Home births: deadly or desirable?

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After six hospital births ... Melissa Read decided to bring her seventh child, Ayla, into the world at home.

“Doctors had told me home births were incredibly risky but I did a lot of research and the midwives understood what I was talking about and how I felt,” Ms Read said.

“It was an incredible experience that was more than I expected for myself, my husband and my kids.”

Independent midwives have slammed reports this week that home births put babies at a greater risk of dying than those born in hospital.

A widely reported ... study showed that babies born at home are seven times more likely to die of complications and 27 times more likely to die from lack of oxygen.

The Australian Medical Association (AMA) and the National Association of Specialist Obstetricians and Gynaecologists used the study to warn against the dangers of home birth.

But the report, which compared 297,192 planned hospital births with 1141 planned home births ... also showed that the perinatal death rate was similar for both kinds of births.

The 16-year long study recorded nine perinatal deaths in the planned home-birth group, seven of which were actually born in hospital, and 2440 deaths in planned hospital births.

Home birth advocates criticised the report, saying the research was flawed. The report itself states “small numbers with large confidence intervals limit interpretation of these data”.

However, homebirth studies in Australia can only include small numbers because less than 1% births occur at home.

“In the 16-year study period there were only three perinatal deaths for which one can reasonably assume that a different choice of care provider, location of birth or timing of transfer to hospital might have made a difference to the outcome,” says the report.

... the study showed there was only a slightly higher risk in choosing a home birth. And if done properly with a low-risk pregnancy, there was no real difference.

Exactly. What the study really shows is that low-risk, midwife-attended home birth is a *safer* option than hospital birth. The issues are around risk assessment and management ... and the right of women to accept or reject advice.

“The risk is mainly in people who have home births that shouldn’t have them, such as having twins, a breach birth or people too far beyond their due date,” Prof Keirse said.

These outcomes of these births is better when they occur in hospital.

“A mother has to be responsible when deciding what kind of birth to have and these mothers are taking unacceptably high risks.”

Prof Keirse said he was scared by the number of women choosing to have home births after already having had a caesarean.

“When a problem happens and you are at home you have no real way of dealing with it,” he said.

“One of these days we will not only lose a baby but a mother as well.”

Homebirth Australia national secretary Justine Caines said the reporting of the study by the AMA was irresponsible.

“I think they are trying to push a political agenda and outlaw or force home birth underground, which is incredibly irresponsible,” Ms Caines said.

“The report says there are 7.9 deaths per 1000 in planned home births, compared to 8.2 in planned hospital births, but they didn’t all stay home births and the real figure of births that actually occurred at home is 2.5 deaths per 1000.”

The study title states it was looking at *planned* home birth and *planned* hospital birth. Actual place of birth was not the focus of the study. If the study focussed on the babies that were born at home, it would have had to include babies who were intended to be born in hospital, but arrived too quickly at home. These births are possibly riskier than planned home birth.

Last year the Federal Government refused to include home birth under its midwifery indemnity scheme.

The decision forced many midwives underground and threatened to increase the number of women ''freebirthing'', or delivering at home without any medical supervision.

This has not happened as the changes will not come into effect until July 1, 2010.

Ms Caines said from July this year midwives were at risk of not being able to be registered under the Commonwealth reforms.

“In the UK there is a legislative right that if the woman choses a home birth there is a responsibility that they have a trained health professional with them,” she said.

In the UK, it is illegal for women to have unassisted births. We do not have this law in Australia.

“A woman has a right to make an informed consent to a home birth and if she understands the advice she’s received it’s not my right to say you can’t do that.”

AMA president and obstetrician Andrew Pesce said the study supported the association’s stance against home births.

“The current evidence would mean we could not support home birth given that it is associated with higher risk of babies dying,” Mr Pesce said.

“The risk of what is happening now needs to be acknowledged and the midwives and people involved in home births need to put plans in place to manage those risks.”

The AMA admitted the study revealed many positives for home birth but maintained it was too great a risk for mothers and babies.

SA independent midwife Julie Garrett said midwives were aware of the complications, but had a duty to support the choice of a mother.

And this is the crux of the matter: midwives do not act irresponsibly. We do inform women of the risks. But women are free to choose amongst options and to make the right decision for them.

Ms Garrett said the culture in Australia needed to change to support midwife-based care as an alternative.

“In England and New Zealand they are bringing in home births, while Holland has an almost completely midwife-based care model. It’s the culture here that needs to change. Women should be able to choose.”

In the UK, NZ and the Netherlands, health policy supports low risk home birth. Even in a country such as the Netherlands, where home brith is a normal birthing option, the home birth rate is only 30%. 70% women need to birth in hospital or choose to birth in hospital, and there is no stigma attached to it. In a country such as Australia, with a caesarean rate in excess of 30%, a maximum of 70% women will be "eligible" by risk-assessment standards, to birth at home. Add to that twins, breeches, women going over 41 weeks or less than 37 weeks, high blood pressure, gestational diabetes, big babies and so on, and you can understand that even if home birth is a government-supported option, it will not be an option for the majority of women.

Melissa Maimann, Essential Birth Consulting 0400 418 448