By Caroline Flint

In midwifery the newest `buzz' word is `the team approach' - wherever you happen to go the midwives are trying to achieve, or indeed have achieved, a `team approach' to care. And this phrase is thought to incorporate all that is good in maternity care: the team approach is better for women, the team approach is better for midwives. Or is it'? Could it just be a meaningless phrase?

The team approach was coined as a synonym for `continuity of care.' Many of us see that working a thirty seven and a half week it is impossible for a midwife to provide continuity of care on her own. Women need to form a relationship with a small group of midwives in order to achieve the desired effect of having someone you know, throughout the whole continuum of pregnancy, labour, delivery and the postnatal period.

Some schemes along those lines have been set up - the aim being that women and midwives could form a meaningful relationship throughout the whole continuum. The team of midwives has taken responsibility for the care of a specified number of women: they are `women based', their care is organized around the women and they are peripatetic.

Other teams have been set up based on a ward model. A consultant obstetrician usually heads the team and the midwives work on a ward. They identify themselves as a cohesive group and call themselves a team, they feel more united and enjoy being together more because they feel that they have a common purpose and a common aim.

When women are admitted to the ward antenatally they get to know the midwives who care for them before and after the delivery. The theory is that the midwives from the ward go to the delivery suite and deliver the women they know. The woman who has been an inpatient antenatally sometimes has this sort of care and for her it is very pleasant - but women who are admitted antenatally are a tiny minority. What happens to the women who remain healthy throughout their pregnancy? What happens to the vast majority of women?

The theory is that these women will meet one of the midwives from their team at some time when they are visiting the antenatal clinic. The ward tries to send a midwife from the ward to the antenatal clinic each time `their' consultant has a clinic. But logistically the chances of the woman meeting and being able to have a meaningful discussion with that midwife is small if the same midwife has to help in a clinic seeing anything up to 100 women.

If the woman goes to the clinic in the hospital a total of five times throughout her pregnancy she has a chance of catching a glimpse of one of the midwives from her team on five occasions. She may even have a meaningful conversation with one of those midwives or even two.

Labour

When the woman goes into labour the chances of her being looked after throughout her labour by one of those two midwives - or even one of those live midwives - are very slim. She is much more likely to be looked after by a midwife she has never met before. Even if the midwife feels at one with the woman, even if her best friend is the team midwife that the woman met in the antenatal clinic, for the woman she is a stranger.

Some postnatal wards run on `team lines'. You can go into postnatal wards across the country and see midwives from team A and team B -only to discover that they work in two separate teams.

Hopefully they care for the same woman today as they cared for yesterday. But if the midwife had a day off yesterday and the woman is going home tomorrow morning `continuity of care' in this situation can mean meeting the woman for a couple of short snatches. As far as the woman is concerned she is still being surrounded by strange faces at this vulnerable time in her life.

I have looked hard at these attempts at continuity of care and it seems to me that the flaw in them is that they are based around the institution and the basic set up of that institution. No attempt is made to change the institution and the midwives are scurrying around trying to achieve something else while actually not changing anything as far as the woman is concerned.

It seems to me that we have to change the emphasis. Once the woman is seen as the paramount individual, once the care is centred on her and her needs ( expressed time and time again over the last decade as 'wanting to have someone with her in labour who she had been able to get to know during the antenatal period') the emphasis changes. No longer is the institution seen as paramount.

Woman centred

It is the woman who is paramount. We can then arrange care to be woman-centred and a small team of midwives takes responsibility for a small group of women.

When the woman goes into labour those midwives take responsibility for being there and will usually have developed a type of `on call' system. After the baby is born the midwives will care for the woman as each day passes.

She knows them all, she has made a relationship with them - they are not just midwives she has caught a glimpse of across a crowded antenatal clinic or smiled at across a `tea party', She has really got to know her midwives.

At the moment `the team approach' is meaningless as far as women are concerned. We might just as well say we are using the 'Monte Carlo method' or the Wiggins Routine' - meaningless phrases, we have to do better than this.

October 1987