IMs and insurance

AIMS Journal, 2017, Vol 29 No 1

Mari Greenfield explores the impact of the NMC’s decisions on indemnity insurance

The decision by the Nursing and Midwifery Council (NMC) that Independent Midwives UK’s (IMUK) insurance was inadequate in January 2017 resulted in the withdrawal of Independent Midwifery services to many women. This report provides information on the immediate impact of that decision.

Background

From 2014, it has been a legal requirement in the UK that all healthcare professionals have indemnity insurance in order to provide healthcare services. This was introduced following a full public consultation and impact assessment. Within the UK, midwives working in the NHS have cover provided through the NHS, private midwives employed by a private or community interest company are insured via their employer. Independent midwives (who are self-employed) are insured via IMUK. On 13 January 2017, the NMC issued a statement that said:

‘The Nursing and Midwifery Council (NMC) today announced that it had decided that the indemnity scheme used by some independent midwives who are members of the organisation Independent Midwives UK (IMUK) is inappropriate.’¹

The NMC statement for parents² affirms that its decision means: ‘any IMUK midwife who is not covered by an alternative indemnity scheme cannot provide midwifery care’

The statement for parents goes on further to explain that it is the view of the NMC that midwives who are insured solely via IMUK cannot attend their clients during the intrapartum period in any other capacity, even if other midwives are present, because:
‘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 attending the birth in a ‘non-midwife’ capacity’.²

An impact assessment was carried out by the Department of Health prior to the legislative changes in 2014. No impact assessment appears to have been carried out by the NMC prior to this series of decisions. However, the decisions had a direct impact on individual women, who had employed Independent Midwives to provide care throughout the perinatal period, including intrapartum care. The decision also directly affected Independent Midwives, with implications for their livelihood, and their careers. The Association for Improvements in Maternity Services (AIMS) wished to gain insight into the immediate effects of these decisions. This research by AIMS therefore provides a snapshot of the immediate impact these decisions have had on those directly affected.

Methods

To understand the impact on individuals, it was appropriate to use qualitative research methodology. However, understanding and reporting on the immediate impact also made speed of data collection and analysis a priority. For these reasons, an online questionnaire containing open questions was selected as the most appropriate methodology.

The online survey contained four questions. Two questions asked for contact details and locality, the other two were open text boxes. These questions are reproduced in Table 1 below, alongside figures showing how many individuals completed each question.

The survey was publicised online by AIMS, and cascaded through social media (including Twitter and Facebook) via Independent Midwives, doulas, AIMS members and various groups concerned with Maternity Services. It was distributed to AIMS e-mail lists, and via birth-related organisations e-newsletters. Both the methods employed, and the publicising mechanisms used limit the audience who were able to access the survey. However, the survey is not aimed at the general population, but at those directly impacted by the suspension of Independent Midwifery services in the UK. The majority of those directly impacted by the decisions would be reached in this way, and would be able to access an online survey.

Responses were collated by AIMS. The data relating to the locality and contact questions was removed to ensure confidentiality. The responses to the two remaining questions were then put into a text file and numbered.

Table 1 Questions	Completed Entries
Please could you tell us, in as much detail as possible, about how the NMC's removal of the ability for IMs to practice affects you.	94
Please could you provide us with your name and email address.	94
It would be helpful if you could provide us with your county and local hospital name, and, if you know it, the name of your trust.	88
Is there anything else that you would like to add?	6

Numbers 1-94 were allocated to responses to the first question, whilst numbers 95 - 157 were allocated to the responses to the last question.

Thematic analysis, as described by Braun and Clarke³ was used to analyse the data. Repeated readings of the data generated initial codes, which were used to search for themes. The data was then organised into the themes, and further re-coding of the data took place until a thematic map was produced. From this map, the themes were defined in relation to each other.

Responses

The survey remained open from 21 January to 9 March 2017. 94 responses were received in that time. The two open text questions were analysed separately. The first question had a 100% completion rate, with the shortest response at 13 words, whilst the longest was 1,373. Most responses to this question were 200-500 words.

Responses to the fourth question were also analysed. The responses to this question were typically shorter than to the first question, with the shortest response being 4 words, whilst the longest was 356. Most responses to this question fell in between 100-300 words.

The identity of the respondents was not asked as part of the survey. However, from the answers given to the first question, it was possible to identify in what role respondents were contributing. The breakdown of respondents is shown in Chart 1 below.

Chart 1 Respondents

The majority of the responses received were from parents, and the majority of parents completing the survey were currently expecting a baby, or had a baby within the last few weeks, and had also employed an Independent Midwife to care for them, and were therefore directly affected by the NMC decisions.

Findings

The aim of the research was to understand the immediate impact of the decisions taken by the NMC in relation to IMUK indemnity insurance. The data was analysed thematically, in response to this aim. Three strong themes emerged from the data in relation to the impact of the NMC decisions. The first theme was the direct and immediate impact on currently pregnant women and their families. The second theme was the impact on Independent Midwives and other birth workers. The final theme relating to the impact was the sense of confusion that appears to exist about the decisions themselves.

Impact on parents
The predominant theme emerging from the data was concern for the impact on parents who had already employed an independent midwife to provide care throughout the perinatal period. The concerns included the health and wellbeing of the expectant mother, the alternative birth choices that were being made as a result of the suspension of Independent Midwifery services, and the financial impact for expectant parents.

The impact that the decisions were having on women’s health were seen as wholly negative, and were described by a number of respondents, who reported feeling ‘physically unwell and incredibly anxious’ (68).

Parents talked about the impact on their emotional wellbeing in particular, describing their distress in clear terms. One respondent discussed ‘the devastation this decision has had on my family and my own emotional well being’ (79).

Some pregnant women who had existing mental health difficulties were clear that the decisions had a substantial negative effect on them ‘There are severe mental health implications for those of us with birth trauma – to have choice taken away from us has very real life consequences’ (110).

Independent midwives replying to the survey also noted the physical health effects that the decisions were having on their clients ‘The pressure during their pregnancy is too much and had resulted in physical symptoms of stress’ (93).

Parents who had planned a home birth with an Independent Midwife were having to change plans. Many felt that, as the NMC had made this decision, they should have provided women with information about the alternatives they had. ‘I believe that an alternative should be provided for the families that have chosen IM’ (104).

This was particularly argued by women who were already at term, who felt the NMC had a responsibility to have produced a joint response with the NHS, directly communicating with the women whose birth plans were disrupted at a very late stage of pregnancy. The fact that no co-ordinated communication was received, and that women or their Independent Midwives had to approach the local NHS services themselves led to some women experiencing negative feelings about the NHS Maternity Services as a result of the NMC decisions. One woman explained that she felt ‘badly let down by the NHS with my first birth... again I feel I'm being let down by the system and caught up in a politically motivated situation’ (48).

Others were unaware that the NMC and the NHS were not the same organisation. One respondent stated that the decisions had convinced her that ‘The NHS is heartless and a bully when it comes to pregnancy and labour’ (106).

This is of particular concern, as many of these women will now need to access NHS Maternity Services.

Women who had approached their local NHS services sometimes found their birth choices were now restricted. A number of women were particularly concerned that their local NHS could not guarantee that a midwife would be available to attend their planned home birth ‘My care has been transferred to my local maternity unit who may or may not be able to provide a midwife for my home birth.’ (88)

Other women felt that, even if their local NHS services would provide a midwife to attend them, they could not trust that an unknown midwife would support them as they needed. This left women with stark choices. Several women were making the choice to have a non-medically indicated caesarean birth as a result. ‘I was planning on IM. If that isn't available I'll opt for an ELCS’ (65).

Another woman had developed a medical condition for which induction was recommended. She had been planning to have an induction in hospital, with her Independent Midwife present, but in the role of a birth companion. The second NMC decision referred to above, that midwives with insurance arranged through IMUK could not be present at a birth in a role other than that of midwife,² meant that her midwife was not able to accompany her as a birth companion. Now,‘As [Independent Midwife]’s not able to be present, I've now opted for c-section surgery as I feel ill equipped to go through an early induction without her.’ (29).

Vaginal births, in normal term pregnancies, provide benefits for both mother,⁴ baby⁵ and for any future children.⁶ The rising caesarean birth rate in Western countries has been linked to rising maternal death rates, and is a concern for the NHS. From this research, it appears some women who would have preferred a vaginal birth, were now choosing elective caesarean births as a result of the NMC decisions.

Another birth option which was mentioned multiple times, especially by women who were currently pregnant, was that of ‘freebirthing’, or giving birth with no healthcare professional present. A doula expressed the view of many respondents that ‘Freebirthing is a valid and informed choice for many women, but the possibility of others taking this route through fear of NHS midwives is scary and seems like tragedy waiting to happen.’ (77)

Midwives who worked both independently and for the NHS were concerned that ‘the removal of this choice will lead to women taking matters into their own hands and reluctantly taking their chances alone.’ (16)

A number of women explained that they felt forced into making this birth choice, because they were ‘having to decide between either having to battle with NHS or to freebirth with no professional support at all.’ (19)

The unacceptability of NHS maternity care to the women who had employed an Independent Midwife was commented upon ‘I would rather choose to freebirth than go back to the NHS.’ (41)

Frequently, the unacceptability of NHS maternity care was as a result of a previous traumatic perinatal experience ‘I will not register with the NHS as I felt coerced into tests I did not consent to at the beginning of my last pregnancy.’ (74)

Women were clear that they were not choosing to forego having healthcare professionals at their birth by choice. Many women were at pains to assert the difference between a situation in which a woman chose to freebirth because she felt it was the best choice, and the situation these women found themselves in, where they would prefer to have an Independent Midwife present, but no longer had that choice. ‘I would birth unassisted, it won't be a freebirth as in my situation I believe it’s safer to have my IM with me therefore I’m being backed into a corner.’ (73)

The responses were unanimous in feeling that the NMC, and/or the NHS, rather than Independent Midwives, were responsible for the removal of choice in birth: ‘The NMC has now left me to face birth alone and possibly to risk my life and that of my baby. Give me back my freedom and my safety.’ (30)

Many women expressed concern for their safety in childbirth as a result of the decisions made: ‘The NMC has removed all possible safe options.’ (46)

Respondents were also concerned that the NMC decisions had had a financial impact on currently expectant parents, and that the NMC had not taken appropriate steps in considering this in the timing of its decisions. A high number of parents who responded were in the ‘horrible position of having to settle the financial situation with our independent midwife whose undisputed expert services we have paid for, but which she is now forbidden to provide.’ (19)

In the NMC document for parents,² the suggestion is made that affected expectant parents could seek care from ‘an alternative independent provider.’

This suggestion was not well received by some parents, who expressed ‘I am more than halfway through my pregnancy – to go elsewhere will incur significant additional cost.’ (38).

The responses to this survey indicate that overall, the NMC decision was felt by respondents to have a wholly negative effect on parents, in relation to health, birth choices, perceptions of safety, and finances.

Impact on birth workers
A number of responses also discussed the impact on birth workers. The Independent Midwives who commented displayed considerable distress at the idea that women needed them, and they were not able to attend them. ‘I am an IM who now cannot support the families that have chosen me.’ (78)

Independent Midwives were concerned about the effect of the decisions upon their clients, and felt a continuing responsibility to them ‘I have clients too upset to be able to engage so am answering on their behalf.’ (93)

The decisions have had an immediate financial impact on Independent Midwives, ‘It's the loss of my livelihood as an IMUK midwife. I'm a single, unsupported parent studying at Masters level.’ (22)

The inability to work had also had an effect on the health of some of the Independent Midwives who responded to the survey ‘I've become ill as a result of the NMC's decision.’ (22)

Several respondents also expressed concern about the impact of the decisions upon other birthworkers. This concern linked back to concerns that more women might be forced into a situation where they unwillingly choose to give birth unattended. This situation was seen as potentially difficult for doulas in particular; ‘I am a doula who is preparing at the last minute to attend unwanted unassisted births.’ (62)

‘I do not want to see doulas being forced into a position of being the only support for a woman who has fear of midwives.’ (77)

NHS Midwives who responded to the survey also expressed the immediate impact that the decision had had on them, as practicing midwives. There was a sense that their future choices were being limited ‘my job as a non IM will be at risk in the future.’ (9)

Some NHS Midwives also felt that the decisions by the NMC had caused them to lose faith in their regulatory body ‘I am a midwife working in the NHS and I feel that the NMC actions are a direct blow to the autonomy of the midwifery profession as a whole.’ (12)

One midwife, working in the NHS, expressed such upset at the decision that ‘I am seriously considering leaving the profession.’ (7)

Lack of clarity over the decisions made
Many respondents expressed confusion over the decisions that had been made. In particular, respondents found the statements issued by the NMC in relation to its role in determining the appropriateness of indemnity insurance contradictory.

‘The NMC's professional indemnity agreement states that the midwife and the indemnity provider are in the best position to determine what level of cover is appropriate. The same indemnity agreement clearly states that the NMC is unable to advise about the level of cover needed.’ (71)

Others also found the statements issued by the NMC as to the specific issue with IMUK’s indemnity insurance confusing.

‘the lack of detail provided by the NMC on why the current indemnity isn't adequate is simply not acceptable. My rights are being removed without adequate explanation’. (67)

There was a general sense from parents that the NMC had a duty to provide explanations to them directly about the decisions made, and that the NMC had not fulfilled this role. One parent respondent summarised the NMC statements as: ‘Your insurance is inadequate but we cannot tell you what we would consider adequate.' (125)

Respondents also expressed anger at the numerical representation of the issue by the NMC in its statement (2017a).

‘the NMC dismiss the significance of their decision saying only 80 midwives out of 41,000 are affected. This misleading and disingenuous use of statistics is clearly intended to imply that over 41,000 midwives have sought and secured insurance themselves when in fact most of those 41,000 are covered by the NHS.’ (38)

Parents expressed the view that they were the people most affected by the decision, rather than the Independent Midwives.

‘The use of the word ‘only’ is particularly offensive in this context.’ (38)

There was also a lack of clarity over how the decision was implemented. Parents were concerned that no consideration appeared to have been given by the NMC to delaying the decision.

‘They could easily have given a notice period that ensured current clients were not affected by their decision to suddenly rule IMUK’s indemnity cover as inadequate’. (38)

Parents asked for clarity from the NMC about their conflation of safety, and indemnity insurance, stating: ‘The IMs are no less ‘safe’ than they were six weeks, months or years ago’. (146)

Overall, the decisions taken by the NMC were confusing and contradictory for those who were affected by them.

Conclusions

Parents employ Independent Midwives for a variety of reasons, but predominant reasons given in this research include women who feel they need care which is greater than the NHS can provide, and women who have had a previous traumatic perinatal experience. These women are at greater risk of experiencing childbirth-related post traumatic stress disorder (PTSD).⁷ The lack of a proactive provision of alternative care by the NMC or the NHS for these women has caused distress. It is possible that direct communication between women affected and the NMC could assist in this situation.

Independent Midwifery services are highly valued by those parents who have chosen to employ them. The decision taken by the NMC has had an immediate impact on those parents who have booked an Independent Midwife. The impact has included parents feeling their emotional health has been negatively impacted. Some women have decided to give birth by non-medically indicated caesarean section, and others have chosen to give birth unattended. None of these decisions are seen by parents as their preferred choice. Other women have chosen to have a home birth with NHS Midwives, but have found that this option is not necessarily open to them either.

There is a great deal of anger and distress experienced by parents who have employed Independent Midwives in the past, currently, or who would wish to do so in the future. These negative feelings are directed towards the NMC, who parents in this research identified as responsible for the current situation. There is also confusion amongst these parents about the difference between the NMC and the NHS. This poses a further difficulty for women who had employed Independent Midwives, who now may need to access NHS Maternity Services. It could be helpful to those women for there to be greater clarity about the role of the NMC, and its relationship to the NHS.

Confusion also exists over some elements of the decisions made by the NMC. This confusion was expressed by parents and midwives (both Independent and employed by the NHS) in this research. Further clarification of the NMC decisions would be beneficial in resolving this.

This research shows that considerable distress and confusion has been caused by the current situation, particularly to expectant parents. It seems likely that the distress in not being able to access Independent Midwifery is likely to continue, unless the situation is resolved. For women who are currently pregnant, any resolution cannot come soon enough.

‘I will never get this opportunity back. And it has all been taken away from me over something that I do not believe was a problem in the first place.’ (80)

Mari Greenfield

References
1. NMC (2017a) Indemnity provision for IMUK midwives is 'inappropriate', says NMC retrieved from www.nmc.org.uk/news/news-and-updates/indemnity-provision-for-imuk-midwives-is-inappropriate- says-nmc/ [Accessed 9 March 2017]

2. NMC (2017b) Information for women and their families currently supported by IMUK midwives retrieved from www.nmc.org.uk/globalassets/sitedocuments/other- publications/information-for-women-supported-by-imuk-midwives.pdf [Accessed 9 March 2017]

3. Braun V & Clarke V (2006) Using thematic analysis in psychology. Qualitative Research In Psychology, 3(2), 77-101. doi:10.1191/1478088706qp063oa

4. Lurie S (2016) Caesarean delivery is associated with higher risk of depressive symptoms, pain and sexual dysfunction. Evidence-Based Nursing, 19(3), 70. doi:10.1136/eb-2015-102267

5. van Reenen SL, & van Rensburg E (2013) The influence of an unplanned caesarean section on initial mother-infant bonding: Mothers' subjective experiences. Journal Of Psychology In Africa, 23(2), 269-274.

6. Moraitis A, Oliver-Williams C, Wood A et al (2015) Previous caesarean delivery and the risk of unexplained stillbirth: retrospective cohort study and meta-analysis. BJOG: An International Journal Of Obstetrics & Gynaecology, 122(11), 1467-1474. doi:10.1111/1471- 0528.13461

7. Ayers S, Bond R & Wijma K (2013) Risk factors for PTSD after birth in a normal population: A meta-analaysis. Journal of Reproduction and Infant Psychology, 31 (3), e3. doi:10.1080/02646838.2014.892345