and proclaim rather than express a view: 'As a paediatrician, you are never going to convince me of the safety of birth centres...' • Quote an obscure paper. 'Among your research references, you made no mention of the Australian paper that found high perinatal mortality among small rural maternity units in northwest, Western Australia'. • Finally, close with the 'worse case anecdote': 'I wonder whether everyone here heard of the small district general hospital that was closed this month after the death of four babies...'