zaterdag 8 juni 2013

Home birth in Europe

Being an independent midwife entrepreneur for more than 40 years I have some problems to share with you. After 20 years being an independent midwife in the Netherlands, I sold my practice in late 1990 and became lecturer, researcher and later the director of one of the Dutch midwifery schools. Since 1998 I  work independently as business consultant in midwifery and as birth activist. Natural birth is the red line in my life.
            During the Aachen 2000 conference on 'Out of hospital birth', a conference I was one of the organisers, the problem of 'the availability of affordable indemnity insurance arrangements for independent working midwives in several European countries' came a cross. We independent midwives entrepreneurs had the idea we should handle this ourselves and would come up with solid long-term solutions.
However we experienced the matter as very hard. After years of studying options and consulting insurers and lobby by national midwifery organizations, governments and the ICM,  the International Confederation of Midwives, we have no solution that fits independently working midwives. To make a long story short. Various options are researched, ideas have been  developed, goodwill was build up, however time is now running out.

In current European working situations registered health professionals, like independent working midwives, can be sued for compensation on narrow grounds. There are however many other forums where an independent working midwife may need legal assistance to defend her practice 1. Indemnity insurance is therefore vital for all independent working midwives in the countries in the European Union 2.

From October 2013 on Europe demands authorised health practitioners holding an Access Agreement to maintain Professional Indemnity protection. Therefore independent working midwives need 'open' excess to professional indemnity protection.

In most European countries this is not possible as these insurances are or 'far too' expensive or 'not available' for independently working midwives. Independent midwives have in general a low income. In the Netherlands and Belgium independently working midwives (Dutch midwives have higher income than the other European midwives) have access to professional indemnity protection. the Dutch midwives have choice and can buy packages, Belgium midwives buy coverage via the membership of the Flemish midwives organisation, VLOV 2.  

In many other European countries there is urgent need for indemnity insurance by change of European law. Not having an indemnity insurance as independent midwife, will lead to the closing of midwives practices; thus midwives will than abandon the independent work for good. The result will be that women will not have anymore the choice to birth at home.

The free choice for the place of birth of women is a human right. In a short and simple opinion on the case of Ternovszky v. Hungary, December 2010, the European Court held that legal authority and meaningful choice in childbirth is a human rights issue . The European Court condemned the state of Hungarian birth policies, ordering to create the necessary regulations as soon as possible. In legal terms, the state of Hungary was violating two articles of the European Convention of Human Rights; the one dealing with one’s right to privacy as well as its antidiscrimination regulation 3.

Having freedom of choice is a fundamental right of women. No freedom of choice is in conflict with the EU Directive of 21 January 1980 and its later amendments on the mutual recognition of midwifery qualifications, the effective exercise of the right of establishment, and the freedom to provide midwifery services (80/154/EEC) 4. Midwives are allowed by European law to serve and guide women at home and elsewhere independently and are allowed to work and establish practices independently if they wish to. Women have free choice for the place of giving birth, home, birth centre of hospital and free choice for the professional who provides her midwifery care 4.

So at the one hand there are legal rights for women and midwives and at the other hand the European Law on Patient Rights which urge the group of independently practicing midwives to have indemnity insurance which is not for sale or too expensive
For a solution of the problem I see at the moment composing a minimal indemnity insurance scheme, arranged and governed by the independent midwives organisations in particular country.
1. A Mutual Guarantee Indemnity Insurance fund. In the past there where set up Mutual Guarantee Insurance funds in countries on continental Europe by the doctors’ social and science organisations. They served their members with cheap insurance facilities for cars, healthcare and later indemnity insurance within a self created and managed Mutual Guarantee Insurance Fund. They supplied their member’s fashioned good prised service and made at the long run good profit, profit which returned directly into the fund. This is ‘a’ way to develop an indemnity scheme for independent working midwives in Europe. This option asks for money, govern abilities, international connections and insurance knowledge. 

2. Micro indemnity insurance. What is important to emphasise is that midwifery care given by independent working midwives is far different from obstetrics and midwifery in hospitals. Independent working midwives are less active and show less interventions during birth. They are specifically building up relations with women and families from early pregnancy on and see the women and their families during pregnancy, birth and in the laying inn period extensively. The mutual build up trust, of women to midwives and midwives to women, is a proven help for better and more spontaneous births.
Therefore we see, in ratio, less claims of the independent midwives group which provide continuity of care, than in the group of obstetricians and midwives working in hospitals, offering fragmented care 2. In hospitals, relations with women fail and communication is not that easy in case of problems without a trusting relation. As mentioned before the independent working midwives service has focus on normal spontaneous non interventional birth of healthy women, hospital focus is on problems and risks. Evidence shows that independent working midwives, providing continuity of care of a known midwife, generate more satisfaction, less interventions and better outcome 5, 6.
'Micro insurance' is like ‘micro finance’. ‘Micro insurance’ is a protection of low-income people against specific perils in exchange for regular premium payment proportionate to the likelihood and cost of the risks involved. This definition is what independent working midwives can use, as one might use this for regular indemnity insurance and except for the clearly prescribed target market, the lower income of independent midwives and lower amount of claims 4. This option asks as well for money, govern abilities, national and international connections and insurance knowledge.
            I am very concerned about the indemnity insurance problem at the moment in Europe. My suggestion is to come forward with ideas, people and money to solve this problem at short notice.
What I know is that without the availability of Indemnity Insurance for an independent working midwife in Europe, home birth in Europe, even in the Netherlands, will fade away. 

1 New Zealand College of Midwives Inc. (2013). Professional Indemnity Insurance. New Zealand: NZCOM.
2 Oudshoorn, Chr. (2007). Independent midwives and liability insurance. Maternity Matters. Australia.
3 Wikipedia. (2013). Microinsurance.
4 van Bemmelen van Gent, E. ( Editor in Chief).  (2012). HUMAN RIGHTS IN CHILD BIRTH. Bynkershoek Publishing. The Hague Institute for Law & Practice Cornelius Bynkershoek.
5 AIMS. (2013). Independent Midwifery Professional Indemnity Insurance. Understanding the situation.
 6 Johnson K C Daviss B (2005). Outcomes of planned home births with certified professional midwives: large prospective study in North America. BMJ;330:1416 (18 June), doi:10.1136/bmj.330. 7505. 1416.

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