Ongoing correspondence from an expectant Mum whose IM happens to also be her mother:
Dear Mrs Smith
I am writing to you in regards to the latest decision you have made regarding Independent Midwives being legally allowed to attend women in childbirth.
I am currently 31 weeks pregnant with my third baby, My 2 previous pregnancies and births my mum who has been an independent midwife for 17 years looked after me, and previous to your decision I was looking forward to my home water birth with my mum by my side again. You have taken this all away from me with your decision.
I trained as a midwife in the NHS and during my training saw some horrific things that has stayed with me and under no circumstances would I want to be looked after in the NHS. If my mum is unable to be by my side I will birth alone.
My understanding of your role was to protect women and babies. Could you tell me how you are protecting me and my baby? You are taking away my right of having my chosen caregiver when I need her most, when I'm vulnerable, when my partner needs support, when I need help, when my baby needs help? I feel guilty asking her, putting her in that situation but I need her with me.
I want you please to reverse your decision not only for me but for all the other women that will be free birthing this year due to your actions and all the babies whose lives will be at risk being born without any caregiver being present when needed.
Although it will be my choice to free birth if anything happens to me my baby or even my mum I will hold you personally and morally responsible. I have 9 weeks left of my pregnancy I really don't want the final weeks be a worry for both me and my mum. I will not let her jeopardise her career I am protecting her so I want you to protect me by letting her lawfully look after me.
I look forward to your response Kind regards Ms H
Dear Ms H
Thank you for your email of 15 January to Jackie Smith, Chief Executive of the Nursing and Midwifery Council. My name is Emma Broadbent and I am the Director of Registration and Revalidation.
I understand that this is an extremely important time for you and that this situation may be causing you some worry and distress.
The NMC supports a woman’s right to choose where she gives birth and who she chooses to support her through that birth. It is important to recognise that the Registrar’s decision relates solely to the appropriateness of the professional indemnity arrangements of those independent midwives who are relying on their membership of IMUK to provide them with indemnity cover. It does not relate to independent midwives who have indemnity cover with other providers. It is still possible for any midwife to practise independently, so long as she has appropriate indemnity cover. A number of IMUK midwives have now informed us that they have found alternative cover for attending women in childbirth.
The legal requirement to hold appropriate indemnity cover was introduced by the Government in 2014, and applies to all healthcare professionals. Its purpose is to ensure that members of the public who suffer injury and loss due to the negligence of any healthcare professional are properly compensated for personal injury caused by such negligence. The requirement fits with and reflects the overarching objective of the NMC; namely to protect, promote and maintain the health and well-being of persons using or needing the services of registered nurses and midwives, and to promote and maintain public confidence in the nursing and midwifery professions.
In your letter, you raise your concerns that your mother will not be able to attend your birth in either her role as a midwife or in a personal capacity as your mother. Our guidance makes clear that a midwife may support a family member or close friend during childbirth in a non-professional capacity, for example, as a birth partner. This is so long as they do not provide any midwifery services. Midwifery services would include, for example, administering Entonox, a prescribed analgesic medication. It follows that whilst your mother may attend your delivery in a personal capacity, you will need to ensure that there is another midwife present with appropriate indemnity cover to provide midwifery services. This requirement is not new and has applied to midwives since 2014.
The decision that the scheme provided by IMUK to its midwives was inappropriate was not taken lightly as we fully understand the impact that it could have both for the individual midwives and the women they care for. However, our overall concern was that the public are protected.
Yours sincerely, Emma Broadbent Director of Registration and Revalidation
Dear Ms Broadbent
Your email is contradictory from the start. I am aware it is a partially revised standard letter being sent to the public however I would like to know how the NMC can state it supports ‘women’s right to choose’ when you clearly do not even know what choices there are for women in childbirth or indeed what her legal rights are. As a lapsed midwife myself I am aware that disregarding women’s choice is not something the philosophy of midwifery in the UK aspires to.
There ARE no other independent midwives other than those in IMUK, only other EMPLOYED midwives working for profit making companies and it is wrong for you to be telling the public otherwise. However, that is not the point. The point is I DO NOT as you have stated “have to ensure there is another midwife present with appropriate indemnity insurance”. My choices and my legal rights are to birth where, how and with whom I choose. Which brings me to the main point and my questions which you have yet to answer. But first I will make myself very clear.
I am having a home but I will NOT under any circumstances, bar life or death (and then it would be ambulance services) have a stranger in my house to disturb the privacy of my birth, which includes a midwife (NHS or other). I am yet to decide but will do based on your answer, whether or not when I am in labour to call my mother as my mother. I am still not clear of what the outcomes will be depending on what choices I make.
I have seen your guidance which states;
“A registered midwife can only attend a woman during a birth if she has appropriate indemnity cover. The midwife cannot avoid this legal requirement by claiming to be attending the birth in a ‘non-midwife’ capacity. This is because the midwife's professional and legal obligations remain the same in these circumstances. The only exception to this is when a midwife attends a birth in a personal capacity to support a family member or close friend for whom they have not previously provided midwifery services.
In other words, the midwife remains a "professional" whatever the precise nature of the midwifery services she is providing, i.e advice, support, advocacy all of which form part of independent midwifery practice.”
It is the underlined section that concerns me most because my mother HAS previously provided me with midwifery services in both previous pregnancies and this one so my questions are:
Can my mother come to my birth as my mother despite the fact she is my midwife currently and was in my last two pregnancies and birth?
If during my birth she is there as my mother but offers support, advice or if I ask her to examine me or listens to my baby’s heart rate and she agrees to do so, will she face a fitness to practice hearing?
If she is there as my mother and I do not ask her to perform any midwifery and a situation becomes an emergency but she can do nothing because she has no emergency equipment (such as resuscitation equipment), and my baby is compromised will she face a fitness to practice hearing because as you point out she is always a professional midwife?
I would like you to answer my questions in a yes or no answer please because I will be making my plans for birth and deciding whose needs I prioritise, (my baby’s, my own or my mother’s) depending on your response.
Please answer my questions urgently
From an NHS midwife:
Dear Mrs Smith,
I am writing to express my shock and sadness at the NMC's decision to immediately cease independent midwifery services.
I am saddened for a number of reasons but my overwhelming sadness is for the loss of women's CHOICE! Furthermore, I am worried for those women and families currently under IM care who now have to abandon all their plans and book with an NHS midwife.
I am an NHS midwife and also a supervisor of midwives. I have always worked within the NHS but I have a great relationship with our local IM and spent time with her. I learnt so much during my time with the IM, mostly about what women want! I specifically asked why the families we visited together had chosen IM over NHS and I heard a variety of reasons some of which were; continuity of care and poor experiences of NHS care. My heart aches for these women and their midwives now, I see them as rudder-less ships lost in a sea of NMC red tape.
I felt compelled to write, as a woman, midwife, colleague, mother, sister and daughter. I want to stand united with others and support the fantastic work of all midwives but specifically IM's and the women who make the CHOICE to employ their services. To instantly decide that IM's can no longer provide care is shocking! How can you explain or defend this. Surely the NMC should acknowledge the holistic health needs of women and their families. I also feel sad for all IM's who have lost their livelihood. These midwives have dedicated their lives to the women and families who CHOOSE to book their services.
2017 is a sad year for midwifery not only have we lost IM but also supervision - the victims of these loses are women.
From a previous NHS and Independent Midwife client
To whom this may concern,
I wish to make a formal complaint surrounding the appalling action you have taken. The sudden allocation of "inadequate cover" definition to the indemnity insurance (of which is the highest cover available to them) IMUK members have had in place since 2014 and withdrawing the right to practice for clients already signed up is not only a breach of human rights (in terms of enabling women to chose the care provider for their birth) but also extremely dangerous and distressing. I can't see how your actions can be anything but detrimental to all women, but especially those who are currently relying on the services of Independent Midwives. The cover these women have is the highest level of indemnity cover available to them on the market. When asked what they can do to comply with your wishes your response 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. 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"
I know this because I was a client of independent midwives for two births (one in 2015 and one in 2016) and before booking on we had an in depth discussion about indemnity insurance to ensure I was happy with the level of cover provided. Your statement
A quote from Jackie Smith within the recent press release states "The NMC absolutely supports a woman’s right to choose how she gives birth and who she has to support her through that birth", the actions you have taken directly revoke any choice that women, already happy with the care provider they've chosen have, and you are basically saying we can choose how we give birth so long as it conforms to your terms - that is not choice. That is coercive behaviour which is all too common within an NHS setting and what most women, myself included, try to avoid by scraping together the money to hire independent midwives. This is not just a middle class luxury. Women who hire independent midwives generally do so because they are unwilling or too afraid to risk giving birth in a hospital setting filled with strangers with various levels of experience and ways of working.
An NHS service can not guarantee the same midwife from booking in, through birth and beyond.
An NHS service can not guarantee a midwife who will work with patients to provide tailored care.
An NHS service can not support women's birth choices without some women having to fight the system when they are at there most vulnerable.
Having to fight the system whilst approaching labour is counter productive to encouraging best outcomes due to stress and anxiety. These produce the very hormones that stop women going into labour to protect them. It is obvious to anyone who researches NHS/hospital births that the service is at best overstretched and at worst, extremely dangerous.
I also note that this investigation commenced following one complaint which I believe to be from a company named Private Midwives, a division of UKBirthcentres. I also note they stand to gain a greater share of the market by pushing smaller independent midwives out via the indemnity clause, and I note they are advertising their services as "fully insured" etc. though there is no mention of the £50,000 excess that they have to pay for each case nor full details about the indemnity - what happens if this company, with negative shareholder equity can not access enough funds for the excess? Surely if the company has negative shareholder funds there must be some worry about the liquidity of the firm? I'm always dubious of any company with a shareholders account in negative figures, and this company shows a very large deficit here. (From the latest abbreviated accounts on Companies House). Additionally, if independent midwives are operating under a company structure, there comes a point where care is compromised by the need to make profit for the shareholders, many of whom are unidentifiable with the controlling shareholder of UKBirthCentres being an IOM company where the shareholders are hidden behind trusts. Of course this complaint is not about this firm, but I would question the motives of instigating this and what they stand to gain. It seems very underhand and I would question if this actually contravenes membership guidelines with regards to professional conduct and representing midwifery in general (in my profession, there are very strict guidelines for conduct so I am hoping there is something similar within yours).
I have never felt so at ease than when these ladies attended my home births. I had absolute trust that they knew exactly what my wishes were and I trusted that if they discussed a transfer to hospital, I would know it was for a valid reason and not because I wasn't contracting regularly enough for them (my body simply does not contract following the usual patterns and this, and the fact I was a first time mum lead to the midwives (NHS) not believing that I was in labour with my first born. When they eventually examined me (whilst making me feel like an exaggerating nuisance) they discovered I was 9cm dilated (as I was already having the urge to push, my body was fully dilated....) I tried to fight the process and it ended up slowing labour (not by much she was still quick) but she also got stuck and we managed with a change of position but this lead to me needing a catheter (eventually as again they didn't believe me, kept telling me I was just nervous or traumatised from the quick delivery.. I wasn't I just couldn't go!). And my breastfeeding support on this occasion was a midwife coming in asking if I had fed her yet (I hadn't as she hadn't shown any signs of wanting too and it kind of slipped my mind in all the rush!) and she preceded to grab my breast like a piece of meat and shove it in the baby's mouth. That breastfeeding journey did not last very long, sadly. My second birth I was more prepared to make my voice heard as I knew my own body. It took longer to get going this time and I managed to hold of further intervention after breaking my waters but whilst in active labour/pushing there were several things done that I hadn't asked for or against my wishes - nothing major, but my entire experience made me realise that if they had their way I could have been in a very bad way. Any drip contractions would have had me on the bed in agony from my SPD and everything would have slowed down. As it was, she came very quickly when she came and I got home on a six hour discharge - though on getting checked over for leaving the midwife didn't believe the baby could possibly be as big as recorded so had to strip her again to weigh her. She was.
Anyway, these were some of the issues in my experience that lead me to look at alternative care providers. When I was pregnant with my third baby I knew I wanted a home birth. My own NHS midwife first suggested it (part of that big drive of theirs for home births) however with our local service you don't meet the home birth team until 36/37 weeks for 1 hour at home and then for the labour (unless they try and tell you you can't have a home birth as they are too busy!). I knew I would be at least 42 weeks and that in order to give birth at home I would be under immense pressure with the NHS to induce. I knew that so long as there were no other complications I was happy to wait for baby to come. I was measuring big so was forced to have a GTT test, despite a blood test a couple of weeks previously showing no GD and despite me having no other symptoms and having not had it in any previous pregnancies despite testing. It wasn't an option, apparently. I also pressed my midwife for reassurance of support in the event I went post 42 weeks - she couldn't give me any. I met my independent midwives and immediately loved their ethos and the way they practice. Patient lead, not just by name but by example. Everything they did was as per my wishes - now obviously I am sure if I had requested to give birth whilst singing in the moonlight next to a pack of wolves they would have advised against it, as they would have done had there been any medical or emotional needs identified that would render a home birth an unsafe option. At this point they would also offer to come to hospital and act in the same capacity as a Douala, providing additional reassurance that their patient would still be listened too and respected in a hospital setting. When I was pregnant with number 4 i did not hesitate to book the same team of midwives. It was important to me to have the same amazing service. This time we didn't give birth until 44 weeks (i believe as a result of carrying out some building work, body was waiting!). Daily monitoring and midwives on call for any needs or questions. Anything at all. We had a scan at 43+1 to check the placenta over and was bullied so horrendously for not agreeing to an induction (baby was not distressed, placenta was still working well, baby big but all babies were big, movements very easy to track as baby back to back... ) spoken down to, almost in a disbelieving fashion that it was unfathomable I would be so stupid. I had to remind them that each and every action they were recommending came with their own risks, despite them not mentioning them and then trying to gloss over them. I knew if I had felt anything was wrong I could go into hospital and request assistance but apparently I am too stupid to make that call.
These details about my births are not just me moaning and belittling the NHS service, this is me trying to show you the difference in care - the difference being why many more are looking to pay that extra to be listened to and given the respect for their birth choices they deserve. And my experiences don't even come close to those with traumatic births and interventions which can lead to post natal depression and anxiety.
I would like to see immediately a change in your stance to at least allow women already booked in with independent midwives and fully aware of the indemnity policy in place, many of whom are due to give birth any day, the ability for their care providers to attend their labours without redress and legal ramifications.
On a long term basis, we must determine a way forward to enable these independent midwives return to looking after women the way they want to be looked after! With respect.Respect for their family situation, their parenting style, their birth choices. You must step up and confirm what level of cover is appropriate and work with them to ensure this is actually available in a truly independent capacity. And where appropriate you must allow women to make an informed choice about whether they feel it is an appropriate level of cover for them.