Why do private midwives need hospital visiting access?

Yes, I gave birth to my four children in hospital. This is #1

In a perfect world, would every woman want to give birth in the privacy of her own home?

Perhaps.

In a perfect world, there would be no sickness, no pain, no decay, corruption ... no need for hospitals either.

But we don't live in a perfect world.  No matter what steps we take to optimise health of mother and baby; to optimise the positioning of the baby in the womb for a normal birth; to prevent infection; to prevent social disorders that result from smoking, substance abuse, and obesity ... no matter ... the midwife is always watching and observing in case complication or illness arises.

Home is a wonderful place for birth when the woman and baby are well, and progressing normally.  At any time the decision to stay at home may need to be reviewed.

Some people may tell me I am being driven by fear in saying this.  We in the 'natural birth' realm see slogans such as 'Trust Birth'.  I hear midwives speaking of the physiological processes in birth as though they come with an iron-clad guarantee.

No! and No!

Don't get me wrong.  Birth is an amazing, awesome process - most of the time.  Natural physiological processes in birth and breastfeeding, together with the cocktail of hormones, and the physical and psychological factors that can influence these processes are truly wonderful - most of the time.

There is no better way for most than the natural process.  God the creator made the woman's body as well as the man's, mysteriously in the image of God, and said it is good.  That is a profound truth.  The balancing truth is that today we are able to protect and save life, through medical intervention, to a greater degree than ever before.

That's where hospitals come in to my thinking today.

I'm not talking now about a perfect world.  However, a better world is a reasonable goal.

There will always be women who need or choose to give birth in hospital.   These women ought (in a better world) to be able to use the services of a known and trusted midwife in hospital.  That option is not commonly available in the world we live in today.  Some women are fortunate that they have a wonderful midwife allocated to care for them in their labour, or even in a caseload/know your midwife program.  But the usual feature of birth in Australia today is that a woman is attended in labour by a stranger - someone she has not met prior to coming into labour.  Women with financial resources and private health insurance might have an obstetrician who has provided their antenatal care, with whom they feel a bond of trust, but that doctor is not in continuous attendance - the midwife/stranger is. 

In a better world, women would be able to engage their own midwife, or small group of midwives, who are committed to providing continuity of care that spans the community and the hospital.

In a better world, midwives would be able to choose to work either privately or as employees of a hospital or health service; either as shift workers, or with a personal caseload, or in one of the multitude of hybrid models of care that are designed to meet the individual needs of the women as well as the midwives.  These options should provide reasonable rates of pay and conditions.  Midwives can only do our job well when we are in good shape ourselves.  We teach women to be intuitive about the needs of their children and themselves - we ought, in a better world, to apply the same thinking to ourselves.

The journey to maternity reform has been an uphill one.  I am hoping that it won't be long before we see a pathway to a better world of maternity care.

Thankyou for your comments.

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.