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.
 

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?
[simple!]
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.

midwifery directions for 2014

Greetings to my little band of readers and thinkers and birth nerds.

In my first blog entry for 2014, not knowing what lies ahead, I hope this new year brings you valuable learning and the satisfaction of knowing that you have contributed well to whatever your work is.

There is an old saying that the pen is mightier than the sword.  I am using the internet to wield a (virtual) pen/sword (whatever that might mean in today's world) in my campaign to protect, promote and support health through childbirth.  The midwifery-childbirth scene is in need of protection. The context is discussion around the future of midwives and homebirth in Australia, stimulated by midwife-blogger Rachel Reed.  I would encourage you to read the post, and the 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.
 

changes in my world

Today the sky is blue, there is a soft, warm breeze, and signs of Spring are everywhere. I haven't thrown open the doors and windows of the house yet, but I would love to be outside, enjoying the sunshine, allowing my skin to drink in that life-affirming warmth, going for a walk, or pottering in the garden.

But I need to work on supporting other midwives who are feeling threatened, and letting the world know what is happening here in Australia.

There is another change in my world, and only time will tell what it means to midwives and to the women who value our services.

Midwives have been told that a midwife colleague has been 'reported' to the regulatory authority for being with a woman in hospital, after transferring that woman to the hospital from planned home birth.

Under the new 'mandatory reporting' rules, a notification must be made if, in the course of professional practice, another regulated health professional "form[s] reasonable belief that a [midwife] has placed the public at risk of substantial harm due to practising their profession in a way tha constitutes a significant departure from accepted professional standards." (ANF Vic 2010)

In the case of an independent midwife transferring care of a woman from home birth to hospital, and continuing to support the woman in hospital: the standard practice of homebirth midwives for many years - that midwife is not covered by any professional indemnity insurance. The 'significant departure' from 'accepted professional standards' is that the midwife is 'practising' without insurance.

Until yesterday, midwives and hospitals accepted the presence of the midwife in a hospital birth suite in a non-clinical, non-decision-making role, as being outside the requirement for insurance. As recently as this past Saturday, I was with woman in a hospital birth suite. The woman had planned homebirth, in my care. I believe the 'risk of substantial harm' in that case would be greater if I abandoned that woman, rather than continuing with her in a supportive and caring role.  I am a midwife, with woman, and my practice must be centred on the woman, not on the setting or model of care, or even the availability of insurance.

However, a new, extremely narrow definition of 'Practice' has emerged, covering any situation in which a midwife uses her skills and knowledge as a midwife.

I will write about what this means as I get opportunities today.

Thankyou, readers, for your interest.

News for privately practising midwives and women planning homebirth

from
Australian Health Ministers’ Conference

COMMUNIQUÉ
5 August 2011

Professional Indemnity Insurance Exemption for Independent Privately Practising Midwives
"Ministers agreed to a further 12 month extension of the exemption to 1 July 2013 while further options are explored with a report back to the next Health Ministers meeting."

My comment:
I don't have time to write much today, as I have a primip in labour, and Saturday morning chores to do in the house. This extension to the Exemption is good news - we can continue planning homebirth until June 2013 at least!
Joy

Your commets are very welcome.