Hannah Dahlen, Associate Professor of Midwifery, University of Western Sydney, writes:
On the 6th June the South Australian Deputy Coroner released a report into the deaths of three babies in South Australia who died under the care of a midwife who is no longer registered, and as we know the coroner has a very important role in making recommendations to prevent adverse events in the future.
The coroner identified some serious system and legislative problems that contributed to these incidents and made some potentially important recommendations, along with some potentially concerning ones.
The potentially positive recommendations are that the practice of midwifery should be permissible only in the case of registered midwives under National Law as this ensures accountability and the meeting of standards that protect the safety of the public. Midwives who are registered are regulated and have to abide by practice codes and standards and follow the Australian College of Midwives National Guidelines for Consultation and Referral, which the coroner commended in his report.
The Australian College of Midwives also has a position statement on homebirths to guide midwives practice in this area.
However, what is most concerning is the recommendation that legislation be introduced that would “impose a duty on any person providing a health service, including midwifery services to report to the South Australian Department of Health and Ageing the intention of any person under his or her care to undergo a homebirth in respect of deliveries that are attended by enhanced risk of complications.”
The concern with this is twofold. Firstly, it may in fact push some women further underground and lead to them not seeking any engagement with health services at all and this will be a significant disincentive to safety and secondly, it could lead to a serious intrusion into the rights of women to determine what happens to their bodies during pregnancy and birth.
Doctors will be tempted to report anyone intending to birth at home, as they generally espouse that no birth is normal except in retrospect and midwives will be forced into a situation of turning in their colleagues and their clients. How far will this McCarthyism potentially go and who gets to determine what is acceptable and what is not when it comes to women’s choices? What next, court ordered caesareans?
The USA has shown us the slippery slope we perch on when fetal rights supersede women’s, with court ordered caesareans, arrests and prosecutions (38 USA states now have fetal homicide laws and these laws are increasingly being used to target women who sit on the fringes of what we would consider acceptable behaviour).
Women’s right to control what happens to their bodies during pregnancy and birth may be enshrined in law but this right is frequently violated in practice. To step into this and attempt to regulate a woman’s body has serious ramifications and undoes hard won battles our feminist forbears fought for and the unintended consequences should give us cause for sober reflection.
Where do we stop once we start and who controls what is acceptable behaviour and what is not and who has the ‘rights’ and who does not and what is risky and what is not?
If you are thinking surely not, or only in America, then consider this: In March this year the WA branch of the AMA called on the State Government to extend recently proposed foetal homicide laws to include applying penalties to women who choose to have a homebirth when there are risk factors in the pregnancy or where they drink alcohol and/or take drugs.
The AMA WA went further saying in essence midwives should be prosecuted as well as they were obviously misguiding these women. Inexplicably they added that they had been reassured that the proposed laws would not impact on women’s right to have an abortion and thus reassured were seeking to criminalise homebirth mothers and/or their midwives. It seems ironic that the same people that defend a woman’s right to choose abortion deny her right to choose her place of birth.
Next into the debate predictably came the Right to Life Association that called for the proposed WA foetal homicide laws to be extended to criminalising abortion, and so it went on. As all the parties bickered over the bone of women’s rights versus fetal rights and most of the feminists remained eerily silent, as they often do when it comes to birth, the question we seem unable to ask is once again is why would women take the ‘risk’ of having a baby at home when they have significant risk factors? Do these women love their babies less or do they fear our health system more?
For the vast majority of women their baby is their number one priority. When they make choices that are not always in the best interests of themselves and their baby one should ask why?
When nearly 1:10 women in some studies are reporting Post-Traumatic Stress Disorder <> following childbirth then we have a problem. While 1:10 maternal deaths are due to suicide, then we have a problem. We have a worrying rise in freebirth (planned birth at home with no professional in attendance). If women are avoiding our system isn’t it incumbent upon us health professionals to work together with women to fix the problems?
As I have written before, homebirth is safe for low risk women attended by competent registered midwives who are well networked into a responsive health service. Where a woman has significant risk factors it is much less safe and hospital is the best place for them to give birth in.
But let us consider this reality in our country .
There has been no insurance for private midwives providing homebirth services since the collapse of HIH in 2001, so there are fewer privately practising registered midwives, leaving unregulated health workers to fill the gap. Privately practicing midwives are not allowed clinical privileging rights to practice in hospital like their medical colleagues.
And on July 1st 2013 if a solution is not found for privately practicing midwives when the Safety and Quality Framework for Privately Practising Midwives Attending Homebirths runs out, then midwives could potentially be disciplined and lose their registration for attending a birth at home. If we were trying to create the ‘perfect storm’ when it comes to homebirth then perhaps we have succeeded in this country.
In 2005, the WHO challenged health practitioners not to ask, “Why women do not accept the service that we offer?” but to question, “Why do we not offer a service that women will accept?
Let’s stop calling for ‘legislating’ against women’s choice or bullying them into submission and let’s start trying to understand why that choice is made and put in place responsive sensitive maternity care systems that cater for the individual and see birth as more than a medical event.
If we can do this we won’t have to erode women’s rights and we can pull ourselves back from the top of this slippery slope we are currently perched on in this country.