Not alone: call for homebirth research

A British study will be replicated here to provide much needed statistical evidence for the continuing debate over midwives' duties. Mardi Chapman reports.

It’s hard to find a more polarised debate than homebirths. Platitudes such as “a woman’s right to choose” flow easily, but when it comes to choosing a place to give birth and who should attend, there are many limits on that choice.

Lack of funding, clinical privileges and professional indemnity insurance continue to threaten homebirth practice and dissention doesn’t only come from the medical profession.

Only 0.03 per cent of women choose a homebirth in Australia but their right to do so continues to generate more discussion and emotion than issues around the vast majority of hospital births.

They aren’t separate discussions, however, according to Associate Professor Hannah Dahlen from the University of Western Sydney’s School of Nursing and Midwifery.

In a recent Crikey.com article (November 14) she asked what is wrong with the Australian maternity care system that some women with risk factors such as twins or a breech presentation would prefer the added risk of a homebirth over a hospital birth.

“These women do not love their babies less, they fear mainstream care more and this is a terrible indictment of our care,” she said.

The Australian College of Midwives (ACM) has released their new Position Statement on Homebirth Services (November 2011) – one of a suite of documents to provide guidance to midwives but also to assure government interests that a quality and safety framework exists around homebirths.

More than 200 submissions were received during the consultation process. The ANF criticised an interim position statement for not being prescriptive enough on minimum educational and experience requirements for homebirth midwives and exclusion criteria to better define low obstetric risk.

In contrast, consumer advocacy organisation Maternity Coalition found the interim statement too restrictive and refused to endorse it as it “undermines women’s rights to informed choice”.

The homebirth debate has simmered for decades but heated up again when homebirths were virtually ignored in the 2009 Improving Maternity Services in Australia – The Report of the Maternity Services Review.

The report said “homebirthing is a sensitive and controversial issue” and that relationships between relevant health professions were not conducive to finding solutions.

As a spokeswoman for the ACM, Dahlen said any stand-off between interest groups was only making the situation worse. She said there was some evidence that “freebirths”, homebirths unattended by registered midwives, were increasing. Results of a study on freebirths are expected by the end of 2012.

“A large part of this is that women feel it is the only way to get the birth they want. Many have had previous traumatic events and fear hospitals more than anything. They may even see midwives as part of the system,” Dahlen said.

She said for some women, money can be the issue – they simply can’t afford a midwife when homebirth is not supported by public funding apart from a very few schemes.

Dahlen said the “war” over homebirths, which had ironically focused on statistics such as perinatal mortality, was creating even more dangerous situations for women and their babies. “It doesn’t matter what evidence is supplied, people seem to become more fixed in their views. We need to let the war go, to be professional and engage with each other,” she said.

That seems to be slowly happening even in the US, the country most like Australia in terms of its historical lack of support for homebirths. A Home Birth Consensus Summit in October brought together a wide range of consumers, health professions, policy makers, insurers and administrators.

“They weren’t debating the evidence. They were there to come up with a position statement about what everyone agrees on,” Dahlen said.

Importantly, one of the resulting Common Ground Statements highlights the importance of collaboration within an integrated system and “respectful, safe, and seamless consultation, referral, transport and transfer of care when necessary”.

These issues, critical for continuity of care and clinical safety, are the current sticking points in Australia. Many midwives are finding it difficult to achieve collaborative arrangements with obstetricians or admitting rights to hospitals.

“Some people are determined to prove that homebirths are not safe,” Dahlen said. “If a homebirth is transferred to hospital, midwives are often facing animosity and aggression, they are reported to the board and they are refused entry. This is the most unsafe situation possible.”

Planned homebirths for low-risk pregnancies in the UK, which enjoy the support of both the Royal College of Obstetricians and the Royal College of Midwives, have again been shown to be safe in a recent British Medical Journal article (published online, November 24).

The prospective cohort study of more than 64,000 women with single pregnancies over 37 weeks gestation found no significant difference in a composite measure of perinatal mortality and morbidity according to place of birth for multiparous women.

The 250 primary outcome events, about 4 per 1000 births, included neonatal deaths, fractures of the clavicle, brachial plexus injury and meconium aspiration syndrome.

Adverse neonatal outcomes were slightly higher in nulliparous women choosing a planned homebirth but similar between obstetric units and midwifery-led units located either on hospital campuses or off-site.

Transfers to obstetric units were about 40 per cent in nulliparous women compared with about 10 per cent in multiparous women.

The UK study will effectively be replicated in Australia from 2012 with a NHMRC funded birthplace study led by Professor Caroline Homer from the University of Technology, Sydney.

Feeding in to the Maternity Services Review recommendations for more research and national data collection, the study will investigate outcomes from about 45,000 births across public and private hospitals including birth centres, freestanding midwifery units and homebirths, both publicly and privately funded.

“We need to continue to grow the evidence and what has to be unpacked are the important pieces of information for women – their chances of a normal birth versus a caesarean section or their chances of good outcomes versus bad,” Homer said.

“We haven’t had a big national study which clearly defined intended place of birth at onset of labour, not at 12 weeks. Smaller studies have also been a bit vulnerable because of their low numbers.”

Dahlen said the final ACM position statement on homebirths has managed to keep most people happy. A companion document, ***National Midwifery Guidelines for Consultation and Referral***, provides best practice around management of risk factors and situations when a woman chooses a homebirth outside the guidelines.

There remains an urgent need for professional indemnity insurance to protect both midwives and the families they support. A government-supported professional indemnity insurance for privately practising independent midwives currently excludes homebirths.

At their August meeting, the Australian Health Ministers Conference agreed that the exemption on the need for homebirth midwives to have indemnity insurance could be extended from July 2012 to July 2013 “while further options are explored”.

Dahlen said there is also a strong argument that government funding of homebirths would be cost effective given the savings on hospital stays.

“Women want everything on the menu. Very few women choose an elective caesarean. Birth centres are a wonderful option in the middle but there are waiting lists and it’s unacceptable that they haven’t been expanded.”

“Homebirths are not going away. Supporting a woman’s right to choose a homebirth attended by a qualified health professional, insured and funded, is the safest option.”