Probably the best way to read these documents is to start with the literature review because it provides the context for the guidance and position statement.
ACM’s literature review was restricted to studies which met all of the following criteria:
Any articles that did not describe studies which included a comparison group, investigate planned homebirths or relate to maternal and/or neonatal outcomes were excluded. This rigorous process identified eleven studies which formed the basis of the literature review. The review covered 352,655 homebirths from Australia and around the world.
In general terms, the studies say that for a low-risk, healthy woman and baby, midwife-attended home birth does not increase the chance of the baby dying or being harmed. Home birth does, however, increase the chance that the woman will have a drug-free, intervention-free birth: that her labour will most likely start on its own, progress normally and lead to a normal birth with little likelihood of needing any stitches. Also, she is far more likely to breastfeed and to experience her birth as very positive and satisfying. This is important because it is well-known that interventions carry risks and that there can be a cascade effect, so that when you begin with one intervention, you often end up doing more interventions as the labour progresses (eg induction leading to long labour, leading to epidural, leading to forceps delivery). This is all minimised in the group of women and babies who birth at home with a qualified midwife who has a link in to the hospital with ready access to obstetric and paediatric care if needed.
However, a small number of studies demonstrated that home birth increases the rate of perinatal mortality. The research suggests that the inclusion of high risk factors in home birth, increases the chance of a baby dying or being seriously harmed during birth (most commonly through low levels of oxygen). Other issues may relate to the time and distance to travel from home to hospital during labour if transfer is needed, as well as the woman’s acceptance or refusal of recommended interventions once she has transferred. It is important to note that the outcomes of women and their babies who transfer to hospital during labour will generally compare unfavourably with those not transferred due to the change in risk status of the women.
The ACM concludes that, “It seems evident from the literature that planned home birth is a safe option for women who are at low risk of complications and who receive care from qualified attendants with adequate access to support, advice, referral and transfer mechanisms.”
With that conclusion in mind, the ACM has developed a position statement on home birth, and following on from that, guidance for private midwives who attend home births. Much discussion has been had about these documents on various forums and email lists. Some excerpts from the position statement and guidance follow:
It is the position of the Australian College of Midwives that home is an appropriate place of birth for women considered to be at low obstetric risk, and that women must be supported in safe, planned homebirth, by midwives and/or other appropriately qualified and regulated health professionals with adequate access to support, advice, and referral and transfer mechanisms.
Some women may choose a planned homebirth even when this is not recommended by her care providers. In such circumstances, a midwife should, after discussions with each woman and in consultation with other health professionals, work with the woman looking for options and resolutions within midwifery professional standards to address the woman’s needs.
Following documented discussions and appropriate consultation and referral as may be indicated, a midwife has the right to decline to continue to provide, or to accept, midwifery care if it is felt that this would require the midwife to practise outside of the midwife’s scope, skills and competencies.
Midwives have a duty of care to each woman they provide care to, and this means that in labour, or urgent situations, a midwife must attend the woman.
In the absence of a consistent definition of ‘low obstetric risk’, low obstetric risk is considered to be a pregnancy, labour and birth that are anticipated to be problem free.
There are some contraindications to a planned homebirth which women should be informed of at booking. These are; • Multiple pregnancy • Abnormal presentation (including breech presentation) • Preterm labour prior to 37 completed weeks of pregnancy • Post term pregnancy of more than 42 completed weeks • Scarred uterus
Issues identified as “B” or “C” in the Australian College of Midwives National Midwifery Guidelines for Consultation and Referral (“the Guidelines”) would require consultation with an Obstetrician prior to proceeding with a planned homebirth. Consultation is mandatory for the midwife providing care.
Women must be made aware of the midwife’s obligation to consult at – or prior to – booking-in.
Ideally, midwives should meet the criteria for gaining notation as an Eligible Midwife.
Midwives must ensure that they have documented processes in place for consultation and referral
Any decision to provide care for a planned homebirth should take into account the possibility of transfer to a hospital and the time needed for transfer to that hospital in the event that this is deemed necessary. Women should be counselled on the possibility of transfer, and midwives should ensure that the supporting hospital is provided with a care plan/documentation around the woman’s intention for a planned homebirth.
Midwives must utilise documented evidence-based guidelines to support antenatal, intrapartum and postnatal midwifery care.
Midwives should undergo a formal professional peer review process at least once every three years.
At – or prior to – booking, the midwife must advise the woman of situations where homebirth cannot be supported. At any time, the midwife is not obliged to participate in a homebirth that the midwife considers will increase the risk of harm to the woman or her baby.
Women must be respected in the choices that they make, and that includes choices to refuse a recommended course of action at any stage of her pregnancy,
An information pack should be made available to women that should include a ‘Terms of Care’ document outlining the terms under which midwifery care will be provided. Information should also include the potential for transfer to hospital for unforseen complications. The following information must be provided to women at the onset of their care, ideally in writing, followed up in discussion and signed by the woman: • Midwifery scope of practice, including the Australian College of Midwives Guidelines for Consultation and Referral; • Philosophy of care; • Choice of birth setting, including requirements for homebirth; • Contact information for the midwife; • Back-up arrangements; • Standards of practice and protocols, including consultation and referral • Responsibilities of the woman; • Confidentiality and access to the woman’s records (privacy agreement); and • Financial arrangements
It’s fair to say that ACM’s position statement and guidance are not ideologically- or belief-driven. It’s clear that the documents are driven by evidence. ACM has tackled the conflicting issue of the woman's negative right to autonomy versus the midwife's responsibility to practice safely and within accepted standards of care. While much is being said on various forums, email lists and face-to-face about these documents, somehow, I can’t help but wonder if the issue is really about the restriction of home birth to low-risk women, or the fact that at this point in time, a woman and private midwife have no option but to birth at home.
In the whole of Australia, there is currently no clinical privileging except in one small hospital. A high risk woman’s only option via this new position statement is to birth in hospital, however her private midwife would not be able to attend in the full capacity of midwife – or even as a support midwife: it has recently come to our attention that the midwife cannot legally attend in hospital at all.
I’ll explain why: the MIGA insurance policy covers privately-admitted patients. If the woman is admitted as a public patient after being transferred from a home birth (either in pregnancy or during labour), MIGA insurance does not provide indemnity cover to the midwife in respect of the birth. Most women planning a home birth will have a back-up hospital booking as a public patient. Hence, when the midwife goes in with the woman, the midwife’s insurance does not cover her. It is against the requirements of registration to work without insurance, except at a home birth. In other words, the midwife would be attending the woman in hospital against the requirements of registration.
In time (hopefully sooner rather than later), midwives will have admitting rights where we can admit, care for and discharge our own private patients, all funded by Medicare and indemnified by MIGA but in the meantime, this is not possible.