It’s easy to get sucked into your practice bubble when you’re a midwife, and put your nose to the grindstone and not look up much. Midwifery is like that; it’s one of the hardest jobs out there, demanding huge amounts of your energy and time, and it’s hard to take a moment to catch your breath, look around, and see what else is happening in the world. However, the other day I had a moment to do just that, and I discovered that independent midwifery in the UK is currently being threatened in a pretty major way.
When those of us over here in the US think about midwifery in the UK, I suspect it’s often done with an envious sigh. Midwifery in the UK certainly sounds a lot better than the deal we’ve got in the US right now. For one thing, there is an integrated healthcare system in the UK, which means that midwives have a seat at the table; they are considered a vital and respected part of the healthcare system, rather than viewed as minority at best, or at worst a fringe element practicing outside the medical system (and there are still plenty of states where some forms of midwifery care, such as home birth, or certain credentials, such as CPM, are still illegal and unrecognized). Of course, it doesn’t help that midwifery in the US is fractured at the moment, with no standard definition, educational path or credential (I’ve talked about this a great deal in previous posts, but if you’re still confused about CNMs v. CPMs v. CMs v. the ACNM v. MANA etc. etc., start with this post here and move on from that). The truth is, they have a much longer and crucially unbroken midwifery heritage in the UK than we have here in the US; the unbroken aspect of it being key, I think. In fact, Mary Breckinridge, an early pioneer of midwifery in the US and founder of one of the first midwifery educational program here (the Frontier Nursing School), was actually trained in England and brought British-style midwifery to our obstetrician-dominated shores. The history of midwifery in the US owes a lot to England.
Right now, as it stands, midwives practice in the UK in one of two ways (and UK readers, please please PLEASE correct me if I’m wrong about this): either as part of the NHS, or as an independent midwife (IM). IMs are fully licensed and qualified midwives who choose to practice outside the NHS, most often in private practice or self-employed, either delivering in a private hospital or more frequently attending home births. They’re able to offer the gold standard of midwifery care: one-on-one continuity of care, meaning that they provide all of the woman’s prenatal care and are also the one at her delivery. Because they work outside the NHS, they charge their own fees and are reimbursed directly by the client, rather than the NHS. Even so, they are still part of the larger healthcare system. In the event that a home birth requires a transfer, an IM is able to smoothly transfer her to a hospital without the usual bruhaha so common here in the U.S., and either continue the care for her client in the hospital as her midwife, or remain with her as her advocate, often going into the OR with her if a cesarean is needed. As it stands right now, most IMs don’t carry malpractice insurance. This is because the number of IMs in the UK is so small that it’s been impossible for them to contract affordable premiums based on the small size of the IM pool. If there is a lawsuit, any damages paid out aren’t covered by an insurance company, and often come directly from the midwife’s assets (not exactly ideal), which means that most pay-outs are incredibly small.
However, a new EU ruling is about to go into affect in October, 2013, which will require that all independent midwives now carry malpractice insurance–or in other words, make it illegal to practice as a midwife WITHOUT malpractice insurance. And given that the pool of IMs sharing the costs of insurance is so small, the insurance premiums would be exorbitantly expensive–prohibitively so. Which means that if they can’t afford malpractice insurance, they’ll be practicing illegally.
Now you might ask, what’s the big deal? Well, the point is that carrying insurance doesn’t improve birth outcomes, it just increases the rate of lawsuits. As Milli Hill writes so succinctly in her article in the Telegraph (Home Delivery: Why Independent midwives are key to the fight for birth freedom):
IMs argue that insurance is a profit-making industry, and that it is good standards of practice that make midwifery safe, not insurance policies. They also point out that by making insurance a compulsory prerequisite of registration, there are implications for the freedom of all midwives, not just independent ones. Potentially, the legislation could further erode birth freedom for women too, with insurance companies gaining a say in where and how they might be happy for births to take place.
If they fail, and Independent Midwifery becomes illegal, this will be a grave blow to birth freedom in the UK. The NHS will be left unchallenged, a monopoly, and a system that already seems to be over-stretched and flawed will be left to continue without an alternative for anyone to compare it to. Women who seek an different option to the mainstream will have no choice but to birth unattended, or perhaps in secret with an midwife practicing illegally. Will this really improve birth safety?
If you’re a citizen in the UK, this is a vitally important issue. Please visit Choose Your Midwife, Choose Your Birth to sign the petition (only UK citizens are able to do so) and to find out more about upcoming rallies and activities (you can even write a letter to MP Dan Poulter, who is currently refusing to meet with IM in the UK).