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Homebirths or births at home: It’s simply not the same thing

Homebirths or births at home

This opinion piece was published on ABC Unleashed in April in response to the misleading media about homebirth. http://www.abc.net.au/unleashed/stories/s2543589.htm

The front page of the Daily Telegraph ran the sensational headline this week ‘Four dead in home birthing’ (April 6th 2009).  The article went on to say that at least four babies had died ‘during homebirths in the past nine months’ and a further four babies had suffered brain damage. This was presented as ‘fact’ although it remains unconfirmed to date. The ‘facts’ we have from the latest Australian Institute of Health and Welfare (*1) (published in 2008), indicate that 708 women had planned homebirths in Australia in 2006 (0.3%) and there were no deaths reported amongst these births. In this same year 2730 babies died – most of them in Australian hospitals. While we must remain committed to trying to reduce these deaths, the reality is this rate has remained unchanged for nearly 15 years, despite a doubling in the caesarean section rate. What has been missed in this debate over the past week is the difference between a planned home birth for a woman with a low risk pregnancy attended by a competent, midwife who is well networked into mainstream services (supported by evidence as safe), and a birth at home where there is no professional care (*2) or where the woman has risk factors in her pregnancy (supported by evidence as less safe).

To put some balance into this argument, the following issues need to be considered. Firstly, the intervention rates during childbirth have skyrocketed over the past ten years in Australia, leaving many women traumatised and fearful. A first time mother in Australia now has a greater chance of having surgical intervention during her birth than of not having it. Miranda Devine’s mocking disregard for the emotional trauma that stems from this reality was evident in her article; ‘A home birth is not safe’ (April 9th 2009). Secondly, options of care for childbearing women remain limited with around three percent of women able to access continuity of midwifery care. Thirdly, around 130 maternity units have shut down in Australia over the past ten years, many of these in rural and remote Australia, leaving women with little option but to travel great distances from family and community to give birth. The rising incidence of ‘roadside births,’ is the unintended consequence of such actions. Fourthly, privately practicing midwives have not been able to obtain affordable insurance since 2000, leading many to stop practicing, with the remaining midwives practicing uninsured and without visiting rights to hospitals. Midwives cannot even order routine blood tests or ultrasounds and often find it difficult to obtain the results for the women they care for, causing delays in appropriate management. Fifthly, there are very few financial rebates women can access for midwifery care, and they pay between $3000-5000 dollars for this service. Some women clearly cannot afford this.

The ramifications of these issues are: more traumatised women due to interventions during birth; fewer options of care – especially continuity of midwifery care; fewer experienced, networked midwives available to attend women privately; and no access for women to a hospital birth under a private midwife. The result has been increasing numbers of unattended births and more women with high-risk pregnancies seeking midwifery care at home. The rise in the numbers of unattended births is ironically being seen in two countries – Australia and the USA – both with the highest intervention rates in birth and limited access to continuity of midwifery care. The answer to all this is not to demonise women but to stop and consider our responsibility as a society to mothers and babies. It is time we made our maternity care system accountable and really listened to what women are telling us. Over 400 submissions from women to the government, as part of the National Maternity Review should not be dismissed as irrelevant, as Miranda Devine seemed determined to do. It is time to make birth safe, physically, emotionally, culturally and spiritually. Never before in history have women been able to reap the benefits of safe and satisfying birth like we can now. We need to give women access to choice and continuity of care, where midwives and doctors are willing and able to work together respectfully. We need to begin to reconstruct our maternity system with women, their babies and families at the centre – not the health professionals and their inevitable turf wars.

In the United Kingdom they have made an effort to do just this, with a joint statement on Home Births produced by the Royal College of Obstetricians and Gynaecologists and the Royal College of Midwives (*3) (April, 2007). In this joint statement they say, “The Royal College of Midwives (RCM) and the Royal College of Obstetricians and Gynaecologists (RCOG) support home birth for women with uncomplicated pregnancies. There is no reason why home birth should not be offered to women at low risk of complications and it may confer considerable benefits for them and their families. There is ample evidence showing that labouring at home increases a woman’s likelihood of a birth that is both satisfying and safe, with implications for her health and that of her baby.” In Scotland they are now urging mothers to give birth at home. In the Netherlands where 30% of babies are born at home, and the caesarean section rate is more than half ours (14% versus 31%), both private insurance companies and government health funds cover only midwives or general practitioners and home birth; or short stay hospital births (anything more women pay for), for low-risk pregnancies. Financial support for care from an obstetrician is only available to women with high-risk pregnancies. For women with low-risk pregnancies in the Netherlands, outcomes of planned home births are as good or better than the outcomes of hospital births.  The often misquoted 'Bastian study' (*4) of homebirth in Australia between 1985 and 1990 showed, “while homebirth for low risk women can compare favourably with hospital birth, high risk home birth is inadvisable and experimental.” The ‘Bastian study’ provided what we call low-level evidence – the study design was retrospective (looking back at what had been done), it included births by non-registered and registered midwives and it used a number of methods to collect the data (e.g. searching newsletters for death notices). The one study you will never hear the medical profession quote is the USA home birth study (*5). This was a prospective study (gathering data as it happens) looking at 5418 low risk women who planned a homebirth with midwives in the USA and Canada in the year 2000. There was no difference between the numbers of babies dying at home or in hospital, but the intervention rates were significantly lower amongst homebirth women. The largest study done to date in the world was published this week (April 2009) and showed out of more than half a million births in the Netherlands there was no difference in outcomes for babies of planned homebirths and babies of planned hospital births (*6). What all this research indicates is homebirth is safe for low risk women under the care of competent, networked midwives who work in collaboration with mainstream maternity services. This past week’s media has revealed the hazard of ignoring this evidence.

Whatever your beliefs about home birth, the facts are this – never in history, and in no country on earth, has homebirth ever been eradicated There are two potential responses to this fact. One, we put in place supportive, safe, collaborative systems of care that respect a woman’s right to choose her place of birth and care provider, like they have in the UK and the Netherlands, or two, we burry our heads in the sand and hope it will all go away. This last choice is the one we have made to date in Australia and it is clearly not working. It’s time to take the proverbial ‘log’ out of our own eye and seriously consider where we have let women down in the maternity system we currently make available to them, before we try to pick the ‘spec’ out of our sister’s and criticise the choices some may make. Perhaps then we will all see more clearly, and hopefully respond more wisely.

1.Laws, P. & Hilder, L. (2008). Australia's mothers and babies 2006. Sydney: AIHW National Perinatal Statistics Unit.
2.Confidential Enquiry into Stillbirths and Deaths in Infancy. 5th Annual Report. Focus group place of delivery. London: Maternal and Child Health Research Consortium; 1998.
3.Royal College of Obstetricians and Gynaecologists/Royal College of Midwives Joint statement No.2, April 2007. Home Birth. RCOG and RCM.
4.Bastian, H., Keirse, M. J., & Lancaster, P. (1998). Perinatal death associated with planned home birth in Australia: population based study. BMJ, 317(7155), 384-388.
5.Johnson, K., C., & Daviss, B. (2005). Outcomes of planned home births with certified professional midwives: large prospective study in North America. British Medical Journal, 330, 1416-1423.
6.de Jong, A., van der Goes, B., Ravelli, A., Amelink-Verburg, M., Mol, B., Nijhuis, J., et al. (2009). Perinatal mortality and morbidity in a nationwide cohort of 529,688 low risk planned home and hospital births. British Medical Journal, DOI: 10.1111/j.1471-0528.2009.02175.x.

Dr Hannah Dahlen is the Associate Professor of Midwifery at the University of Western Sydney. She has been a midwife for more than 20 years. Hannah is also an executive member of the Australian College of Midwives, NSW Branch. She has researched women's birth experiences at home and in hospital and published extensively in this area. Hannah's website is www.hannahdahlen.com.au

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