Monday, January 25, 2010

Bev's review of politics and homebirth

Over half of the submissions to the Federal Government Inquiry into Maternity Services in March 2009 were from consumers and nearly 60% asked for greater support for, and access to, homebirth. The extreme naivety of leaving home birth off the agenda because "it would polarise the professions" has caused chaos. If you believe in the chaos theory, midwives and mothers have emerged victorious. Midwives and homebirth are now on the agenda.

Home birth families around the country have been fascinated to read the new South Australian study published in the MJA (Medical Journal of Australia) on Monday 18th January. For babies born at home there were only 2.5 deaths per 1000 actual homebirths making homebirth 328% safer for babies than birth in hospital. When the detail of the study was exposed and the data analysed correctly by experienced exponents of research analysis, the perinatal mortality for homebirth is 2.5 babies per 1000 births compared to 20.1 babies per 1000 births in hospital.So women can safely choose homebirth in South Australia.

Sophisticated high level research in the United Kingdom, Netherlands, New Zealand and Canada has already confirmed that women are more satisfied with midwife led birth. In spite of false claims by the erstwhile leaders the of the AMA (Australian Medical Association) this South Australian research study, reinforces the view of advocates for women, that home birth is now only way for women to claim back normal birth. In fact one leading obstetrician Marsden Wagner in the USA puts it more bluntly "get the Hell out of Hospital".

The other good news from the study, was that homebirth provides: a lower incidence of episiotomy (an unkind cut), higher incidence of intact perineum, less 1st. 2nd and 3rd degree tears than in hospital women, less incidence of post-partum haemorrhage, no statistical difference in babies' apgar (colour breathing) score.

The new study assessed the outcomes of almost 300,000 births in South Australia from 1991 to 2006 which resulted in approximately (8.2/1000) or 2550 baby deaths in hospital. Of the 1141 planned home births the rate was declared to be 7.9/1000 EXCEPT that 7 of these 9 births died in hospital.
The claim that the research demonstrated that baby’s had a 7 times more likelihood of dying in homebirth is false.
The attribution to planned homebirth for at least 4 of those deaths which were congenital abnormalities, is specious.
There is no explanation given for the approximately 2500 deaths in hospital.
The other false claim of "27 times more likely to die of birth asphyxia " ( lack of oxygen either before during labour or at birth) is exposed when it is clear that only one baby died for that reason at home during the selected 16 years. The mother refused to go to hospital due to previous bad hospital experience.

Caesarean surgery, removing the baby through the mother's abdomen, is taking place for one in three women and higher in Australian private hospitals. These doctor led positively reinforced decisions are nothing short of assault and battery of women. Obstetrician David Elwood from Canberra stated to Norman Swan on Health Matters on 2.11.09 "now that we manage surgically so well then there is no turning back to normal vaginal birth" he further stated that "we" set the surgery for 39 weeks. "I was up during the night recently performing a caesarian (surgery) because a woman came into labour before 39 weeks.". Even more scary another doctor Caroline de Costa from Qld stated to Norman Swan that women "now have right to choose between vaginal and abdominal birth".

Duty of care, that is, "first do no harm" seems to be missing. In Brazil the abdominal surgery rate for birth is 80%. According to recent research from South America, repeat surgery for future births, is putting women at risk of loss of fertility, haemorrhage and/or death. Recent strong causal links have been made with the high incidence of asthma. Lack of exposure to normal flora of the mother's skin and the absence of squeezing out fluid from the lung as in normal vaginal birth are stated to be the reason. High rates of psychosocial and physical illness are also linked to this surgery.

It is interesting that M. Keirse who was co-author of the South Australian study was also co-author of 3rd Edition of a Effective care in Pregnancy in which it was stated that it is inherently unwise and perhaps unsafe for women with normal pregnancies to be cared for by an obstetric specialist. The Health Minister Nicola Roxon, stated in a letter to me, that the Australian Government has recommended a review of the high rates of abdominal surgery for birth and intervention . Federal MP Darren Chester from East Gippsland spoke to me of the high regard in which he held the midwives of East Gippsland who were lead carers in their children's births. Matt Viney State MP from Warragul told me that two of his children were born at home with a midwife.

Most of the placards and speakers at the rally I attended outside the Melbourne office of the AMA on Wednesday 20th January last, called for Dr. Pesce’s resignation. The AMA were called on to ask for his resignation. The AMA as a group of medical professionals must be prepared to take responsibility for the gross distortion of facts by its leading representative

• This attempt to frighten women is an indictment on the current maternity system in Australia - it that which needs fixing - removing homebirth won’t do this.

Beverley Walker Mother of 4 Grandmother of 7.
Midwife Ethicist & Health Scientist
Lobbyist and Activist.

Wednesday, January 20, 2010

Pictures from today's rally outside AMA house in Melbourne

There was a good turnout at this rally - 100+ adults and at least as many beautiful, healthy, happy, intelligent children and babies-at-breasts.
Midwives travelled from Echuca, Castlemaine, Bendigo, the Otways, and metro practices.
(Dr) Richard Di Natale from the Greens reiterated support.
Mothers came from Ballarat and the Barwon coast and the 'burbs.
Have a look at this Crikey article. 10/10 to Melissa Sweet for looking behind the spin!

Also see the Croakey blog (s) in response.


Sunday, January 17, 2010

Homebirth statistics

The Medical Journal of Australia will release a paper tomorrow claiming increased death rates from homebirths in South Australia over a 16-year period (1991-2006).
[Link to the Editorial, and the Paper]

Midwives and homebirth activists have reviewed the paper titled Planned home and hospital births in South Australia, 1991-2006: differences in outcomes (Authors Kennare RM, Keirse MJNC, Tucker GR and Chan AC).

Although this paper is presented in the AMJ as research, it is just a report on what has actually happened. It is not a research study, and should not be held out as such. There is no ability to control for biases. This report has no statistical power, and any conclusions drawn from it are no more than opinion.

South Australia's high profile midwife Lisa Barrett has provided comments at her blog.

Click here for Homebirth Australia's comments; here for further informed discussion.

The following comments and response have been attributed to NSW midwives Hannah Dahlen and Caroline Homer. (Source midwives yahoo group)

Summary of key issues regarding the MJA homebirth paper

• There is no way to tell if these planned homebirths were under the care of a registered midwife between 1991-2006 (sixteen years). This is also a retrospective population based study (low level evidence)
• One of the problems is that the planned home birth group includes women who planned homebirth at booking but then developed risk factors and had their babies in hospital. There are probably only two women whose babies died who started labour at home planning a homebirth and one of these was a twin pregnancy (high risk). The others had all transferred before the onset of labour. The authors admit they ‘could not differentiate all planned homebirths according to whether transfer to hospital had occurred before or during labour.’ So for low risk women who start labour at home the risk is very low - 1 death in 16 years.
• There was a high rate of post-term pregnancy (3.8% vs 1.2%); twins (five sets of twins); VBAC 8.8% - so not a low risk population.
• Significantly less intervention in homebirth group: C/S 9.2% vs 27.1(one third); instrumental birth 4.4% vs12.8% (one third); Episiotomy 3.6% vs 21.7% (one sixth). More than three times the rate of intact perineum in homebirth group (seven years missing data on episiotomy and perineal injury).
• No difference in major maternal morbidity measures of severe perineal trauma 1% vs 1.8% and postpartum haemorrhage 5.5% vs 4.4%
• The numbers of planned homebirths are small (1141) (birthed at home n=792; in hospital n=349). You cannot look at the rare outcome of intrapartum death in such a small sample (CI 1.53-35.87)(there is 1 intrapartum death at home and 1 in hospital). You also can’t look at intrapartum asphyxia due to the low numbers (CI -8.02-88.83) (1 at home and 2 in hospital). You would need about 10,000 births at home to show this. Also they don‚t say how they define this and bias is possible. The authors state the ‘small numbers with large confidence intervals limit the interpretation of these data.’
• There is no difference in perinatal mortality (stillbirths and neonatal deaths within 28 days of birth) between home and hospital (7.9 vs 8.2/1000). Perhaps the authors were surprised by this and looked further trying to find something. For those born at home the perinatal mortality rate is 2.5/1000.
• The numbers of perinatal deaths are also small (9 deaths). There were two deaths actually occurring at home and 7 in hospital. Of these, only 3 are related to perinatal asphyxia.
• The deaths in hospital were: (1) one had lethal congenital abnormalities (known beforehand and a decision made to be born at home), (2) 1 had hydrops and (born in hospital), (3) 1 was unexplained with a cord entanglement (born in hospital), (4) 1 had pulmonary hypoplasia after a early rupture of membranes and (born in hospital), (5) 1 was growth restricted with an abnormal karotype (born in hospital) and (6) 1 'seriously' postdates, induction in hospital without fetal monitoring (the woman refused) and eventuated in a stillbirth and (7) one was a woman with known haematological risk factors whose baby had a lethal abnormality.
• Of the 2 other deaths at home (8) one was at home after a waterbirth which was not found to be the cause of death but increased monitoring may have identified the baby was in distress and (9) one was a second twin (first twin born at home and second twin born after a delay in transfer). Three therefore are potentially preventable and related to the model of care:1 - waterbirth at home; 2 - second twin; 3 - postdates.
• Therefore 3 deaths in 16 years - two of which had risk factors.
• Therefore, 1 death in 16 years where there were no risk factors.
• There were no differences in Apgar scores or NICU admissions but infants born at home were half as likely to receive specialised neonatal care compared to planned hospital birth
• The paper also highlights that the system must be so terrible for some women that they would choose to give birth outside of it than in it even with risk factors. Therefore, this is an indictment on the current system - that needs fixing - not removing homebirth.
• The conclusion of the paper is actually very sensible about risk assessment, transfer and fetal monitoring.

• Despite a malfunctioning system where midwives are uninsured and have no visiting rights the perinatal mortality rate is no different. This is remarkable.
• The intervention rates are to be commended
• Risk assessment, transfer and fetal monitoring will be improved when private midwives are no longer excluded from mainstream services so we should be aiming for this not continuing the witch hunt against private midwives.
• Some women will always choose homebirth so we should support this choice with safe responsive systems of care. The authors state that ‘women's autonomy in choosing reproductive behaviour is a fundamental human right enshrined in Australian law'.
• The excess mortality continues to be found in high-risk women and women need to be informed of this risk.
• Freebirth is rising and this is a concerning outcome of restrictions on options like homebirth and trauma from hospital births

Friday, January 1, 2010

How will midwives access the 'exemption' ?

An announcement was made in September 2009 that midwives will be granted an exemption from the requirement to have professional indemnity insurance when we attend homebirth. For more detail and links, click here.

Three special requirements were listed:

- A requirement to provide full disclosure and informed consent that they do not have professional indemnity insurance.

- Reporting each homebirth

- Participating in a quality and safety framework which will be developed after consultation led by Victoria through the finalisation of the registration and accreditation process.

(These provisions will only apply to midwives working in jurisdictions which do not prohibit such practice as at the date of the implementation of the scheme. Northern Territory does not permit any midwife to practise privately.)

In preparation for the implementation of the government's reforms, a draft Quality and Safety Framework for private midwifery care in Australia has been released by the Victorian health department for comment.

Victoria has responsibility for developing the draft framework and for managing the national consultation with key stakeholders. Consultations are planned to take place in late January and throughout February.

Written feedback will be taken up until 1 March 2010.

The consultation will be led by Professor Jeremy Oats, Director Victorian Maternity Newborn Clinical Network and Julie Jenkin, Manager, Maternity Services Program, Department of Health, Victoria.

Midwives in Private Practice (MIPP) has requested an opportunity to present our response verbally (as well as in writing) to the consultation.