Is midwifery practice controlled by the insurer?

what the stork brought!

Is midwifery practice controlled by the insurer?



If the answer is 'yes', is that a problem?








Recently I wrote about indemnity insurance: who benefits?
The insurance company is a business that can only exist if it protects the interests of its shareholders and employees.  In that article I wrote:

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 defense schemes which cost more than some midwives earn.

Today I would like to focus on a case study, published recently by an insurer of midwives, guiding midwives in the potentially difficult scenario of the client who refuses to follow a midwife's advice.


The case study, titled Terminating the midwife/client relationship (April 2014) suggests that midwives can be insured only if there is zero tolerance for departure, by the midwife or the client, from a very narrow compliance pathway.  That in a situation where the client declines advice from the midwife, the midwife will jump ship - terminate the relationship she has with that client.

I think the advice in this case study is wrong, and MIGA needs to withdraw it.

Many readers will know MIGA is the insurance company that provides professional indemnity insurance (PII) for independent midwives, underwritten by Treasury. It's the only option for midwives who have hospital visiting access.  That's a monopoly.

The big issue of concern in this case study is: "The client signed a service agreement with the midwife agreeing to comply with the requests and recommendations of the midwife."
 
???
 
agreeing [UP FRONT] to comply ... !

Is that reasonable?

What's the point of rhetoric like 'informed decision making' in that sort of relationship?
 
There is no legal obligation that I know of (outside of this sort of service agreement that has been made by the risk management/legal team of the insurer) to ask a woman to sign over her rights, particularly the right of refusal, which is a human right. 

Midwives practising privately, who are planning to attend homebirth, are required by NMBA to have a statement signed by the client that she understands there is no PII for homebirth with a midwife.

The relevant provisions of the National Law and the Board’s requirements are:

Section 284(1)(b) informed consent has been given by the woman in relation to whom the midwife is practising private midwifery

Informed consent must be given by the woman who is the client of the midwife who is in private practice.  Informed consent is defined specifically as written consent given by a woman after she has been given a written statement by a midwife that includes:

·        a statement that appropriate PII arrangements will not be in force in relation to the midwife’s practice of private midwifery in attending a homebirth, and

·        any other information required by the Board.

  [Guidelines for professional indemnity insurance arrangements for midwives]

The case study is based on a scenario in which the midwife believes her ability to care safely for the woman and her baby has been irretrievably compromised, because the woman, now ten days past her 'due date', declines consultation with and review by a doctor/ hospital antenatal clinic.

I want to express surprise at this scenario, and I realise that the MIGA team who prepared this case study probably sent it to one of the midwives insured with them for checking and review.  That thought only adds to my sense of concern!  The scenario presented is hardly a decision point that could be the cause of irretrievable compromise to the relationship.  Most privately practising midwives would have experienced this scenario many times.  The clinical scenario described in the case study is certainly a point for discussion and accurate documentation, but in my mind it would be unthinkable to abandon the woman at that point, on such flimsy grounds.

The case study mentions the ACM guidelines which list post-term pregnancy (7.1.22)  as >42 weeks (not 41+3), category B - 'consult' - which may be with another midwife. The guidelines have a guiding principle of informed choice (3.2.2), stating that "The woman is free to accept of reject any procedure or advice".

Notions of a woman's right to decline, and to make informed decisions in any professional care situations are well established.  The midwifery profession cannot provide safe professional services for women if such blatant and uninformed control is delegated to the insurer, whose primary interest may not be the safety and wellbeing of mother and child.  The scenario described in this particular case study could very easily leave a woman feeling that she has no option than to 'free birth', without any professional attendance.
 

What do we mean by 'professional advice'?

The Australian College of Midwives (ACM) has invited comment and response on its draft position statement on "Midwives working with women who seek care outside of professional advice"

I am working on a response, and would love to hear from other members who have used Appendix A in the past, and who are now including Appendix B in your paperwork (see previous post). 

I have headed this post with the question, "What do we mean by professional advice?"  There seems to me to be an assumption in the draft document that 'professional advice' is a uniform thing. I don't think it is. eg (Draft) Principle "5. Midwives should attempt to understand why women are seeking care outside of professional advice."  (Good idea, but hardly a principle to guide action.  I'll have to come back to that later.)

Sometimes the midwife disagrees with the advice from another professional, while agreeing with what the woman wants.  So is the midwife's advice professional advice?  

I see quite a few women who plan homebirth, for whom I think homebirth is a very reasonable choice, but the professional (obstetric) advice they receive is that they must be cared for in hospital for labour and birth. 

An example would be a woman who has indications from the guidelines, such as having her 6th+ baby, or a woman who has had a previous caesarean, and possibly another indication such as a post partum haemorrhage (pph) at one of her previous births. The Guidelines don't comment on planned place of birth, but out here in the real world, the only option for many women to access primary maternity care from a known midwife - best evidence based care according to many - is to ask the local midwife to attend them for planned homebirth.

In this scenario, the professional advice from me, the midwife, if I had meet this woman in early pregnancy, is that, provided there are no valid reasons to interfere with, or interrupt the spontaneous natural processes in pregnancy, birth, and thereafter, a woman is protecting herself and her baby by seeking out care that protects normal physiological birthing.  The previous caesarean, the previous pph, and the grand multiparity, although each significant factors in planning maternity care, each point to the advisability of spontaneous birthing: spontaneous onset of labour, spontaneous progress in labour, and spontaneous completion of the birthing process.  The professional care provider who is most likely to be expert at providing this package of care is the midwife who has a primary care caseload, regardless of the planned setting for birth (hospital/home).

This same woman may have initially booked with an obstetric managed service, planning birth in a private hospital or a public hospital.  As the chosen model of care becomes apparent to the woman, she may "seek care outside professional advice", and find a midwife who is willing to work in harmony with her natural processes, unless there is a valid reason to refer her for obstetric intervention.  Once again, the midwife is not being asked to do anything outside the usual scope of  a midwife's practice.  The midwife who agrees to provide care for this woman is not stepping outside professional boundaries in any way, even though she is providing care that is quite different from the standard in the mainstream.

Knowing the boundaries of midwifery practice is something that seems quite obvious to me, yet I know that some of my colleagues do not understand these boundaries as I do.

A woman who is planning homebirth, having had a caesarean for her previous birth, asked me if I am supporting her plan.  

I responded that I don't feel that I must support her plan. My duty of care in any birth is to act to protect the safety and wellbeing of the mother and her child.  If there is no reason to go to hospital, homebirth becomes the obvious choice at the time.  At present, prior to onset of labour, the plan is quite reasonable, and there is a good chance that it will continue as a reasonable choice.  I provide primary care, with a planned option for transfer to hospital if needed.  I cannot tie myself in to any commitment of setting for birth.  That is of secondary importance.


It's dinner time now.  Next time I get a chance to write I want to explore the principles that underpin decision making by midwives when women "seek care outside of professional advice"

documenting a 'Record of Understanding'

The National Midwifery Guidelines for Consultation and Referral (ACM Guidelines) are an essential tool for midwifery practice.  They set out, in a systematic way, the situations in which a midwife will initiate a conversation, or a consultation, or a referral of a woman receiving primary maternity care into a specialist level of care.

The third edition (2013) has recently been published (pictured here).  To order a copy, click here.

A new appendix to the new edition is called a 'Record of Understanding', to be used when a woman chooses to act outside the Guidelines or against the advice of her midwife. As I read through the Record of Understanding for the first time, my thoughts went to situations in which I might consider using this tool.  Recent situations in which I have prepared a written record of discussions between myself and a client, when the woman has chosen a pathway that may be at odds with usual professional advice include women who are planning homebirth after a previous caesarean, or women who have had a large number of children.

When using the new Guidelines' Appendix B: Record of Understanding, I will be required to ask the woman to answer, in writing, a series of questions:

1. What information, evidence, or concerns have you considered in your decision to decline the hospital's advice to have an elective caesarean?
2. What questions/ concerns do you have?
3. What is your understanding of the answers you received to your questions or concerns?
4. Did you discuss your maternity care option(s) with your midwife and/or other care providers? Why/why not?
5. What is your understanding of those decisions?
6. What questions do you have about your midwife's recommendations to you?

Decision-making in maternity care is always complex, and ongoing until the completion of the episode of care.  For example, a woman who finds that her baby is presenting as breech near Term is confronted with a whole series of big and small decisions: each one either opening or closing potential pathways.  The one basic choice that a woman has any degree of control over concerns the way the baby will be born: either spontaneously, or with medical management.  My role, as the woman's midwife, is to go with her and provide accurate information as she considers her options.

It seems to me that this 'Record of Understanding' has taken professional documentation to a new level, and this disturbs me.  The matter that I take issue with is the expectation, in the Guidelines, that a woman will provide written answers to these questions.  The unmentioned assumption seems to be that this documentation will be produced in the event of a coronial inquest or other professional inquiry.   I have a duty of care to the woman, and this includes supporting informed decision making.  The woman has no reciprocal duty to provide me with reasons for her choices.  The Australian Medical Association acknowledges this fact in its statement on maternal decision making.  A woman may have her own reasons for declining a recommended course of action in her maternity care, and should not be coerced or placed under pressure to explain that reason. 

The potential value of a written 'Record of Understanding' as it is described in the new Guidelines is that midwives and women will be forced to confront difficult decisions in a way that clearly has not happened in some of the well-known recent cases that have been reported publicly.