John Elder March 22, 2009
JANET Fraser is in labour. Her plan is to drop the baby on the loungeroom floor, or wherever feels good at the time. Has she called the hospital to let them know what's happening? "When you go on a skiing trip, do you call the hospital to say, 'I'm coming down the mountain, can you set aside a spot for me in the emergency room?' I don't think so," says Fraser, whose breathing sounds strained.
This is pretty much where we end the conversation that started with me calling Fraser and asking if it was true that her organisation, Joyous Birth, was advocating that women go it alone giving birth at home, with no midwife ...
"Free-birthing, plenty of women do it," she says. In fact, Fraser is doing it right now. "I prefer to be an autonomous care-provider," she says.
By the time she tells me the birth of her third child is "impending", Fraser has already talked intensely about the likelihood that home births attended by midwives will be illegal from July next year, when the national registration scheme for health professionals kicks in ...
She has also talked about how the Joyous Birth group, of which she is national convener, wasn't encouraging women to free-birth as a means of flouting the law, but to run their pregnancies and birthing in the manner they desire.
"If that happens to be free-birth, then you go for it ... We don't advocate hospital-based birth or being beholden to all sorts of authority figures," she says.
Janet Fraser's son, 5, was planned as a home birth, but came into the world via an emergency caesarean after Fraser was transferred to hospital. Her daughter, 2, was born at home ...
Fraser is 40. She hasn't seen a doctor or any health professional since becoming pregnant this time. No ultrasound, no genetic testing, no internal examinations, no stethoscope. [Internal examinations do not form part of the routine care of pregnant women.] Does she have any feeling for how long the labour will go? "I could do this for days. My daughter's birth was 50-something hours. You just do it — it's just birth, a normal physiological process."
At the time of publication, Ms Fraser's labour was continuing to progress slowly.
[A very small proportion of Australian choose to birth at home].
The home-birth crowd has always been loud, but if they are more strident of late it's possibly because they are feeling left behind in an evolving birth scene, where hospital midwives are increasingly required to train for emergency situations, including home-birth complications.
St George [Hospital] is one of a number of hospitals in NSW trialling home-birth programs where two midwives are required to attend a birth, and the home births need to be sanctioned according to a set of low-risk protocols [that do not see the majority of women as low risk, and therefore the woman cannot access that services. Women are not "cleared" for home birth until 36 weeks when they have a compulsory swab to determine if they have group B strep, which may or may not be present when they do into labour, perhaps some 4 - 5 weeks later]. Independent midwives generally work alone, with a more lenient policy on risk. For example, independent midwives will home-birth twins, breech presentations and ... VBACs.
The status of midwives is the key to where birthing is headed. The Maternity Services Review has recommended an expanded role for them. One option on the table would see their services covered by a Medicare rebate for the first time. However, this would not be extended to independent midwives attending home births.
There is growing enthusiasm for the case that continuous care by a midwife through the prenatal, birth and post-natal stages tends to result in happier and healthier outcomes for a pregnant woman. And that if the midwife role was expanded ... then a significant portion of ... hospital resources could be freed up, and the nation's health bill somewhat reduced. [Not to mention the outcomes for women and babies would be greatly improved].
Within this context, home birth might sit more comfortably in the public mind as a viable option.
Justine Caines, secretary of Homebirth Australia, [says]: ... "It's only the home-birth mothers who have experienced one-to-one midwifery who advocate for change ... The vast majority aren't passionate about their experience basically because ... The system basically treats them as someone to shuffle through. The whole passion around home birth is about the experience of one-to-one midwifery care."
Caines sees midwives as the great hope of the overburdened health system. "We fund private obstetrics to hundreds of millions of dollars through Medicare … fees for services that don't relate to case load. Most of it is a waste of money," she says.
"(Federal Health Minister) Nicola Roxon could offer a $5000 birth package that would cover continuous care for each pregnancy … as opposed to women engaging in private obstetric care spending $20,000 believing they have the best care money can buy.
"I have a midwife come to my home every day for the first seven to 10 days. The most expensive is $4000 for the entire package … and no health fund covers it. People could get better, cheaper care."
Barbara Vernon, chief executive of the Australian College of Midwives, says this message gets lost in media sensationalism sparked by organisations such as Joyous Birth and a small number of midwives who don't make risk minimisation their primary focus, whereas most midwives working privately — and there are only 50 registered with the college, possibly 100 throughout the country — are "very risk-averse".
"Midwives have the skills and equipment for the safe care of a mother and baby in a home-birth situation, and they recognise quickly when something's going wrong.
"What fails to compete with the sensationalism is … the evidence showing that a trust relationship between a woman and a midwife, established from early in the pregnancy, means that the woman in labour is feeling safe and less anxious. It's a better experience."
Vernon says the flow-on effects of continuous midwife care include shorter labours, a reduced need for drugs and pain relief, reduced admissions to neonatal intensive care, reduced vulnerability to post-natal depression and improved rates of breastfeeding to 12 months of age.
"Even if she has a caesarean, the woman is not traumatised by the process ... "It's the women who get run over by the system that feel most vulnerable after that experience. They can't understand why all of that happened."
... is a hospital-governed home-birth system the answer to mainstreaming home birth? Free-birther Janet Fraser says: "It would be a disaster if hospitals ran home birth. Hospitals are dangerous."
Justine Caine says: "Not until obstetric care is kept in check. The problem with most of (the trial schemes) is that women and midwives are not able to make decisions. Hospital midwives are handmaidens of the doctors. Obstetricians call the shots and much of the exclusion criteria is not based on evidence."
Veteran private midwife Robyn Thompson, who has spent 30 years assisting home births, says: "It wouldn't be a disaster. I'm welcoming whatever it takes that makes it good for women."
Thompson says the average transfer rate over those 30 years had been about 17 per cent ... "You anticipate what's happening..." ..... Barbara Vernon says: "RANZCOG has a position statement where home births are not endorsed. But some women are going to always birth at home." [And therefore the approach needs to be one of harm-minimisation, not making home brith illegal by denying midwives access to professional indemnity insurance, and therefore registration].
- I guess the real question is - who owns birth? Midwives? Obstetricians? Maybe it's time for women to claim birth. ...... Home-birth advocates insist that doctors only have a role to play when a birth becomes problematic. They say doctor intervention has led to skyrocketing induction, epidural and caesarean rates, issues that were at the heart of the Maternity Services Review. [And this is true. Midwives do not intervene in these ways. We cannot perform caesareans, we do not authorise inductions and we cannot insert epidurals. These are in the medical domain.]
In April 2007, Melbourne lawyer Ann Catchlove was told by her obstetrician that she needed a caesarean with her first child because her pelvis was not big enough. "He said, 'You can keep going if you want but we'll still be here at 3am'," she says ... The doctor told Catchlove that her future babies would have to be delivered by caesarean. Research on the internet convinced her otherwise. "I found the original caesarean probably wasn't necessary."
She also found research that indicated vaginal birth after caesarean was a reasonable option. She started thinking about a birth centre "but none of them would accept me".
Last November she gave birth to a son at home. "... once I'd made the decision, and met the midwives, I never had any doubts. There's an idea of hippies burning incense in the background, which is wrong. They were very focused on safety … the birth itself was very smooth and relaxed, other than the pain. I felt very safe and in control."
Obstetrician Pieter Mourik warns ominously that graveyards are full of "failed home births". He has called Janet Fraser's Joyous Birth group "a bunch of nutters" and Fraser herself "a fool". When told Fraser was free-birthing at home, Mourik was quieter than usual, less on the soapbox.
Fraser had said she didn't expect anything to happen for another couple of days; that nothing bad happened quickly in a labour and that there would be time to get to hospital if things went wrong.
Mourik paused. "She told me (during a debate) she'd had a caesarean. That's how a uterus is most likely to rupture. If that happens, there won't be time … Well, I wish her well."