Thursday, March 24, 2011

Homebirth via public hospitals

A midwife from Casey Homebirth service, at a maternity conference, with the 'gear' that she takes to a home

In December 2009 we noted at this blog the announcement that some Victorian women would be able to access homebirth via a publicly funded pilot scheme.

Two metropolital hospitals, Casey in the South-East and Sunshine in the West, have their homebirth programs up and running. We have also been told by a reliable person that Monash Medical Centre, a level 5 hospital in Clayton, is planning to offer homebirth as part of comprehensive maternity services this year. [Click on the highlighted words to go to the websites of the hospitals mentioned]

I have recently met up with a group of the midwives employed at Casey. I was impressed at their enthusiasm for their work. They told me they are loving the work.

Homebirth is a basic aspect of midwifery practice. It allows the practitioner an opportunity to develop a strong midwife identity, accepting the authority in decision-making at any time in the episode of care, and particularly at the time of birth. Homebirth is 'PLAN A' - the woman giving birth spontaneously, without medical intervention, and the midwife acting in harmony with normal physiological processes.

Working in a public hospital homebirth program enables midwives to practise one-to-one (caseload) primary maternity care without taking on the professional marginalisation that is experienced when midwives go into private practice.

Midwives who have moved into private practise may not value this aspect of the hospital program to the same degree as those who take the hospital caseload-homebirth positions.

Hospital midwives are able to provide care for the group of women booked in their caseload, with structured 'backup' processes from other midwives in the program, and arrangements for handing over care if a labour is very long. These midwives value their employment contracts, through which they have a reliable income, employment benefits such as sick leave and long service leave, and their relationship with their clients is separate from their ability to earn a living.

By way of comparison, independent (private practice) midwives value the strong commitment they make to individual women, and very rarely ask another midwife to take over. The 'employment' arrangement is a private one, between the individual woman and her private midwife or midwives.

Both options - private and public - have potential advantages and disadvantages.

‘Hospital at home’ is a reality. Hospitals are over-crowded, and it makes sense to provide services in the home when possible. The hospital risk management includes the latest gadgets that may be useful, such as the 'Neopuff TM' machine shown in the picture above. With the strict policies on inclusion in the program, it’s very unlikely that the midwives will need to use the neopuff. That will come out in audits down the track.

The inclusion by hospitals of this item should not be seen as suggesting that all midwives attending homebirths need to carry such equipment. There would need to be some compelling evidence that babies born at home would be better off. Hospital babies, many of whose labours are induced when they not quite ready to be born, depressed by narcotics, and premature, ... are the ones that would clearly benefit from the Neopuff TM.

Homebirth via public hospitals is a valuable addition to publicly funded maternity services. Women and their babies benefit, as homebirth requires the promotion of normal physiological birthing, feeding, and nurture processes. Midwives benefit in being separated from reliance on unnecessary medical interventions.

I anticipate that there will, in time, be an exchange of midwives between the public and private homebirth options. This will be good for midwifery, and good for birthing women.

Comments by readers are most welcome.


Anonymous said...

I would suggest that carrying equipment like that is a bit of overkill. Most midwives are not just "in the moment" at a birth but are constantly looking ahead and if they think that the baby will be so compromised that they would need this equipment they are likely to discuss this with the family and transfer in to hospital.
I believe that most independant midwives carry some equipment to ventilate the baby in the unlikely event that ventilation at birth is required.
The need for neonatal resuscitation is greatly reduced when healthy women have physiological labours and births.

Sarah Stewart said...

I carried basic resuscitation equipment to the home births I attended. The snag with more advanced resus is you must keep up your skills. I never took ventilation equipment because I wasn't skilled at it...figured I'd do more harm than good. So I relied on bag and mask.