Is this the end for independent midwives?
Malpractice insurance problems
In Britain midwives and obstetricians care for normal and abnormal pregnancies respectively and are regulated by the Nursing & Midwifery Council (NMC) or the General Medical Council (GMC). In the NHS, they work on broadly similar pay scales, (midwives £22 – £99K, obstetricians £26 – £102K), albeit with more of the latter at the upper points.
Not so in the private sector. Celebrity obstetricians cater to princesses and footballers’ wives in The Portland or St Mary’s Lindo Wing, and make serious money, while most independent midwives, driven by a desire to encourage natural childbirth, or to help mothers let down by the NHS, charge low fees for their 24/7 availability. Few earn even as much as their NHS sisters, making it difficult to afford personal indemnity insurance.
The issue came to a head for obstetricians about 20 years ago. Until then all doctors paid the same premium, a few hundred pounds, but in the early 1990s birth injury awards rose steeply and insurance companies introduced differential premiums; for obstetrics about £10,000 a year. The taxpayer picked up the tab; crown indemnity for all NHS doctors. The Duchess of Cambridge’s private obstetrician still has to pay a whacking great premium, but he can afford it!
NHS midwives had always had crown indemnity. Independent midwives had a modestly priced insurance scheme through their Royal College and rarely got sued; few of their patients would have dreamt of it. But as medical malpractice claims, often backdated many years, went through the roof, underwriters got nervous and ramped up premiums. For cover equivalent to that in the NHS, the premium would now be about £1,000 per birth supervised; more than most independent midwives could afford.
Some gave up. Others put their homes in their partner’s name, so if they got sued for millions, they could declared bankruptcy. So long as they were open about their lack of cover their patients could either go back to the NHS, or take the risk of missing out on compensation. As far as I know things went OK – patients don’t like suing individuals, and lawyers follow the money – until a few years ago, when the Department of Health ruled that they must have insurance. This seems to have been partly to comply with an EU directive (click here) and partly in response to a review by a fellow called Findlay Scott (click here), although Scott simply recommended how best to achieve the politically driven aim of mandatory insurance.
The independent midwives association, IMUK, found an affordable scheme. The details seem to be secret; at least I’ve not seen them. Presumably the levels of cover are rather low. Soon someone persuaded the NMC to investigate the scheme’s financial viability. Some say it was the Department of Health, others disgruntled patients who’d missed out on damages. I’ve even heard it claimed that private birth centres, hoping to do down the competition, were behind it. We may never know. But whatever the cause, the NMC, prodded into action, has just ruled (details here) that the IMUK scheme is underfunded, and that midwives depending on it face removal from the register. Eighty or so independent midwives must close shop forthwith, and send their patients back to the NHS.
Views on this matter depend partly on whether you believe that informed adults should be allowed to take risks, go rock climbing, smoke cigarettes, or give birth at home under the care of an uninsured midwife, without the nanny state interfering. The answer is of course yes, unless your action endangers others. Rock climbing is fine but smoking in an enclosed public space is not. What about endangering your unborn baby?
To over simplify. The legal (and many feminists’) view is that, unless the mother deems it so, an unborn baby is of no consequence up to the moment of birth; she can smoke, go rock climbing, even abort it, and it’s no-one else’s business. An informed adult woman should be free to have a home vaginal breech birth after Caesarean (HVBBAC) under the care of of her uninsured neighbour trained on Wikipaedia! I think this is broadly the view of Birthrights, the human rights in childbirth organisation (click here), who buttress their philosophical stance with the claim that if independent midwives are forced out of business, some women will give birth without any health professional present.
Others argue that the baby is the person most likely to get damaged. It deserves protection not only from incompetent midwives, who should be forced to get proper insurance, but also from feckless parents who take the risk of employing uninsured midwives. If independent midwives are driven out of business, and unhappy mothers get forced back into the NHS, or deliver alone, that’s tough. Get over it.
I fear the latter view will prevail; we Brits seem to rather like collective government-mandated solutions to our problems. But my sympathies are with Birthrights. The case of HVBBAC above, is fictitious. Women don’t choose independent midwives for trivial reasons, and rarely take unreasonable risks with their baby. Even if things turn out badly, the baby will still get the full panoply of UK health and social care, albeit without any extra financial compensation.
But women must be fully informed about their midwife’s insurance cover, or lack of it. If I can’t find out the details, how can a mother? IMUK’s website simply says “All members hold mandatory professional indemnity insurance” (click here). That’s not good enough.
The ramifications of this extend beyond the tiny numbers directly involved. Independent midwives are a huge benefit to the rest of us who work in that monolithic monster, the NHS. They make us question our assumptions, keep us on our toes, and look after the women we’ve failed.
Come on IMUK. Be open and honest about your level of indemnity cover. Please don’t price them out of business NMC.