Women’s Birth Rights Under Threat

Women’s Birth Rights Under Threat

by Sally Dillon

The sun streamed into our loungeroom as my second son swam into my arms. Covered in creamy vernix, my baby nestled contentedly against my chest, cocooned by the warm water of the birthpool, as I leaned back against my husband, buzzing with adrenaline and love.

I sought the eyes of my three-year-old son, Tasman, who had watched my beloved midwife and friend, Betty, help deliver his much-anticipated sibling. A couple of women friends – one caring for Tasman, another taking photographs – had shared this joyous moment.

There was an amazing energy in the room: excitement, wonder and joy. Banjo’s birth was the culmination of a nine-month relationship between Betty and our family, which saw her visit us monthly, then weekly, then daily in our own home, getting to know us and to empower us to birth naturally. After the birth she continued to visit to help us care for our new child.

It was an extraordinary moment in what was in many ways just another ordinary day. We woke early, ate breakfast, met with friends, did some washing and played in the loungeroom. Except that on this day I also had the most extra-ordinary birth, at home, surrounded by my family and friends.

There was no panic, no nervous dash to a hospital, no stark room, no uniforms, no strange faces, no pressure, no bright lights and no intervention. Just a knowledge that my body knew what it had to do and that I had the caring support of loved ones and a midwife who had helped bring thousands of babies into the world.

For my husband there was the chance to be an active partner in the birth, providing physical and emotional support in a place he felt comfortable.

For Tasman there was no terror at being separated from a parent and no mystery as to where the new baby came from. Just two hours of helping dad fill the birth pool, working on his sticker book and occasionally wandering over to mum as I leant against the kitchen table: ‘What doing?’ ‘Having a contraction darling.’

And then a new baby brother, whose first action on coming into the world was to slowly and deliberately turn his head towards the voice he’d heard so much in the womb as Tasman shyly told us the sex of his sibling: ‘A girl, with a penis!’

Twenty minutes after being born Banjo nuzzled against my chest, seeking a nipple and then latching on without any help. He fed beautifully as I caressed the vernix into his chubby limbs.

Tasman helped cut Banjo’s umbilical cord once it had stopped pulsing. Then, with Banjo cuddled against his dad I luxuriated in a hot shower in my own bathroom. I then sat in a fluffy bathrobe in my rocking chair, nursing Banjo as my sons exchanged presents. We cut the cake Tasman and I had made in preparation for our Birth-Day party, and the grownups popped a bottle of champagne.
Sadly, few Australian women and their families have the privilege of experiencing a lovingly supported pregnancy and beautiful birth like this. Less than 1% of women – around 700 a year – plan to birth at home, supported by a private midwife. The cost (up to $5000) of a midwife whose services are not covered by Medicare; the unfounded belief that birth is safer in a hospital; and the shortage of midwives who are willing to practice without professional indemnity insurance contribute to this low homebirth rate.

Push to Make Homebirth Illegal

And, if new recommendations before the Federal Government are adopted, from July 2010 it will become illegal for registered midwives to provide private homebirth services to Australian women.

Many people had hoped this year’s much-anticipated report from the federal Maternity Services Review would help stem Australia’s disturbing trend towards interventionist, obstetric birth. Instead, it includes recommendations that, if adopted by the Federal Government, will see homebirth outlawed.

This is because all health professionals are required to move to a National Registration scheme by July 2010. A prerequisite of this scheme is professional indemnity insurance. However, such insurance has been unavailable to private homebirth midwives since 2001, on the grounds that the pool of people requiring it is too small.

It is illegal to practise midwifery without registration, and the offence carries a jail term.

While the Federal Government stepped in to subsidise indemnity insurance premiums for GPs and obstetricians in 2002, no such assistance was offered to private midwives. It was hoped that the Review would see this policy changed, but instead the Review Report has recommended against the government offering indemnity insurance support for private homebirth midwives.

It makes this recommendation as part of a wider opposition to homebirth, with the Review Team concluding it ‘does not propose Commonwealth funding of homebirths as a mainstream option for maternity care at this time.’  [1]

The review’s antagonistic stance towards homebirth is perplexing for several reasons. First, the majority of the 960 submissions explicitly supported homebirth, making it most-represented single issue. For the hundreds of people writing these submissions homebirth is a satisfactory model of maternity care and one they would like to see extended.

Secondly, large studies have shown that homebirth with a qualified midwife is as safe as birthing in a hospital (see the boxed text ‘Homebirth: Is it Safe?’).  And third, the Review ostensibly supports a midwifery-driven model (as opposed to an obstetric one) that would improve women’s access to midwifery care and information about pregnancy and birth. The Review’s recommendations also propose culturally appropriate care for indigenous women, better support for women in pregnancy and postnatally, and more collaborative relationships between caregivers. All these things can be achieved by supporting private homebirth midwifery.

Instead, the Report ignored its own public consultation process, declaring that it would not support homebirth because it ‘is the preferred choice for…[only]…a small number of women’ and that supporting the practice ‘risks polarising the professions’ of obstetricians and midwives.

Homebirth – Is It Safe?

In April this year a study of almost 530,000 low-risk births over seven years in the Netherlands, where almost one in three mothers birth at home, concluded that there was no difference in death or serious illness among either mothers or their babies if they gave birth at home rather than in hospital [8].

Another recent large-scale study of 5000 women planning a homebirth in the US and Canada found that outcomes for mothers and babies were the same as for low-risk mothers giving birth in hospitals, but with a fraction of the interventions. [9]

Sadly, the widely promoted view that childbirth is unsafe has seen the seeds of doubt sewn by recent sensationalist media articles against homebirth fall on fertile ground. In particular, it has seen journalists accept claims from obstetricians without further research.

The safety of childbirth in hospital remains largely unchallenged. However, of the 821 perinatal deaths in NSW in 2006, 96.2% of them were among planned hospital births and only 0.2% of them in planned homebirths. [10]

Worrying Precedent

Whatever your views on homebirth, it should be worrying that such reasons could provide the foundation for decision-making in a democratic nation.

Firstly, being in the minority should not be an acceptable reason for discrimination in public policy. Would the government refuse education funding to a religious school because it only catered to a small group of students? The small numbers of women using homebirth midwifery services is probably a result of public policy: if homebirth was Medicare funded and private homebirth midwives backed by professional indemnity insurance more women would choose to birth this way.  More midwives would also be willing to offer the service.

Secondly, in refusing to support homebirth midwifery in an attempt to placate obstetricians intent on protecting their turf the Review Team has set a dangerous precedent, that of placing the demands of a private business lobby ahead of the desires and needs of consumers.

Women, the bearers of the children, are being treated with disregard, as merely the meat in the sandwich.

The High Cost of Birth

Australians should be concerned about the high cost of the current maternity system. Childbirth is the highest volume area of health and accounts for the greatest number of bed stays. In addition to the state-administered hospital budgets, Medicare Safety Net payments are soaring. Payments made to obstetricians under the Safety Net have increased by approximately 300% over the past four years. In 2007 Safety Net payments for obstetric services cost the taxpayer $98.6 million, sapping 31% of the Safety Net budget. [2]

Taxpayers are also paying for current birth practices through the 30% rebate on private health insurance. Private hospitals have caesarean rates of up to 80%, well above the World Health Organisation recommended level of 10 to 15%.

In addition, since 2002 the Federal Government has spent around $900 million on providing professional indemnity insurance support to GPs and obstetricians, and in underwriting their liability. [3]

It is disturbing that despite all this investment, Australia’s neo-natal mortality rate hasn’t improved in the past 15 years. Perfectly healthy women with low-risk pregnancies are being cared for in a highly managed, high-cost environment to the detriment of other vital health services.

Supporting homebirth midwifery is one way the government could begin to redress the imbalance in its health spending while improving outcomes for birthing women.

The Issue is Freedom of Choice   

The Review states that its ultimate goal for Australian mothers is ‘safe, high-quality and accessible care based on informed choice’. It is useful to look more closely at each of these aims.

Firstly, safe and high-quality care does not have to mean obstetric, hospital-based care. The World Health Organisation maintains that employing obstetricians as the primary caregiver for low-risk pregnancies is an inappropriate use of funds that makes obstetricians less available to those women who need them most. Similarly with hospitals: WHO is critical of the large public health strain of providing beds for every labouring woman in facilities that are equipped to deal with every type of obstetric emergency. [4]

Secondly, supporting private homebirth midwifery, and expanding the number of professionals offering the service, could help provide more accessible care. This is a major problem in Australia, with the closure of around 130 maternity units in the past decade. This has deprived many women of the opportunity for continuity of care and the support of family and friends in a familiar environment, and imposes the expense of having to travel to a major centre before the birth.

And choice? When less than 5% of Australian women have access to midwife-led care you can hardly describe the system as one that offers freedom of choice. This, under WHO guidelines, is the freedom for a woman to birth ‘in a place she feels is safe’. [4] Whether that is her home, a birth centre or a hospital, women should be supported in that choice and given access to professional care in that setting.

However, such freedom of choice is opposed by the groups such as The Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) and the Australian Medical Association (AMA), whose submissions repeatedly stated their opposition to homebirth and pleaded with the government to maintain ‘Obstetrician led maternity care’ [5]. The AMA’s submission also criticised birth centres.

The medical lobby’s opposition to homebirth puts the future of existing hospital-run homebirth programs in doubt. Publicly funded homebirth has been available for a small number of women for many years in Western Australia and South Australia through Community Midwifery Programs.  More recently it has been available through a few hospitals in Sydney and Wollongong, Alice Springs and Darwin.

Amid such an atmosphere of hostility how can such programs thrive?

Even if these programs are maintained and hopefully even expanded under the overhaul of maternity services there will still be a need for private homebirth midwives to help women who can’t access these schemes.

The Review’s recommendations run counter to state policy, contradicting NSW Health’s homebirth directive to meet the needs of women requesting homebirth. They also put Australia behind international trends: in the UK the Government has pledged to give all women the option of a homebirth by the end of 2009.

The Gold Standard of Care

Caseload midwifery, where one midwife cares for one woman, is the gold standard, as recommended by WHO for the 75 to 80% of women who experience normal, healthy pregnancies. WHO says, ‘The midwife appears to be the most appropriate and cost effective type of health care provider to be assigned to the care of normal pregnancy and normal birth, including risk assessment and the recognition of complications.’ [4]

WHO points out that midwifery care helps avoid situations where the normal physiological process of birth is treated as a medical procedure, which ‘interferes with the freedom of women to experience the birth of their children in their own way, in the place of their own choice; it leads to unnecessary interventions.’ [4]

This is backed up by a study released last year that showed benefits for women in midwife-led care include fewer hospital admissions, fewer epidurals or any need for pain relief, fewer surgical cuts to the perineum, fewer forceps and vacuum births. Midwife-led care was also found to result in increases in normal vaginal births, greater feelings of control during labour and birth, higher breastfeeding rates and shorter hospital stays for babies. Significantly, this research showed no difference in the numbers of babies dying – though fewer appeared to die before 24 weeks gestation under midwife care. None of the other major complications of pregnancy and birth were any different. [6]

Why Women Choose to Homebirth with a Private Midwife

Women who choose to homebirth have researched their options, educate themselves of the natural risks of childbirth and take whatever steps they can to prepare themselves mentally and physically for birth. They have often had a negative birth experience within the hospital system.

It is important to make a distinction between homebirth with a private, registered midwife and freebirth, in which the woman births at home without professional support.

Homebirthing women develop a relationship with their midwife, who visits their home at a time convenient to the family. The midwife is available on call and will not change shift halfway through a birth.

Although homebirths are usually achieved without intervention, a private midwife’s intimate knowledge of their client means they can detect complications early. If needed they can administer emergency care during transfer to hospital: a woman can usually be transferred in the time it takes to prepare an operating theatre.

Homebirth midwives also continue to visit post-natally, providing emotional and physical support for breastfeeding, settling and other baby-care issues.

Conclusion

Even if you think homebirthing is not for you, the issue is that the Maternity Services Review does nothing to redress the lack of choice for all women in birthing services in Australia. The Review’s recommendations are based on the prevailing – and flawed – ideology that pregnancy is a medical condition that needs to be managed in a hospital.

There will always be women and babies who need specialist medical care. However, that should be the exception rather than the norm.

What Australian women need is a maternity health system where obstetricians work cooperatively with midwives to deliver true freedom of choice. If those choices are limited to birthing only within a hospital and only in a way that makes the obstetric lobby happy then women are being short-changed.

In the United Kingdom the Royal College of Obstetricians and Gynaecologists and the Royal College of Midwives have released a joint statement supporting homebirths, saying, ‘There is no reason why home birth should not be offered to women at low risk of complications and it may confer considerable benefits for them and their families. There is ample evidence showing that labouring at home increases a woman’s likelihood of a birth that is both satisfying and safe, with implications for her health and that of her baby.’ [7]

Our Federal Government needs to follow the UK’s lead by pledging to give women choice in where they birth. Private homebirth should be Medicare funded, and professional indemnity insurance for private homebirth midwives should be subsidised.

WHAT YOU CAN DO
1.    Write to Minister for Health & Ageing Nicola Roxon at Parliament House Canberra ACT 2600 (or at Nicola.Roxon.MP@aph.gov.au, though snail mail is better), saying that you want women to retain freedom of choice in how they birth. Ask that homebirth be Medicare funded and that the government support homebirth midwives in obtaining indemnity insurance.
2.    Write to your local MP with the same message. Your MP is your voice in parliament: the more MPs who petition Nicola Roxon to support homebirth the better. Ask to meet MP to discuss the issue.
3.    Sign the petition at http://www.ipetitions.com/petition/australianhomebirth/
4.    Ask your friends and family to do the same.

The fundamental issue is one of women’s rights. How is it more acceptable for a woman to choose an elective caesarean (without clinical need) than for a woman to choose to birth at home? How can a democratic government legislate to direct a woman where she should engage in the most intimate of acts, and with whom she shares this remarkable event?

References:
    1.    Improving Maternity Services in Australia: The Report of the Maternity Services Review, Commonwealth of Australia, February 2009
    2.    Improving Maternity Services in Australia: A Discussion Paper from the Australian Government, Commonwealth of Australia, 2008
    3.    Medical Indemnity Policy Review Report: Achieving Stability & Premium Affordability in the Australian Medical Indemnity Marketplace, Medical Indemnity Policy Review Panel, Commonwealth of Australia, February 2007
    4.    Care in Normal Birth: A Practical Guide, World Health Organisation, 1997
    5.    ANZCOG, SA & NT Regional Committee Submission Document, Maternity Services Review, October 2008
    6.    ‘Midwife-led Versus Other Models of Care for Childbearing Women’, Hatem M, Sandall J, Devane D, Soltani H, Gates S, Cochrane Database of Systematic Reviews 2008, Issue 4
    7.    ‘Homebirths: Joint Statement No.2’, Royal College of Obstetricians and Gynaecologists and Royal College of Midwives, April 2007
    8.    ‘Perinatal Mortality & Morbidity in a Nationwide Cohort of 529,688 Low-Risk Planned Home & Hospital Births’, A de Jonge, BY van der Goes, ACJ Ravelli, MP Amelink-Verburg, BW Mol, JG Nijhuis, J Bennebroek Gravenhorst SE Buitendijk, BJOG: An International Journal of Obstetrics and Gynaecology, April 2009
    9.    ‘Outcomes of Planned Home Births with Certified Professional Midwives: Large Prospective Study in North America’, Johnson KC and Daviss B, BMJ 2005; 330:1416, 18 June
    10.    ‘NSW Mothers & Babies 2006’, New South Wales Health, Sydney, March 2009