Much has been published recently about the very unfortunate death of a mother following a homebirth with private midwives. No details have been released that could allow us to form an opinion that this woman’s death was “because” she birthed at home, and it is also possible that an appropriate and timely transfer was arranged and that she died of complications that arose in hospital. I am not privy to any more details than what can be found in the local press. Even though at this stage, no-one really knows how or why Caroline died, many people have taken the opportunity to make assumptions as to the exact cause of death, and more so, they are certain that her death would have been preventable and hence avoidable had she birthed in hospital. I am astounded that anyone could make such assumptions – and that the media would publish such opinions – when they are not grounded in fact.
So, what do we know?
Maternal mortality includes deaths in women up to a year after giving birth or within 42 days of termination of pregnancy. The maternal mortality rate in Australia varies between about 8.4 and 11.1 per 100,000.
Direct maternal deaths are those that result from obstetric complications of pregnancy. This includes such things as amniotic fluid embolism, haemorrhage, infection and hypertensive disorders of pregnancy.
As well as direct maternal deaths, there are also indirect maternal deaths, and these are deaths that result from pre-existing disease which maybe aggravated by pregnancy or birth. This can include such things as heart disease, psychiatric causes, epilepsy and so on.
It has been suggested that since 1999, there has only been one other woman who has died following a homebirth attended by a midwife. The AIHW report for 1997-99 also describes another maternal death following a homebirth, however that was an unattended homebirth (ie, the woman had given birth at home without a midwife present). Both women died of postpartum haemorrhages.
The question we need to ask, is whether these reports of maternal death following homebirth reach statistical significance. In statistics, a result is statistically significant if it is unlikely to have occurred by chance. It is possible that the two maternal deaths following midwife-attended home births are the only deaths we will have for the next 50-odd years; or it could be that in the next few years, we will have far more maternal deaths following midwife-attended homebirths. Certainly, other countries do not report an increased maternal mortality rate for women birthing at home with a midwife.
All of this said, it is incumbent on every midwife who attends homebirths to advise women of the increased risk of death and serious injury should a major complication occur at home. This is related to the lack of resources, staff and facilities at home and the time and distance needed to transfer to hospital in an urgent situation. This, however, is also the case in a smaller public or private hospital, where if something should go horribly wrong, those facilities would also not have the immediate capability to provide the best possible assistance.
In the event of major complications, a team effort is really needed: midwives, obstetricians, anaesthetist, operating theatre, intensive care unit, medications, IV lines, equipment for monitoring the heart and respiration and blood pressure, ultrasound imaging and so on. However, it also needs to be said that this would only be in very rare and exceptional circumstances that can mostly be known in advance. We also know that serious complications that can result in death are more likely when women have had interventions in labour and birth.
This is why women are encouraged to birth in hospital if their medical history suggests that they are at a higher risk of life-threatening complications in birth (eg epilepsy, clotting disorders, high blood pressure, and so on), and it also why midwives are reluctant to attend any form of intervention in the home setting. At the slightest hint of a complication, a responsible midwife will advise her client to transfer to hospital in the interests of safety.
All of this said (and done), low risk does not mean no risk. A perfectly healthy, low-risk woman experiencing a normal pregnancy and a normal labour can still experience a massive postpartum hemorrhage that cannot be effectively managed by the equipment available at a home birth. It also could not be managed at a small private or public hospital where theatre staff, anaesthetists, monitoring equipment etc might not be readily available. It is important for women to understand that while this is highly unlikely to ever happen, should it happen, it does increase the risk of death or serious injury (eg brain damage). It is a difficult task counselling women in very rare but very serious possibilities, and birthing women need to feel free to make the best decisions for them and their families, in the full knowledge of all possibilities. Midwives should not withhold this information from women as it is materially significant to their decisions about place of birth.
Certainly, the media takes the view that all homebirth deaths could be prevented by having those women birth in hospital. This may be true. Or maybe not. Private midwives examine the deaths of women in hospitals, and often comment that those deaths might have been preventable had those women birthed at home or with a private midwife in hospital. Cases of women dying following unnecessary caesareans. Women suiciding in the early postnatal period with no support in caring for their baby and ineffective antenatal planning for the possibility of postnatal depression. Women dying of postpartum haemorrhage following induced labour (induction is a risk for PPH) for hypertension: it might surprise you to know that rates of high blood pressure are very low amongst women cared for by private midwives. A PPH in a woman who had had a caesarean for her third baby – a breech baby: this woman could very easily have proceeded with a vaginal birth, especially given that it was her third baby. Avoidance of the caesarean might have meant no PPH and saved her life. These are the sorts of cases where hospital doesn’t “save” women from death: it might be seen, in some cases to actually cause the death, however the media will never report on this.
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