But this time, Ms. Harrell … is afraid that if she insists on having her baby at home, she will make her midwife … an outlaw.

Seven of New York’s 13 home-birth midwives … had an agreement with St. Vincent’s Hospital Manhattan that its doctors would back them up in an emergency. But the bankrupt hospital closed on Friday, and those midwives have been unable to negotiate new practice agreements with other hospitals or obstetricians, as required by state law, leaving them in the position of risking their licenses if they choose to deliver babies.

The loss of that 25-year relationship with a sympathetic hospital has left some home-birth midwives not only fighting for the legal viability of their practice but having to justify their very existence. Officials at several hospitals said … they were skeptical of the safety of home births and were concerned about the malpractice implications of taking over their clients in emergencies.

… “This is who we have to get a signature from — people who don’t believe in what we do and that we compete with,” …

The 13 midwives attend about 600 births a year, and about 50 of their clients expect to deliver in the next month.

To them and their clients, having the option of a home birth is an affirmation of their reproductive rights. It is also a reaction against the highly medicalized climate of hospital births, which, they say, has contributed to a Caesarean-section rate of more than 1 in 3 births … with some hospitals having rates above 40 percent …

To the medical establishment, home birth represents a rash choice by women who refuse to believe that things can go dreadfully wrong in an instant …

A large study of planned home births in the United States and Canada … found substantially lower rates of medical intervention compared with low-risk hospital births (high-risk pregnancies rarely, if ever, culminate with a home birth) and a similar rate of infant mortality. No mothers died. About 12 percent were transferred to the hospital. The midwives considered the transfer urgent in 3.4 percent of all intended home births.

… written practice agreements with hospitals or doctors have been a condition for all midwives to practice in New York State since 1992. But obstetricians have become increasingly wary of signing with home-birth midwives since the Congress of Obstetricians put out its strongly negative statement in 2008 …

… Fifteen other states … allow midwives to practice without them …

… midwives … expected that at least some of their clients would insist on delivering at home even without signed hospital backup. (They can still go to an emergency room and be treated.)

Ms. Harrell, 33, said she trusted her midwife … who delivered her first child … she said she was leery of trying to build a relationship with a doctor so late in her pregnancy. But she worried about putting Ms. Leonard in an untenable position.

She was delivered at home after her mother, Leah, rejected advice to have a caesarean section … because her first baby … had been born that way …

A surgical birth – about 30,000 are performed in NSW each year – would have cost the public hospital system about $8000.

If she had been admitted to a neonatal special care unit, like 70 per cent of babies born by caesarean, including her big brother, it would have cost another $900 a day.

But her entry to the world, in a Dee Why lounge room, cost taxpayers nothing …

[Midwives] are calling for another urgent meeting with the Health Minister, Nicola Roxon, before the new rules come into effect in July.

ASK any expectant mother what she’s hoping for when she gives birth, and she’ll probably tell you the most important thing is to deliver a healthy, happy baby. But in recent years there’s been great debate about the best way to do this.

Is the ideal to have a child in the relaxed comfort of your own home, or does the medical expertise provided in hospital far outweigh the notion of giving birth in your own living room?

Although homebirth advocates argue the former, it appears the choice may soon be taken out of their hands.

Reports last year revealed that four babies in Sydney died in homebirths in the space of nine months, the NSW Government responded with a strong announcement: from July 2010, independent midwives will be unlikely to gain professional indemnity insurance – effectively making it illegal for them to assist at homebirths. The consequence? Homebirths are facing extinction.

Obstetrician Dr Pieter Mourik believes the ruling will stop women taking unnecessary risks.

“Women who choose to give birth at home expect everything to be normal, but they often don’t consider how far they are from expert help …” he says.

“Eighty per cent of women can have their babies in a paddock – but the problem is choosing these women. You just never know what will happen.”

However, Justine Caines, spokesperson for Homebirth Australia, says putting a blanket ban on homebirths will simply drive the practice underground.

… “Many mothers have had bad experiences in hospital and won’t repeat that.”

“Only a tiny minority of foolish women would risk their own lives and that of their precious babies for an ideal,” he says.

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.

The parenting social networking site BellyBelly.com.au found 94 per cent of the 400 respondents opposed the amended legislation …

… 30 per cent of respondents said they would consider freebirthing – giving birth without medical assistance – if not allowed to choose their own midwife.

Under the Federal Government’s draft health practitioner regulation law, independent midwives could be deregistered unless they have private indemnity insurance.

So far, the government has failed to include homebirths in the indemnity scheme while insurance companies refuse to insure private midwives.

Proposed changes … would also see midwives forced to work alongside obstetricians.

…”there is so much information available that people feel like they can read on the Internet or in a book how to catch their own baby … some people may also have philosophical reasons …

Federal Health Minister Nicola Roxon … has introduced a Bill that means doctors would have the power to veto a midwife’s involvement in births.

Self-employed midwives say this would stop them being able to help with home births.

Almost one in three respondents to an online survey … said they would find an alternative way to birth at home, even if that meant “freebirthing” – without a … midwife.

In New Zealand, Canada, the UK and the Netherlands, giving birth at home is a reasonable choice, supported by both governments and insurers.

In Australia, however, the choice is threatened by proposals from Health Minister Nicola Roxon to leave midwives without insurance or funding to assist home births.

The curbing of that choice started last year when Ms Roxon initiated the Maternity Services Review and announced Medicare funding for midwives in the 2009 budget. In conjunction, she proposed the National Registration and Accreditation Scheme (NRAS) legislation, which would require health professionals to hold indemnity insurance so as to safeguard consumer safety.

… the great omission in her proposal was homebirth midwives, who were not offered funding or indemnity insurance … In effect, this would condemn homebirth midwives to operate illegally if they wanted to continue delivering babies.

… Gary Hastie, who has delivered all four of his children at home while supporting other home birthers, believes homebirthing “is the most natural process for the woman”.

However, he has observed an increasing fear of home births, distrust of a woman’s ability to have a natural birth and a demonisation of … woman’s choice. “It’s a woman’ right to choose where and how and with who she gives birth,” he said.

Nicola Roxon says she supports women having a choice, but is concerned with the consumer and ensuring a system of registration. It is “about lifting standards and ensuring that people are both registered, accredited and insured,” she said.

… Dr Ted Weaver, says it is not only the size of Australia that is a problem, but also cultural differences. “The infrastructure in other countries is completely different from the infrastructure in Australia–these countries have a tradition of home birth.”

Dr Weaver said the biggest danger lies when women get transferred to a hospital after complications arise …

Doubts are expressed too about how qualified Australian midwives are. Dr Weaver says: “Their [overseas] midwives are better trained and act along more stringent guidelines, and the selection for home birth is much more rigorous than in Australia.”

… While most high-risk women will be referred to a hospital by a midwife, … a very small portion of these women who consciously choose home birth … if they are considered “high risk”. “High risk” includes women who are having twins …

There was no rushing to the hospital, no midwife … Just Jennifer and her husband, home alone, giving birth.

“I think a lot of people think a woman who would want to have an unassisted birth would be a little bit crazy,” said Margulis, who holds a Ph.D. in literature, and is a contributing editor for Mothering Magazine. “I think I may have had that reaction as well. I am definitely not a crazy person. I am a very educated, thoughtful and caring person. I am not a person who takes a lot of unnecessary risks. The whole point is it is not risky if you do your homework.”

Nationwide, 90 percent of births still take place in hospitals with doctors attending … 8 to 10 percent are with midwives in hospitals or birthing centers. And 1 to 2 percent are at home.

… Internet traffic and books on the subject indicate more women are choosing to take control with what is becoming known as freebirth because they are concerned about the United States’ dismal record of maternity care and skyrocketing rate of Cesarean births, now at nearly 32 percent of all births …

… “… they are trying to find a way to work around a system they see as very problematic.”

Though the United States spends more money on childbirth than any other nation, it has one of the world’s worst records for infant mortality and maternal mortality …

… Margulis, a freelance writer, decided to have her fourth child at home without the help of a doctor or midwife. There are signs more women are choosing to do this … because they want a more private and intimate birth.

… an obstetrician and gynecologist at Massachusetts General Hospital in Boston and assistant professor at Harvard medical School, said most women can give birth alone without any problem, but there are still small numbers — as high as 10 percent — who will run into complications, often without warning.

“What worries me is that very often women who have absolutely no risk factors develop an emergency complication,” she said. “I can’t imagine how you can possibly recognize that yourself, particularly if you have no medical training. Sometimes you have only minutes to intervene.”

Tracy said the increase in C-sections appears driven by the high rate of obesity in America, more births of twins and triplets, more women asking for them, as well as the fear of lawsuits …

“None of these make it, I think, a wise choice to have a delivery in a setting where no one has any training,” she said.

… [Margulis] had a bad experience with her first birth in a hospital, and her second birth, which was with a midwife at home. A midwife also assisted with the third, but this midwife had half of her own 10 children unassisted, and was an inspiration for the idea. Margulis began interviewing midwives for her fourth birth, but as she learned more about doing it herself, she became convinced she could.

“I felt like when I read other peoples’ stories, I felt like those were the most amazing women in the world and they were all so much stronger than I am,” she said. “… if we let our bodies do what they evolved to do, what they know how to do, then any woman can have a safe unassisted home birth.”

Jennifer Block, author of the book, “Pushed,” said while it is impossible to track the numbers of women doing unassisted childbirth, they are highly educated, committed, motivated, and frustrated with mainstream medicine.

“… Women should be able to be in control and still have trained support with them. Emergencies do happen. I can’t imagine trying to resuscitate my own infant, or if I had a hemorrhage.”