Friday, October 18, 2013

does private midwifery have a future in this country?

Pear blossoms: it's spring time in Melbourne
This question presents itself to my mind. Should I encourage younger midwives to take up the opportunities for private practice?

There are a couple of major challenges which, depending on decisions outside our control, may either open up or close down this career option for midwives.

  • (affordable and appropriate) professional indemnity insurance: This is a global problem, and next week in the UK "Due to new EU legislation that demands all health professionals possess indemnity insurance by October 25, independent midwives will be rendered illegal overnight – unable to pay the premiums of £20,000 per year, which for some is more than their annual salary." (The Telegraph) and
  • hospital visiting access

Professional indemnity insurance 
One of the wonders of the digital era for me as a blogger is that I can retrieve what I have written in the past.  A search of 'insurance' on this site took me to posts I had written in mid 2009, when the decisions about not indemnifying midwives for privately attended homebirth were made by the government. 

Then came the news that we would be given a 2-year exemption for homebirth.  That exemption has been extended a couple of times, and is now in place until 2015.

The two options for private midwife insurance are products marketed by MIGA and Vero Mediprotect.  The former is underwritten by the Treasury, and indemnifies midwives for claims arising out of their practice, as long as the birth is in a hospital where the midwife has been credentialed for clinical privileges.  If a MIGA-insured midwife attends a woman who plans to give birth in the home, she/he does so uninsured.

The Vero Mediprotect insurance is several thousand dollars cheaper than its competitor, does not have any government underwriting, and does not have any intrapartum (birth) cover.  Since hospital visiting access is available to only a few midwives in the S-E corner of Queensland, the only indemnity cover most midwives need is for antenatal and postnatal services.

Why is professional indemnity insurance (PII) mandated?
The Australian governments have been committed to mandatory PII for many years.  I know this because I was a member of the Nurses Board of Victoria (NBV) for three years 1999-2001, and I sat on the legislation committee.  

Until that time, midwives had been able to buy PII that was capped at 5 or 10 million dollars.  Then the bottom fell out of the global PII market, and the underwriters (Lloyds of London) ceased providing cover for midwives.  This effect was passed down to the Australian Nursing Federation (ANF) which, until then, had included PII cover for all members within their membership fee.  ANF continued to provide PII cover for all members EXCEPT independent midwives.

When I informed the NBV of the fact that all independent midwives were now without PII, an attempt was made to have me resign quietly.  I resisted, and with the support of other members of the Board, retained my position.  I attempted to argue that if the government was intending to mandate *something* (in this case, PII) of all health professionals, it was the job of the government to ensure that that *something* was accessible and affordable.  If the provision of that *something*, PII for midwives, was delegated to the insurance industry, the insurance industry became a de facto second tier of regulation of the midwifery profession.  The insurance industry's first commitment is not to what's called 'public interest'; safety and wellbeing of mothers and their babies.  The insurance industry is a business that exists to make money for its shareholders.

I would love to see a test case in which some brilliant lawyer could argue that this free market situation, where everyone is required to insure themselves, regardless of the feasibility, is not reasonable for a regulated profession that provides an essential service. That it is in the public interest to enable midwives to practise, as much as it is in the public interest to have a regulated profession. Countries such as Netherlands, Canada, NZ have insurance arrangements that do this. Midwives (and women) have to accept certain boundaries and constraints.  I believe that, in a free society, women should always able to employ midwives if they want to, and midwives should be able/expected to attend births in hospital as well as home.

... which brings me to the second point, hospital visiting access.

Hospital visiting access
Many Australian independent midwives have become so used to working outside hospitals, and see hospitals as 'bad' - to be avoided if possible - while homebirth is 'good' - for all sorts of reasons.  This approach is simplistic, and potentially harmful to the mother and her baby.  Even if 95% of women who truly wanted to give birth spontaneously, within physiological processes (that we know often work well in the home), that leaves 5 women in every 100 for whom home is not a safe place to give birth.  Those 5 women have a need for professional midwifery services, just as much as the woman who experiences an uneventful process.  A midwife is 'with woman': the setting for labour and birth is a secondary consideration.  

If midwives are serious about promoting and protecting health in childbirth, we must protect the 'normal', while at the same time being expert in timely recognition of situations when intervention is needed.  We must work to make hospitals as well as homes settings where a woman's own natural processes in giving birth are respected and protected.

1 comment:

Denise Hynd said...

WA Greens Senator Rachel Seiwert's advisor told me in July Bill Shorten tried to bring in a National Injury Insurance Scheme in concert with the National Disability Scheme in the last days of the Rudd Government.
Togther they would have provided national cover equivalent to the ACC in NZ which is part of PIII for LMC midwives in NZ.
All midwives in Australia need to make sure these remain on his government's agenda!