Wednesday, October 23, 2013

Caseload midwifery - women do well, midwives love it, so what's the down side?

Five beautiful cousins enjoying a day out at the Weribee Zoo

A recent publication on Caseload midwifery brings together evidence from leading Australian midwifery researchers and academics.  Caseload midwifery is good for the mothers, good for the hospitals, and good for the midwives.

"In Australia, the growing popular choice for expecting mothers is to stick with one midwife from pregnancy to post-natal care. Anne Marie George looks at why caseload midwifery has more to offer than a boutique service." [article]

Good for mothers:
  • less use of medical interventions in labour than women in standard care
  • less use of painkillers (aka 'dangerous drugs')
  • 22% fewer caesarean births than women randomly assigned to 'standard' care.
Good for hospitals:
  • saves the hospital money
  • appropriate use of midwives compared with rostered staff
  • less sick leave for midwives
Good for midwives:
  • autonomy, giving the midwife a strong professional identity
  • flexibility, enabling the midwife to integrate midwifery work with other daily activities
  • arrangements for backup when needed
  • commitment to the women

Everything good comes with a price tag.  If caseload midwifery is so good for women, for employers, and for midwives, what's the down side?

I am writing from my own experience, over the past 20 years, with a caseload.  The caseload research referred to above was done in hospitals, while my experience has been in private practice.  The place of birth for most of the women in caseload research has been a public hospital, while my work has been with women who are usually planning homebirth.  But the commitment of the midwife is the same, regardless of where the birth is intended, or who pays the midwife.

When I began to practise independently, with my own caseload, I experienced the development of a strong midwife identity that has only grown over time.  I began blogging before we knew what a blog was.  In 1996-97 I wrote The Midwife's Journal, bringing together my experience and learning as a midwife against a backdrop of ordinary daily experiences of my life.  I appreciated the flexibility and freedom that caseload midwifery offered me, when compared with rostered shift work.

From my perspective, caseload midwifery is all about families - the family that is being made/extended with the birth of a new little person, and the family of the midwife who commits to being 'with woman' throughout the journey.

Most midwives are women, and most women have children, and the responsibility for caring for children is, for considerable periods of time, a mother's responsibility.  And so it should be.  It would be ridiculous for the amazing processes of bonding and attachment that are mediated by a hormonal cocktail through the pregnancy-birth-nurturing continuum to simply shut down.

If a midwife is also a mother of dependent children, she needs reliable support at any time, day or night, in order to take a caseload.  This fact prevents some midwives from taking up the caseload options - until the children are old enough.

I began caseload midwifery in 1993, when the youngest of our four children, Josh, was 12.  I knew that he, and his three older siblings, were reliable and responsible, and could be trusted to let themselves into the house after school, find something to eat, get on with his homework or music practice, and would be safe if I was out.

The down side of caseload midwifery is the very thing that makes it so valuable.  Commitment costs the midwife.  Getting up at 11:30 pm or 3:00 am is never easy, but that's what a midwife does - for the woman in her care.  Going through a journey that presents difficulties or distress is never easy, but if the midwife is 'with woman', they go through it together.

I began this post with a picture of our five precious grand children - the next generation in our family.  Midwives who have caseloads are guardians of the next generation, protecting wellness and promoting health in families.

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.