Why planned attended homebirth should be more widely supported in Australia

Why planned attended homebirth should be more widely supported in Australia

Dr Lareen Newman on why Homebirth should be supported with an interesting editorial reply from Obstetrician, Dr David Ellwood.

This article argues that the continuing reluctance on the part of professional and bureaucratic bodies in Australia to provide for and support planned attended homebirth for low-risk women is unfounded according to the research evidence. It also suggests that such lack of support might be encouraging some planned but intentionally unattended homebirths to occur in Australia, particularly as in recent years there appears to have been an increase in popularity in freebirth (or do-it-yourself homebirth). The article calls for RANZCOG and Australian state health departments to support planned attended homebirth for low-risk women in the face of what is now a considerable amount of evidence showing its safety, when compared with unplanned homebirth and hospital birth. The article raises a number of challenging issues for obstetricians, midwives and managers or planners of maternity services.

This article is written following the 2008 release of the American College of Obstetricians and Gynecologists’ (ACOG) revised Statement on Homebirth, in which it ‘reiterates its long-standing opposition to home births’, and in anticipation of the review of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) equivalent which is set for November this year.[1,2] The article questions the continuing reluctance on the part of professional and bureaucratic bodies involved in maternity care to provide for and support planned attended homebirth for low-risk women, in the face of the balance of the research evidence which does support its safety.

For the past 50 years or so in English-speaking developed countries such as the USA, Britain and Australia, choosing a planned homebirth has been seen by the general public as ‘risky’, and this picture has generally been reinforced by doctors and cultural stereotypes. This is reflected in the fact that both the ACOG and the RANZCOG currently provide a blanket statement of non-support for any type of homebirth, without any discussion of the balance of the medical research on risk of maternal and infant mortality and morbidity for low-risk women, without any comparison with the risks for low-risk women of hospital birth, without differentiating whether the homebirth is planned or unplanned, and without differentiating whether the birth is attended by a qualified and experienced homebirth midwife (or general practitioner (GP)) or is completely unattended. The ACOG Statement relies solely on what ACOG ‘believes’ and cites no research whatsoever to support the claim that ‘studies comparing the safety and outcome of births in hospitals with those occurring in other settings in the US are limited and have not been scientifically rigorous’.

By comparison, the RANZCOG Statement on Homebirth does at least cite some research evidence, although this is simply listed at the end and not discussed in the text, which is particularly disappointing for consumers of maternity care. Furthermore, despite the RANZCOG Statement being essentially against homebirth, it still lists in its references the largest yet prospective study that supports homebirth, in concluding that ‘planned home birth for low risk women in North America using certified professional midwives was associated with lower rates of medical intervention but similar intrapartum and neonatal mortality to that of low risk hospital births in the United States’.[3] The case against homebirth in Australia is also frequently supported in the general debate by the misquoting of Bastian et al. by focusing on the finding that ‘the death rate in Australian home births was higher than comparable births nationally and home births in other countries’, yet conveniently failing to mention that ‘the higher perinatal death rate in Australian home births was due to the inclusion of predictably high risk births’. The authors’ actual conclusion was that ‘while homebirth for low risk women can compare favourably with hospital birth, high risk homebirth is inadvisable and experimental (post-term birth, twin pregnancy and breech presentation)’.[4]

Both the American and the Australian/New Zealand College Statements therefore fail to acknowledge the balance of the research evidence that planned homebirth results in no greater mortality or morbidity for mother or infant if the pregnancy is deemed to be low risk, if the labour/ birth is attended by suitably qualified and experienced health professionals, and if the woman lives within reasonable distance of back-up obstetric services.[5–7] The latest data show that 744 women planned a homebirth in Australia in 2005, and of these 81% actually birthed at home.[8] The College Statements also ignore the social and psychological aspects of birth that are important to women as consumers and that are more likely to be accommodated in the demedicalised environment of a homebirth. The ACOG Statement even goes so far as to disparage consumers seeking homebirth as being ‘trendy’, ‘following fashion’, or joining a ‘cause celebre’. The situation is considerably more progressive in the UK, where the Royal College of Obstetricians and Gynaecologists and the Royal College of Midwives released a Joint Statement on Homebirth in 2007 which does acknowledge the balance of the research evidence which differentiates between risk levels and supports homebirth for women with uncomplicated pregnancies.[9]

Despite the lack of official support by RANZCOG, two publicly funded models of care which include an option for planned attended homebirth have operated in Australia for the past ten years in South Australia and Western Australia through a community midwifery program in each state, albeit for only limited numbers of women.[10,11] Publicly funded homebirth also became available from 2005 (again only for small numbers of women) in New South Wales through the St George Public Hospital at Kogarah, and in the Northern Territory in Darwin and Alice Springs.[12,13] A government policy or guidelines on homebirth exist for Western Australia and New South Wales.[14,15] The South Australian Government also released its first Policy for Planned Birth At Home in July 2007,[5] but at the time of writing there appear to be institutional and bureaucratic delays to its implementation through the health department and/or public maternity hospitals. The policy’s implementation would expand publicly funded homebirth options beyond South Australia’s single community midwifery program at present.

Limited government funding and limited support from obstetricians in Australia mean that the only way most women can have a homebirth is to pay privately for the services of an independent (privately practising) midwife. For those who cannot afford this, who live in an area where independent midwives are not available or not allowed to practice, or where they have no access to an independent midwife that they consider suitable, the option to have a freebirth without professional help appears to be becoming more attractive, either to avoid the financial costs of planned homebirth or the perceived contact with medicalised maternity care for a hospital birth. Freebirth may also be attractive to women who have no access to hospital waterbirth, or to in- or out-of-hospital birth centre care (for which places in Australia, for example, are limited to less than 10% of birthing women and which have been closing down rather than expanding in recent years).[8] Data from the United Nations show that when medicalised hospital services do not meet women’s emotional or social needs or their basic human rights then women will avoid these services, even if this means birthing at home without a qualified maternity professional and putting their own or their baby’s health at greater risk in clinical terms.[16]

Recent years have indeed seen the growing popularity of the grassroots movement of freebirthing (otherwise known as do-it-yourself homebirth, unassisted birth, unhindered birth, pure-birth, solo birth, or couples birth: Wikipedia).[17] A freebirth is a planned homebirth that the parents arrange to be intentionally unattended by any midwifery or obstetrically trained health professional, even if professional care is sought during pregnancy. In this respect freebirth goes far beyond traditional planned homebirth which is intentionally attended, predominantly by midwives or GPs, and unplanned homebirth which is unintentionally unattended due to a precipitous labour ‘before arrival’ at a hospital. There is no official data collection for freebirths in Australia. However, using South Australia as an example, about ten births a year are registered at home for which there is no midwife’s form for a planned homebirth (note: South Australia births account for only 7% of the national total).[18] However, if freebirthers are attending hospital antenatal care and postnatal care and just birth unassisted at home they may be counted with the babies who are ‘born before arrival’ (BBAs) at the intended hospital. South Australia recorded 73 BBAs in 2006, while New South Wales recorded 369 in 2005.[18,19] Anecdotal evidence from consumer groups and childbirth educators since early 2007 shows that consumers are now beginning to ask about freebirth, whereas previously it was never raised. Further indication of popularity as opposed to occurrence may also be shown by Unassisted Pregnancy & Childbirth Australia (www.purebirth-australia.com) having 985 registered members, and recording an increase in website hits from just 350 a month in March 2006 to around 3000 in June 2007.[20] Freebirth has also attracted increasing attention in the popular media, with headlines such as ‘If you thought a homebirth was radical, prepare yourself for freebirthing.’[20–25]

It can be argued that the increasing popularity of freebirth with consumers is partly a result of the lack of mainstream provision and public funding or reimbursing for planned attended homebirth for low-risk women. A brief review of freebirth websites (based mainly in the USA, Britain and Australia) and of media articles shows several reasons why women choose freebirth, and these do include the lack of independent homebirthing midwives in a particular area, the unaffordability of private-midwifery fees, and the lack of publicly funded homebirth, as well as the belief that the set of risks associated with homebirth are no higher than the set of risks for hospital birth, which is associated with excessively high medical intervention rates (e.g. caesarean rates around 30% in the USA and Australia, and up to 50% for first-time mothers in some private hospitals).[21–29] However, all that the medical fraternity in the USA and Australia appear to be doing in response to women turning to freebirth is simply to warn of ‘the dangers’ without any recourse to the balance of the medical evidence, and without supporting the alternative of safe, planned, attended homebirth.[30][31] In light of the already undiscerning College Statements about homebirth, consumers could well interpret such comments about freebirth as just another ‘cry wolf’.

This article therefore questions the continued denial of support by the ACOG, the RANZCOG (as reflected in their official Statements on Homebirth), and by various state health departments for low-risk, planned and professionally attended homebirth, because homebirth under these criteria is supported by research evidence. The continuing lack of support is causing cognitive dissonance in the minds of maternity consumers who are aware of the increasing research evidence base, particularly through their increased access to the Internet, but who fail to see this evidence reflected in the Statements and in mainstream public maternity services. It is therefore time for the Colleges and health departments to move forward and support safe homebirth (planned and attended homebirth for low-risk women) as part of comprehensive mainstream maternity care in its own right. It would also be encouraging to see this support reflected in obstetricians’ attitudes as they provide their skills as specialists in complications in friendly, accepting and accessible hospital-based services for women who transfer from a homebirth (both with an independent or hospital-employed midwife). At the same time it would also be prudent to improve the level of ongoing monitoring, evaluation and publication of clinical outcomes and consumer satisfaction associated with all models of care and places of birth in Australia so that this evidence can inform consumer choice and individual practitioner practice, as well as the future government provision of services. As Bastian et al. pointed out, such an audit would help detect patterns of avoidable problems, while also ensuring that women who choose to birth at home in Australia are provided with effective care and support in their choice.[4] The author looks forward with hopeful anticipation to the next version of RANZCOG’s Statement on Homebirth, which is due for review in November this year.

References:
    1.    American College of Obstetricians and Gynecologists. Statement on Homebirths. Media Release, 6 February 2008.
http://www.acog.org/
    2.    Royal Australian and New Zealand College of Obstetricians and Gynaecologists College Statement: Homebirths, 2006.
[Accessed on 12 February 2008.] Available from URL: 
http://www.ranzcog.edu.au/publications/statements/C-obs2.pdf
    3.    Johnson K, Daviss B. Outcomes of planned home births with certified professional midwives: Large prospective study in
North America. BMJ 2005; 330: 1416–1422.
    4.    Bastian H, Keirse MJ, Lancaster P. Perinatal death associated with planned home birth in Australia: Population based study.
BMJ 1998; 317: 384–388.
    5.    Department of Health South Australia. Policy for Planned Birth at Home in South Australia. Adelaide, SA: Government of South Australia, 2007.
    6.    Leslie MS, Romano A. Appendix: Birth can safely take place at home and in birthing centres. Journal of Perinatal Education – Supplement 2007; 16: 81S–88S.
    7.    World Health Organization (WHO). Care in Normal Birth: Report of a Technical Working Group. Geneva: WHO, 1997.
[Accessed on 15 February 2008.] Available from URL: 
http://www.who.int/reproductive-health/publications/MSM_96_24/MSM_96_24_…
    8.    Australian Institute of Health and Welfare. Australia’s Mothers & Babies 2005. Perinatal Statistics Series. Sydney, NSW: National Perinatal Statistics Unit, 2007.
    9.    Royal College of Obstetricians and Gynaecologists, and Royal College of Midwives. Homebirths. Joint Statement No. 2 April 2007. [Accessed on 20 February 2008.] Available from URL:
http://www.rcog.org.uk/index.asp?PageID=2023.
    10.    Nixon A, Byrne J, Church A. The Community Midwives Project: An Evaluation of the Set Up of the Northern Women’s Community
Midwives Project. Adelaide, SA: Northern Metropolitan Community Health Service, 2003. 
http://www.whs.sa.gov.au/pub/final_document_Evaluation_CMP.pdf
    11.    Community Midwifery Western Australia. Annual Report 2005–06. Fremantle, WA: Community Midwifery WA Inc.
http://www.cmwa.net.au/Downloading/Annual%20Report%20October%202006v2.pdf
    12.    South Eastern Sydney Illawarra Health Service. Media release: St George home deliveries, 24 April 2007. New South Wales Health.
    13.    Department of Health & Community Services. Media release: new beginnings for homebirth, 2005. Darwin, NT: Northern Territory Government. 
http://www.nt.gov.au/health/news/2005/news_new_beginnings_for_homebirth….
    14.    Department of Health Western Australia. Homebirth Policy and Guidelines for Management of Risk Factors. Perth, WA: Principal Nursing Advisor’s Office, 2001.
    15.    New South Wales Health Department. Homebirth Policy Statement. Sydney, NSW: Government of New South Wales, 2000. 
http://www.health.nsw.gov.au/nursing/images/cir2000-53.pdf
    16.    United Nations Population Fund (UNFPA). State of the World Population 2004. New York: UNFPA, 2004.
    17.    Unassisted Childbirth. Wikipedia. [Accessed on 20 February 2008.] Available from URL: 
http://en.wikipedia.org/wiki/Unassisted_childbirth.
    18.    Department of Health (2007). Pregnancy Outcome in South Australia 2006. Pregnancy Outcome Unit, Epidemiology Branch, Government of South Australia.
    19.    New South Wales Health (2007) New South Wales Mother & Babies 2005. NSW Public Health Bulletin, 18, S-1.Tait A. I gave birth completely alone. Marie Claire, Feature 2007; September 5. 
http://au.lifestyle.yahoo.com/b/marie-claire/2379/i-gave-birth-completel….
    20.    Boodman SG. Do-it-yourself delivery. Washington Post, 31 July 2007.
    21.    Gosline A. Extreme childbirth: Freebirthing. New Scientist Print Edition 2007; 2585: 40–43.
    22.    Groskop V. Going it alone. The Guardian, 9 May 2007. [Accessed on 15 February 2008.] Available from URL: 
http://www.guardian.co.uk/society/2007/may/09/health.medicineandhealth
    23.    Robotham J. Hard labour: A family’s search for maternity care. The Sydney Morning Herald, 10 October 2004.
    24.    Switzer R. No doctor, no midwife – Women go it alone. The (Melbourne) Age 2007: 27 May. 
http://www.theage.com.au/news/parenting/no-doctor-no-midwife-151-women-g… fullpage#contentSwap1
    25.    Bornfree website. [Accessed on 20 February 2008.] Available from URL: 
http://www.unassistedchildbirth.com/uc/whatisuc.html
    26.    Freebirth Q&A. [Accessed on 10 February 2008.] Available from URL: 
http://www.birthkeeper.com/Freebirth.html
    27.    Shanley LK. Unassisted Childbirth. Westport, CT: Bergin & Garvey, 1994.
    28.    Unassisted Childbirth Australia. [Accessed on 5 February 2008.] Available from URL: 
http://www.purebirth-australia.com.
    29.    Davies H. Dangers in DIY birthing: Doctors warn mums-to-be against consulting web for advice. The (Brisbane) Sunday Mail, 3 June 2007, p. 19.
    30.    Kelland K. Freebirthers dismiss fear and bring babies home. Reuters 23 May 2007. [Accessed on 22 February 2008.] Available from URL: 
http://www.reuters.com/article/healthNews/idUSL2148514320070523.