Midwife led maternity care

It's easy to rattle off phrases such as 'woman centred care' or 'continuity of care' or 'continuity of carer' or 'evidence based care' because that's the politically correct language (from a maternity care point of view) of our day. These words are popping up repeatedly in the documents that are being prepared by government agencies in preparation for the implementation of the government's maternity reform packages. We should all feel very confident, shouldn't we?

There is one evidence based care option that has largely been avoided in the process; 'midwife led maternity care'. It's not PC in Australian maternity circles to talk about anyone leading care. We are being told that we need to talk about 'collaborative' care.

Quoting from the NHMRC Draft National Guidance on Collaborative Maternity Care,
"Principles of maternity care collaboration:
1. Maternity care collaboration places the woman at the centre of her own care, while supporting the professionals who are caring for her (her carers). Such care is coordinated according to the woman’s needs, including her cultural, emotional, psychosocial and clinical needs.
2. Collaboration empowers women to choose care that is based on the best evidence and is appropriate for themselves and for their local environment.
3. Collaboration enables women to make informed decisions by ensuring that they are given information about all of their options. This information should be based on the best evidence, and agreed to and endorsed by professional and consumer groups.
...
9. Collaboration aims to maximise a woman’s continuity of carer by providing a clear description of roles and responsibilities to support the person that a woman nominates to coordinate her care (her ‘maternity care coordinator’)."
[you can read it all here]

It sounds excellent: the woman nominates her 'maternity care coordinator'. Those who want a midwife can arrange midwife led care. Right?

Not really. I will try to explain.

Some who want a midwife as maternity care coordinator will, hopefully, be able to have a midwife who is employed within public hospital birthing programs similar to those that already exist. The midwife will be able to coordinate the care, but only within the hospital's protocols, as is the case in many midwife care models today. That's where there may be a problem. These protocols are strictly controlled by the hospital's medical authorities.

This is not midwife led care.

It's a hybrid that restricts midwives, and is unlikely to make much difference to outcomes when compared with the standard care in those hospitals.

Examples of restrictions experienced by midwives working under hospital protocols are already emerging. A mother who has had previous home births, and who is booked in a hospital homebirth program (one of the Victorian government's 'pilot' homebirth sites) has been told she will NOT be permitted to have a physiological third stage. The midwife is REQUIRED to inject an oxytocic, actively managing third stage. Another mother who has had previous home births has been told she is not permitted to give birth at home under the 'pilot' because one of her previous births was a caesarean. She has been told that a pilot program is very closely watched, and her presence in the pilot would skew the figures.


A recent Lamaze blog post by Amy Romano, titled
What’s Behind the Cochrane? (or…, “The Good News About Midwives Gets Better!”) explores 'gold standard' research in maternity care. When we look at the best research evidence into models of maternity care, we can conclude that optimal care is midwife led care. That means a woman has a known midwife who not only provides the primary service throughout the pregnancy, birthing, and postnatal phases; who is the responsible professional in attendance at birth; and who accesses/ refers to specialist services when and if required.

Amy Romano warns:
"Women often believe that going to an obstetrician practice that employs midwives is getting “the best of both worlds.” The Cochrane review of midwife-led care in fact tells us that such arrangements are ineffective, inefficient, and may be hazardous to the health of women and babies."


At present there are very few options of midwife led maternity care in mainstream Australian public hospitals. (There are none in private hospitals).

What we don't know yet

The big changes facing midwives who provide private midwifery services and attend homebirths will be implemented from 1 July - only two and a half months away!
Most professional planning, particularly in the field of primary maternity care, is done many months before the date.  We know that we will be required to have professional indemnity insurance that covers everything we do professionally, excluding homebirth.
What we don't know yet includes:

Who will provide the indemnity insurance?

What that insurance will cost?

What 'excluding homebirth' means, precisely.  When does homebirth begin and end, for the purposes of this insurance?

What will we be required to do to access the exclusion for homebirth? 

We have been informed that the Quality and Safety Framework [see the MiPP blog], for which national consultations with stakeholders have been held, will be released next Monday 19 April.

As I have written previously on this blog, I am confident that private midwifery practice will continue past 1 July. We expect to be able to buy private indemnity insurance products that 'cover' all aspects of our practices, except homebirth, and to meet the other requirements that are yet to be finalised.

As far as I know, insurance brokers who are looking into providing this special insurance product for midwives' private practices have not yet put any offers on the table publicly. The Australian College of Midwives has informed members that it has a product which will be available for a fee in addition to membership fees. The Australian Nursing Federation (Victorian Branch) has informed members that it is also negotiating a product suitable for members who are independent midwives.

Midwifery group practices or business (such as the business linked to this blog, Aitex Private Midwifery Services) which employ midwives for private services will also need to access professional indemnity insurance to cover the services provided by their employees.

Questions about professional indemnity insurance for midwives

Questions asked in the Senate Community Affairs Committee in February by Senator Rachel Siewert have shone some light on the changes midwives are facing as a result of the federal government's maternity reform. The complete Hansard is available. I have selected excerpts below (in italics) for comment.

Under the maternity reform package that has now passed both houses of Parliament, midwives will be required to have collaborative arrangements with doctors in order to be eligible for the government's insurance product which will be linked to Medicare, prescribing and ordering tests.

The doctors are not *required* to reciprocate. The logical question that arises is, will the requirement of collaborative arrangements with doctors allow the doctors to control or veto midwifery practice?

This is not a far-fetched notion. Even today, before any of these reforms come into effect, some doctors refuse to provide services, such as ordering blood tests, if they know a woman is planning homebirth attended by a private midwife. Women have been told by their GPs that the GP is not willing to accept the 'risk', from an indemnity point of view, of collaboration with a midwife. Midwives who try to make collaborative arrangements with local hospitals, establishing transparent and seamless processes for referral and transfer to hospital care when appropriate often face barriers and difficulties.


The questions asked by Senator Siewert, and the responses by the Department of Health and Ageing (DOHA) are very useful for those midwives who are trying to understand how these reforms will impact on our ability to practise midwifery, and what changes we may be incorporating into our professional lives in the coming year.

It is clear from the Hansard excerpts below that some insurance providers would refuse to cover obstetricians or GPs whose collaborative arrangements with uninsured or 'underinsured' (ie no cover for homebirth) midwives. This is fairly logical, and will potentially put a stop to the midwife's efforts to comply with the law.  
Reforms that give with one hand and take away with the other are of no use to anyone.


The actuarial advice to the Department is interesting, being based on "the historical data relating to claims experience of obstetricians in Australia." Perhaps they could think of no better comparison. But it would be similar to comparing the risk associated with employing a swimming instructor to guide your child in developing skill in the water, with the risk of major surgery on the child. 


Hansard Page: CA 118

Senator Siewert asked:

When the Department asked medical indemnity insurers whether an insured doctor would remain insured if they have a collaborative arrangement with a midwife, even if the midwife is not insured for home births, can you give us the process that you have used, the questions that you asked and their response.

Answer:

Prior to Ms Huxtable’s letter to the Committee Secretary on 21 January 2010, the Department had spoken to four of the five medical indemnity insurers in Australia who insure doctors. The Department has since received written advice from all five insurers that a doctor collaborating with a midwife will not result in a doctor's medical indemnity policy becoming 'void'.

The five medical indemnity insurers were asked to respond to three questions.

1. Would a medical indemnity policy issued by your insurer to a member/insured respond on behalf of the insured in the event of a claim against the insured in relation to an incident that involved collaboration with a midwife?
All insurers responded "Yes"; with most noting that this would be to the extent that their insured was liable and was acting within the scope of practice covered by the policy.

2. Has your MDO and/or insurer advised any insured(s) that their policy would not respond if a claim involved collaboration with an uninsured midwife? If so, what is the reason for the policy not responding?
Four of the five insurers responded "No". The fifth has responded to two member queries. The insurer’s answer is at Attachment A.

3. Has your MDO and/or insurer advised any insured(s) that their policy would not respond if a claim involved collaboration with an underinsured health professional (including an underinsured medical practitioner)? [Note: 'underinsured' refers to a situation where an insured is not insured for the full scope of his/her practice, and where the insured actually provides services in relation to his/her full scope of practice during the period of cover.]
Four of the five insurers responded "No."

The fifth responded as follows:
“Members are certainly advised that they must select the appropriate practice category, retroactive date, make accurate declarations of risk history etc. Members who are acting as supervisors/trainers are advised that they must have the appropriate qualifications/training and experience for the nature of their practice and select the appropriate practice category for the training/supervision they are providing. Trainees providing health services under the supervision of a trainer rely on the indemnity of the trainer and are advised of the expectation that their trainer/supervisor must have the appropriate qualifications, training and experience and indemnity for that role. That advice is provided because if not then they are in effect “underinsured”. The situation of anticipating underinsurance however does not normally arise (and hasn’t previously to my knowledge) because underinsurance is not usually known until after the event and usually at the time the claim is made.

That is not the situation here as it is now understood that midwives currently do not have any medical indemnity insurance for home births.”
Attachment A
Response from an insurer to questions about doctors collaborating with midwives

Question 2

Has your MDO and/or insurer advised any insured(s) that their policy would not respond if a claim involved collaboration with an uninsured midwife? If so, what is the reason for the policy not responding?
I understand that the insurer has been contacted by 2 members in relation to midwife queries.

The first contact (some months ago) concerned a hypothetical situation requesting the insurer’s views on the scenario and the level of cover afforded by the Insurance Medical Indemnity Insurance Policy in such a situation.

The Underwriting Committee reviewed the scenario and in response to the questions asked advised that;

 There is a general requirement that members have the appropriate recognised qualifications, training and experience for the health services they provide.

 The insurer’s Constitution at 1.2 details Objects of the Company and states at 1.2(c) “to promote honourable and to discourage irregular practice”.

 The medical indemnity insurance policy does not cover independent contractors and in the event of a claim in relation to the actions of an uninsured health service provider, any associated/related health practitioner could also be named in proceedings even if due only to the fact that they held indemnity insurance.
Consequently, it was the view of the Committee that the scenario put forward (where an injured mother or baby may not have access to compensation) did not meet the insurer’s requirements under its Constitution. The Committee observed that on this basis it would not seem appropriate for a member to be involved. The Committee also observed that there was no appropriate practice category for the nature of practice proposed (which was not shared care as defined and not obstetric practice).

The Committee stated that based on the scenario presented that if a member notified the insurer that they were to become involved in such practice (such notice being a requirement under 5.1.5 of the Insurance Policy), that it is likely that the insurer would give notice in accordance with 12.2.2 of the Insurance Policy (where the insurer asks the policyholder to cease a practice and if they do not do so, cover will cease for that practice after 14 days).

The Committee observed that the above would not apply to actual good Samaritan or emergency matters where there is no expectation/anticipation of a member’s involvement in the care of the patient.

Member contact 2 (this week). In summary the member held a “General Practice - consultations and office procedures (non-procedural) practice category. GP’s in that practice category who meet the general requirements of appropriate recognised qualifications, training and experience are permitted to provide shared ante-natal care. As required under shared care the member had referred the pregnant patient early to hospital to book in and had continued to provide care appropriate for shared ante-natal care on that understanding.

The member wrote to us because it had subsequently come to their attention that the patient had not presented the referral/booked-in to hospital and apparently intended to have a midwife assisted homebirth.

The member was advised that;
 their current practice category was no longer appropriate (as they were no longer providing shared-care as defined)
 if there was an intention to continue to provide ante-natal care outside of the shared-care requirements permitted under their current practice category
 that they needed to provide the insurer with documentation showing that they had the appropriate recognised qualifications, training and experience for any expanded ante-natal role and

 members who met the qualification, training and experience requirements for management of pregnancy outside of shared-care arrangements normally selected an Obstetrics category.”


Hansard Page: CA 119

Senator Siewert asked:

Could you provide us with the data on which the actuarial assessment was based that assisted the Department to work out the cost of the Commonwealth supporting indemnity insurance for midwives, particularly midwives who are practising in hospitals and the numbers of births and dangers thereof. Also tell us if state by state is relevant information.


Answer:

The assessment by the Australian Government Actuary was based on the historical data relating to claims experience of obstetricians in Australia. Other matters were factored in, including the key assumptions listed below.

The Actuary’s analysis assesses actuarial and financial risk, rather than the clinical risk of dangers of birth. The actuarial analysis was prepared at a national level and the Actuary was not asked to undertake state by state analysis, as the small number of midwives would not have led to meaningful analysis.

Key assumptions were:

Number of eligible midwives 196 midwives in 2010-11, rising to 712 midwives in 2013-14
Average claim size $227,000
Percentage of claims over $1 million 7%
Number of claims per 1,000 births 1.1 claims
Full time caseload of each midwife 40 births per annum
Claim inflation rate 6%
Claim discount rate 6%