Publicly funded homebirth in Australia

Publicly funded homebirth in Australia: a review of
maternal and neonatal outcomes over 6 years

Authors: Christine Catling-Paull, Rebecca L Coddington, Maralyn J Foureur and Caroline S E Homer, on behalf of the Birthplace in Australia Study and the National Publicly-funded Homebirth Consortium

From the Medical Journal of Australia (Med J Aust 2013; 198 (11): 616-620.):

Results: Nine publicly funded homebirth programs in Australia provided data accounting for 97% of births in these programs during the period studied. Of the 1807 women who intended to give birth at home at the onset of labour, 1521 (84%) did so. 315 (17%) were transferred to hospital during labour or within one week of giving birth. The rate of stillbirth and early neonatal death was 3.3 per 1000 births; when deaths because of expected fetal anomalies were excluded it was 1.7 per 1000 births. The rate of normal vaginal birth was 90%.

Conclusion: This study provides the first national evaluation of a significant proportion of women choosing publicly funded homebirth in Australia; however, the sample size does not have sufficient power to draw a conclusion about safety. More research is warranted into the safety of alternative places of birth within Australia.

These results are consistent with the large Dutch study (de Jonge et al 2013) comparing maternal outcomes from (low risk) homebirths with a comparable group of (low risk) women giving birth in hospitals in the Netherlands concluded that:

"Low risk women in primary care at the onset of labour with planned home birth had lower rates of severe acute maternal morbidity, postpartum haemorrhage, and manual removal of placenta than those with planned hospital birth. For parous women these differences were statistically significant. Absolute risks were small in both groups. There was no evidence that planned home birth among low risk women leads to an increased risk of severe adverse maternal outcomes in a maternity care system with well trained midwives and a good referral and transportation system."

The two Victorian publicly funded homebirth programs, at Sunshine and Casey hospitals, were not included in this study, which took data from 2006-2010. 

For more discussion about risk and homebirth, go to villagemidwife blog.

questions ...

...

"Do you [the midwife] consider that after you have informed the woman of risk, such as twins, that it is appropriate for you to agree to homebirth?"


"In your opinion, what is more important: the right of the woman to have informed choice, or the safety of the mother and baby or babies?"


"If a woman who was having quadruplets told you she wanted to give birth at home, and you informed her of the risk, would you agree to attend her for homebirth?" 

"Isn't the reality that if the midwife says 'Yes, I'll come to your homebirth of quads, isn't the midwife giving the green light to the woman's wishes?"

Continuing from the previous post, I want to further record and begin to explore lines of questioning that have been pursued by the barrister acting for AHPRA, in a formal hearing into the professional conduct of a midwife who attended births for two women classified as risk categories C and/or B in the ACM National Midwifery Guidelines for Consultation and Referral - in this case the 2004 version of that document.  In both cases there was a transfer of care to hospital; mothers and babies are well.  

The legal expert's job in the hearing is to prove allegations that the midwife acted in an unprofessional manner when she attended these births privately at the homes of the women.  The case relies heavily on the categorisation of risk in the ACM Guidelines.

The midwife has retained the services of a barrister to defend her.  The costs have accumulated to in excess of $20,000.

The panel of three, appointed by AHPRA to hear the case, includes one person who is a nurse academic, who lists RM (registered midwife) in her cv that is available online.  This person has published in her field, but there is no mention of midwifery or maternity in the titles listed.  This person has listed memberships in professional organisations, and there is no mention of any midwifery or maternity related organisation.   The other two members of the panel are a lawyer, and a nurse whose specialty area is psychiatry.

I am recording this point because there is an expectation in hearings into professional conduct that the evidence will be heard by peers.  The panel in this case was totally lacking in peers, and the one member who listed RM should perhaps reconsider her use of the title RM.  Midwives continue to be judged by nurses, as nurses, despite the reforms that have restored the register of midwives.
 

The pursuit of information by the Board's barrister, who acted like a blood hound, included many questions about choice and risk and safety.  The complexities of informed decision-making over time, and within that woman's real world, were barely acknowledged.  The relationship between 'risk' and 'safety' was not explored.  If the 'guidelines' identify 'risk' ... it's *obviously* unsafe, and not suitable for a midwife to be providing primary care in the home.

The midwife expert witness called by the defense barrister brought some clarity and sense to the hearing, with her consistent and persistent assertion that safety can only be achieved when a mother's right to informed decision making is protected and upheld.


ps
Midwives and others who promote humane maternity care around the world have been alerted to the criminal case against Hungarian midwife-obstetrician Ágnes Geréb.  For an update on this case, click here.