Perinatal death associated with planned home birth in Australia

In response to Peter Sullivan's article that home births are not
justified in Australia. I challenge this assertion and point out to Mr
Sullivan and the Australian public that there is nothing unsafe about
birthing at home where the birth is planned, attended by a skilled
practitioner and where there is low risk of complications. There are
numerous published articles in the medical journals of Australia, Britain,
the United States and those of Europe to confirm this. Even the Bastian
et. al report that Mr Sullivan refers to, concludes that low risk home
births in Australia have good outcomes.

Also stated by Mr Sullivan was that the rigid criteria of the
Australian College of Midwives governing the practice of independent
midwifery are neither "enforced nor policed". This is no different for the
Royal Australian College of Obstetricians and Gynaecologists. They too
have rigid criteria but are neither "enforced nor policed" other than by
their own peers. It is as inappropriate for obstetricians to police
midwives as it is midwives to police obstetricians. They cannot dictate
how the other should practice, nor does their training make them experts
in the others field. There are health care complaints bodies in each
state that exist to handle improper health care delivery.

It is interesting that Mr Sullivan raises the subject of "policing".
In his own country there appears to be a serious lack of "policing" of the
high rate of obstetric procedures such as epidural anaesthesia, episiotomy
and electronic fetal monitoring in the face of strong evidence against
their routine use. Furthermore the fact that the World Health
Organisation promotes a caesarean rate of no higher than 10-15%, brings
into question the inadequate scrutiny of Australian caesarean rates that
in some hospitals exceed 20%. There is no adequate scrutiny of obstetric
practice outside their own profession. In particular there is no mandate
for evidence based practice. Whilst there is a large body of evidence
concluding that these routine practices and high caesarean section rates
are not producing better health outcomes for women and in fact produce
poorer health outcomes, the obstetric model of care continues with
practice in this manner, unquestioned.

Mr Sullivan states that home birth is not justified in Queensland or
in most parts of Australia because of geographical distance. Given that
the majority of Australian birthing women dwell in major metropolitan
areas with access to tertiary hospitals in the event of complications
distance is not a major concern for most women.

Mr Sullivan's comments regarding the incidence of Aboriginal
perinatal deaths cannot be taken out of context. Despite some
improvements, Aboriginal and Torres Strait Islander peoples remain the
least healthy identifiable population group in Australia. Regardless of
place of birth they experience higher rates of maternal mortality and
their infant mortality rates remain unacceptably high. Many communities
have little access to clean water and adequate sewage facilities.

In addition I believe the following factors will compromise the
safety of birthing at home in Australia:

• Women are afraid of birth due to a culture of fear promoted by
prevailing "obstetric myths" and a society that largely perceives birth as
a pathological condition fraught with pain and danger. To birth at home
with such fear would be unsafe. Effective, supportive childbirth
education classes focussing on active and natural labor and the woman's
innate ability to birth are required to turn this culture around. This
applies for all women, not just those choosing to birth at home.

• Intimidation of independent midwifery practice drives it underground
instead of embracing it as a safe and reasonable option for many women.
This perpetuates an avoidance of evidence based practice by many
practitioners both midwives (in the home and hospital) and obstetricians.
Fear and intimidation by hospital staff may force an independent midwife
to take undue risk. Similarly, in the hospital setting midwives may feel
intimidated and avoid questioning routine interventions practiced by
obstetric staff.

• Failure to match practice with research evidence. Practitioners other
than midwives, and indeed midwives themselves must insist on evidence
based practice much of which clearly advocates midwifery models of care,
minimal use of obstetric intervention and supports the model of home birth
as a safe alternative to hospital birth. All practitioners caring for
women in pregnancy and labor, in all settings must continually keep
abreast of published research with a view to improving the quality of care
and health outcomes for women.

• A lack of support for independent midwives which is vital to the safety
of home birth. Respect, good communication, support and back-up services
for homebirth midwives and their clients will encourage prompt
consultation/referral and transfer where indicated. Hospital protocol
should reflect this.

• The profession of Midwifery has been undermined and midwives are often
practicing merely as obstetric nurses. Midwifery needs to be understood
as the practice of providing woman-centred care and support during
pregnancy and labor and facilitating the normal process of physiological
labor to take place. This is not the same as obstetrics which deals with
the complications and pathology of pregnancy and labor. Midwives are
trained to recognise such pathology when it arises and consequently refer
the woman to an obstetrician.

• Lack of support for Bachelor of Midwifery Degrees that will enhance the
training of midwives and enable them to practice independently and/or
within midwifery centred care facilities in hospitals with skill and
confidence.

The reality is that pregnancy and birth for most women are normal
healthy conditions. Regardless of place of birth, in order to foster
their innate ability to bear children, women need encouragement and
support in the form of positive active child birth education and high
quality continuity of care by a midwife. Published research supports
this. For those women who encounter complications during pregnancy or
birth beyond the capacity of the midwife to manage (the World Health
Organisation suggests this applies to about 10-15% of women) referral to
an obstetrician is thankfully available.

If practitioners such as Mr Sullivan are committed to quality care
appropriate to the diverse needs of Australian women and believe in women
being able to choose for themselves health services that meet their needs,
they cannot fail to recognise these factors and support change. It is of
no use to the consumer seeking a model of care that meets their needs, for
a health professional of Mr Sullivan's standing to say home birth is not
justified. I ask, why is he not strongly supporting and advocating the
implementation of Bachelor of Midwifery Degrees; education for
professional childbirth educators and funding for the provision of
effective classes for women; the mplementation of mechanisms where
midwives will receive optimal support and back up from institutions and
colleagues and the implementation of genuine women-centred midwifery
models of care in hospitals? The only compromise to the safety of home
birth is the failure to support it as a safe and reasonable choice that
women have the right to make. Similarly, midwifery models of care in
general must be recognised for their improved outcomes and integrated into
hospitals settings. Until obstetricians support these changes I cannot
believe they have the best interests of pregnant and birthing women at
heart.

Robin Payne

Choices for Childbirth; This consumer group is a non-profit, non-commercial enterprise. It is a
community group run by consumers of maternity services for consumers of
maternity services. Everyone involved including myself works voluntarily