Thousands of people are rallying in Canberra today to demand that the Federal Government take homebirth seriously. Although Health Minister Nicola Roxon announced a last-minute back-down on proposed changes that would effectively ban private homebirths from July 2010, the threat has merely been postponed. The Rudd Government continues to demonstrate a profound lack of understanding of the reasons people choose to give birth at home.
Last year, Federal Health Minister Nicola Roxon established a Maternity Services Review and took the very positive step of announcing Medicare funding for midwives in the 2009 budget. She chose, however, not to offer funding or indemnity insurance to homebirth midwives, which would have meant that they would be operating illegally if they continued to deliver babies after legislation to establish national registration for health professionals, the National Registration and Accreditation Scheme (NRAS), came into effect.
The NRAS legislation requires all health professionals to hold indemnity insurance. That in itself is an appropriate requirement and one which is considered a standard measure of consumer safety. There’s evidence that the Federal Government understands this, having spent close to $1 billion subsidising the premiums of medical practitioners since the 2001 medical indemnity crisis.
But this understanding stops short of comprehending the very sound concerns which motivate women and their families continuing to choose homebirth.
So why do women choose homebirth? There are many reasons but a few crop up regularly. One is that homebirth offers a very supportive "model of care", whereby care during pregnancy, labour, and birth as well as through the early post-natal period is provided by one midwife. By the end of their pregnancy most women will have a close and trusting relationship with their midwife.
Immediately after a baby is born, the homebirth midwife will visit daily and then regularly thereafter for four to six weeks. Breastfeeding support takes place in the comfort of one’s home. Private homebirth midwifery combines one-to-one clinical assessment with strong emotional support. The midwife the woman has come to know and trust is always only a phone call away.
Contrast this with mainstream maternity care. Pregnancy consultations are usually short; often women need to wait for long periods. In the vast majority of cases, the intimate act of giving birth will take place with strangers present. Even for women who choose private obstetric care, an unknown midwife will provide most of the care during labour. When women leave hospital, they must establish a new relationship with post-natal service providers — who are in short supply. Women who find early parenting difficult or suffer post-natal depression are forced to share their story with yet another stranger.
Hospital-based maternity care is designed to meet the needs of clinicians and facilitate organisational efficiency. While a minority of women find childbirth does happen satisfactorily within these parameters, the majority find this difficult and may experience medical interventions to start labour, to keep labour going, to help with the pain of labour and perhaps to actually birth the baby. Homebirth offers women the very best chance of going through pregnancy, labour and birth without medical intervention.
Consumer advocates have devoted many years to the development of better maternity care and improved choices for women. Most are not opposed to interventions in birth if women are informed and have a full complement of choices available. This currently does not happen. Less than 5 per cent of women can access one-to-one midwifery care within hospitals; homebirth is currently neither funded nor insured and private health insurance all but exclusively funds the closed shop of "private obstetrics".
The majority of women who have given birth at home would be very reluctant to give birth in hospital unless absolutely necessary. Once they have experienced health care that genuinely understands their needs as central, they have little interest in entering a hospital system that seems to herd women through.
There are many ways in which the hospital birth system is far from ideal. At home women are able to work with their body, minimising pain by being active and upright. Unbelievably, many women who give birth in hospitals are coaxed to give birth lying down on a bed, defying gravity and giving themselves the most difficult labour as they push their baby "uphill". Why do so many maternity health professionals prevent women from using gravity to assist their labour? It is one small but significant sign that women are not the central consideration in hospital based maternity care.
There is a considerable difference in philosophy around childbirth expressed by hospital-based staff and homebirth midwives. In law we have a presumption of innocence until guilt is proven. In health should we not be expected to be healthy until proven unwell? In maternity care, women are regarded as walking time bombs unlikely to be able to achieve normal birth. Essentially, women are not trusted.
The mass media contributes to this view with sensationalised reports of pregnancy and birth drama. When did you last encounter a media story about a woman who gave birth without medical intervention, was well supported, and left the experience feeling powerful?
Most women who give birth at home feel well supported and have a very positive experience. Many want to shout it from the roof-tops — especially those who have had a previous caesarean or who have experienced birth-related trauma.
A growing number of women who have experienced birth trauma are refusing to give birth in a hospital again. Some of these women are so adamant that, if they are unable to afford or find a homebirth midwife, they may go it alone and give birth without a health professional. It is unacceptable that women are put in this position.
Consumers of homebirth need to be very well informed, firstly so that they can find a midwife, and then to combat the wealth of misconceptions and ingrained views about safety. It is absurd that a family who will make thousands of decisions as they raise a child may in future be prevented from deciding how and with whom their child enters the world. The premise that adults cannot be trusted to make sound decisions around care in childbirth is both paternalistic and backward.
Homebirth is a safe and appropriate choice — and is one backed by considerable evidence. The mortality data for homebirths and hospital births with similar populations returns equivalent results, but the rate of interventions for homebirths is much lower. This means women who give birth at home are far less likely to experience the morbidity that is often associated with medical interventions, including induction, epidural, and surgical birth.
Women will continue to want to choose homebirth. If the care of a private registered midwife is made unlawful, women may choose to give birth without a registered health professional or with a midwife who has gone "underground". This should not be the only path to a homebirth in Australia in this day and age. If Nicola Roxon’s proposed accreditation scheme comes into effect, Australia will be on par with the US state of Alabama, a state which still practices capital punishment and where homebirth midwifery is unlawful. That dated thinking is in striking contrast to what is happening in countries like Canada, New Zealand, the United Kingdom and the Netherlands. These countries don’t just permit homebirth, they have recognised its value by setting up national homebirth schemes.
We have the opportunity now to decide which of these two paths we take.
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