Thursday, April 17, 2014

indemnity insurance: who benefits?

It's a simple question.  Who benefits from indemnity insurance?

We're all familiar with insurance: home and contents insurance, vehicle and third party property insurance, health insurance, travel insurance ...  Some are mandatory; some are not.  

Narrowing the field a little ...
... to mandatory indemnity insurance for midwives as regulated health professionals.  Who benefits from that?

The obvious answer is that the consumer - the mother+baby who receive professional care from the midwife - are potential beneficiaries.  When/if a mother or her baby experience adverse outcomes that may have been avoided under professional care that may have been done differently, that mother or baby are able to sue the midwife for the loss they claim to have suffered.

An eye for an eye!

The matter is placed in the hands of lawyers.
If the midwife has indemnity insurance, the insurer advises and supports the midwife.  The insurance policy may have exemptions and limits that are taken into consideration.
Sometimes a settlement is reached without going to court.  Money is paid to the person who suffered loss, and that's the end of it.
Or the case is scheduled to be heard in the appropriate law court.
If the court agrees that the midwife was culpable, an order is made that a sum of money be paid to the person who suffered loss in the care of the midwife.
Who benefits?
The person who was harmed.

The complication is the availability/affordability of indemnity insurance.  This is a global problem.  No-where in the world is there an indemnity insurance product for individual midwives that provides assurance of sufficient funds to pay out for the life-long health needs of a baby who is severely disabled by hypoxia at the time of birth. 

It's not a new problem.  I have been attending births without indemnity insurance since it became unavailable in 2001.   I (and others in this country) have been permitted to continue practising without insurance for births, while our government agencies attempt to solve the problem.  Midwives in oz are at present exempt from having indemnity insurance for privately attended homebirth, because it's not available. This exemption will be reviewed by June 2015.

Australia's national regulatory board published a research report on professional indemnity insurance for midwives in December 2013.

The UK Department of Health has rejected a proposal by Independent Midwives UK, concluding that government funding of midwives' insurance will not give patients protection (DoH News story 6 March 2014).

German midwives and mothers have been holding huge public rallies - see hebammenblog and scroll down to 13 March (and use translation if, like me, you don't understand German)

It does seem to me that privately practising/independent midwives will 'die out' as soon as the laws mandating indemnity insurance are applied. Because the stakes are so high in childbirth, insurance becomes too expensive except through large corporations (hospitals) or medical defence schemes which cost more than some midwives earn.

I am considering this threat to private midwifery practice from as many perspectives as I can.  Readers may consider my concerns to be tainted by self-interest, because I practise midwifery privately.  But, as I am close to retirement from attending births, I see myself as a commentator who knows the terrain well.

From a professional perspective, the cost of indemnity insurance demands consideration.  Midwives who are taking a full caseload (40+ births per year as primary carer, as well as other midwifery services) are paying between approximately $2,000 to $7,500 annually.  Neither of the policies on offer covers homebirth; the more expensive policy covers birth attendance in a public hospital at which the midwife has been credentialed and awarded clinical privileges.  The number of women planning homebirth with a privately practising midwife is small - less than 0.5% of the birthing population.  Midwives who take too many bookings burn out quickly, and women lose faith with their private one-to-one midwife if she is not available to attend their births. 

That's the top end of the scale. 

Midwives who have a very small caseload; perhaps only a few bookings for primary care per year, are also required to have indemnity insurance, and the minimal cost is approximately $2,000.  Those midwives, possibly living in rural towns or properties, may work part time as employees in the local hospital, and see their small 'private practice' as an expensive hobby.   

From a professional business perspective, there is clearly a point at which the cost of private practice outweighs any perceived benefit.   

As fees for indemnity insurance increase, and the cost is passed on to the client, some midwives will not be able to earn enough to afford meaningful PII, unless they charge high fees that make their services unaffordable to the majority of women.

It's a self-defeating cycle.

costs progressively rise - 
midwives burn out or fail to attract enough business to continue offering their professional services - 
reduced access to private midwifery services for women

However, the bigger issue (imho) is the myth that mandatory indemnity insurance is somehow in the public interest, when the vast majority of cases of cerebral palsy, for example, cannot be linked to an action or omission by any professional care provider (hospital or home), and there's no claim on anyone's insurance.

From a social perspective, does our society think that midwives should be free to provide services privately (independently) to women, in a way that is affordable and accessible? 

Or the other side of the same coin, that women should be free to engage a midwife privately? 

Most women in our society like to be able to control who provides other personal, intimate services such as hair cutting, or beauty services for removal of unwanted hair, so why would they not want to have a say in who attends them for the most intimate of professional services?

But most women in our society have no idea of the scope of a midwife's practice, or indeed of their own birth-right: to give birth safely and triumphantly under amazing natural forces.
The midwife's ability to protect, promote and support normal birth is limited by the professional/regulatory control: a state's duty to protect the public through the regulation of the profession.

The UK government article that I referenced above suggests that midwives should be able to form 'social enterprise' businesses that purchase insurance for members. To me (I do enjoy the one-to-one relationship between me and the woman for whom I provide primary maternity care) this sounds like layers of unhelpful nanny state control that provides only a mirage of safety.

The indemnity insurance situation for midwives in Germany is different from that in Australia or UK.  A German midwife informed me that "Our "independent" midwives do not practice "privately" or "outside" the system.  Here their service are still covered by national healthcare and their "extinction date" has just been pushed back another year as the insurers will offer indemnity insurance for another year to come (with another raise of 20% and limited for another 12 months and the sum covered cut down to half of what it covered before…)

Back to the initial question:
Who benefits? 

  • when a midwife's indemnity insurance does not cover what midwives do?
  • when the increasing costs of providing midwifery services prevents some midwives from offering their professional services, thereby reducing access of women in the community to midwives?
  • when the increasing pressures associated with providing midwifery services lead to burn-out and break-down and unsustainable commitments being made
  • when the increasing costs of providing midwifery services leads to business models that focus on risk management and the bottom line $$ rather than the woman-midwife partnership?

Who benefits?
  • Not the consumer/client/woman+baby
  • Not the midwife
  • Not the community
someone else!

Dear reader, today I have only touched on these matters.  What solutions can we propose?
In the present climate I see reports of cases before the coroner that are likely to have had good outcomes if they had been managed differently.  I read reports of midwives taking extreme positions on management of women with known risk. 

I have phone calls from women who think they would like homebirth because they don't like hospital.   

The solution is not to be found in ever-tightening rules being imposed on midwives.

The solution is not to be found in governments throwing money at the insurance industry.

One aspect of the solution, as I understand birth, must be that a midwife can arrange to provide care for women in hospital as well as home.  

I would like to see the 'villagemidwife' concept available in any town or community where a midwife chooses to work in a professional capacity, providing primary maternity care for individual women.  The setting for births in this midwife's practice must be determined by the woman's and baby's needs at the time of birth.

A society that provides regulation of midwifery must also ensure the ability of the midwife to practise midwifery.  That is the only way to protect the public.  A society that makes midwifery unaffordable, inaccessible, or restricted to homebirth, is depriving its mothers and babies of one of the most basic health promotion services that human existence has ever known.

Monday, April 07, 2014

A midwifery half-truth: doing nothing

A couple of weeks ago I wrote about the myth of choice.

The midwife 'doing nothing' is a similarly misleading notion: not quite a myth, but definitely a half-truth. It's only one side of the coin.  It sets a potentially dangerous precedent, devaluing the expert professional activity of the midwife, being actively 'with woman' in the interest of safety and wellbeing of mother and child, to the point we have today: an epidemic of unattended births ("free births") in the community.  The rationale is like this: "If the midwife does nothing, then we don't need a midwife."

Today I want to critically explore what midwives are doing when we may appear to be 'doing nothing': what happens when I spend time on the couch in an almost dark room in the wee hours, with my eyes closed; what I am doing when I take up some simple knitting or crochet project as I wait for a baby to be born.

Let's consider the pregnant_woman/mother+baby to be central in this discussion.  What does that woman hear from her own intuition, from midwives, from other professional maternity care providers, from family, and from other sources?

There are many voices, and the value that the woman places on each of those messages varies from one to another.  Social media has, for at least the past decade, played an increasingly powerful role, as indeed this blog site offers information and discussion.  The current generation of mothers is the generation who uses online searches to 'research' a question, who follows multiple social media sites, who is prepared to ask questions.  Whereas previous generations had the 'disease of the month' prompted by an article in a publication (such as Reader's Digest), today's generation can search and often self-diagnose - with dubious effectiveness.  Gadgets can be bought: a pregnant woman can set herself up with a fetal heart rate monitoring device, a blood pressure machine, digital scales for the baby, and any number of other potentially useful, potentially useless pieces of equipment.

But I digress.

Back to the assertion I have made, that 'doing nothing' is a half-truth.  Further, I suggest the notion that the midwife does nothing, without taking into consideration the enormous and life promoting role of the midwife in any professional setting, could have negative consequences for idealistic, impressionable, inexperienced midwives, and for women in their care.

A woman who is labouring strongly, who has invited me into her home to attend her for birth, will have spent time with me during the pregnancy, discussing and planning and preparing for this climactic time.

I am in her home; I have moved quietly into her intimate space, and
  • I assure myself that mother and baby are well, through observation, active listening, and auscultation of baby's heart sounds after a uterine contraction
  • I communicate my assessment and any concerns to the mother, and support her, reassure her if appropriate 
  • I prepare the space so that I can maintain my written record 
  • I prepare equipment that may be needed, such as the newborn 'bag and mask', and oxytocic for mother
  • I recognise any idiosyncratic matters or instructions that are given, such as "don't open the door because the cat might escape"
  • I make a mental note of this woman's progress up to this point in time, how she is responding, what professional observations are reasonable, and what I expect to see happening
  • I assume a protective role of the space, knowing that interruptions and intrusions and interventions can be disruptive: for example, telephones are not welcome in the birthing room.
  • I may sit on a chair or rest on the couch in an almost dark room in the wee hours, with my eyes closed
  • I may take up some simple knitting or crochet project as I wait for a baby to be born.
Doing nothing?  No way!

Even if the labour and birth are 'uneventful', even if the baby is born quickly and easily (from an observer's point of view), without any instructions from me, my presence is the essence of my professional action.  I bring the capacity to intervene, when there is a valid reason.  I bring the ability to minimise interruption that may increase anxiety in the labouring woman, so that the woman is free to progress, unaware of what's going on in my mind or in the outside world.

Dear reader, if you know the ICM Definition of the Midwife, and other foundational statements and codes in our profession, you will understand what I am saying. 
"... This care includes preventative measures, the promotion of normal birth, the detection of complications in mother and child, the accessing of medical care or other appropriate assistance and the carrying out of emergency measures." (ICM 2011 - emphasis added)

Those who understand the promotion and support of normal, physiological processes in birth will know the masterly inaction of authentic midwifery.  This is not 'doing nothing'!

Midwives need to protect women from an idealistic message that tells only part of the midwifery story, and may confuse those who genuinely need the midwife to act in the interest of wellbeing and safety of mother and/or baby.  If that were not the case there would be no need for a midwife.

Your comments are welcome.

Tuesday, April 01, 2014

Obstetric violence in Australia today?

This is the definition of obstetric violence, presented by UK obstetrician Dr Amali Lokugamage at RCOG World Congress 2014 in India:

"Obstetric violence is the act of disregarding the authority and autonomy that women have over their own sexuality, their bodies, their babies and in their birth experiences.
"It is also the act of disregarding the spontaneity, the positions, the rhythm and the times the labour requires in order to progress normally when there is no need for intervention.
"It is also the act of disregarding the emotional needs of mother and baby throughout the whole [childbearing] process" 

Jesusa Ricoy-Olariaga 2014

Today I want to carefully reflect on a couple of births and other maternity experiences that are very close to home.  
I want to carefully measure the maternity culture that I know and participate in, in and around Melbourne today.  
I want to ask in what way I am contributing to obstetric violence.
I want to seek ways by which adverse aspects of a culture can be changed.

[Please note that names and some of the details in the cases have been changed for anonymity]

Case study 1
Bess was a 30 year-old, carrying her third child, planning homebirth.  I have been her midwife for each of her births, and her first and second baby were born at home in my care.

At about 36 weeks, Bess visited her GP, who looked at her abdomen, and said her baby was too small - growth restricted (IUGR).  The GP quickly arranged an ultrasound scan, which appeared to support the diagnosis, and an appointment for Bess at the tertiary hospital.  The GP spoke to me about her concerns, and I wondered if I had missed something.  

.... fast forward to 38 weeks
Bess was advised to go to hospital to have an induction of labour.  She asked me if I thought her baby was too small.  I did not.  However, I told her "If I'm wrong, and there is a valid reason to get this baby born (as she had been advised by the hospital and the GP), you have more to lose than if I'm right."

... fast forward to a couple of days after the birth of her baby (whose weight was well within the normal range).
Bess told me she did not feel traumatised by the experience: rather, she had faced the challenge head on, and accepted the intervention of induction of labour by artificial rupture of the membranes (ARM).  She had progressed unmedicated, and gave birth without assistance to a healthy baby boy.   When she was told, a couple of hours after the ARM, that it was time to commence IV Syntocinon, she declined and was quite definite about not needing further intervention.  She knew from the tone of the contractions she had experienced that her baby was on his way. 

Obstetric violence monitor (using the above definition):
-1  Bess was pressured by (albeit well-meaning) doctors and maternity care system that introduced fear of harm to her baby, when in fact her pregnancy was progressing normally
-1  Spontaneous onset of labour was denied
+1 Bess was able to decline further intervention after the ARM
+1 Bess considered that, despite experiencing pressure to comply with medical plan, her decisions had been respected, and she felt emotionally supported

Score: Pass - Case 1 is not an example of obstetric violence

Comment:  There are many contributing factors in any decision-making.  The choices that a woman has around her maternity care, and the decisions she makes at any time, are not equally weighted.  The support she has, both professional (eg from a known and trusted midwife) and personal (eg from partner, family, friends) will probably influence outcomes, especially if the decision-making pathway is not clear.

Case Study 2.
Deb was a 38-year old mother who had had two caesarean births, both prior to labour.  Deb wanted a VBA2C (vaginal birth after 2 caesareans) for this birth.  She considered herself well informed about making this plan, and made sure that her written birth plan was included in her hospital record.  She had felt cheated in her previous caesareans, and longed for the spontaneity and bonding between mother and baby in normal birth.

Prior to the onset of labour, Deb had some bright bleeding from her vagina.  She went to the hospital, and had some electronic fetal monitoring and other investigations.  The doctor told Deb that her baby did not seem to be distressed, but that he strongly recommended a repeat caesarean immediately.  Deb explained to him that she would accept a caesarean birth, even though it was not what she had so much hoped and planned for, if the hospital would permit her to keep her baby with her, skin to skin, in the operating theatre, in the recovery room, and when they had returned to the postnatal bed.  The doctor went away to make this arrangement, but was told the hospital did not provide staff for that option: that the baby and his/her father would be taken to the postnatal ward, and the mother reunited with them as soon as she was released from the recovery room.

Deb then refused the emergency caesarean.  Deb's baby was, a couple of days later, still born.

Obstetric violence monitor (using the above definition):
-1  The emotional needs of the mother were disregarded
-1  The emotional needs of the baby, as understood by the mother, were disregarded

Score: FAIL - Case 2 IS an example of obstetric violence

Comment:  Deb's case is clearly complex from an obstetric/medical point of view, and I have cherry picked a few facts in coming to my conclusion that this is an example of obstetric violence.  The hospital disregarded the clearly expressed emotional need of this mother, and used inflexible staffing arrangements as the reason for denying her request.

In what ways am I contributing to obstetric violence?
There is no simple tick-box for obstetric violence in maternity care today.  As evidence emerges about the finely orchestrated hormonal processes in birth and nurture of the new born child, the expectations of women will change.  The providers of professional maternity services must also integrate the contemporary knowledge into our care.

One of my own babies was born with a fractured clavicle, and aspirated mucus, as a result of rather rough handling by the doctor.  The mucus was cleared from her lungs using suction and percussion, and the clavicle healed as expected.  But that child became fearful and anxious when ever her throat became inflamed.  She had a definite memory of pain that had been caused by the failure of my accoucheur to permit me to give birth to her spontaneously.  She had experienced obstetric violence.  I did not feel or know that I had been traumatised - the requirement for me to be lying on my back with my feet in stirrups was standard at that time.

At about that same time, in the 1970s, there were dark and horrible secrets in many facilities where children received care.  Predatory sexual activity, and physical and emotional abuse, were tolerated within the system.  A blind eye was turned.  It has taken several decades for the light of public scrutiny to be directed towards those institutions, and for the people who experienced such abuse as children to have an opportunity to tell what they can of their stories.  

In reviewing birth as I know it in Melbourne today, I want to ensure that I and my colleagues are not tolerating - turning the blind eye - situations of abuse and violence against women and babies.

The maternity system as we know it today does not protect, promote and support natural physiological processes in birth and nurture of babies.  It does not follow the standard, that "In normal birth there should be a valid reason to interfere with the natural process." (WHO 1996)

It is possible that future generations will look, aghast, at the way mothers and babies are being treated in the early 21st century, in the same way that we are shocked by revelations of institutional abuse of children in the C20.