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.
Jim Thornton
Ripe-tomato.org 
Jim, you have outdone yourself again. Never one to be convinced by emotional appeals, you nailed it in saying that “Women don’t choose independent midwives for trivial reasons, and rarely take unreasonable risks with their baby.”
I will keep you posted on my publications on this issue, the subject of my PhD thesis (in the making).
Well said Jim
Allow women to spend their proposed birth budget paying the insurance premiums for independent midwives. Expand the role, give the opportunity to many. Let us work together and keep the normal normal and move efficiently when this is no longer the case. The thing that is missing from UK maternity care is trust.
That’s an idea.
A great post Jim and my sympathies largely align with yours, even if I am perhaps a little more protective of unborns.
Something I don’t feel we’ve got to grips with yet properly in maternity is risk. Who can make decisions to take it, and who is ultimately responsible. My understanding is that in years past, because it would ultimately be the consultant(s) of the hospital you booked with who would take the rap if something went wrong, we became very risk averse; lots of “admit for observation” and that sort of thing. Some of this is sensible, some of it is unnecessary arse-covering.
But we cannot know the specific quantified risks associated with certain conditions, and it is impossible to give a personalised probability of an event. Perhaps a woman has mildly elevated blood pressure towards term, but no symptoms and is aproteinuric. Almost certainly, she will be absolutely fine and deliver with no problems. But there is just a chance it will rapidly develop into pre-eclampsia. Mild polyhydramnios is another one – probably nothing, but associated with a slight increase in risk of cord prolapse, and probably fetal abnormality too.
For this reason, for all the talk of “empowering women” (which I fully support), midwives – either via the NMC, or IMUK, or whoever – need to be in position where they can, if they wish, step up and take responsibility for whatever level of risk they choose. But these things still get run past a consultant who makes that decision and therefore ends up taking significant responsibility! No one can say “it’s definitely safe for you to have a pool homebirth with XYZ condition”, and the likelihood is the consultant will recommend delivering in a unit with anaesthetics, theatre, blood and neonatal care on hand, just in case. In that situation, why should it even be a decision for a consultant? They should simply be able to say “there is an unquantifiable risk of XYZ”, and midwives can then decide whether or not they wish to offer their independent services and take that risk on themselves.
Declaration of interest: I’m an obstetrician. But it feels at times like when it’s a decision for a doctor, the doctor’s neck is on the line, and if something bad happens that doctor is accountable. But when we talk about how important it is to support women who want independent midwives, home births and so on, suddenly we’re empowering women to take the risk on themselves… Yes madam, of course you can have your macrosomic baby at home in a pool without monitoring despite your two previous sections… As long as you understand this comes with a risk, and you’re willing to take that risk on yourself!
I can’t tell you how often I end up arguing (amicably!) with midwives on labour ward *against* intervention. Why is this woman on a CTG? No, she doesn’t need IV fluids just because her heart rate has gone up a bit – she’s in labour! And so on. And yet some of these same midwives – unwilling to take any decision that might deviate from routine to down right over cautious without express permission from a doctor – can be heard in the coffee room, complaining about how much we over-intervene!
If midwives want to be and be seen as independent practitioners empowering women to have the births they want, they surely must take a share of that risk. I’d love to hear their opinions!
Hi Anonymous. I’m an IM. Just for the sake of absolute clarity, it’s never ‘a decision for a doctor’. It’s always a decision for the woman involved. Legally. Morally. Always. Thanks.
A woman decides to recommend Caesarean section to herself based on a particular clinical situation/reason?! Don’t think so Claire.
Of course it’s her decision to weigh the risks and benefits and accept or decline any recommendation – to start a medication, to transfer in to hospital from homebirth and so on. But midwives and doctors have to know when to suggest these things, and they’re held accountable on this basis, as you well know.
Hi Anonymous. Just for the sake of absolute clarity it is never ‘a decision for a doctor’ but always a decision for the woman concerned. Legally. Morally. Always. Thanks