On average around 700 Australian women choose to give birth at home each year. Some have a history of sexual abuse or have had traumatic hospital experiences, some want to feel more in control, some want a natural or water birth, and others simply want the one-to-one continuity of care they can get with a midwife.
However the future of homebirths in Australia is unclear.
Under the National Registration and Accreditation Scheme announced last year, privately practicing midwives are able to obtain professional indemnity insurance for pre-natal and post-natal services for the first time since 2002.
The scheme takes effect on July 1 this year in NSW, QLD and Victoria, and in the other states as it is legislated.
It does not, however, cover privately practising midwives for the intrapartum (delivery) stage of childbirth.
Under the scheme, midwives can no longer work without appropriate professional indemnity insurance relating to the care they provide.
This would have effectively made it illegal for private midwives to deliver homebirths. But, following strong opposition from midwives and homebirth groups, the government has offered an exemption for the intrapartum stage for privately practising midwives until June 30 2012.
The government is yet to announce what will happen after the exemption expires. But there is a concern that if homebirth were to be outlawed, as originally legislated, it would merely drive it underground.
“It would lead to women birthing without the professional attendance of a midwife,” said Professor Hannah Dahlen, head of the Australian Midwives Association, “it would make it more risky.”
“Some women will always choose homebirth; that’s just the way it is”, agreed Professor Caroline Homer,
Opinion on the safety of homebirth is divided.
Some studies have shown a greater risk in homebirth. The Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) deem homebirth unsafe and states that no model of care should be offered for homebirths, as this would provide “de facto evidence of an acceptable margin of safety”.
However numerous studies indicate that for low-risk women, there is little difference in safety between home and hospital.
Although he believes hospitals remain the safest option, Professor Michael Chapman – Director of Women’s and Babies’ Health at St George and Sutherland hospitals – said if mothers are properly screened, have given birth at hospital before, and midwives have undergone extra training to deal with emergencies, the risks are “very small”.
If you trade off “the relaxation it’s alleged to produce in women”, he said, “against the incredibly low risk of a problem, then it’s reasonable”.
Studies have also revealed that in countries such as the UK and the Netherlands, where infrastructure for transfer and referral is in place, the risk associated with homebirth is lower.
“There is good international evidence”, said Homer, “that homebirth for women who have low risk of complications and who are receiving care from a registered midwife who is working in a system where there is easy access to transfer and referral… homebirth is as safe as hospital birth.”
As well as through privately practicing midwives, there are currently publicly funded homebirth programs available through hospitals – including St George. These programs will not be affected by new laws because midwives working in hospitals are insured through the public health system. But so far these programs are not very widespread.
Homer said increasing the number of publicly funded homebirth models would be a “good strategy to… increase women’s access to homebirth”.
While the position of RANZCOG is that these programs are not feasible in Australia because of “vast distances in rural settings, and heavy city traffic in Melbourne and Sydney”, Homer believes there is no reason why Australia is so different. “We just haven’t developed the systems; it’s not that they can’t be developed”, she said.
“It certainly could be (extended)”, agreed Professor Chapman, “but it does require appropriate training and experience.”
Chapman said that the St George homebirth “transfer rate was around the 10% mark and had had no prenatal deaths or any major problems.”
An alternative to homebirth is to increase the number of birthing centres, which offer ‘at-home’ style births conducted by midwives and are usually located in or near hospitals. But these too are not yet widespread enough.
“Women are booking in at 5 weeks pregnant”, Homer said. “Women who really need or want a birth centre, who don’t know that… miss out.”
Another option is to improve the hospital system to better cater to women’s needs, including the ones that drive women to choose homebirth in the first place.
“Too many high risk women are opting for homebirth,” said Homer. “We need to make the hospital system better so that women who have risk don’t feel they don’t have any option.”
She said the most important thing was for women to have caregivers they trust.
“Continuity of caregiver is fundamental,” she said. “Women do not want to have see 30 caregivers through a pregnancy, which is what happens in most standard maternity services now.”
“We need to be able to give midwives access to hospitals, friendly reception and collaborative respectful relationships,” said Dahlen, “so that if a woman has risk factors, the midwife will say, ‘Well, I will be there with you, and we are going to continue to respect and care for your needs’.”