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.

for the record ...

A couple of dodgy situations have arisen in the Melbourne private midwifery world this past week, and I am noting them here, for the record.  People will not be named, but be assured, these stories are not fictional.

Story #1 - Woman W1 and doctor GP:

W1: (39 weeks pregnant, planning homebirth) "My midwife told me to ask you for the paperwork I will need to register the baby's birth, and get the baby bonus."
GP: "I have never been asked for that paperwork.  In fact I don't know where to get it."

For readers who are unfamiliar with the process, this paperwork is issued after birth by the midwife who attends a birth at home, or by the hospital where the baby was born. 

The GP phoned a well known and respected midwife to inquire as to how to obtain the paperwork.  That midwife immediately questioned the request.  If W1 is in the care of a midwife, that midwife should issue the paperwork, and sign the declaration to enable registration with Centrelink, baby bonus or paid parental leave, adding the baby's name to Medicare card, and other standard processes including obtaining a birth certificate.  Simple as that!

In this case W1 is probably planning homebirth without a registered midwife in attendance.  Call it freebirth or pure birth or attended by a birth worker or whatever you like.   A GP would be unwise to issue the birth paperwork, unless she or he was also prepared to attend the birth and sign the professional declaration.

Story #2 - Lay birth attendant LBA phone call to midwife M2:

LBA: "I am looking for a midwife who will visit the woman W2 in her home once labour has started, and do an assessment so that we can be sure she is at least 4 centimeters dilated."
M2: "Why do you want this?"
LBA: "Because W2 had a caesarean birth last time and she does not want to go to hospital until she is in established labour ..."
M2: "Let me get this straight.  You are asking me to visit when you call me, check mother and baby, give you that information, then go away?"
LBA: "Yes."

A midwife is immediately wary of this request for a number of reasons.  Here are a few:

• the professional relationship is between a midwife and a woman; not the woman's friend, or partner, or employee.

• information obtained in an assessment (maternal observations: frequency, strength and duration of contractions; fetal observations including lie, presentation, position, heart rate; and dilatation of the cervix) will not necessarily give the information that W2 or LBA are after.  The skill of midwifery includes interpretation of clinical observations over time.  

• the midwife cannot delegate professional responsibility for midwifery care to an unqualified, unregulated person.

 A midwife would be unwise to attend a woman in labour unless she or he was also prepared to attend the birth and take professional responsibility for decisions made.  An exception would be if another midwife who was unable to attend a client who said she was in early labour, asked the midwife to provide a 'locum' service and report back.

 One of the realities of physiological birth is that the labour must begin spontaneously - in the woman's own time.  Most women make the decision themselves as to when to ask their midwife to attend, or when to go to hospital.  Sometimes they get it wrong - too early, too late!  Sometimes just right. 

This dilemma will not be resolved by having a private midwife provide a one-off consultation.  If people want that sort of information, they could 'do it yourself' DIY.  They could get hold of a fetal monitor and listen to the baby's heartbeat as much as they want to.  They could get hold of a little internal camera that takes pictures of the cervix.  The technology exists.  Also blood pressure monitors, a thermometer, ...  

'DIY' will never replace the midwife, who is 'with woman' in a partnership that requires trust and reciprocity throughout the episode of professional care.  

AMA position statement on Maternal decision-making

Maternal Decision-Making - 2013

Source: Australian Medical Association (AMA) 28/03/2013

1. A pregnant woman has the same rights to privacy, to bodily integrity, and to make her own informed, autonomous health care decisions as any competent individual, consistent with the legal framework of that jurisdiction.
   
2. A pregnant woman’s capacity to make an informed decision should not be confused with whether or not the doctor (medical practitioner) considers her decision to be reasonable, sensible or advisable. A doctor may not treat a competent pregnant woman who has refused consent to treatment. Recourse to the law to impose medical advice or treatment on a competent pregnant woman is inappropriate.
3. Most pregnant women strive to achieve the best possible health outcomes for both themselves and their unborn babies. ...

[Please click here to read the 10 points of the position statement.]

Position Statements often seem dry and meticulous, but they actually carry considerable weight.  It may seem strange that the AMA feels the need to declare that a competent woman has the right to make her own decisions - isn't that generally understood?

An article by Health Reporter, Melissa Davey, in today's Sydney Morning Herald newspaper noted the new Position Statement, and observed that "Previously, more emphasis was placed on on how maternal behaviours may damage a foetus, rather than the autonomy of a woman's decision."

[Read more: http://www.smh.com.au/national/health/trauma-pushes-mothers-to-home-birth-20130420-2i6wu.html#ixzz2R4VWeejx

In other words, in the past doctors were expected to take action that 'prevented' mothers from making foolish decisions, that may have led to adverse outcomes for their babies.  It's called 'shroud waving', and it usually works.


More discussion at villagemidwife.

MATERNITY SERVICES FOR TEMPORARY WORKERS IN AUSTRALIA

Public hospitals in Melbourne, and in other parts of this country, have closed their doors to women who do not have Medicare.  Women who present needing care at a public hospital are being told they must pay an $11,000 deposit, or leave without being attended to.  They are told to go to a private obstetrician, and make a booking at a private hospital, with an estimated $15,000+ cost to the woman.

The more affordable alternative is private midwifery services for planned homebirth, costing around $5,000.  However, an estimated 20% of women who are planning homebirth need to be transferred to hospital when their care needs exceed the capacity of midwives in the home.  These women arrive, with their midwife, at a public hospital, because they have no other option.  The midwife's duty of care to the woman and her baby is to refer to an appropriate service; regardless of the cost. 

Women who are in Australia on temporary work visas, such as 457, must have private health insurance.  However, it seems that the available insurance policies are woefully inadequate when maternity services are needed.  Women who have spoken to independent midwives, seeking to arrange their intrapartum and immediate postnatal care, have said that they simply can't afford the hospital fees.

This situation is unacceptable!

The time of childbirth, more than any other time of life, requires skill from the care providers, leading to security for the mother.  Although 'birth is not an illness' (WHO Fortelesa Declaration 1985), illness can quickly arise in pregnancy and birth, threatening the lives of the mother and her child.   

The data that midwives send to the Victorian Government Perinatal Data Collection Unit, and similar units in other States and Territories, and sent on to the Australian Institute for Health and Welfare, Mothers and Babies reports, does not give a field to identify the woman who are ineligible to use the national free public hospital services.  The outcomes will never be reported - they are likely to remain under the radar.


Is there a solution?

I would suggest at the very least that public hospitals need a process by which overseas workers, many of whom are from the poorest countries of the world, are able to access affordable maternity and neonatal care.  Yes, midwives can provide basic primary care in the community, at an affordable rate.  But, when a woman needs specialist obstetric referral, surely a 'no frills' option can be provided by the public hospitals, at considerably less cost than what is on offer from Melbourne's plush private hospitals.

Your comments are appreciated.

Midwifery under the spotlight at obstetric malpractice conference

The 5th annual obstetric malpractice conference will be held in Melbourne, June 20 and 21 this year.

Key issues to be covered:

• Developments of the National Disability Insurance and Injury Scheme and National Injury Insurance Scheme and implications for obstetric practice
• The Coroner's perspective on inquests involving perinatal death
• Lessons learned from the midwifery indemnity model in New Zealand
• Practical and legal implications of the Open Disclosure Standard
• Practical legal measures for when a baby is born with Hypoxic Ischemic Encephalopathy or other unexpected birth outcome
• Managing the Risks inherent in women's choice in obstetric care
• Perinatal Review Process
• Medico-legal risks of female genital mutilation and female elective surgery
• Race-based pregnancy care. Is that good medicine?
• Implications of new genetic technologies on prenatal diagnosis
• Wrongful birth damages - the first detailed damages judgment
• FACILITATED PANEL DISCUSSION: Awful Lessons I have learned by being an expert witness
• PANEL DISCUSSION: Medico-legal risks and ethics of female genital mutilation

This list of topics includes several of considerable significance to midwives who practise privately.  However, there is one major hurdle for anyone who may be considering making a booking: the cost!  Even with earlybird discount, $1,700, added to the potential loss of income if a baby in the midwife's caseload needs to be born, and accommodation costs, is a LOT of money in midwifery-land.

The opening address on Day 2 is 'Lessons to be learned from the Home Birth Cases in Vic and SA' - speaker is the coroner Judge Ian Gray. It would seem to me that we need to have midwives who are practising privately in Victoria and South Australia to hear what is said and to respond if appropriate. 

Midwives who face disciplinary hearings or coronial investigations find ourselves, our actions, and our 'outcomes' thrust into the spotlight, within a legal and professional framework that may seem quite foreign to contemporary midwifery philosophies.  Midwifery notions of informed decision making and partnership and choice can be discarded as meaningless by legal experts who rely on guidelines rather than professional clinical decision making. Click here and here for recent examples.

I do not wish to suggest that midwives always get it right - there will always be a need for unbiased outside review of serious morbidity and mortality, or unprofessional conduct in professional health care.
  

Issues around a woman's right to decline treatments (usually medical) that are considered 'evidence based', or 'best practice' will be reviewed from obstetric, legal, and consumer perspectives.   The management of breech births is a good example, and two consumer presenters, Rhonda Tombros and Ann Catchlove, who are also lawyers, will discuss:

Breech birth: consumers, choice and consent

• Women with breech presenting babies near term often find themselves with limited birth options. Some change care-providers, hospitals or even travel interstate to access the opportunity to attempt a vaginal breech birth
• This presentation will explore issues around consumer choice and consent in breech birth with a focus on the legal and ethical issues that arise when women are given no option for birth other than planned caesarean section
• How can care-providers and hospitals facilitate care that is both safe and respects women's decision-making autonomy?

Both women come with a proven track record, in challenging obstetric dominance of women giving birth.  See Breech Birth Australia and New Zealand, and the breech fb group, and Maternity Coalition.

Midwives discussing this conference via the Eligible Midwives facebook group have called for recordings of the proceedings to be made available after the conference.  I will keep readers informed.


Post script:
Midwives may apply for financial assistance via Government Scholarships (administered through ACN http://www.acn.edu.au/sites/default/files/nahsss_continuing_professional_development.pdf).

Ireland: No Country for Pregnant Women

Press Release - AIMS Ireland

No Country for Pregnant Women

This past weekend, as the nation celebrated International Women’s Day and Mother’s Day, an Irish Maternity Hospital initiated an invasive procedure on a pregnant woman against her will. ‘Mother A’ was denied patient autonomy and the right to informed refusal when the drastic and unprecedented measure of an emergency High Court sitting was called in order to compel her to undergo a Caesarian section. The risk of uterine rupture was cited as one of the main reasons for the urgency in this case but this risk is widely reported as being 0.1% or 1/1000. This is what Dr. Michael Turner, Obstetrician at the Coombe Hospital has called: “exaggerated, professional scaremongering...and it must stop”. (VBAC Conference, 2012)

State-sanctioned coercion of medical procedures on pregnant women or any other competent adult is not only unacceptable but it is also unlawful in other jurisdictions, such as the USA and the UK (Re AC [1990] & Re S [1998]). ‘Informed consent’ and ‘informed refusal’ abuses are common issues reported to AIMS Ireland by women.

Jene Kelly of AIMS Ireland states: “there is an overwhelming acceptance by the public and some maternity service providers in Ireland that a pregnant woman’s right to informed consent, or informed refusal, is not reliable and that women who exert their rights are selfish. It is this mentality that has allowed atrocities such as symphysiotomies, miscarriage misdiagnoses, unnecessary hysterectomies by Dr Neary and all the other reported assaults against women by our maternity system to continue to go unanswered in Ireland for so long. This is no country for pregnant women. ”

AIMS Ireland reports that women who are bullied into consenting do not fulfill the principles of informed consent and therefore are entitled to sue the doctors for assault. For example, a woman who was forced to have a caesarean section against her wishes in the UK sued the doctors (Ms S v St George's NHS Hospital Trust, 1998) and was awarded £36,000 damages. It is time that Irish women did the same. Threatening women, bringing women to the high court, removing women’s rights and choices - these bullyboy tactics do not promote trust between women and their care providers. How can you trust a system that doesn’t acknowledge your rights? Women are choosing to leave the system as a result.

Annette is one of these women. She is lobbying the HSE for a homebirth following a previous Caesarean section. The HSE currently does not recognize informed choice for homebirth for women who fall outside strict exclusion criteria in site of a European Court of Human Rights ruling recognizing a woman’s right to decide how and where she births. Annette does not meet criteria following her previous Caesarean, despite having subsequent successful vaginal births. Annette asks: “Is it HSE policy to use the High Court as a method of intimidation and coercion, when a patient tries to exercise her right to informed decision making, as laid out by the European Court of Human Rights (Ternovsky v Hungary, Under Article 8)? We are humans, with great intellect. We are capable of informed discussion and decisions regarding our pregnancies and births in the best interests of ourselves, our babies and our families. I feel anger, disappointment and bewilderment. Today as a woman and mother, I grieve.”

###

AIMS Ireland Press Contacts:

Jene Kelly 087 681 9095

Krysia Lynch 087 754 3751

Barbara Western 086 385 3344

AIMS Ireland is a consumer-led voluntary organisation that was formed in early 2007 by women following their own experiences in the Irish maternity system. Our mission is to highlight normal birth practices, which are supported by evidence-based research and international best practices, and campaign for recognition of maternal autonomy and issues surrounding informed choice and informed refusal for women in all aspects of the maternity services; from Caesarean section to homebirth. AIMSI campaigns on the grounds that birth choice is a basic human right as declared at the International Conference of Human Rights and Childbirth, “It is a fundamental human right for women to choose the circumstances in which they give birth, with whom and where, including a choice between hospital and home birth” and Article 8, European Court of Human Rights

Medicare review

The federal government health department has engaged consultants to review the incorporation of Medicare into midwifery practices.  Yesterday the MAMA practice was visited, and focus groups and interviews carried out with midwives and mothers.

I don't know if or when the public (you and I) will see any such reports, but this sort of review is expected a couple of years after major policy and funding changes by our government.

A midwife/maternal and child health nurse asked the reviewers to note that the maternity reform initiative, subsequent to the Maternity Services Review, is notable in its lack of public education or advertising.  The government's response to the Review was a  "$120.5 million Budget package Providing More Choice in Maternity Care – Access to Medicare and PBS for Midwives. This Budget package provides Australian women with more choice in maternity care whilst maintaining our strong record of safe, high quality maternity services."



More "choice in maternity care" is not accessible if women don't know about it.  Medicare rebate for midwife-attended births means nothing if midwives can't have visiting access to hospitals.  Yet the rationale for the reforms is more safety and better outcomes for mothers and babies: achieved through continuity of midwifery care.


Any other government health initiative, such as immunisation, or safe sleeping, or smoking cessation or ... is presented to the target audience public with the aid of professionally prepared TV and radio advertising, brochures, posters, and the like.

Midwife primary care with Medicare rebates is the best kept secret in the country. 

Why aren't there posters about continuity of care from a known midwife in places where women of childbearing age will see them? Why haven't we seen letters sent to doctors explaining how they can collaborate with midwives? Why are hospitals working harder than ever to actively prevent midwives from achieving visiting access? 

Your comments are, of course, welcome.