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Dear Heidi Alexander
I am emailing you regarding the recent decisions regarding indemnity/insurance which are affecting many independent midwives in the UK.
I planned an NHS home birth for my daughter, who was born in late 2015. Like myself, she ended up being born at Lewisham hospital as I was transferred in at the end of my labour, due to failure to progress.
Despite 'failing to progress', I delivered a healthy, if not rather large (9lb 2oz) baby girl naturally, with no drugs and no medical intervention. However, I was rushed to push out my daughter, despite there being no medical worries for her safety and was stitched up painfully.
After many months of not having healed, it transpired that I had internal tears which had been missed. I attribute this to being needed to be rushed off the labour ward as I was an unexpected arrival as a transfer in from a home birth and I believe they wanted me out of the room.
Had my mother not been advocating on my behalf I know that I would have ended up with unnecessary medical interventions, for example as soon as I arrived they wanted to fit an cannula 'just in case'.
After my daughter's birth I decided for my next baby, I would again birth at home but that I would hire an independent midwife.
Due to the injuries sustained when I was encouraged to push despite not being ready, follow up appointments have suggested consultant led care for my next birth.It is highly unlikely the NHS would 'allow' a home birth because of this.
Despite having no pain relief and delivering naturally, as my daughter was big, again, it is unlikely the NHS will 'allow' a home birth.
I wished to hire an independent midwife as during my labour I had 5 different midwives. My baby was unlatched during her first breastfeed so I could be stitched. Attempts were made to coerce me into staying the night in hospital as my baby 'hadn't fed well'.
I deserve continuity of care. I deserve to be supported in labour and after the birth by a someone who knows and respects me. I deserve to have the opportunity to labour in my timeframe, not an NHS tickbox. I deserve to have the option to pay for this care if I so wish.
I look forward to hearing your thoughts on this matter.
Dear Andrew Jones,
I am a doula (childbirth supporter) currently working in and around Harrogate and I am writing regarding the recent announcement that the Nursing and Midwifery Council (NMC) have removed the right for women to use an independent midwife (IM) at their birth, effective immediately. As well as removing from registered midwives the right to work outside the NHS, this change removes women's right to choose their carer in labour. It is a travesty and a dangerous disregard for women's rights. Currently the IMs are not even permitted to accompany their clients into the hospital to birth as an alternative, leaving these families with no care providers familiar to them, as many have never accessed the NHS.
There are approximately 10 independent midwives who work in the Harrogate district who have a handful of women immediately in need of maternity care. It is not known what, if any, support the Harrogate and District NHS trust will give to the independent midwives so they can safely care for the handful of pregnant women in Harrogate who were due to give birth at home with an IM in attendance. Right now, I know of at least one family who is close to full term pregnancy, who are now planning to give birth at home alone with no trained attendant. While birthing alone (known as freebirth) is a perfectly legal choice--when it is unwanted, unplanned, and unexpected, it can be extremely dangerous. These families are scared, but they are even more scared of entering the NHS system to birth in the hospital for no medical reason, or trusting the NHS to be able to send a midwife to their home. I am familiar with several births in Yorkshire in the past year without a NHS midwife in attendance as planned and desired (called BBA- "birth before arrival") because the local Trusts are chronically short-staffed and frequently unable to send midwives to women labouring at home. This often results in ambulance teams being called in an emergency, or babies being born in the car on the way to the hospital. Removing access to midwives at this time does not improve public safety.
This is of immediate public health concern to the Harrogate District.
To reiterate, women have been given no notice, meaning those imminently about to give birth who have paid for contracted services with someone they have built trust and respect with are now faced with the removal of that support. The NMC or the Trusts have presented no alternatives to both the midwives, who have effectively lost their careers, and the women who do not have a trusted choice for birth. The IMs will lose their registration if they provide labour care to their clients who have paid for this care.
This decision must not be allowed to stand unchallenged. The NMC have dismissed the indemnity arrangements currently in place whilst failing to give any guidance as to what would be acceptable. Independent midwives currently have indemnity though IMUK, a professional body who arrange group cover. From the beginning of the imposition of indemnity insurance, independent midwives' numbers have drastically dwindled as it is prohibitively expensive, and there is no other indemnity alternative available to independently practicing midwives, so there is no acceptable solution available now. This has contributed to the increased burden on the NHS system.
This is of immediate public health concern to the Harrogate District. Thank you for your attention to this matter and for your ideas on how to provide this insight to the Harrogate and District NHS Trust maternity services and ambulance teams who will be unfairly burdened by this act.
Dear Mr Quince,
I am writing to you with great concern regarding the recent decision by the Nursing and Midwifery Council (NMC) to prevent independent midwives who are working under IMUK, from providing birth care to their clients with immediate effect.
According to the NMC’s statement, “the indemnity scheme provided for IMUK members was not able to call upon sufficient financial resources to meet the costs of a successful claim for damages for a range of situations”.
However, when asked by members of IMUK what a suitable level of cover would be, they were told, "We (the NMC) are unable to advise you about the level of cover that you need. We consider that you are in the best position to determine, with your indemnity provider, what level of cover is appropriate for your practice. You should seek advice as appropriate from your professional body, trade union or insurer to inform your decision. You need to be able to demonstrate that you fully disclosed your scope of practice and to justify your decisions if asked to do so”.
The NMC are claiming that there are some independent midwives who have secured appropriate insurance, however this is incorrect. They are talking about private midwives who are employed by a company. As far as I’m aware, the only truly independent, self-employed midwives, are those members of the IMUK.
It is impossible for the members of IMUK to meet guidelines that do not exist! As a result of the NMC’s failure to provide a figure for “adequate” insurance, the basic human right to make autonomous decisions regarding your own health care has now been taken away from birthing women all over the country.
There are many reasons a woman might opt to utilise the services of an independent midwife. For some, it is a lack of community/homebirth support in their geographical region. For others, it is the benefit of continuity of a named caregiver (i.e. one named midwife who they develop a trusting relationship with). Some women will have a history of sexual assault, for which the usual NHS journey of multiple caregivers and unknown midwives providing vaginal examinations, will be wholly inappropriate. Others will have suffered birth trauma and feel that they would benefit from the individualised care that is provided by an independent midwife. Previously, in a hospital birth, independent midwives were able to accompany their clients in a non-clinical role - similar to that of a doula or other birth partner. The NMC have now deemed this an action for which these 80 midwives could be struck off the register and potentially face legal action.
Although the NMC stated that it “absolutely supports a woman’s right to choose how she gives birth and who she has to support her through that birth”, they are acting in stark contrast to this statement by refusing women the right to choose their own caregiver.
Personally, I suffered birth trauma related PTSD as a result of an emergency ceasarean with my first baby at 33 weeks. Given that my second pregnancy was unremarkable, I wanted a home birth (HBAC) with my second baby. I endured various unsupportive encounters within the NHS, as I was deemed “high risk” due to my previous ceasarean. This prompted our decision to seek out independent midwives, who supported us in our choices, and cared for me and my family ante- and postnatally. If this situation had arisen when I was due to birth my second baby, I would have been given two choices: Firstly, to go back into the NHS, who by and large, were unsupportive of my choices. Secondly, to free birth, which is to have a baby without a midwife in attendance. I would have been pushed into the decision to free birth my son, who required resuscitation as he was not breathing when he was born, and I would have had nobody there to help.
This is the very real situation that women are being put in, as a result of this completely unethical and unfathomable decision by the NMC. I would appreciate your assistance, as my member of parliament, to investigate this matter further. Yours sincerely,
N.B the following letter addresses a couple of other upcoming changes to midwifery that will also pose a risk to midwifery in general
Dear Mr Thompson,
I am writing to you as one of your constituents in order to request your help. Although the subject is health and would normally be a devolved matter, in this case it concerns the Nursing and Midwifery Council (NMC) and therefore is reserved to Westminster. These matters also impact many of your constituents, both as midwives, whether NHS or independent, and as patients or clients. My apologies about the length of this letter, but I thought it would be most useful for you to have as many facts of the situation as I could muster. I have included my complaint to the NMC in this email as well. Several situations have arisen recently, all caused by the NMC, which in my opinion jeopardise public health, the future of midwives and the rights of women to choose who, where and how they give birth, as well as the ability of midwives to practice autonomously and according to evidence based practice and women's wishes, rather than sometimes outdated hospital protocol and defensive practice.
Firstly, the NMC conducted a public consultation into changes to midwifery, specifically to remove statutory supervision for midwives and to remove the Midwifery Committee as a statutory committee of the NMC. I include a link to the government summary of the responses to the consultation: https://www.gov.uk/…/at…/file/582494/Consultation_report.pdf As you can see, the public responses to both of the central questions were overwhelmingly negative, however the NMC have decided to go ahead with the changes regardless.
Midwifery supervisors are not purely there to investigate misconduct, they have a very important role in guiding and supporting midwives and also women who wish to discuss any part of their plans for birth, especially if these go in any way against hospital protocol. Hospitals usually require women to fit into their system rather than trying to cater for individual women's needs. This is to some degree understandable; however it doesn't always have the best outcomes and can therefore become expensive for the NHS and emotionally devastating for women. The supervisor's role is to listen to a woman's needs and facilitate the appropriate care. When women feel listened to in pregnancy and childbirth, they tend to have more straightforward and therefore inexpensive births. Without supervisors, women will be left to speak to managers who might be far too likely to try to avoid litigation to want to accommodate a woman's individual wishes.
When excessive defensive practice is used, the outcomes are likely to be worse and more expensive, ironically. For example, the US has one of the worst maternal and neonatal death rates in the developed world, despite, or more likely because of, the high medicalisation of birth. Interestingly, they have very few midwives and most of their maternity care is conducted by doctors and obstetric nurses. Research studies show that women who have midwives as their primary care providers in pregnancies tend to have better outcomes in both physical and mental health.
The NMC is the only regulator to have a statutory committee like the Midwifery Committee, which is why it was recommended that it should be dispensed with. However, removing it would mean that midwives have even less representation and understanding within the NMC than they do already, midwifery being a very different profession to nursing, with entirely different levels of responsibility. The changes will be made via a Section 60 Order and will amend the Nursing and Midwifery Order 2001 and the Nursing and Midwifery Council (Midwifery and Practice Committees) (Constitution) Rules 2008 and revokes the Nursing and Midwifery Council (Midwives) Rules Order of Council 2012.
Secondly, as you may know, a law came into effect in 2014 which made it compulsory for all private health practitioners to have indemnity insurance. This caused a big problem for independent midwives, as at that time there was no insurance that covered them. Independent midwives are different from midwives in NHS or private employment, in that they are able to operate independently from an employers' protocols and are able to accommodate a client's needs much better. They are generally the guardians of natural birth and many are able to safely facilitate things like vaginal breech and twin birth, home birth, and other variations of normal, as well as providing continuity of care to women, which isn't usually available within the NHS. They are able to get to know their clients and pick up problems that might be missed within the NHS, as they aren't limited to short appointments with potentially different midwives at each one.
Previous to the new law being passed, potential clients signed a disclaimer at the time of booking to make clear that the midwife had explained that she didn't have insurance. The NMC was asked to provide guidance as to what would be an appropriate level of cover, and their reply was: "We (the NMC) are unable to advise you about the level of cover that you need. We consider that you are in the best position to determine, with your indemnity provider, what level of cover is appropriate for your practice. You should seek advice as appropriate from your professional body, trade union or insurer to inform your decision."
To date, they have still not issued guidance as to what they consider adequate insurance cover to be. IMUK, the membership organisation for independent midwives, found a product with advice from several medical insurance experts, and independent midwives were able to continue practicing, albeit at an increased cost.
A short while ago, due to a complaint by UK Birth Centres Ltd, a private company providing midwifery care, the NMC wrote a letter to all independent midwives asking them to provide evidence of insurance and threatened to deregister any that weren't deemed to have enough cover.
Finally, they gave two weeks’ notice to all members of IMUK three days before Christmas, that their insurance wasn't sufficient (despite several medical insurance experts saying that it was) and that they would no longer be able to practice independently, nor even attend the births of their clients in a supporting rather than medical capacity. Their reason given for this was public safety. As insurance has nothing to do with safety, and everything to do with a client being able to sue the practitioner for more money, this statement is patently untrue. I'm sure you will agree that two weeks’ notice over the Christmas period is at best incredibly disruptive and at worst cynical and designed to cause as much distress as possible. This means in the short term that all the women who had employed an independent midwife in order to have continuity of care and to know who it was that was going to be with them for the birth of their child, have been left having to scramble to make alternative arrangements, ending up with the very opposite of what they wished to achieve. It also leaves the NHS in the unfortunate position of having to suddenly find space and midwives for hundreds of women in a very short space of time, some of them with extremely complex needs and medical history, which is certainly not in the interests of public safety. In the medium to long term it means that women's choices in childbirth have been reduced even further than they already are and the accumulated wisdom and experience of independent midwives is in danger of being lost. The problem will be compounded even further once statutory supervision is removed.
I include links to letters and statements by Birthrights and IMUK: http://www.birthrights.org.uk/wordpress/wp-content/uploads/2017/01/Birthrights-signed-letter-to-NMC-13.01.17-public.pdf http://www.imuk.org.uk/news/nmc-decision-regarding-indemnity-arrangements-for-imuk-members/
All of these problems follow a damning report by the Council for Healthcare Regulatory Excellence in 2012 which found that there are "weaknesses in governance, leadership, decision making and operational management", "poor financial stewardship", and "problems with the NMC's management and business systems", amongst other things. Midwives appear to be relegated to second class status with inadequate representation and understanding within the NMC of their roles and responsibilities. With nearly 700,000 members, the NMC has the largest professional register in the UK. I expand this already very long letter with an example of why these changes compound to spell disaster for many women and have the effect of impacting women's rights to bodily autonomy.
A woman (let's call her Mary) is pregnant with her second child. During her first pregnancy, she accepted induction as she had gone past the gestation which hospital protocol suggested at the time. As is often the case with inductions, she ended up being subjected to a cascade of interventions which ended with an emergency Caesarean section and her baby being in the Neonatal unit for several days. Since then, Mary has read lots of articles and research studies and has decided that the option most suited to her and her situation would be a home water birth. She has weighed up the risks and benefits and believes that, on balance she is more likely to have a safe and problem-free birth. Her local hospital's protocol advises that all women who have had a previous caesarean section should not be offered a home birth (some hospitals even advise all women to have repeat caesareans, despite all of the evidence to the contrary).
Normally Mary would approach the local Supervisor of Midwives in order to negotiate getting the birth that she wants, but this role no longer exists. The person she speaks to is a manager, whose job it is to represent the hospital's best interests and not the woman's. The NMC no longer have to have midwives advising on policy, regulation or complaints, so Mary isn't able to obtain an NHS midwife to attend her at her home birth. She would like to hire an independent midwife to achieve what she wants, but they are no longer able to practice because the insurance they have has been deemed unacceptable by the NMC. Mary's choices are now to comply with hospital protocol and running a much greater risk of birth interventions and therefore repeat of caesarean, or to give birth at home without anybody attending her. Neither of these are what she wants or believes to be safe.
I, and many others, believe it is time for the NMC to be thoroughly updated and for nurses and midwives to have entirely separate regulators, as befits two entirely separate professions. I would be very grateful if you could help in any way possible in resolving these issues for the sake of midwives and all future parents. If you need any further information or there is anything I can do which would be helpful, please do not hesitate to contact me.
Many thanks for your attention in this matter.
PS As a bit of light relief after my mammoth email, I include a couple of pictures from the "Choose Your Midwife, Choose Your Birth" protest march on Holyrood in 2013. The first one is of me, marching through the streets of Edinburgh not just like a metaphorical fanny, but dressed as an actual vulva. The second is of your colleague, Colin Beattie, making the difficult choice between vulva cupcakes.
Begin forwarded message:
Subject: Independent midwives, supervision, and the midwifery committee
Reply-To: ALC As I understand it, the task of the NMC is to safeguard the wellbeing of the people under nurses' and midwives' care. I believe that you were asked to provide guidance as to what adequate insurance would be for independent midwives, and you replied that it was not within the NMC's remit to do so.
Your decision now to penalise independent midwives for not having adequate insurance cover at such incredibly short notice is jeopardising the health and wellbeing of the very women who you are meant to be protecting.
You have put women who have booked independent midwives for their birth under an enormous amount of stress, especially those who are due or post-dates now. Many of them have booked an IM because they have gone through a traumatic experience during a previous birth, which has left them deeply emotionally scarred. These women need an extraordinary amount of care in order to have the birth that is safest and healthiest for them and their babies, which cannot be given under current NHS conditions, as there simply aren't enough midwives to do so.
Adding to their emotional distress at this most vulnerable time in their lives is very negligent and irresponsible, yet this is exactly what the NMC is doing. Many of these women now feel that they have no option but to give birth alone at home, which I'm sure is hardly what the NMC would advise as the safest option. Going ahead with removing supervision is also completely going against the interests of women who need to discuss giving birth against hospital or NHS protocol. As you must know, this protocol is often not evidence based, at best outdated and at worst purely there to attempt to reduce litigation.
Supervisors are not just there to regulate midwives, they are there to assist women to achieve the birth that they want in the safest way possible. You have ignored the overwhelmingly negative responses to your consultation because you seem to have the agenda of turning midwives from autonomous practitioners to US-style obstetric nurses, whose actions must be governed by insurance companies.
This is utterly unacceptable and is patronising in the extreme to women, the vast majority of whom are entirely capable of making an informed decision and can decide for themselves how important insurance is to them. I was perfectly happy to sign a disclaimer in 2006 and 2008, acknowledging that my independent midwife did not have perinatal insurance. I don't consider that statutory insurance makes a health practitioner's practice safer, quite the contrary in fact. Having to abide by an insurance company's dictates in order to limit litigation appears to have the opposite effect, as demonstrated by the appalling maternal death statistics in the US.
The actions of the NMC in a) penalising IMs despite refusing to provide guidance in 2013 as to what adequate insurance is, b) ignoring your consultation and going ahead with plans to do away with supervision, and c) ignoring the overwhelmingly negative responses to removing the midwifery committee, amount to what looks very much like a witch hunt against all midwives.
This is an utterly unacceptable situation and seems to demonstrate that you do not have the best interests of midwives or, arguably more importantly, the women under their care, in mind.
I and many others believe that it is time to remove regulation of midwives from your control and set up a separate midwifery regulator.
Your track record in fitness to practice investigations is also notorious, you seem to unduly penalise midwives and most especially independent midwives.
I am forwarding this complaint to the Parliamentary and Health Service Ombudsman and to my MP, and will be requesting that he looks into this situation and takes all steps necessary to ensure that women will continue to benefit from the wisdom and experience of supervisors and independent midwives in the future.
I would appreciate the NMC's response and explanations for these extraordinary three decisions, which benefit neither patients nor midwives, but merely serve to undermine women's choices and midwifery in general.
Dear Mr Barclay,
I am writing regarding the recent decision by the Nursing and Midwifery Council to prevent Independent Midwives from providing intra partum care due to the NMC judging their professional indemnity insurance to be inadequate. I believe this decision to be entirely inappropriate, the communication from the NMC has been misleading and the impact on families unable to access their chosen support is unacceptable.
During my first pregnancy (in Bedfordshire) I received good support from local NHS services and had an uncomplicated birth at home. In October last year I had my second child having moved to this area in the interim. I was dismayed to discover that this area did not have a home birth service. The community midwife I saw would have loved to offer me the choice and support I needed but was prevented from doing so by the constraints of the local service. I attempted to resign myself to a hospital birth. However, I became increasingly stressed and fearful at the prospect of having to travel to hospital in labour and give birth in an unfamiliar environment.
I reached a point where my mental health was deteriorating and I could not bear to think about the birth. My stress was increased by the knowledge that the physiology of a normal birth depends on the hormones produced by feeling safe and relaxed. I felt that by being so worried I was sabotaging my chances of an unassisted delivery and the more this worried me the more stressed I became. At this point we made the decision to hire an independent midwife.
From the moment I met her I felt safe and was able to relax and enjoy the remainder of my pregnancy. I am a registered nurse and I expect evidence based care and the chance to make informed decisions. My independent midwife provided this. I judged her as a fellow health care professional and she was exceptional. The care I received was safe, evidence based and person centred. After making the decision to hire her we also discovered my baby was in a breech position, having an independent midwife was the only way to guarantee that a midwife with the clinical skills to safely support a breech vaginal birth was available when I went into labour. Thanks to her I had a wonderful birth at home.
Hiring her was not a luxury, it was necessary for my mental health and to allow me my choice of care. This is a right which is now denied to other women by a deeply flawed decision.
The NMC say they are acting to protect women and babies in the event that something goes wrong. I believe this statement is misleading as compensation is only awarded when negligence or malpractice is proved. By booking with an IM I greatly reduced my chance of experiencing negligence or malpractice. My midwife ensured that every decision I made was fully informed, had anything gone wrong it would have been an unavoidable tragedy and I would have had no claim on her insurance whatsoever.
The IMUK insurance scheme has been independently assessed as adequate by industry experts. It is my understanding that the actuary appointed to investigate by the NMC stated that the risk modelling involved is so complex they could not investigate fully in the time allowed. I believe that taking a step that has removed the right of women to have their chosen care provider without a full investigation is appalling.
The NMC also say that they are unable to advise on what constitutes adequate insurance and it is for individual registrants to decide this in consultation with their professional bodies and indemnifiers. It seems absurd that they cannot state what would be adequate while being able to say that a product specifically developed for the purpose is inadequate. They advise midwives to secure alternative cover to allow them to continue to practice. There is no other scheme for self-employed midwives.
These investigations into the insurance cover of IMUK midwives was triggered by a complaint from UK Birth Centres, a private company which provides maternity care. This ruling has effectively created a monopoly for them. I am extremely concerned about the ethics of the NMC investigation given that they stated they currently have no plans to investigate any other providers’ indemnity. UK BC are now advertising themselves as “the only national provider of maternity services within adequate insurance” outside the NHS. I am uneasy that they are making this claim without having been subjected to the same scrutiny.
I am hopeful that this will be resolved by a legal challenge if the NMC cannot be persuaded to reconsider. However, this is having a devastating impact on families and women who are expecting babies now. They do not have time to wait for the legal system. As a temporary measures the RCM has suggested that NHS trusts might offer honorary contracts to independent midwives to allow them to practice under the trusts insurance. Some trusts have shown themselves to value women’s choice and have found ways to facilitate this. I would ask you to contact the trusts accessed by women in your constituency and ask them if they are doing so and if not how they can justify it. This can only be a stop gap measure but it is the only thing that will help women who are pregnant now.
Please can you demonstrate your commitment to supporting choice and autonomy for women by asking the Department of Health how they are planning to support independent midwives and adding your voice to those asking the NMC to be transparent about the process they used to reach this decision and what they would consider adequate insurance.
I look forward to receiving your response.