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Concerns continue about unsafe home birth practices: Dr Andrew Pesce

Dr Andrew Pesce, a Sydney obstetrician and gynaecologist and former president of the Australian Medical Association, writes:

Croakey readers will recall the controversy surrounding the publication of a review of planned home births in South Australia between 1991 and 2006. The study was published in the Medical Journal of Australia in January 2010.

At the time, the presentation of data which indicated a statistically significant increase in the numbers of babies dying following a planned home birth led to significant debate and even hostility from readers who claimed it gave a distorted view the risks of home birth. The corresponding author, Marc Kierse, reinforced the main message of the paper that, in the absence of proper risk assessment and limiting planned home birth to low risk pregnancies, home births in Australia led to higher rates of perinatal death.

Since that study, the two States which publish their perinatal statistics in ways which identify outcomes in planned home births separately to all other births have published their latest reports.

The Perinatal and Infant Mortality Committee of Western Australia published its review of perinatal outcomes from 2005-2007 in December 2010. It found:

“Of the 658 planned home births in the period, the Committee reviewed seven deaths, six of which occurred at term or post-term gestational ages. From the information available, three of these deaths were considered to be possibly avoidable. The perinatal death rate for term home births was 3.9 times higher than for hospital term births”.  All of the deaths in the planned home births occurred under the care of registered midwives.

In June 2011, the South Australian Maternal, Perinatal and Infant Mortality Committee published its review of pregnancy outcomes for 2009. Of the 160 planned home births that year, there were 5 perinatal deaths, a perinatal death rate of 3.1%. This compared to an overall perinatal mortality rate of comparable weight babies weighing more than 1500g of 3/1000. So in 2009, the chance of a baby dying in a planned home birth was more than 10 times the state average. All of the home births included in the statistics were cared for by registered midwives.

On the above evidence, it remains clear that planned home birth in Australia as currently practiced is leading to the deaths of a number of babies who would otherwise have survived if their birth was planned in a hospital maternity unit. This is occurring in pregnancies cared for by registered midwives, as well as during  “freebirths” where women give birth at home without any medical or midwifery care.

It is likely that a large part of this excess perinatal mortality is due to women with high risk pregnancies choosing to plan a home birth. In the South Australian report, this view is reinforced by the following new recommendation:

“All home births should be conducted in accordance with the ‘Policy for Planned Birth at Home in South Australia’; specifically that the mother should be transferred for hospital care when a planned home birth is complicated by the presence of meconium stained liquor…”

There is also a restatement of recommendations from previous reports which “remain pertinent”:

“Planned home birth for twins, breech presentations and post-term infants is associated with unacceptably high risks. A previous caesarean section is a contraindication for home birth.”

It is noteworthy that in the Netherlands, a country with the longest history of a well developed health system supporting planned home birth, such high risk pregnancies are not considered eligible for planned home birth and women are transferred to hospital when risk factors emerge in pregnancies previously classified as low risk.

The Australian College of Midwives published a position for planned home birth in August 2011, reinforcing the importance of limiting planned home birth to low risk pregnancies.

“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.”

This position statement was endorsed by the Nursing and Midwifery Board.

The result of this quite reasonable statement was the opposition to, and often vilification of, the ACM and N&MB by individuals and home birth lobby groups advocating support for women’s choice of home birth notwithstanding the risks this might pose.

Similarly, the South Australian Coroner, and SA Health Minister John Hill – a reasonable man who has been sympathetic to low risk women seeking planned home birth – have recently been publicly savaged for seeking to investigate the causes of deaths of babies during home births.

No Minister will consider funding a system of maternity care which supports unsafe clinical practice. Until those individuals and groups which advocate for publicly funded home birth unambiguously and publicly state home birth is unsuitable for high risk pregnancies, their advocacy will remain at the fringes of the maternity system.

If they can cross that Rubicon, they might find that they have broader support than they realise.

 ***

For previous related Croakey posts

More critique of the homebirth study and its reporting

MJA editor responds

Shooting the messenger?

More indepth reading

 

 

 

 

Comments 2

  1. Pam Harnden says:

    The issue that this doesn’t address is one of informed choice. I would like to remind people of the RANZCOG guidelines for standards of maternity care in Australia and New Zealand,
    “1.5 Women who have been fully informed regarding a recommended course of action, and the potential consequences of not pursuing such management, should have their decisions respected if they decline.”p.6

    I would also like to remind people of the following from the National Guidance on collaborative maternity care document published by the Australian Government NHMRC,
    “Documentation should include clear and consistent records of: information provided to the woman and indications that the messages have been understood, informed consent, responsibility and accountability for decisions, and the woman’s understanding of risk and her responsibility for her own choices and decisions about care, especially if these decisions are in conflict with professional
    advice (in such circumstances it must be clearly documented that the woman has accepted a certain level of risk).
    A woman decides who she involves in this decision-making process, be it a health professional, partner, doula, her extended family, friends or community, and should be free to consider their advice without being pressured, coerced, induced or forced into care that is not what she desires (McLean and Petersen 1996).Women have the right to decline care or advice if they choose, or to withdraw consent at any time. Therefore, if a woman declines care or advice based on the information provided, her choice must be respected (UNESCO 2005). Importantly, women should not be ‘abandoned’ because of their choice (FPA Health and Read 2006, Faunce 2008; NHMRC consultations 2009).” p.14

    The ACM therefore are the only organisation that sought to deny these rights to women and actively encouraged midwives to refuse to attend a woman in labour by issuing this ‘interim home birth statement’. I also stress it was an INTERIM statement which has now been voted on my the membership to be withdrawn. I would remind any midwife that under the law as it stands should a woman have consulted her at any time during her pregnancy that a therapeutic relationship has been established and should she then refuse to attend that woman in labour she could be prosecuted.
    The real issue is that where informed consent has taken place there is no protection for the midwife she looses on all counts. Can be prosecuted should she refuse to attend, prosecuted if she attends and struck off. I love that you wish to portray us as ‘demons’ but please stick to the real issues and quit with all the professional personal attacks.

  2. Debbie Slater says:

    In moving to a system that supports planned homebirth for women at low risk of complications it is important to commensurately look at how our health system supports women of ‘high risk’ within the hospital system. Many women (not all) plan a homebirth because they want the same midwife throughout their antenatal care, labour, birth and for several weeks postnatally: what they are choosing is the model of care not the place of birth per se. It is therefore incumbant on health services to step up to the mark and provide these models within hospital settings – particularly where women are unable to choose this model of care at home because of their ‘risk status’. The evidence supports these models as leading to good outcomes for women and indeed they are mandated as part of the National Maternity Services Plan. Health departments must increase provision of midwifery-led models of care within hospitals and primary care settings, and need to ensure that eligible midwives with Medicare provider numbers are able to admit the women in their care to public hospitals – something they are by and large failing to do. Medical practitioners have a part to play in this and must be willing to enter into collaborative arrangements with midwives – as Dr Pesce has already done. Health Services should also be looking at ways to reduce the primary caesarean section rate, as this plays a significant part in the increasing number of so-called ‘high risk’ women within the system – through a focus on normal birth. NSW have already taken a lead on this. Dr Pesce talks about crossing the Rubicon (which many midwives and consumers have done), but many medical practitioners have their own Rubicon to cross: that of accepting that homebirth is an acceptable place of birth for women of low obstetric risk. In my work as a consumer representative in maternity services and involved in the provision of low-risk publicly-funded homebirth service, I too often come across medical practioners who fail to support homebirth at all and, in some cases, actively make it difficult. In order for maternity services to work for women, everyone (midwives, women and doctors) has to work together in a spirit of cooperation and collaboration. This involves a bit of give and take on all sides. Only then will women be the winners.

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