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Independent Midwifery – the end of choice?

by Ann Charles on March 8th, 2013
Pregnant belly with four hands hugging it

As you may already know, Independent Midwives may no longer be able to practise after October 2013.

This is because there are some rules coming into force which means it will be compulsory for all healthcare professionals to have Professional Indemnity Insurance (PII).

Due to the costs involved, nobody has been willing to insure Independent Midwives, so this effectively means that once the rules change, the option to have a self-employed Midwife during labour will no longer be available to women in the UK.

The background to all of this is explained in a way much better than I can do on the Birthrights website.

Um, Ann – what the hell is an Independent Midwife?

Glad you asked!  An Independent Midwife (IM) is someone who is qualified and registered as a Midwife but is self-employed.  Most Midwives in the UK work for the NHS, and there are some private Midwives who work for other companies (e.g. private maternity hospitals).  An IM works outside of both of those models (although some also do cover work elsewhere).

IMs have the same registration and supervision standards as any other Midwife; the only difference is that they are their own boss when it comes to doing the tax returns!  Although in theory they can provide any type of Midwifery care, a lot of IMs are very focussed on women-centred models with the emphasis on normality.  They tend to specialise in home births and there are several who have become expert in breech (bottom or feet-first) and vaginal twin/triplet birth.  It’s becoming harder to find this expertise within the NHS.

Right, lovely.  So – why the fuss?

There’s a shortage of Midwives in the UK at present.  Forcing IMs to have insurance which is impossible to obtain will mean that they can no longer be hired by women for support during labour.  Although there is some insurance available for antenatal and post-natal work, it is unlikely that as many women will hire IMs if they aren’t able to have them as their Midwife in labour.  So this makes it likely that many IMs will leave the profession at a time when the country already needs more trained maternity staff.

In addition, there are some concerns that even if insurance were available, healthcare professionals might have to comply with the terms of the insurance.  So there’s an ideological point about whether or not private companies should be allowed to dictate what can and can’t be done by a qualified healthcare practitioner.

Hypothetical example: a healthcare professional is allowed to offer Miracle Treatment X by her professional governing body.  However, no insurance provider will cover Miracle Treatment X if it is done on a Wednesday.  Can the healthcare professional offer Miracle Treatment X on Wednesdays?

If the answer is ‘no’, then that’s a restriction on the treatment choices available to the public.

(I have not been able to unpick the wording to be able to tell if the regulations mean a healthcare professional has to have insurance, or whether they have to have insurance and abide by the coverage of the insurance.  If you know the answer, please leave a comment below!)

But what’s wrong with NHS Midwives?

Nothing!  There are wonderful Midwives working in the NHS.  However, if a woman wants to have dedicated one-to-one care, or has a birth type that the NHS finds hard to support, then they currently have a choice – to book with an IM.  If IMs vanish, then we lose another option for how to ‘do’ Midwifery in the UK.

But isn’t having insurance a good thing?  What if something went wrong?

There is an argument which says that having insurance is a good idea.  At present, if there’s an incident which leaves a child or parent with severe injuries or disabilities, you would not be able to sue an IM backed by an insurance provider for compensation, because s/he wouldn’t have one.

IMs currently inform their clients of their lack of insurance.  If a client were to sue, then the IM’s own house and property would be on the line.  It could be argued that this provides a better level of protection than conventional insurance – the Midwife’s entirely worldly goods are at stake if anything goes wrong.  However, any compensation awarded may not total as much as an insurance company payout and a family might be less comfortable with suing an individual v suing an individual covered by an insurance firm.

I have an opinion on this.  What do I do?

There are several options:

1)   Complete the Department of Health consultation on the introduction of mandatory insurance for healthcare professionals.

Tip: If you are only commenting on Midwifery, there’s a button on one of the earlier questions which allows you to flag up that your comments should be read with Midwifery specifically in mind.  The form also seems to hide the questions right at the bottom on some pages.  To make sure you don’t miss a question, ignore all the ‘next’ buttons until you have scrolled right to the bottom of each page.

2)   Write to your MP.

3)   For those who wish to show their support of Independent Midwives, there is a ‘Peaceful Protest’ being organised on the 25th March 2013 in London.

4)   Consider adding your name to the e-petition requesting that the government provides a way to meet the insurance requirement for IMs.

5)   Talk to your contacts in the insurance industry – are there any firms who could be persuaded to provide cover?

6)   Talk to any very rich people you know – can anyone start an insurance fund?

I am not advising you to have an opinion one way or the other but if you wish to take part in the consultation, the deadline is the 17th May 2013.

If you’d like to see an Independent Midwife in action, then watch ITV’s Home Delivery at 9pm on Thursday, 21st March 2013.

The photo used in this article is by Joelle Inge-Messerschmidt.

What do you think? Should insurance for Independent Midwives be compulsory?  Have I missed an important detail on the background to all this?  Please have your say in the comments below!

From → Midwifery

  1. Independent midwives are only a choice for those that can afford it. They represent elitism in action. I would much rather the government addressed the shortage of midwives in the NHS and worked to educate and inform them about women’s right to have the birth THEY want, with the support of the midwife, rather than have the most convenient birth for the caregiver imposed on them. For the majority of women independent midwives are not an option and as the wealthier can afford them, they are unlikely to push for improvements in NHS standards as it doesn’t affect them.

    • Independent midwives are expensive compared to free maternity services but worth every penny. They provide the only assurance of one-to-one care so critical for the physiological birth process to unfold unhindered. Affordability is a question of prioritisation for many (not all). I would forego the cot, the play pen, the numerous gadgets & toys marketed, the upgrade of car or the latest in cosmetics any day to prioritise an IM if it seemed my birth choice couldn’t be provided for on the NHS. Having lost faith in being attended by NHS midwives for a planned homebirth who were so stressed & overworked that I was counselling them, I was fortunate to be gifted the cost of an IM. I am not wealthy. It was the best investment I have ever made. I enjoyed an empowered undisturbed birth with a wonderful IM that I know wouldn’t have been possible without 1:1 care with someone I had established a relationship with through late pregnancy. I felt guilty at first, privileged, but realised I was easing an overstretched midwifery service so in a way, I was not overburdening it still further. It was the best gift I could have given my son – a peaceful & gentle start to life. Far from “not pushing for improvements”, it was such a life-affirming experience that I’ve set up a social enterprise Syntonic Birth and dedicated my life since to raising awareness about birth, educating women, campaigning for improvements and doing everything I can to improve birth so that more women can enjoy it and more babies can be born gently and respectfully into the world. Yes, the NHS maternity services need improving, we need more midwives, fewer interventions, sensible legislation so as to support not undermine choice. Dismissing IMs and those who benefit from them is not the answer and there are many like me who, as a result of incredible IM care, care passionately about improving things for others too. A holistic approach is needed by all, including governments legislating.

      • You were indeed fortunate to have been gifted the cost of your midwife, most of us are not so fortunate.
        My real problem is this concept of “choice” that I keep hearing – that IMs must be supported to ensure choice for women, but its only a choice for those who can afford it – or who are “gifted” it by someone who can afford it. There is no choice for the average woman. You say you would have done without the cot and gadgets and toys to afford it? Well what about those who already have to do without the gadgets and toys because they can’t afford them? None of my babies have ever had anything new – everything from their cot to their nappies comes from ebay and most of the items I own have been used and re -used by several of my children. I am fortunate that we spaced them so that the eldest are now adults and I have only 2 teenagers and a toddler at home, which has enabled our modest income to support us – but there is no way I could raise £4 -5 thousand pounds to pay for anything! I wouldn’t dream of spending anywhere near that on gadgets, toys or cots, so if I went without them, I’d still have to raise thousands of pounds to afford an IM. And I don’t consider myself poverty stricken – there are many, many families much worse off than my own – so where do they get the funds for an IM? I doubt they would have families well off enough to gift them thousands of pounds What about women on benefits? Don’t their “choices” matter? The truth is, It is not a choice, it is a privilege and that’s a disgrace.

    • Edy Grant permalink

      Hi Siobhan,
      I totally agree with your post.
      We have 5 children. First was “elective” C-section due to breach presentation, second and third were born at home with the same IM and fourth and fifth at home with NHS midwives.
      Our second pregnancy and birth was great experience and to me worth the £2500 (this was the cost 9 years ago). However we were unhappy with standard of care with our third baby (can write more if interested) and we felt, that the £2500 was def not well spent.
      It left us feeling rather bitter, as it felt that although our experience was bad, we should have still been grateful for the option of having IM.

      When we seeked different IM for our fourth baby, we were shocked even further when we realised, that we have been “black listed” because we made our feelings clear to our IM after the disappointing second home birth and she made sure, she portrayed us as “difficult” clients and we have been therefore denied services of IM, who was going to be our IM, but decided we were not worth the trouble.
      She was happy to accept £50 consultation fee, only to ring me a few weeks later (after she made checks about us with our ex IM), saying she wont be our midwife, because she didn’t like what the other IM had to say about us.

      Now this I also would call elitism and considering we struggled to pay for IM every time, having to take up loans, this was horrible experience for someone, who only tried to get the best care for our babies, being scared that we might not be able to get birth we wanted on the NHS.

      Needles to say, we went on to have our baby #4 and #5 at home and with fab support of NHS midwives, our #5 birth was very similar to independent care, 1:1 at home, 1 hour appointments, other family members involved and our birth was just as we wanted.

      And this is def what we need to campaign for – care like this should be available to all women, not only those who can afford it. Birth the way women want should not be a privilage.

  2. Chantal permalink

    Give me a break. Independent midwives are much much more affordable than having you prenatal care, labor and postpartum with a doctor and in the hospital. The total cost of it all would have been $5,000 for me here in San Diego. Not everyone could afford that so they go with their insurance and don’t the birth that they would like. In the end this ends up costing the government far more money. It is ridiculous and to call it elitist is as well.

    • This article refers to Independent midwives in the UK. In the UK we don’t pay for NHS care, so having a hospital or home birth with a doctor or an NHS midwife is completely free to all. Only the wealthy can afford private health insurance here, which wouldn’t cover an Independent Midwife anyway, only a midwife based at a private hospital. So it is indeed elitist as the vast majority of women are unable to afford the services of an independent midwife. Please don’t call me ridiculous when you have little idea what you’re talking about

  3. And an independent midwife costs the equivalent of about $6000 here, so more expensive than your doctor.

  4. I am an Independent Midwife, why? Because the type of care I give (continuity of care, personal, holistic care) is rarely available on the NHS. This kind of care is the gold standard and the NHS should be providing it – however, mostly it isn’t. People think that I care of rich women, which is very far from the truth – I have women who pay me over a very long period of time (many years occasionally), because they value the care that I give. Please remember that we all pay for the NHS service through our taxes and national insurance contributions, it is not free! Just free at the point of delivery, that is a very different thing. As a midwife, I would love to be able to provide my care via the NHS model, however, at the moment, it is just not possible,.

    • I understand that we all pay for the NHS but the point is, its paid for and requires no further out of pocket expenses. Whichever way you look at it, most women will never be able to afford the services of an IM, so it is by definition an elitist service. And as for taking years to pay off – is that what we want? Each child bringing with it years of debt for its birth?
      The services you offer may not be available on the NHS, but they should be.
      And to Jan Smith – how fortunate you are to be able to pay for medical services the rest of us have to do without, no matter how terrifying or traumatic our births may be. Maybe if you and others like you demanded better from the NHS insead of buying your way out, we might be all able to have the births we want.
      And you don’t need an IM to have a peaceful, empowering, amazing birth, you can get it on the NHS if you insist on it.
      I have had 7 children, 2 in hospital and 5 at home with NHS midwives. Every single one of the midwives, bar one, was supportive. And that one was quickly replaced when I made my feelings clear about her lack of support for my birth choices. Nothing was traumatic about my births because I expected and insisted on proper support from the NHS, and I got it. And I was repeatedly told by midwives that if more women insisted on natural childbirth and educated themselves about their options, the NHS would have no choice but to support their choices. Time and effort would be better spent educating women of their rights and choices within the NHS than wailing over IMs who only offer a “choice” to the privileged few. Midwives who,incidentally, get their training on the NHS, funded by bursaries also provided by the taxpayer and then leave the NHS to work in the more lucrative private sector.

  5. Jan Smith permalink

    For the cost of a three piece suite my second child was brought into the world in as peaceful and relaxed a manner as I could possibly imagine thanks to a wonderful relationship built with my Independant Midwives during my pregnancy. A stark contrast to the terrifying experience of my first labour in which lack of continuity and communication put my baby at serious risk and meant her first days were spent in SCBU. I wholeheartedly wish the NHS could provide this service but until they do please give women the option.

    • My 3 piece suite cost me £50 from ebay. Many women pay less than that in charity shops. Many more, rely on furniture mines run by social services to get a free suite, or else they do without. Similarly, they rely on NHS midwives, or they do without. Where’s their “choice”? Choice should not be directly correlated to bank balance, as is the case with IMs
      Many people could do with a reality check.

  6. I am not sure why the rude personal remarks are considered appropriate. It is all about choice. IM are expensive but it depends on what you are comparing it too.

    My first birth – in hospital – was traumatic, unpleasant and left me with physical scars that had to sorted out months later due to a Junior, unsupervised Doctor, deciding I needed to be cut and stitched up so tight I couldnt move without pain for weeks, pumped so full of drugs in labour that I was almost unconscious during the actual birth.

    None of this was in my birth plan – it was left unread during the whole process and when i asked why any of this was necessary was told they were busy, didnt have time to read notes, and there were more babies on the way so were in a hurry to finish.

    Next baby – at home – was a revelation in comparison. Quiet and welcoming rather than noisy and chaotic

    Third baby – went down the NHS route to be told that there was limited choice, I could request a water birth, the same midwife for care, in fact, I could ask for anything I liked but it would all depend on the day if it was available.

    As I wasnt intending on a re-run, I opted for a Birth Centre, staffed by midwives not Doctors, NHS but supported by the local community – always in danger of closing – If that option had not been available I would gone down the route of IM.

    It is all about choice at the end of the day

    • But its not all about choice is it – its all about money. Its only a choice if ypu can afford it. Its not a choice for me and others like me, who make up the vast majority of women in the country. So, because we haven’t the money to afford it, we can all just go to hell- Is that it?You could have had a home birth on the NHS. You could have refused interventions and told THEM how you would be giving birth. That’s what I did. I refused induction when I went 19 days overdue, all drugs, I allowed only manual monitoring with an ear trumpet etc. They told me for my last home birth that there “may not be a midwife available and I would have to go in if that happened” I tiold them that I was having a home birth with or without them, but if anything went wrong due to lack of medical care due to their failure to provide a midwife that I would sue the NHS for negligence. The supervisor of midwifes put a note on my records that if, when I went into labour there were insufficient midwifes that they were to call her personally at home and she would come out to me herself. Because I had no money to buy a choice, I had to demand my choices within the NHS and I got them. And because of my 5 homebirths, there are 10 NHS midwives who have seen another safe, happy intervention free birth and 5 student midwives, who know what normal birth can be. That may change some attitudes. Buying my way out by hiring an IM changes nothing.

      And I haven’t made any rude personal remarks, so I don’t know what or who you are referring to.

  7. Thank you all for taking the time to comment on this – the options we have around birth will always arouse passion!

    Bringing it back slightly more to the specific topic of the situation IMs in the UK may face in October: what about a Midwife’s right to choose how she works? Physiotherapists, for example, may work in the NHS, privately, or both. Should Midwives be excluded from this? Over 100 micro business owners may cease trading if these rules are brought into force – is that fair? And what do you feel about the possible limitations all Midwives may face if insurers bring in rules restricting practice (I’ve not been able to research into this fully myself but IMUK has a statement which says that all healthcare professionals may be affected by the new policy:

    I’m not trying to sway the discussion one way or the other but am interested to hear what you think (bonus marks if we can stay with attacking arguments rather than each other 🙂 )

    Thanks again for taking the time to comment and share your experiences. This is a relatively new blog so I feel very privileged to have had so many responses. And at least we can all agree that one-to-one care with people we know and like is very important 🙂

    • I doubt people would be up in arms shouting about choice, if we were talking about physiotherapists! My problem is not particularly with the concept of IMs, its how they choose to market themselves as being about “choice” They are not about choice – they are a way for well off women to buy their way out of the system, rather than demanding action to improve the system we have. Its a case of “as long as I’m alright, Jack….”
      IMs take the free training and education that the NHS gives them – they don’t even have to pay for their own living costs whilst training, they get a bursary, which doesn’t have to be paid back and then as soon as they are trained, they leave the NHS to set up on their own. At the very least they should have to pay back what they have taken They are a drain on the NHS, which then makes cuts elsewhere and so they actually deprive most women of real choice,

  8. And there are always constraints about how certain professions can work. We don’t have private policemen or paramedics here. In some places you need a licence to be an estate agent! A crystal healer will never work for the NHS – there are always constraints attached to any job. Maybe IMs should try working in the US – in many states they would be arrested! And in others they’d be fine – the USA is all about choice – as long as you can afford it. Our IMs would fit right in.

  9. I also find it strange that you would assume that anyone who has an opinion on this who be supporting IMS on this insurance issue – I refer to the section above where it says “I have an opinion on this, what do I do?” which then goes on to explain how to support the IMS cause. Is that the only opinion there is? Cos let me tell ya, I have an opinion on this…oh yes indeedy! and as you will have gathered by now, it doesn’t involve lobbying MPS or signing epetitions in support of elitism!

    • Hi Siobhan,

      I haven’t made that assumption – the consultation is open to everybody and I tried to word each option in such a way that it was clear it wasn’t something anyone had to do. Have you filled it in?

      On the training issue – there isn’t any other way of training to become a Midwife in the UK. Ditto doctors etc!

      It is possible to work as a paramedic outside of the NHS, but I take the point you are making.

  10. Sundown permalink

    It IS about choice. Without IMs the NHS would (will) be a monopoly. There will be no pressure to improve and offer services that it should, but doesn’t. Many, many of us fight tooth and claw for improvements to NHS services as well as supporting IMs, so please, Siobhan, do not assume that those of us who would choose IMs don’t care about improving NHS services. Most people who care about birth rights care about all options, and that includes IMs as a choice for those who can use them AND improving NHS services. And regarding the NHS funding their training – that is true, but if the NHS looked after their midwives properly, they wouldn’t need to look for alternative options of work. As it is, IM’s, without the NHS’s restraints, can continue to develop essential skills that would otherwise be lost such as vaginal breech or twins delivery. This is essential to everyone – not just those who can afford IMs – as the NHS sometimes pays for IMs to offer these services, and once they’re gone, they’re gone forever.

    If you actually look at the save IM campaign, Siobhan, you will see that it’s a complete package of trying to save IM services as they are and *at the same time* trying to make NHS services closer to the IM service. It is completely unacceptable that the NHS offers such a poor maternity service but while they do we need IMs. Our daughters need IMs. If you don’t want to fight for them, that’s your perogative but please do not make (erroneous) presumptions about those of us who are devoting every “spare” moment to trying to keep independent midwifery alive. I’m sorry that it’s not a choice for you. It’s not for me, either. I will not have any more children. But I am desperate to make sure it’s an option for other women out there. Just because you can’t benefit from something does not make it any less essential for others out there. Try to see the value that IMs bring to all of us, rather than thinking of them as elitist and therefore, by your logic, not of value.

    Or, if you wish to choose to not see their value, move on and use your energy somewhere positive.

  11. Anna permalink

    I think what really gets to me is that not all women are in a position to be able to/want to fight during pregnancy/when in labour. Those who do and are, I have huge respect for and the difference they make can be invaluable. But sometimes a woman simply wants to sit back, relax, and birth her baby in the peace and calm that she deserves. That every woman deserves. I don’t give a flying banana how or where a woman births, but that should be in a setting and state of her choosing, and the ability to do that is being slowly eroded.

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