In a recent post, Dr Andrew Pesce, a Sydney obstetrician and gynaecologist and former president of the Australian Medical Association, raised concerns about the safety of current home birth practices.
In the article below, Hannah Dahlen, Associate Professor of Midwifery, University of Western Sydney, and national media spokesperson for the Australian College of Midwives, suggests the need for a more wide-ranging debate whose ultimate goal should be making all births – whether they take place at home or in hospitals – as safe as possible.
Broadening the discussion about home births
Hannah Dahlen writes:
Once again the home birth debate rears its ugly head in public, and we spin the well-worn wheels of argument in the ever deepening intellectual (or not so intellectual) rut, hoping that somehow we will gain traction with one more scientific study or State mortality report and move the debate forwards in the direction that subscribes to our particular belief system.
After more than 20 years of reading, researching and being engaged in clinical practice I have come to the conclusion that the answer to this debate is not statistics but a shared responsibility. It is time to work together on what we agree on, whilst learning to compromise or accept that which we don’t agree on.
The principles we tend to agree on include respecting the right of women to choose where and how they give birth; making sure the best evidence is provided to women making this choice; ensuring that the practitioners attending women who choose home birth are skilled, regulated and networked into a responsive system that has women at the centre and not professional self interest.
Home birth has always been a choice women have sought in every country in the world and in every epoch in history. The numbers of women having a home birth have doubled in the USA and Australia in the past four years.
Home birth will not go away, it is here to stay, so let us all share the responsibility for making it safe and satisfying, as should be our goal with all maternity care options.
The paradigm of risk in much of the developed world is one that holds home birth as risky and hospital birth as safe.
The assumption (not entirely wrong) is when things ‘go wrong’ home is not the best place to be; however conversely we could argue when things are ‘going right’, hospital is not necessarily the best place to be and can be the cause of things going wrong as women enter what has been described as the cascade of intervention.
The reality is there are advantages and disadvantages with both places of birth, therefore we are left with a couple of options – we recognise women’s choice as valid and try to reduce the disadvantages and improve the advantages of all options of care (shared responsibility), or we obstinately put our heads in the sand and hope if we ignored it long enough home birth will go away (the current attitude to home birth in Australia).
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 home birth have been made safer.
The continued focus on the safety of home birth in research (primarily perinatal mortality) often leads us up a blind ally – not that perinatal outcomes are not important – but they hide agendas and underlying discourses and will not end the debate.
Handpicking research to prove your point is something we are all expert in and sadly the public who trust us to provide an ethical and objective lense remain ever more confused.
So I will begin by agreeing with Dr Pesce (I think). While home birth advocates often cite research which is supportive of the safety of home birth and home birth critics cite papers that show a lack of safety, the studies examining the safety of home birth 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.
Likewise, studies have shown that when women with high-risk pregnancies give birth at home the perinatal mortality is increased. In fact, the evidence is now substantial enough that we can identify where the greatest risk lies; for example, women giving birth to twins (especially the second twin) and breech babies.
Looking at small State reports of 160 births, where one or two deaths will alter the perinatal mortality rate dramatically, is not a sensible approach.
Any statistician will tell you when events are rare, large numbers are needed to make sure statistical errors are not made. However, we should never dismiss any evidence that may help us improve our practice and we must always be willing to learn and improve.
So, if we are agreed (mostly) that homebirth for women with risk factors in their pregnancy leads to an increase in adverse outcomes compared to hospital birth, where to next?
Well this is where we must move from the current kindergarten approach of beating one another up with handpicked statistics, to the adult approach in the debate and towards a shared responsibility.
Keeping in mind the well-founded assumption that home birth is here to stay, there are three issues we need to consider. Firstly, why do women undertake a birth at home with risk factors? Secondly, how do we define safety? Thirdly, do we really want to take away a woman’s right to self-determination.
Why do women undertake a birth at home with risk factors?
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 expensive, has many consequences and is counterproductive to optimising normal birth and healthy mothers and babies. The ramifications of these issues are: more traumatised women due to interventions during birth; fewer options of care – especially continuity of midwifery care; fewer experienced, networked midwives available to attend women privately; and limited to no access for women to a hospital birth under a private midwife.
A woman wanting to have a vaginal breech birth in hospital will often have to fight hard and search far and wide to find a doctor to support her choice. A woman wanting to have twins in hospital without being forced into having an epidural or having the second twin virtually extracted from her body, will also have to fight hard to have her choices respected. A woman wanting to have a vaginal birth after caesarean in a birth centre may find she is ‘banned’ from this option and has limited choices available to her.
So when these women seek care outside our mainstream system, whose fault is it really?
The answer to all this is not to demonise women for their choices but to stop and consider our responsibility as a society to mothers and babies.
It is time we made our maternity care system accountable and really listened to what women are telling us and how in fact we are failing them. When a woman chooses to have a homebirth with risk factors present, the question we need to ask is not ‘what is wrong with her’ but rather ‘what is wrong with a maternity care system that provides such limited options and inspires such fear that she would take on the added risk’?
These women do not love their babies less, they fear mainstream care more and this is a terrible indictment of our care.
How do we define safety?
When health professionals, and in particular obstetricians, talk about safety in relation to homebirth, they usually are referring to perinatal mortality. While the birth of a live baby is of course a priority, perinatal mortality is in fact a very limited view of safety.
With suicide during pregnancy and the postnatal period now one of the leading causes of maternal death in Australia, the UK and USA, we are very remiss to not consider safety in a much broader context.
Cultural, emotional, social, 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. Not only does it dominate women’s thinking, research indicates ignoring its importance is potentially deadly.
Do we really want to take away a woman’s right to self-determination?
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. I find it ironic that 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. The law in this country is on the side of women and self-determination.
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 with such vigor. The unintended consequences of regulating the ‘pregnant uterus’ should give us cause for sober reflection. Where do we stop once we start and who controls what is acceptable behavior and what is not?
I genuinely believe that most health professionals are united in the belief that a woman’s right to self-determination should be protected and is protective. There have been attempts of late to regulate midwives more closely to try and indirectly regulate women.
Midwives are being reported to their registering body AHPRA with increasing frequency and some of the reports are highly vexatious. This also is concerning because when midwives are forced to abandon women who step outside accepted guidelines, then freebirth (birth at home with no health professional in attendance) – which is rising in our country – becomes an even worse option with regards to safety.
The home birth is about more than safety
It is becoming increasingly apparent when midwives and obstetricians stop warring over the safety of home birth that the argument is far more complex.
The debate around home birth 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.
Home birth also represents starkly the different philosophical frameworks held by midwifery and medicine, 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.
It is time to stop talking about the statistics and start working together to make home birth and hospital birth as safe (physical, cultural, emotional, social, psychological and spiritual) as it can be.
Perhaps then the right women will give birth in the right place at the right time and with the right health care provider and have outcomes that are both safe and satisfying.
This endpoint is something we all agree on, now let’s work together to get there.
Note: The Australian College of Midwives (ACM) Position Statement on Homebirth Services and Guidance for Midwives Regarding Homebirth Services along with a comprehensive ACM Homebirth-Literature Review that Dr Pesce referred to were interim guidelines out for consultation and have since been altered. The final documents were released last week by ACM. As you will see the right for women to choose their place of birth and care provider is strongly upheld.
These arguments assume that obstetricians are male- the womans body etc.
Hence discussion with underlying assumption of sexism
A quick look would show that the medical workforce is not male dominated.
There are a lot of female obstetricians.
They are as reluctant as their male colleagues to be involved in a situation that might leave a dead or maimed baby
Lets face it, the AMA are Australia’s most powerful trade union, and they will do anything in their power to maintain their monopoly over medical services. If that means stopping home births, they will stop home births. Ironically of course, they make sure there aren’t enough doctors regardless by restricting drastically specialist numbers.
Stop this outrageous closed shop now!
I am saddened by your comment. It shows great lack of knowledge and gives insight ++ into your preconceived ideas that unfortunately seem to also come all-too-frequently from the mouths of our federal & state politicians.
1] The AMA is not a Trade Union and has never been able to be. It is expressly disallowed from any trade union type role because of its structure as a diverse professional representative organisation.
2] The AMA has no control or even influence, unfortunately, over doctor numbers trained or registered in this country. Our calls for government to increase doctor training numbers in an orderly and sustainable way back in the mid 1990s were scornfully rejected with much personally directed invective [ I was on the receiving end ].
3] Specialist training requires practical training environments & posts, trainers, time to train, a realistic monetary value to be assigned to training and certain standards to be maintained. All of these issues are, again unfortunately, beyond any sort of control of the AMA. The facts are that most training of specialists is done on an honorary basis by College members/trainers [not AMA], training posts are linked to public hospital beds – all under great pressure of numbers, resources etc. [not under any control of the AMA]. Training of specialists takes TIME to do and time is under impossible efficiency pressures in public & private health delivery environments [ the AMA has no influence over the length of a minute, an hour or the number of hours in a day! ].
More modern generations of health care providers and students want a better work-life balance – much of the best training happens outside of those parameters [ again not controllable by the AMA ]. No one, including the AMA, has yet figured how to assign & allocate a financially viable value to the training process – everyone wants the outcome but no-one wants to pay!!
john2066, please think and learn before emotionally ‘lashing out’. You can ban the AMA if you like …. make them disappear and the only result will be that you will have no-one to blame. All else will remain the same.
Thanks Hannah. A thought-provoking piece. I agree that the definition of “safety” in regards to childbirth is limited, but understandable given the current business model of health care. Obstetricians are only interested in the successful delivery of a viable infant – that is what they are trained to do and the professional consequences for them are dire if the worst happens and the child or the mother dies as a result of the childbirth process. With the pressure of several mothers in labour and having to attend each one in a birthing unit, the obstetrician has at his/her disposal the tools to bring forward or delay a birth so that each mother receives “timely” care. All very ethical and above-board. That is not to say, however, that the definition can not be changed – a wider lens of maternal and infant health and wellbeing should be considered and this, I feel, is where the midwife model is applicable and is not inimical to the medical model.
In an ideal world midwives and obstetricians should be working together. This continuous sniping only does harm to all concerned.
liliwyt, I agree with you except for the bit about “all very ethical and above board”. It depends from whose perspective you are look. It is certainly not ethical to induce my labor (or delay it!) or inject me with hormones to hasten delivery of the placenta (or any other of the tools at the disposal of the obstetrician) because of the pressure the obstetrician is under! Ethical childbirth can only be achieved when intervention is undertaken soley for the health of the mother and baby–not to conform to the time constraints of the system. If we broaden the definition, we will have to confront some of these practices which are about the system, not the individuals who enter it. I agree, working together is always preferrable, regardless of how realistic that is, the sniping won’t solve anything.
Everything old is new again. There is nothing new in this article. For 38 years practising responsible midwifery has always been about the woman and what she needs, never any argument about this. Midwives have and still work in mutually respectful relationships with general practitioners and obstetricians. Nothing has changed, and nothing is new in these recommendations, except for the interference of politicians who rub shoulders with the likes of Dr Pesce for their own political and financial gain. The new breed of AMA and Politics has some belief that they can control every other profession and women too. Not so, midwives will continue to fight for their professional rights, and women will fight for their bodily and womanly rights. Midwifery is a respected profession in it’s own right, mutual recognition of the very different skills does not mean control of one profession over another.
Midwives provide midwifery services not obstetrics, and vice versa. Midwives provide their services for women, in keeping with the International Confederation of Midwives and statuatory regulations. Midwives who are self-employed are not beholden to doctors or institutions, they are employed by, and contracted to the women and are accountable for their actions.
Most importantly midwives are not ‘support persons’ when they enter the institutuion with a woman they responsibly transfer for the opinion of another professional. Midwives, when they cross the threshold of the hospital entrance will not accept this insult of pseudo deregistration, change of status, or change of title just because they consult with a team of institutionally employed professionals. When midwives who work ‘with women’ in any setting consult and/or refer they do not change the status of MIDWIFE to ‘support person’, they do not relinquish their registration, qualification or experience. There is no ownership of the woman or the midwife. Harmony within the team depends on the respect individuals have for the woman, and they together are the link in consultation with her for the best possible outcome, each respected for their level of knowledge, their experience, and most importantly for their ability to sit and communicate with, and talk eye to eye, face to face, with the woman at her level, not over her in a stance of dominance.
There are many responsible doctors in the Australian community who happily respectfully work with women and midwives. So the debate that continues is more about removing the politicians, the modern poorly informed restrictions, and multitude of position statements and guidelines that attempt to impede the practice of the qualified midwife, and let the professionals who are skilled and mutually respect the woman and her rights get on with what they are educated and qualified to do. Hospitals are for the sick and injured, not for the healthy. Keeping women out of hospitals for the sick and injured, returning to Community Birthing Homes and facilitating homebirth for the majority of women is the safest, and most responsible way for pregnancy, labour, birth and postnatal 6 weeks in this country. Mature Midwife.
Hi Jenny – I agree, the “ethics” are questionable and perhaps I should have parenthesised that phrase as you did. My point was that, certainly from the obstetricians’ and hospital administrators’ pov, it is preferable to deliver a baby “safely” and in some respect to control the timing of that using the medical technology available to them. It is certainly not against the law to do so. And my understanding is that you would have a hard time finding an Ethics Committee that would disagree with that, although proving “informed consent” may be problematic.
Does that make it right? No. As a woman, I agree it is not ethical (using the purest definition of the term) to use those means as part of a system that is more interested in KPIs than my and my baby’s wellbeing.
Hi liliwyt. Yes, when looked at from the pov of hospital docs and admins, true, that would look “safer” to them. But, (and I sense we are agreeing), if a broader view is taken, it would include better attention to the more subtle ways in which otherwise unnecessary (to health) interventions in a low risk, healthy pregnancy and birth, can impact upon the overall health and well being of both mothers. No one would argue against safety. However, our very understanding of the term “safe” requires some unpacking. I believe we haven’t even begun to understand (scientifically) the impact this kind of institutional treatment can have on mothers and babies.
Like the midwife above states, hospitals are for sick people (and I’m glad they are there when we need them, I take access to them as a right, an entity to be questioned and improved in an ongonig basis and called upon when necessary) but pregnant and laboring women should generally not be included in that category. To do so can only be politically driven and fear based.
When I ask women why they choose home birth their reply is “I want to feel safe”. Home is where they feel safest. For some women this is their first birth – most are well read, but there are those that are not. For a few the choice is a “can do” idea. If there are problems of access to a midwife some search far and wide. The commitment to have a home birth is matched by the statements about giving birth as one of pure joy compared with previous experience/s in various hospital settings. Statements such as “why did I ever go to hospital?” I wish I had known that this is what it is like. Most women I speak with about choice of home birth, have experienced a traumatic time in hospital. They speak of feeling out of control, noisy place, the staff are rushed and if they had a surgical birth their baby was taken away to a special care nursery and they found this alarming. They felt that if they had agreed to have to have an induction and if it led to a Caesarian Birth they felt cheated especially when they found the reasons were specious if not wrong. Many had heard of home birth choice and that is what they want the right to do. There are those I also hear from who want a hospital birth because they need a break for a stressful situation at home and those reasons are sometimes because of abuse at home (usually alcohol related) and this is across the spectrum of poor or well off homes. Work related fatigue and large families is another reason for choosing hospital given by some women. Respite these days is really only for those that can afford private care – otherwise early discharge is the custom in public hospitals. I am interested that Dr. Pesce is still talking up mortality and not acknowledging morbidity – Post Natal Depression and post surgical fatigue and poor breastfeeding statistics due to lack of support and access to the baby as a result of major abdominal surgery and chemical inductions, haemorrhage, infection, episiotomy and sometimes even hysterectomy.
I am supportive of a better dialogue between professionals to achieve safe hospital birth and safe home birth. From my times when hospital birth prior to chemical and surgical terminations of pregnancy (inductions) was rare and when doctors were real and men were men and women had been running their own hospital in Melbourne (Queen Victoria). while the playing field was not fair or equal then there was respect for each other in that field – dialogue worked. For me dollar driven obstetrics means that dialogue is impossible when midwives are not acknowledged with remuneration nor are their private practices are not equally supported by government funds through Medicare. That “dog don’t hunt”.
I wonder whether those above are aware of threats to the current government about millions of AMA dollars would be spent to prevent midwives accessing Medicare. Doctor owned and subsidised Insurance is not an even playing field. When mortality rates in hospital are still around 9.00 per thousand with limited transparency of the why and Caesarian Rates are way above WHO recommended rates in private hospitals something in the state of this Nation is on the nose.
Yes there are female obstetricians but unfortunately their mentorship is not focused on care of the woman in labour of afterwards with breastfeeding it is focused on how fast can we get this woman in and out of hospital. One private obstetrician in a major teaching hospital refuses to come to births after 5.00 pm and encourages 38 week inductions on weekdays. When pushed by a woman who was able to disprove the supposed reason for the induction in her haste to expedite the normal vaginal delivery pulled on the cord and broke it. Leading to a great deal of distress for the grandmother the mother and the husband. The is woman was not allowed to move around in labour. Enuf said –
Great debate! So much would be made much easier if the medico-legal implications, risks & costs of the types of decisions being discussed here were removed from the field of play in obstetrics & paediatrics completely.
Lets be novel and enshrine in water-tight legislation that women take full personal responsibility for their birthing choices and decisions. They can seek the education and opinion that they wish or are able to access. They make their decisions and then wear the full consequences of their decisions. Society doesn’t wear the cost consequences. Insurers don’t have to factor in the payout and legal process costs. Midwives and obstetricians are freed up from onerous protocols, legal standards and crippling costs. Decisions have consequences!
For the record, I am not an obstetrician or a medical practitioner that has ever had responsibility for a delivery in 34 years of practice.
Kim, I’m all for personal responsibility, and certainly that plays a role. But let’s not pretend that anyone’s decisions are made in a vacuum. What information will be made available to women prior to making that decision? Which women will be empowered and which will be disadvantaged by such legistlation? There are a lot of things to consider before wiping our hands of social responsibility. As a society we are not very good at encouraging people or helping them to understand their bodies, I think a lot needs to change before personal responsibility can be at the centre of this debate.
This essay presents an unusual view of the safety of birth – one which, I suspect, would not be supported by the majority of our community. Dahlen acknowledges that there are several well-defined risk-factors that threaten the lives of newborns in the homebirth situation. These include the readily-identifiable conditions of breech presentation and twins. If any other health care profession identified these causes of neonatal mortality and injury, but failed to adapt their guidelines to minimise the risk, there would be public outrage. How many parents truly value the home environment over the safety of their baby?
Dahlen presents the argument that perinatal mortality isn;t everything in birth safety – that maternal pshchological morbidity is important too. Of course it is. However, this essay reflects the other side of the argument – the severe and long-lasting psychological effects on BOTH parents of losing a child in childbirth. Is Dahlen really asserting that the psychological morbidity to a mother from having an unexpected cesarean delivery is greater than the extreme and ever-lasting grief for both parents of losing a newborn?
Finally, if it is true that the greatest cause of maternal death in the child-bearing years is psychological distress, we must remember that, in the past, it was childbirth. It’s important not to forget that the advances in clinical care for both pregnancy and delivery are the reason that maternal mortality within labour and delivery are so low in our societies. In the developing nations, where women cry out for access to the clinical care that we can be so critical of, the balance of safety is very stark.