Opinions divided on a special delivery

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The popularity of homebirths is growing, as is confusion about new regulations

WHEN Anna and Chris Rummey gave birth to their daughter Rosemary earlier this year, they did so in the comfort and security of their own home. The Rummeys had earlier attended a prenatal appointment with a local hospital, but the experience put them off.

"The hospital midwife wasn't really interested in us," Anna says. ... We walked out feeling like we were just another number."

The Rummeys' decision to give birth at home was based on reading accounts from other women about how positive they found the experience ...

" ... I was never separated from Rosemary, not for a second. As soon as she came into the world, I held her straight away, and the three of us were tucked up in bed by midnight. The other good thing was that all our pre-natal care was with the midwife, so when the baby was born it was already a familiar environment."

Not everyone is supportive of the practice, however. The Australian Medical Association has been particularly vocal in its opposition to homebirth. Although AMA president Andrew Pesce doesn't oppose homebirth under all circumstances, he stresses that homebirth regulations in Australia leave a lot to be desired.

While the midwives who attend homebirths are regulated (midwifery is a regulated profession in Australia), private homebirth services are currently unregulated. What this means to the public, is that there is no rubust system in place to provide an assurance of quality and safety.

He thinks the situation could be improved by limiting homebirth to low-risk births, and reacting in a more timely fashion to emerging complications. "Unfortunately a lot of women who do have risk factors continue to try [to] give birth at home. And that's where you get babies dying, for example in the case of twins, where there is a one in eight chance during homebirth that one of them will die."

Andrew is describing the debate about choice versus safety in high-risk pregnancies and births. A factor that I don't believe has been adequately exposed is the altered dynamics in the relationship between a midwife and woman in a homebirth situation, compared with a hospital situation. As a midwife in a homebirth, you are invited into the couple's home. You are a visitor. In hospital, the couple is on the hospital's territory. The hospital can say what goes. Not so in a homebirth. In some instances, the midwife will advise transfer, but if a the a midwife is attending a woman in labour and the woman refuses to go to hospital, the midwife cannot force the woman to go.

What's needed is a more welcoming approach from hospitals and a genuine respect for the decisions that women have made. When women feel supported to have natural VBAC, twin and breech babies vaginally - with no continuous monitoring, no epidural, no vaginal exams, physiological birth positions, phyiological third stage, waterbirth and so on, perhaps fewer women will plan to birth at home in the event of "high risk" situations.

Pesce cites The Netherlands as an example of a country with a safe homebirthing scheme. There, 30 per cent of women give birth at home, albeit down from 60 per cent in the 1960s.

The Netherlands uses a risk assessment process for homebirth. Under this risk assessment, only 30% women birth at home. This is in a country that has a well-supported and established homebirth philosophy. Importantly, the philosophy is not about choice, it is a black-and-white approach to low risk birth at home, and high risk birth in hospital, either under the care of an obstetrician or a midwife.

He also cites a Flinders University study published in the AMA's Medical Journal of Australia, which he says shows the risk of a baby dying is seven times greater for homebirths.

The overall risk of a baby dying was the same at home or in hospital. And for births that actually occurred at home, the death rate was significantly lower than the death rate in hospitals. What this study shows, yet again, is that low risk birth at home, attended by a midwife, is very safe. For women with risk-associated pregnancies, homebirth is less safe than birthing in hospital.

... Mark Ragg, a medical specialist at the University of Sydney, disputes the claim. He says the research doesn't show planned homebirths to be linked to a higher risk of perinatal deaths.

"[It] shows that planned homebirths are about as safe as planned hospital births," Ragg says. "The results say the mortality rates were similar for those two categories. If you pull it apart and look at particular areas, you'll find that homebirths were less safe in some areas, but you would also find that hospital births were less safe in some areas. But the overall picture is that they are equivalent".

... New laws ... have cast the future of homebirth in Australia into doubt. The law will allow midwives to provide Medicare-funded care, providing they sign up to a national register.

But to be included in the register midwives will require professional indemnity insurance, not available at present to those offering homebirths. The government proposes a two-year buffer period for those who can't find insurance, but many midwives see this as a stop-gap measure.

... Caroline Homer, professor of midwifery at the University of Technology, Sydney, suggests banning homebirth would drive it underground. She acknowledges, though, that many women want assurance that if things do go badly they can seek damages. "In Australia we don't have a no-fault policy around health and a way of funding long-term complications," Homer says.

"If the baby is born brain damaged or has long-term problems, often the only way you can get money to support that is to sue somebody."

Some see birth centres as a compromise. Attached to hospitals but staffed by midwives, they offer a more down-to-earth environment than a hi-tech labour ward and include options such as water birth.

Homer thinks they are a good option for women wanting to give birth in an intimate environment, but with the safety of a big hospital next door. "I think they're a fantastic option. We need more of them. What we also need, though, is for labour wards to look more like birth centres."

While it would be great to expand birth centres, it will be a very costly exercise and may take years to complete. A more rapid and cheaper approch would be to convert half of the current delivery suites into birthing rooms, complete with cushions, a couch, soft lighting and oil burners. The delivery bed can be pushed to the side of the room, the monitoring equipment can be removed from the room, unnecessary equipment can be hidden behind cupboard doors, and if baths are not sufficient for birthing in, women can bring in their own birth pools.

Andrew Pesce, too, thinks birth centres are a good idea, but argues there shouldn't be funding for standalone birth centres, only those attached to hospitals.

Weaver, on the other hand, says the hospitals should be improved.

"Hospitals have traditionally been very hierarchical, and haven't been very receptive to choice," he says. "So I think we really need to listen to the consumers and see what they want, and try to design systems of care that are safe but still give women a measure of choice."

But Anna Rummey would be hesitant to use a birthing centre for her next child, largely because there's no certainty a space will be available.

Hence the importance of modifying delivery suites into birthing rooms. Birth centres only have limited booking available, and most birth centres are oversubscribed.

"You're at the mercy of how many women are birthing that night," she says. "It's not guaranteed that you'll get one of the birthing suites. You might not be able to have a water birth if there's another woman using the tub."

... "I don't think that homebirth will be made illegal. Anything you make illegal still happens, but it happens underground and in a less safe way. It would be an unhelpful process, an unhelpful law for everybody."

Melissa Maimann, Essential Birth Consulting 0400 418 448