Home delivery too hot to touch

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Supporters of homebirth are asking why the topic is still seen as too hard to handle in this country, writes Thea O'Connor | March 28, 2009 Article from: The Australian

WHEN Natalie Hemingway gave birth to her son 10 months ago, doing so at home seemed an obvious choice. She had already given birth to her daughter at home three years earlier, and both of her sisters had been born at home.

"That's what I saw when I was growing up, so birthing at home was normal to me," says Hemingway, 27, who lives on Sydney's lower north shore.

Homebirth in developed countries was the norm up until the past 50 years or so. In Australia today, homebirth can seem a radical choice, and the women who chose it anything from brave and alternative to misguided and loopy.

The recent federal government review of maternity services has done little to help bring the practice into the mainstream. It has inflamed an already heated debate over homebirths by stating it does not support Medicare funding of independent midwives attending homebirths ...

Part of the problem is that both advocates and opponents of homebirths have research evidence to support their arguments.

According to Hannah Dahlen, associate professor of midwifery at the University of Western Sydney and spokeswoman for the Australian College of Midwives, the best available evidence comes from a large prospective study of 5000 women planning a homebirth in the US in 2000.

The results, published in the BMJ in 2005, showed that the rate of babies dying during labour or within 28 days of birth ... was 1.7 deaths for every 1000 uncomplicated intended homebirths. The study (2005;330:1416-1419) said this was similar to risks in other studies of uncomplicated home and hospital births in North America.

Dahlen says it is also similar to the risk of first-time mothers having an uncomplicated birth in an Australian birth centre ... or Australian hospital ... (2007;34:3:194-201).

When the high-risk births ... were included in the analysis of the US study, the rate was two deaths for every 1000 births.

- When women have home births with a midwife, and they are low-risk (term, singleton baby, head down, no blood pressure problems etc), home birth has been shown in many studies to be safe. Not only that, women who have home births experience a greater level of satisfaction with their experience, and mush lower rates of intervention compared with hospital birth.

The highly regarded Cochrane database ... concludes that "there is no strong evidence to favour either home or hospital birth for selected, low-risk pregnant women".

Andrew Pesce, president of the National Association of Specialist Obstetricians and Gynaecologists, believes we have enough evidence to worry. He points to Australian data that indicates babies have a two to three-fold increased risk of death with homebirths.

A study of 7000 planned homebirths in Australia between 1985 and 1990, published in the BMJ (1998;317:384-388) reported that deaths occurring during labour and not due to malformations or immaturity were higher than the national average. ...

Dahlen counters that this study provides low-level evidence: the study design was retrospective, it included births by non-registered midwives, it used a number of methods to collect the data, including searching newsletters for death notices ...

- While there is strong support for midwife (registered, qualified) assisted home birth for low risk women, there is very little evidence that birth at home without a qualified and registered midwife, for women who have risk factors, will yield a good outcome.

Pesce also refers to the 12th report of the Perinatal and Infant Mortality Committee of Western Australia. It documents a 2000-04 death rate for babies that is three times higher for homebirths. The report said the numbers were too small to be conclusive.

... In December 2007 the West Australian Department of Health stated "a preliminary review of medical records indicates that it is likely the setting of the birth did not affect the outcome in at least five of the six deaths".

- We need clarity on this matter. Babies die in hospitals and they die at home too. The question needs to be thus: In low risk, healthy women, is the home birth death rate higher than a low risk, healthy opulation of women birthing in hospital. The answer, according to a large North American study, is no.

Distinguishing the outcomes of uncomplicated births from high-risk births helps to make sense of the conflicting data ...

The study concluded that while homebirth for low-risk women could compare favourably with hospital birth, high-risk homebirth was "inadvisable and experimental".

The Australian College of Midwives supports this conclusion.

Dahlen says women should still have the right to attempt high-risk births, provided they are well informed of the risks, as well as their chances of success.

- A woman's right to autonomy must be respected. It would be great if high risk women were supported to achieve the birth they want within a hospital setting.

"Women wanting to give birth vaginally after a caesarean, for example, have a 70 to 85per cent chance of success," she says.

Versus hospital VBAC rates which sit between 2% and 15%.

"I don't know of any other area where the battle over women's bodies is as intense as this. We have to make sure we don't end up with situations like those in parts of the US, where midwives are put up on criminal charges and women are arrested and taken from their homes to hospital if they are intending any birth at home the medical establishment considers risky."

Keirse, who has also worked in obstetrics in the Netherlands, characterises the debate as a demarcation dispute. "Holland went through that in the 1970s. When midwives were granted free access to hospitals in the early 1990s, that made a big difference and contributed to improving safety rates."

Britain's Royal College of Obstetricians and Gynaecologists and the Royal College of Midwives have managed to agree. Their 2007 joint statement, which supports homebirths for women with uncomplicated pregnancies, reads: "There is ample evidence showing that labouring at home increases a woman's likelihood of a birth that is both satisfying and safe." ... In the Netherlands, 30 per cent of all births take place at home.

"The culture is conducive to homebirths in Holland," says Keirse. "It's an accepted government policy and the midwives who conduct homebirths are considered part of the medical profession. They have rights that allow them to continue caring for their clients if they need to transfer to hospital.

"In Australia, there can be large distances between home and hospital, independent midwives have no hospital rights and they are not incorporated into the healthcare system.

"This means that training of homebirth midwives isn't regulated, which it should be."

- The training of midwives is most certainly regulated. All registered, qualified midwives have a university degree or two or three. Some are educated to maters level.

One research finding that is not disputed is that homebirths result in fewer medical interventions ... compared with the relatively low-risk hospital group, intended homebirths were associated with lower rates of electronic foetal monitoring (9.6 per cent v 84.3 per cent), episiotomy (2.1 per cent v 33 per cent), caesarean section (3.7 v 19.0 per cent) and vacuum extraction (0.6 v 5.5 per cent).

Melissa Maimann, Essential Birth Consulting.