Q: Is malpractice insurance for homebirth midwives standard and what is a reasonable transfer rate? - Page 4

[purslaine]

Originally Posted by Alenushka 

Freedom comes with responsibility.  IF OB does something wrong, he will be sued and insurance will pay for baby care. The care can run in millions

If HB MW is negligent and has no insurance then who will be paying for her and mom's freedom? We are, the taxpayers.

That does not seem fair to  me.

This is created by a system that somewhat forces HB MW's underground.   If HB MW were legal in every state, and insurance was available to them at a reasonable rate, I might have more sympathy for this POV.   

At the end of the day, I prefer birth choice, even if it means society picks up the cost in the few places where things go really wrong.  

[Buzzbuzz]

"buzz buzz….if you felt (and the research you did supported the idea) that birthing with person A was the best choice, but person A did not have insurance, would you actually go with person B (who did not have as great a track record) because they had insurance?  I wouldn't - at the end of the day I prioritise care over insurance.  I do know that for many of us, there is no split.  Some of us can have a HB with a great midwife who has insurance.  Sadly, for some of us, this isn't an option - it comes down to HB with an uninsured midwife or  hospital birth or UC."

When I had my homebirths, I was convinced that the midwife would diagnose trouble early enough that I would have plenty of time to transfer.  This, in my mind, rendered her lack of insurance unconcerning since any high risk scenarios would occur in the hospital and be covered by the hospital/doctor insurance.  This was, obviously, complete BS.

With regard to your scenario, I am fortunate that I don't live in an extremely rural area where my choices might be so limited.  At this point, I would consider malpractice insurance to be a point on which there could be no compromise and would continue to search for a good provider that had it.  Probably, in my state, that would mean agreeing to a CNM attended birth at a birth center attached to a hospital. 

I have plans to retire, to be able to provide economic support for my kids for college, to travel occasionally, etc.  These are really important to me personally and I would not put those plans under threat with an uninsured provider again. 

[MarleneCPM]

In a perfect world, we wouldn't need malpractice ins, but everyone could get it. Unfortunately, this is not a  perfect world. Malpractice, used appropriately, would be a good thing, if it was affordable &  attainable. I't's not. 1st flaw: In it's purest form, it would make negligent practitioners pay for their mistakes. Period. In reality, it pays for Immediate & long term advanced medical care (not to  mention "mental anguish, loss of income," etc. compensation) to "victim" & family, for any less than perfect birth outcome, whether or not it was the practitioners fault.
 

[MarleneCPM]

whoops, was not finished with that other post.
2nd flaw: The cost of 1 years malpractice is more than I make in 5 yrs, so there is no way I, & many homebirth midwives can afford malpractice! However, if malpractice were truly only used for damage caused by providers negligence, it might be affordable, but that is not the way it works in real life.
3rd flaw: many homebirth midwives cannot get  malpractice, even if they could afford it.

Besides the inherent flaws in the logic of every HCP having malpractice, it may be true that docs should have malpractice, because both parties (the doc & the pregnant woman) don't get to know each other very well, making the birth riskier for both parties. On the other hand, when one gets authentic traditional homebirth midwifery care, there are many long chatty, home visits. If you are not completely comfortable w each other by the time of birth, you change arrangements & don't birth together. I feel like if anyone felt like they needed to be protected from my care, they would hire someone they were more comfortable with, not stay with a provider they didn't have confidence in.

   As for a reasonable transfer rate, that depends on the experience, skills & legal  restrictions of the HCP &  the risk factors of clientele she is working with, as well as what other alternatives are available. For instance, in Haiti, I found the hospitals to be very under-equipped to deal  with emergencies, therefore, there are many times  might choose to handle a problem at home there, where if I was here in the US, I would transport. Even here, in the poor rural areas, I might choose to stay home for something that I would transport for, if I had any confidence that the hospital could handle it better than I could do at home.
 

[iowaorganic]

Thank You MarleneCPM for sharing- very informative :)

[Buzzbuzz]

Hi Marlene,

Thanks for the thoughts.  However, I think this:

"it may be true that docs should have malpractice, because both parties (the doc & the pregnant woman) don't get to know each other very well, making the birth riskier for both parties. On the other hand, when one gets authentic traditional homebirth midwifery care, there are many long chatty, home visits. If you are not completely comfortable w each other by the time of birth, you change arrangements & don't birth together. I feel like if anyone felt like they needed to be protected from my care, they would hire someone they were more comfortable with, not stay with a provider they didn't have confidence in."

does not really address the situation we are discussing.  What you are talking about is the protection for the MIDWIFE (not the family) in situations where malpractice insurance does not exist.  What you're saying is -- by being friends with my patients, it makes it less likely that they will sue me. 

For me the discussion has instead revolved around whether protection for the harmed family (provided by malpractice insurance) should matter.

I do agree that tort reform and implementation of universal healthcare would greatly change the calculus of the amount and extent of malpractice payouts (and the cost of malpractice insurance) but I think we need to address the situation as it exists on the ground now.

From my reading, I do not believe that OBs make substantially more per birth than the numbers I am seeing for midwives, so is the economic difference really in number of patients for you versus them? 

[flatlander]

It would be nice if there was a single source that really spelled out all the differences between CPMs from state to state. Because there really are a lot of state regulations that vary wildly.
 

Disclaimer: I'm no insurance expert. However, I really do think it's the case that CPMs aren't even allowed to get malpractice insurance in some states. That is, it's not just a matter of it being expensive. But they are actually prohibited from getting the insurance in some places.

So, CPMs and homebirths might be legal in some places, but they still might not be allowed to get malpractice insurance. It's not always just the case that they can't afford it because it's prohibitively expensive.

Also, has anyone read Baby Catcher by Peggy Vincent? She was a midwife (a CNM that did homebirths, I believe) covered by malpractice insurance. And she shares a personal experience of supporting a mother as a labor support person, and ultimately got sued. Obviously the perspective is from the author, the midwife -- so there is no denying that it's biased from her point of view. However, I still think it's a valuable read and shed some light on what these types of situations can be like.

[joycnm]

In regards to malpractice insurance, I too, am a home birth CNM, and do not carry it.  In my case I truly don't need it because my entire clientele is Old Order Mennonite who are forbidden to sue by their culture/religion.  But, another factor distinguishes my clientele from the average American woman.  They don't expect that every baby born is going to live or even be perfect and that if a baby doesn't live or isn't perfect, someone better pay for it.  Abruptions happen, cord prolapses happen,preterm babies can have life-long problems,  babies are born with cerebral palsy without a clear-cut reason.  Just because a baby is born imperfect doesn't mean the parents don't have to pay (even partially) for the care of their children. The blame game and malpractice insurance go hand-in-hand.

[BroodyWoodsgal]

Originally Posted by joycnm 

In regards to malpractice insurance, I too, am a home birth CNM, and do not carry it.  In my case I truly don't need it because my entire clientele is Old Order Mennonite who are forbidden to sue by their culture/religion.  But, another factor distinguishes my clientele from the average American woman.  They don't expect that every baby born is going to live or even be perfect and that if a baby doesn't live or isn't perfect, someone better pay for it.  Abruptions happen, cord prolapses happen,preterm babies can have life-long problems,  babies are born with cerebral palsy without a clear-cut reason.  Just because a baby is born imperfect doesn't mean the parents don't have to pay (even partially) for the care of their children. The blame game and malpractice insurance go hand-in-hand.

Having family who work as medical malpractice attys has opened my eyes so wide to what "malpractice" ends up looking like in a lot of cases. The firm they work in is one of the top med malpractice practice firms in the county, so, these aren't ambulance chasing, sleazy lawyer types...these are highly intelligent, highly educated people who, together with very highly respected experts, put together air tight malpractice cases. They win. A lot....and a lot of the time, their triumphs disgusts me. You would think that "malpractice" means a doctor or medical staff really dropping the ball. But that's not the case a lot of times, it seems. I hear story after story which shock me. Med malpractice in this country seems to be a game between lawyers advocating for a somehow damaged client and lawyers representing a hospital. Many of these doctors are NOT actually "royally messing up" and people receive really substantial payouts for things that are just shitty luck. But the game goes on. I don't get it.

I'm not saying that is the case every time and goodness knows that we've all read stories around here that just take you to your knees with sadness and anger and outrage at the behavior/negligence of some docs/MWs....but I DO believe that not every baby is meant to be born perfect. I DO believe that luck/chance has a lot to do with outcomes. I DON'T believe that every prolapse, every abruption, every dystocia, even when handled by a super competent MW, is going to turn out all roses....and if it doesn't turn out well, I don't think it's automatically anyones fault.

[jgale]

Just wanted to comment on the malpractice issue--as a CNM who is required by law to carry malpractice insurance, it IS prohibitively expensive in my state and has contributed to the dearth of homebirth CNM's who are the only midwives in this state who are regulated and legal.  (CPM's have to practice under the radar so their clients to not get the benefit of having an open and upfront collaboration with MD's and hospitals when necessary).

What if your child suffered a birth injury and it was NO ONE's fault?  What if the midwife did everything right and your child still suffered a life-long injury that required expensive care?  And what if you sued her anyway because you needed the money for your child's care?  And what if your midwife's insurance company forced her to settle and admit liability where there was none because it was less expensive for the company?  And then because she had been sued and admitted liability, what if the insurance company then raised her premiums or denied her coverage?  So now she is forced out of practice because she can't afford her malpractice premiums which are mandated?

Having a home birth means accepting some responsibility for the outcome.  I would certainly hire a midwife who didn't carry malpractice insurance.  Would I hire a midwife who regularly delivered twins, breeches and diabetic or hypertensive moms at home?  No I would not because I believe that safe home birth begins with appropriate risk screening and (to me) that means a healthy mom with a singleton baby in a vertex position--and I want my midwife to have the same understanding of what is safe.  Would I hire someone with NO mechanism for hospital back-up who would be afraid to show her face at the hospital for risk of legal action?  No I would not because to me safe home birth means having appropriate mechanisms to transfer care when necessary. 

Buzzbuzz, to hear you talk about suing a midwife like you might apply for insurance benefits makes me feel sick to my stomach.  Being sued is a devastating experience that can ruin someone's career and livelihood and is a major cause of many of the problems in obstetrics in our country.  Instead of requesting malpractice mandates, why not write to your legislator and demand that medicare and social security benefits for the disabled be adequate.

Jessi

[Buzzbuzz]

I agree that there are numerous problems with both health insurance coverage and with the "deep pocket" mentality.  However, I cannot see that the solution to those issues is not to provide any recourse for families that have been harmed by *ACTUAL, REAL* malpractice.  Its like saying that because some people commit welfare fraud, we should eliminate welfare entirely.

"They don't expect that every baby born is going to live or even be perfect and that if a baby doesn't live or isn't perfect, someone better pay for it."

I don't expect that either.  However, I expect that medical professionals will act in accordance with the standards of their profession.  The midwife cannot agree to take on the care of patient and then act in negligent fashion. 

[Buzzbuzz]

"Buzzbuzz, to hear you talk about suing a midwife like you might apply for insurance benefits makes me feel sick to my stomach."

If my child was seriously harmed by a WRONGFUL act or the NEGLIGENCE of a healthcare provider, yes, I would view it as my duty as her parent to sue.  

If she needed therapies uncovered by insurance or life-long support or an aide or any other type of assistance am I supposed to look her in the eye and say "Honey, I know X would be a tremendous help to you but we can't afford it.  It was more important that the person that hurt you could go on with her life as normal and continue to practice."

[purslaine]

Originally Posted by Buzzbuzz 

I agree that there are numerous problems with both health insurance coverage and with the "deep pocket" mentality.  However, I cannot see that the solution to those issues is not to provide any recourse for families that have been harmed by *ACTUAL, REAL* malpractice.  Its like saying that because some people commit welfare fraud, we should eliminate welfare entirely.

"They don't expect that every baby born is going to live or even be perfect and that if a baby doesn't live or isn't perfect, someone better pay for it."

I don't expect that either.  However, I expect that medical professionals will act in accordance with the standards of their profession.  The midwife cannot agree to take on the care of patient and then act in negligent fashion. 

Originally Posted by Buzzbuzz 

If my child was seriously harmed by a WRONGFUL act or the NEGLIGENCE of a healthcare provider, yes, I would view it as my duty as her parent to sue.  

If she needed therapies uncovered by insurance or life-long support or an aide or any other type of assistance am I supposed to look her in the eye and say "Honey, I know X would be a tremendous help to you but we can't afford it.  It was more important that the person that hurt you could go on with her life as normal and continue to practice."

Both of these statements are reasonable.

What is not reasonable is that midwives have been forced underground and are often unable to get insurance.  

[Imakcerka]

Originally Posted by joycnm 

In regards to malpractice insurance, I too, am a home birth CNM, and do not carry it.  In my case I truly don't need it because my entire clientele is Old Order Mennonite who are forbidden to sue by their culture/religion.  But, another factor distinguishes my clientele from the average American woman.  They don't expect that every baby born is going to live or even be perfect and that if a baby doesn't live or isn't perfect, someone better pay for it.  Abruptions happen, cord prolapses happen,preterm babies can have life-long problems,  babies are born with cerebral palsy without a clear-cut reason.  Just because a baby is born imperfect doesn't mean the parents don't have to pay (even partially) for the care of their children. The blame game and malpractice insurance go hand-in-hand.

Really?  Every pregnancy I had didn't leave room for me to feel eh... if it dies it dies.  or jeez I guess I would be okay with my baby having serious issues.  It's not about HB, it's not about UC it's not about hospital births.  It's about accountability.  If I went into everything glass half full or accepting a poor outcome and chiding myself for my apparently too HIGH expectations... I might as well do nothing.

When you put your life and the life of your child in another persons hands... one who touts experiences and know how you tend to have some decent expectations.  And to not have them is ridiculous.

[joycnm]

When I started my career as an L&D nurse 25 years ago I bought the hospital mentality that if we just intervened enough we could save every mom & baby.  Also, conversely, I thought if we lost a baby or mom it was because we didn't intervene enough.  I was young and naive then. I never, then, thought this mentality would cause a 50% c-section rate in some hospitals and at least a 75 % pitocin rate as well, not to mention the almost criminal use of fetal monitors.  Still, 25 years later, my heart still tells me that every baby & mom can be saved; but, finally, my brain knows that is not true.  Moms and babies will die despite our best intentions.  I guess my Mennonite women are just more advanced in their thinking than the rest of us.  Imakcerka, they don't think "if it dies, it dies..." and that's being disrespectful to this group of people.  They just don't think someone is "accountable" and has to pay them money in return for their lost child like it's the lottery.

[GoBecGo]

I'm in the UK.

Here all midwives practising must be registered with the RCM (royal college of midwives).  At the moment there are both NHS midwives (who work for hospitals or health boards) and independent midwives (who can be hired at their own cost by the individual families seeking care).  And NHS homebirth is free.  An IM homebirth is £2700-£4000 depending on area.  

Up until a number of years ago all midwives had malpractice insurance included in their RCM membership.  Then a few years back they put out a referendum saying "Covering the IM's for malpractice is effectively costing you NHS mw's £10/year extra on your membership.  Should we just drop their cover?"  The IM's (about 3% of members) voted no.  The (underpaid, overworked) NHS midwives mostly voted yes.  So IM's lost their malpractice insurance.  In the UK the problem isn't one of cost, it's one of availability, most insurance providers simply will not cover ONE midwife, they want a group, and there aren't enough IM's to form enough of a cohesive group in any area (Scotland has different laws from England, so the insurance can't be shared - atm i think there are 5 IM's practising in the whole of Scotland, and several of them are part time only).  The available insurance would mean an increase of around £1000 per woman in fee, if the midwife is practising responsibly (and not booking excessive women to lower the shared cost).  There is no offset or financial assistance for women using IM's in the UK.

In most areas NHS HB's are available if: one is deemed low risk, one is lucky enough to get on the list (limited availability) and one is lucky enough to go into labour when a mw is available to attend you.

In August 2013 it will become law for all practitioners, including IM's, to carry malpractice insurance.  The outcome of this in the UK seems at the moment to be the certain end of independent midwifery.  Which means an end to HBAC's, HB's for those over 35, HB's for those who had a previously complicated labour (even when the complications were caused by intervention), HB's for those who didn't get on the list, HB's for those who went into labour when the assigned mw was ill/on another call/on leave.  In short it will mean an end to choice for a lot of us women, a loss of individualised care for those of us who want or need it (i suffered 7 years of child sex abuse and the NHS want me to give birth with a psychiatrist team to make sure i don't murder my baby because i professed that i don't like to be touched in intimate places by strangers!  I just wanted a MW i KNEW!).  

So no, my IM didn't carry insurance, her transfer rate was 11%, her cs rate was 8%.  She was and is an excellent care giver.  The women of Scotland will miss her when she's gone.

[Buzzbuzz]

 Moms and babies will die despite our best intentions.  I guess my Mennonite women are just more advanced in their thinking than the rest of us.  Imakcerka, they don't think "if it dies, it dies..." and that's being disrespectful to this group of people.  They just don't think someone is "accountable" and has to pay them money in return for their lost child like it's the lottery.

So, out of curiosity, if you had committed malpractice that resulted in a serious brain injury for one of your Mennonite patients would you feel any obligation to help cure the harm you had caused?  What would you do to make it right (or at least better, since of course you couldn't make it right)?

Do you not acknowledge your own accountability?

[Imakcerka]

Originally Posted by Buzzbuzz 

 Moms and babies will die despite our best intentions.  I guess my Mennonite women are just more advanced in their thinking than the rest of us.  Imakcerka, they don't think "if it dies, it dies..." and that's being disrespectful to this group of people.  They just don't think someone is "accountable" and has to pay them money in return for their lost child like it's the lottery.

So, out of curiosity, if you had committed malpractice that resulted in a serious brain injury for one of your Mennonite patients would you feel any obligation to help cure the harm you had caused?  What would you do to make it right (or at least better, since of course you couldn't make it right)?

Do you not acknowledge your own accountability?

Probably not, what happens happens and that's just good enough for them. 

[BroodyWoodsgal]

I would venture to guess that some interpretations of the definition of "malpractice" are a little looser than others around here. :(
 

[Imakcerka]

I think so brood, my main concern is that if an accident happens it's not because of negligence.  It's not because of a lack of knowledge.  Life happens and no you cannot ensure that everything will be perfect.  But don't go into with "whatever happens happens" attitude.

And Joycnm, you're the one disrespecting people here.  Those women are easy prey the way you describe them.  A quick paycheck and nothing more.  They deserve better.  While there is an element of trust in god involved, "man" is also involved and even Gods know man can f things up.