Hospital back-up bookings for planned homebirth

Midwives practising privately in and around Melbourne have, for many years, used the booking and emergency referral arrangements provided by the Women's hospital. The process has been simple: the midwife can fax the woman's details to the hospital, and the woman is given a hospital record number confirming the booking. The midwife provides copies of any blood test and other investigations relevant to the pregnancy, and contacts the hospital if and when obstetric referral is required.

In the past two years, after the Women's hospital relocated from the old Carlton site to its present site in Parkville, and, coincidentally as the numbers of births increased with the recent 'baby boom', restrictions have been placed by the hospital on which women are able to make bookings. For women who are experiencing uncomplicated pregnancies (which is usually the case for women planning homebirth), only those who live in the Women's local area are able to make a booking.  The hospital was apparently bursting at the seams.   Midwives who had previously brought women transferring from planned homebirth to the hospital from distant locations are now referring women who need medical attention to the nearest public maternity hospital.

Some midwives objected to the change.  Transferring to the Women's had been a well-managed matter, that the midwife could confidently navigate.  Professional respect between the independent midwife and the hospital staff, and vice versa, was generally upheld.  This of course tends to reassure the (labouring-birthing) woman, who is at the *centre* of the care.  [The good relationship between Midwives in Private Practice (MIPP)s and the Women's has been written about previously in this blog - eg see July 2008]

The Women’s hospital is now undertaking a review of ‘Services provided by the Women’s hospital in relation to women who choose to give birth at home’. A letter to participating midwives states that The Women’s “has identified a number of issues associated with its existing homebirth backup arrangements and, in recent months, significant concern regarding the clinical risks has heightened.” The Women’s Executive “has decided to review the current arrangements in order to clarify the Women’s role and responsibilities in this area and to determine the most appropriate processes for supporting women who choose to give birth at home.”

The fact that "significant concern regarding the clinical risks has heightened" in recent months, in relation to homebirth, is a matter that midwives who attend homebirths care a great deal about. Has there been some change in the way midwives practise, or in the way midwives and women planning homebirth proceed through their decision-making processes?  Is there a problem specific to the Women's, or ...?

MIPP leaders have also been aware of some issues that would come under the heading of 'clinical risk'.  During the past couple of years, with the federal government's Maternity Services Review; the passing of new legislation requiring professional indemnity insurance which was not accessible; the 'exemption' for homebirth; and the Medicare provisions for participating eligible midwives - this has been a time of unprecedented stress and concern for midwives practising privately, attending women for planned homebirth. 

An application was made some months ago to the Victorian Perinatal Data Collection Unit (VPDC) by MIPP for retrospective information on the birth outcomes of women identified as ‘at risk’, having been recorded as planning to give birth at home in the care of a midwife, and that they have one or more of the following obstetric risk categories: 

Multiple pregnancy; 

abnormal presentation (especially breech); 

preterm labour prior to 37 completed weeks of pregnancy; 

post term pregnancy 42+ weeks; and 

previous caesarean birth. 

There has been an unexpected delay in obtaining the data requested, as 2009 data cannot yet be publicly released. We understand that the delay has been related to the change from manual data entry to electronic data entry at some sites.  We will inform our members and readers as soon as something becomes available.  The VPDC publishes data on actual homebirths (and outcome data for each hospital providing data to the system) each year.  The MIPP audit is seeking information on outcomes specific to 'at risk' pregnancies and planned homebirth.

Thankyou to anyone who has read this far.  We will keep you updated on matters of interest to the private midwifery community, as information becomes available.

Your comments are welcome.