Wednesday, June 30, 2010

in sympathy

The midwifery and homebirthing communities in Victoria are in mourning at the tragic death of our colleague Mary Reilly.

Our heartfelt sympathy goes to Mary's children, her extended family, and her community.

Sunday, June 20, 2010

Insurance for homebirth midwives

With only 10 days left before legislation requiring midwives to have indemnity insurance for all our private practice excluding homebirth, we midwives want to know what insurance product is available, what it will cost, and how it will impact on the service we provide for women and babies in our care.

I am taking care to update readers in a factual way, although when you have read to the end of this post you may be less than confident in knowing the way forward. What you read here is the opinion of the writer, with links to the information provided by the insurance companies. This information may change from time to time as the sites are updated.

A previous post on this blog has information about the two products on offer, and links to their sites.

Updating the situation:
The VERO Mediprotect insurance provides indemnity only for prenatal and postnatal midwifery services. It has an excess of $2,500 with each and every claim.

The MIGA insurance, which covers prenatal, birth in hospital, and postnatal care claims to be "the sole provider under a new Government supported Scheme to provide Professional Indemnity Insurance to privately practising midwives" (from the MIGA website), now linked to the front page of the College of Midwives.

A News Flash from MIGA (18 June) states that "Over the next few days we will be updating the policy and other information on our website to reflect the changes which essentially relate to the collaborative requirements and employment."

A third avenue by which midwives have investigated obtaining insurance that meets the new legislative requirements is through membership in the nurses and midwives union, ANF. In several States (Vic, Qld and WA), all ANF members, EXCEPT independent midwives, have a professional indemnity insurance cover of $10 Million, with legal representation and support thrown in. The curious fact is that this policy is sourced from VERO. Members have pointed this fact to the ANF professional, legal, and industrial departments and written emails and letters reminding ANF that now homebirth is exempt, surely the risk to the organisation is minimal, and no greater than the 'risk' any other member's private practice engenders. ANF must have private practice nurses working in high risk nursing such as diabetes, wound care, and probably many other fields, and these members are indemnified. To date, ANF Victorian Branch has consistently rejected members' attempts to engage on this matter, responding with rather dismissive letters that contain obvious inaccurate information, while ANF Qld and ANF WA branches have given some members a positive response - that their membership insurance will meet the requirements of the new legislation, EXCLUDING homebirth.

I have written about this publicly because midwives who are members of ANF expect their union to apply its principles of fairness and support for workers to them as well as our colleagues who are employed. ANF has in the past decade hidden behind the belief that midwives in private practice, and homebirth, are high risk and cannot be insured. With the exclusion of homebirth, ANF now has the opportunity to stand up for members who are midwives. This matter is now being referred to the federal ANF level.

Back to the two insurance options, VERO-Mediprotect and MIGA.

Advice from Paul Currall, Director, Medical Indemnity Section at the federal Department of Health (dated 15 June 2010) is that:
"Professional indemnity insurance is a registration requirement, .... The obligation is on the midwife to have appropriate insurance arrangements in force, and midwives will need to consider whether the Mediprotect policy is appropriate for them. As it is a registration requirement, if it becomes an issue then it will be the Nursing and Midwifery Board which is the relevant body."

[Note that the complete contents of the email that this advice appeared in are copied below for those who are interested.]

In conclusion, here are some of the apparent differences between the two insurance products currently on offer (as I understand the situation. If I have missed anything please let me know).

  • the less expensive option
  • excess of $2,500 with each and every claim

My opinion: this insurance product appears to meet the requirements at present for midwives in private practice, covering prenatal and postnatal care, and excluding homebirth.  A woman in the care of a midwife who is skilled in basic midwifery as primary carer is extremely unlikely to experience incidents which would lead to claims on such an insurance policy. When a woman in our care is transferred to hospital, the midwife who accompanies her has no practising rights in the hospital.

  • the more expensive option
  • offers medico-legal support
  • requires risk management at the instigation of the insurer
  • no excess
  • Option A provides cover for midwives eligible for MBS/PBS and hospital birth
  • Option B is similar in cost to VERO-Mediprotect, BUT is available only "if providing no Intrapartum Care at all in your private practice"*

My opinion: this product will be useful when midwives practising privately are able to attend their clients to give birth in hospital, limit their practice to hospital birth, and when the clients are able to claim Medicare rebates (due to commence November 2010). * Since the raison d'etre for the midwife as primary carer is continuity of care, enabling the development of trust and reciprocity between the woman and her known midwife, what's the point of providing NO intrapartum care? [sigh! They just don't get it, do they?]

The MIGA insurance appears to usher midwives into a new era of defacto regulation by in insurance company that exists to make money for its shareholders. In essence, as far as MBS/PBS eligible midwives are concerned, the NMBA becomes a rubber stamp committee.

NOTE: The views expressed in this post are that of the author only and are not intended to be advice. Individual midwives should of course make their own investigations before determining which insurance product is most suitable for their practice.

Question from the College of Midwives to the Medical Indemnity section of the Health Department:
"Is it the case that a midwife wishing to apply for an MBS provider number will need to purchase the MIGA policy? That’s what I’ve been presuming, because I know that the provider number will not discriminate between a midwife doing pregnancy care only and one doing everything, so presumably they have to be insured to do everything?

"The answer to this question will as you would no doubt anticipate be of particular interest to the HB midwives, who are weighing up now whether to take up the MBS option or to simply practice under the exemption with the Vero policy."

Response to the above question, from Paul Currall (dated 15 June 2010):
"Professional indemnity insurance is a registration requirement, not a separate requirement for MBS/PBS access. The obligation is on the midwife to have appropriate insurance arrangements in force, and midwives will need to consider whether the Mediprotect policy is appropriate for them. As it is a registration requirement, if it becomes an issue then it will be the Nursing and Midwifery Board which is the relevant body.

"A midwife wishing to apply for an MBS provider number must meet the NMBA's requirements for registration as an eligible midwife. These are the same requirements that a midwife needs to meet in order to be eligible for the MIGA insurance policy.

"If the midwife meets the NMBA requirements for registration as an eligible midwife, then she/he can apply to Medicare Australia for a provider number to gain access to MBS rebateable services. In the case of a midwife who has insurance cover for ante and post natal services only (and provides intrapartum services for homebirth), access to MBS funds will only be available with respect to clinically relevant ante and post natal midwifery services.

"If a midwife is an eligible midwife for the purposes of the National Health Act 1953 and is approved to prescribe medicines in the state and territory in which she/ he will be practising, the midwife can apply for approval as an authorised midwife, a PBS prescriber, and be allocated a prescriber number."

Sunday, June 13, 2010

in the newspapers

The words 'home birth' and 'midwives' have appeared in headlines of articles in the Sunday Age today. Here are the links to the articles:

With a little Sunshine, home birth rate is due to expand
June 13, 2010

"THE number of home births in Victoria is on the rise, with a publicly funded program using midwives from Sunshine Hospital gaining popularity.

"Since the pilot scheme was launched in January, hospital midwives have overseen seven home births. [continued]

Many midwives unaware new laws affect them
June 13, 2010

"LEGISLATION giving midwives greater authority over the maternity care of Australian women will be launched at the end of the month, but it could take years before real changes are delivered. [continued]

Readers may be wondering, is this good news?
Has all the political activism around birth, and particularly home birth, paid off?
Are Midwives in Private Practice (MiPP) in Victoria, the group managing this blog, happy with progress?
Are mothers who want to give birth at home confident that they will be able to access the professional midwifery services that they desire?

Please send a comment if you have an opinion on this. Unfortunately many will answer 'No' to each of these questions.

Midwives' opinions range from grudging acceptance that a midwife's scope of practice has been restricted, through the government's reform, to a very narrow interpretation of 'normal'; to outrage that we are being forced to give up our right to autonomous practice.

A recent blog by South Australia midwife Lisa Barrett on collaboration has drawn valuable comment.

The Save Birth Choices blog discusses the fact that Homebirths are legal but Midwives not indemnified
"Women choosing a homebirth and their midwives will take little comfort from the implementation of the Rudd Government’s professional indemnity insurance cover for practising midwives this week. [continued]

The newspaper article featuring the birth of baby Banjo through the Victorian government's pilot homebirth project at Sunshine Hospital (situated in Melbourne's Western suburbs) is good news. Women who are able to access the pilot, who might not have even considered privately attended homebirth, are given an opportunity to proceed through their birthing journey with known and trusted midwives, who are able to provide homebirthing care.

Midwifery is not for the faint-hearted. Being professionally responsible and accountable for the birth of a baby, whether in a hospital building, or in a home under hospital protocols, or in a home as an independent practitioner requires a midwife who prioritises consideration of the wellbeing of the woman and her child at all times. Midwifery cannot be fear-driven. Birth is not an illness. The midwife who understands working in harmony with natural physiological processes, who commits to protecting and promoting wellness in birthing and nurturing the newborn child, adheres to the principle that "In normal birth there should be a valid reason to interfere with the natural process" (WHO 1996).

When birth is not normal, or when a valid reason arises to interfere with the natural process, the woman who is partnered by a trusted midwife is able to make informed decisions as she progresses through what can be a frightening and unpredictable journey.

Thursday, June 3, 2010

Writing a letter

This is a compelling account of a birth and the trauma suffered by the woman.

Quote from Pulse: Voices from the heart of medicine

"I wrote the letter because I wanted the doctors and hospital staff to understand my perspective and to appreciate the devastating impact that this event had had on my life and family.

"I also wanted them to consider the inept and unfeeling care we'd received from first to last--including the failure to get me into a delivery room quickly enough, the brutal response to the hemorrhage (which better care might have prevented in the first place) and the inappropriate discharge of my ill newborn.

"I wanted them to change the way they conducted business so that no one else would have to endure what I did."