January 21st, 2010:

They write:

…One of the problems is that the planned home birth group includes women who planned homebirth when booking in for care 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). This latter woman persisted in having a homebirth due to ‘unsatisfactory hospital experiences.’ 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 started labour at home the risk was very low – 1 death in 16 years

There is no way to tell if these planned homebirths were under the care of a registered midwife.

This was not a low risk population of women – there was a high rate of post-term pregnancy … twins … and … previous caesarean section.

… There were two perinatal deaths that actually occurred at home. One baby had lethal congenital abnormalities (this was known before labour and a decision made for the baby to be born at home). The second death at home was after a waterbirth which was not found to be the cause of death but a review identified that increased monitoring may have identified the baby was in distress.

One perinatal death occurred in hospital after a transfer after the birth of the first twin. The first twin was born at home and second twin was born in hospital after a delay in transfer and subsequently died.

There were 6 perinatal deaths in the planned homebirth group where the baby was born in hospital. Presumably these women were transferred to hospital during the antenatal period as antenatal risk factors developed. Transferring to hospital if or when risk factors develop during pregnancy is appropriate practice.

Of the six deaths in hospital: one had hydrops fetalis … one death was unexplained with a cord entanglement seen after birth; one had pulmonary hypoplasia … after a early rupture of membranes; one was a growth restricted baby with an abnormal karotype … one was born to a woman who was very overdue … and underwent induction in hospital without fetal monitoring (the woman refused) and her labour eventuated in a stillbirth; and, one was a woman with known haematological … risk factors whose baby had a lethal abnormality … all these were born in hospital.

Only three of the deaths are thought to be related to perinatal asphyxia.

Three of the deaths were thought to be potentially preventable and related to the model of care. These were the baby born after the waterbirth at home; the second twin who was born after an intrapartum transfer and the baby born after being very postdates. Therefore, there were 3 deaths in 16 years – two of which had risk factors present. That means that there was only one death where there were no risk factors in the 16 year period.

… You would need more than 10,000 births at home to show clinical relevance and have some confidence in the statistical significance in relation to perinatal mortality rates. The authors acknowledge this in the paper and present their data with caution in the paper stating that the ‘small numbers with large confidence intervals limit the interpretation of these data.’

The facts are there was no difference in perinatal mortality … For those actually born at home the perinatal mortality rate is 2.5 per 1000 births, which is comparatively low.

… The paper 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. This is an indictment on the current maternity system in Australia – that needs fixing – removing homebirth won’t do this.

What was missed?

The conclusion of the paper is very sensible recommending risk assessment, transfer and fetal monitoring.

So then why did the data get so grossly misinterpreted?

The reality is despite a malfunctioning system in this country where midwives are uninsured and have no visiting rights, and homebirth is unfunded and often hard to access, the perinatal mortality rate was no different.

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.