A highly polarised debate between midwives and obstetricians runs the risk of ignoring the voices of women and families – how can we move the discussion forward?
Homebirth is an option for only a few women in Australia through publicly funded models of care and for women who choose to hire a privately practising midwife. The private models of homebirth remain unfunded and uninsured. Recent maternity service reforms have excluded private homebirth from insurance cover and Medicare rebates, despite 60 per cent of the over 900 submissions to the recent Maternity Services Review mentioning homebirth, with women describing in detail the benefits and barriers in accessing this option of care.1 This is out of step with maternity service reforms in comparable countries such as New Zealand, the UK and Canada, where homebirth is supported as a mainstream option with public funding and affordable insurance available. As a result, a small number of women (0.3 per cent) choose to have a planned homebirth in Australia and a further 0.5 per cent of women give birth in places other than planned hospital or home.2 This group includes birth before arrival (unintentionally unattended birth at home) and freebirth (intentionally unattended birth at home).
Why not just go to hospital?
The intervention rates during childbirth have skyrocketed over the past ten years in Australia, leaving many women traumatised and fearful. A first-time mother in Australia now has a greater chance of having surgical intervention during her birth than of not having it. This is not safe, either physically or psychologically. It is also expensive, has many consequences and is counterproductive to optimising normal birth and healthy mothers and babies. While it is indeed very safe to have a baby in Australia, the perinatal and maternal mortality rates have remained virtually unchanged for over a decade, despite a steep rise in obstetric intervention. Fragmented care received during what is a major life event further impacts on women’s satisfaction. The ramifications of these issues are:
- more traumatised women due to interventions during birth;
- limited options for continuity of midwifery care;
- fewer experienced, networked midwives available to attend women privately; and
- very limited access for women to a hospital birth under a private midwife.
The rise in doulas and the numbers of freebirths births is being seen in two countries – Australia and the USA – both with high intervention rates in birth and limited access to continuity of midwifery care.3 While there has been little research into freebirth in Australia, there is some evidence this is increasing.3,4 Where homebirth is not offered as a valid choice (funded and accessible) to women there also appears to be a corresponding increase in the incidence of freebirth.5
What does the evidence say?
One argument against the practice of giving birth at home is the lack of scientific evidence or different opinions as to what that evidence actually says. While homebirth advocates cite research that supports the safety of homebirth and homebirth critics cite research that show a lack of safety, the studies examining the safety of homebirth have consistently found comparable perinatal mortality among low-risk women giving birth at home with a midwife and low-risk women giving birth in hospital, but lower intervention rates and maternal morbidity.6–12 Likewise, studies have shown that when women with high-risk pregnancies give birth at home the perinatal mortality is increased.13–15 There is good evidence to support low-risk homebirth with a qualified midwife who is well networked into a responsive maternity care system as a safe, reasonable and cost-effective birth option that results in less medical intervention and government spending on maternity care and high levels of satisfaction.
‘It remains a woman’s right in Australia to determine what happens to her body during pregnancy and birth and most midwives and doctors value this right.’
The more complex, but equally relevant, argument about how women understand safety and how safety is examined scientifically is debated less and considered less valid by some. Cultural, emotional, psychological and spiritual safety rarely appear in the mainstream debates about the safety of homebirth, yet qualitative research would indicate this dominates in women’s decision-making regarding choice of place of birth.16,17 With suicide a leading cause of maternal death in Australia,18 the UK and USA, we can no longer dismiss the importance of women’s psychological wellbeing.
Is evidence the answer?
The continued focus on the safety of homebirth in research (primarily perinatal mortality), while important, is not going to end the debate that has now raged for a couple of hundred years. If we discovered conclusively through a randomised control trial (RCT) that perinatal mortality is higher among babies born at home, would this end the debate and would homebirth cease? The answer is no. Those who support homebirth would argue women’s right to choose, the generalisability of the study, the inclusion of women with risk factors and the long-term benefits that can’t be measured by an RCT. What if we found through a RCT that the perinatal mortality was the same or better, would this end the debate? The answer again is no. Those opposed
to homebirth would argue generalisability, sample size and differences in population, geographic distances and professional standards. Research will not end the debate; If anything the debate is becoming more polarised with each scientific publication. So, where to next?
Can we reach middle ground?
Of course we must continue to take a scientific approach to studying the outcomes associated with the place of birth, but we must also find new ways to do this and embark on new and more insightful strategies to come to a balanced middle ground in this debate. If our aim in undertaking research is only to prove the danger or benefit of homebirth, we will miss a vital opportunity to examine how we can all work together to make birth, at home and in hospital, safer for all women.
The most successful example we have of achieving the middle ground is the joint statement from the UK on homebirth, where all the evidence (43 references cited), not just that which suits an agenda, is examined and defined support is given for homebirth by the Royal College of Obstetricians, Royal College of Midwives and National Childbirth Trust.19 This is the inevitable benefit of joint health professional and consumer statements rather than profession-specific ones, as bias and belief is directly challenged and moderated.
The debate is about more than place of birth
The debate around homebirth is about more than place of birth or associated perinatal mortality, it raises deeper and more complex issues: the right of women to have control over their bodies during childbirth, the rejection of the prevailing medical model and risk paradigm of pregnancy and childbirth, societies’ belief that they have an investment in the product of childbirth and therefore should determine what is considered safe, the culture of childbirth in a country and the position and status of women within a society. Homebirth also represents starkly the different philosophical frameworks held by midwifery (essentially a social model of care) and medicine (essentially a medical model of care) and hence the debate over this issue is ideological, contested, longstanding and circumscribed by relationships of power. Sadly, it is rarely about women and women’s voices are often dismissed or denied in the debate. While the law in most developed countries stands strongly behind the consumer on the issue of choice and self-determination, this fundamental human right is repeatedly breached in practice and during debates. On the one hand, the same professionals who fight for the right for a woman to terminate her pregnancy will fight against her right to give birth at home. On the other, the professionals that fight against a woman’s right to choose an elective caesarean section without medical indication will fight for a woman’s right to have a homebirth. We appear to be consistent at least in our inconsistency.
The reality is there are advantages and disadvantages with all places of birth for different women at different times with different practitioners; therefore, we are left with a couple of options. We recognise women’s choice as valid and we try to reduce the disadvantages and improve the advantages of all options of care or we obstinately put our heads in the sand and hope if we ignore it long enough homebirth will go away. Never in history and in no country on earth has this ever happened, but in some countries concerted efforts to cater for women’s choice means hospital birth and homebirth have been made safer.
Ultimately, whatever your beliefs, homebirth will not go away. It remains a woman’s right in Australia to determine what happens to her body during pregnancy and birth and most midwives and doctors value this right. Perhaps it is time finally to exchange the entrenched divide between midwives, consumers and obstetricians on the issue of homebirth for a shared responsibility.
ACM Homebirth Position Statement
The Australian College of Midwives (ACM) developed an interim homebirth position statement in August 2011. The College sought feedback and received over 250 submissions, which are being considered by a Review Panel. Membership of the Review Panel arises internally from the ACM Branches and the Consumer Advisory Committee. It is anticipated that, by the end of 2011, the ACM National Board of Directors will have considered recommendations made by the Review Panel. Once endorsed by the ACM National Board of Directors, the College’s Position Statement on Homebirth will be available on the ACM website.
- Dahlen H, Schmied V, Tracy S, Jackson M, Cummings J, Priddis H. Homebirth and the National Australian Maternity Services Review: Too Hot to Handle? Women and Birth. 2010;(Online 2010).
- Laws PJ, Li Z, Sullivan EA. Australia’s mothers and babies 2008. In: AIHW, editor. Canberra 2010.
- Dahlen H, Jackson M, Stevens J. Homebirth, Freebirth and Doulas: Casualty and consequences of a broken maternity system. Women and Birth. 2011;24(1):47–50.
- Newman L.A. Why Planned attended homebirth should be more widely supported in Australia. ANZJOG. 2008;48:450–3.
- Freeze RAS. Unassisted childbirth in North America. Iowa: Graduate College of the University of Iowa; 2008.
- Johnson K, C., Daviss B. Outcomes of planned homebirths with certified professional midwives: large prospective study in North America. BMJ. 2005;330:1416–23.
- Olsen O, Jewell MD. Homebirth versus hospital birth (Cochrane Review). Issue 3 ed. Oxford: Update Software; 2001.
- Olsen O. Meta-analysis of the safety of homebirth. Birth. 1997 1997;24(1):4–13.
- Murphy PA, Fullerton J. Outcomes of intended homebirths in nurse-midwifery practice: a prospective descriptive study. Obsterics and Gynecology. 1998 1998;92(3):461–70.
- Wiegers T, Keirse MJNC, van der Zee J. Outcome of planned home and hospital births in low risk pregnancies: prospective study in midwifery practice in the Netherlands. BMJ. 1996 1996;313(7068):1309–13.
- de Jonge A, van der Goes B, Ravelli A, Amelink-Verburg M, Mol B, Nijhuis J, et al. Perinatal mortality and morbidity in a nationwide cohort of 529,688 low risk planned home and hospital births. BJOG. 2009;DOI: 10.1111/j.1471-0528.2009.02175.x.
- Janssen P, Saxell M, Page L, Klein M, Liston M, Lee S. Outcomes of planned homebirth with registered midwife versus planned hospital birth with midwife or physician. Can Med Assoc J. 2009; published at www.cmaj.ca on August 31, 2009.
- Bastian H, Keirse MJ, Lancaster P. Perinatal death associated with planned homebirth in Australia: population based study. BMJ. 1998 1998;317(7155):384–8.
- Symon A, Winter C, Inkster M, Donnan P.T. Outcomes for births booked under an independent midwife and births in NHS maternity units: matched comparison study. BMJ. 2009;338(2060).
- Kennare RM, Keirse MJNC, Tucker GR, Chan AC. Planned home and hospital births in South Australia, 1991–2006: differences in outcomes. MJA. 2010;192:76–80.
- Dahlen H, Barclay L, Homer C. Preparing for the first birth: Mothers’ experiences at home and in hospital in Australia. Journal of Perinatal Education. 2008;17(4):21–32.
- Edwards N. Womens decision making around homebirth. AIMS Journal 1997;8(4).
- Austin MP, Kildea S, Sullivan E. Maternal mortality and psychiatric morbidity in the perinatal period: challenges and opportunities for prevention in the Australian setting. MJA. 2007;186(7):364–7.
- RCOG/RCM Joint Statement No. 2 (2007) Homebirths http://www.rcog.org.uk/files/rcog-corp/uploaded-files/JointStatmentHomeBirths2007.pdf .