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Aug 24, 2009

We’re not homebirth wingnuts, we just want equal treatment

The issue of homebirth is up there with abortion -- it divides the community into those who think it is OK, and those who don’t, writes Homebirth Australia's Justine Caines.

The issue of homebirth is up there with abortion — it divides the community into those who think it is OK — and those who don’t. Sometimes no amount of evidence, opinion, or research will convince either side.

Bernard Keane’s article in Friday’s Crikey is based on two incorrect pieces of information. The first is that “no one is stopping Australian women who want home births from choosing them”. The second is that there exists “considerable evidence” that home births are dangerous.

Let’s start with the first. As of July next year it will no longer be legal to have a home birth attended by a registered private midwife in Australia. This is not “wingnuttery” or the collective delusion of home birth advocates across the country, it is simply a fact. The reason is that the state and Commonwealth governments are implementing a National Registration and Accreditation Scheme for health professionals.

As part of this scheme a health professional must hold professional indemnity insurance in order to register to practise. Private midwives are presently unable to obtain such insurance because there is no insurance product available for them to purchase: collectively they form too small a pool to make it financially worthwhile for an insurer to provide that product.

The legislation currently before Parliament proposes indemnity insurance to some midwives. It is not at all clear who these midwives will be only that they are “eligible” and that they will work “collaboratively” and that they won’t attend home births. Extending this legislation to cover home birth midwives is the only realistic way that home birth with a registered private midwife will remain an option for Australian women after July 2010.

This is why so many women (and men) across Australia have written to Nicola Roxon, visited their local MPs and made submissions to the recent Senate inquiry concerning this legislation.

The second piece of incorrect information is that home birth is an inherently dangerous and high risk option. There is a body of evidence regarding the safety of home birth. The most recent published study (only a few months ago), of over half a million low risk births showed that women and their babies were as safe at home as they were in hospital. Even the Australian home birth study published over a decade ago found that low risk women were no less safe at home giving birth.

That study did point out that the practices of unregistered midwives versus registered practitioners was the issue of concern. The fact is that flawed research from the 1970s which falsely concluded home births were not safe has mis-informed government policy for decades.

The UK Department of Health website states that “for a healthy woman experiencing a normal pregnancy with no major complications anticipated during the birth, studies have shown that it is equally safe to be attended by midwives in the comfort of your own home as to have your baby in hospital.” The Department of Health in the UK has made one of its priority targets for 2009/10 to give more mothers-to-be the opportunity to choose to give birth at home.

One could write many pages setting out the breadth of evidence that supports home birth as an option for women but that distracts from the fact that at its heart this debate is not about safety or risk or insurance. It is not a turf war about whether obstetricians or midwives should be the most important care provider for pregnant women. It is about whether all Australian women have the autonomy to make their own choices about how they will give birth — a fundamental choice about a fundamental life experience.

In this country we accept that a woman has a right to choose an abortion. But as of July next year we won’t accept that a woman has a right to choose to give birth at home attended by qualified and registered caregivers.

There is also an underlying horror that home birth women are daring to ask the Government to look at funding their birth choices. This is simply a matter of fairness. Women who give birth at home are the only women in Australia whose birth choices receive no funding at all. At the opposite end of the birth spectrum a woman can have a non-medically indicated elective c-section under the care of a private obstetrician and her choice will be funded.

This choice will ensure that she can use up even more of the taxpayers money by being guaranteed to have more intervention, a longer hospital stay, possibly more postnatal morbidity and potentially her baby going to a neonatal special care unit. The Government will contribute towards the costs of all the specialists who will need to be involved in her care — an obstetrician, a back-up obstetrician, an anaesthetist and a paediatrician.

Additionally in the event of her obstetrician negligently causing her or her baby an injury she can take legal action because the Government has supported the insurance premium payments for her obstetrician and will reimburse the obstetrician’s insurer for the costs of high claims. The cost nearing the billion dollar mark. The Department of health and ageing recently stated that Australian obstetricians faced adverse events at the rate of 1.1 per thousand. In New Zealand where midwives care for 80% of women the adverse incident rate with a midwife has been 5 in the last 300,000 births. This makes Australian data 66 times higher. C’mon the taxpayer has footed a billion dollars in premium support.

Home birthing women are not asking for any special treatment from the Government. They are simply asking that they still be able to choose to home birth with registered midwives after July 2010 and that the Government treat them in the same manner as it treats all other women giving birth. Bernard Keane calls it “wingnuttery”, we call it equity.

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37 thoughts on “We’re not homebirth wingnuts, we just want equal treatment

  1. Kathryn McCallum

    Thanks Justine for telling it like it is.

  2. JaneShaw

    Whether you are in favour of home births or not, no one could argue that this article has any wingnuttery in it. Well done on producing a calmly informative piece.

  3. Greg Angelo

    It appears that the problem in this case is not the government preventing home births, but the requirement for the claimed technical specialists involved to carry appropriate indemnity insurance. It would appear that these simple solution to this problem is for the advocates of home birth to underwrite personally the insurance indemnity necessary to enable registered midwives to deliver at home. On this basis, registered midwives could obtain the insurance necessary to provide their clients with the necessary means of redress should they make an actionable mistake, and the cost of such redress would be borne by the advocates.

    On this basis the risk of this potentially risky procedure would be borne by the advocates of this practice and not by the community as a whole. If the home birth process is as safe as the advocates claim it is, it should not be difficult for a dedicated group of supporters to pledge the necessary financial support to convince an underwriter to manage the risk.

  4. MD

    Good article Justine, clears up a few things including several of my own misconceptions about the situation. It seems that the problem has come about due to the collision of two changes, one being the changes to the medicare schedule to include more allied health items (including midwifery) and the other being changes to the system for registration. One provides more “choice” while the other appears to be having the unintended consequence of taking it away.

    However, you are still asking for special treatment. What you are asking for is the Government to pay for liability insurance for one group of health professionals, working as private contractors, to make house calls. This is unique in the whole health system. The question is not whether it is special treatment you’re asking for, it’s whether that treatment is deserved. Are you lobbying the insurance industry with the same vigour asking them to provide an appropriate insurance product?

    And once again, you’re comparing apples with oranges – the overall rate of adverse events with all obstetric patients vs the rate of adverse events with (by definition) low risk patients are not comparable. If you look at the adverse event rate in specialist women’s hopsitals they are higher than in other hospitals. Why? Because of the fact that these centres are dealing with all the high complexity, difficult, high risk births. Adverse events do not mean mistakes!

    Home birth is safe, as long as you select the right mums and the midwives are good at what they do. You’ve convinced me. Now go and convince the insurers.

  5. Kindred

    Thank you Justine for so clearly and intelligently setting the record straight. Women simply must maintain the right to birth where and how they want, and social, beaurocratic structures must bend to that right, not the other way around.

  6. Ann Jorgensen

    Greg – you’re a genius! What a sensible and well-thought out response to the problem. While we’re at it, the Government should also cease all of the insurance premium and claims support that it provides for obstetricians. Those that advocate for hospital birth can put their money where their mouth is. After all if its as safe as they claim it is, it shouldn’t be difficult to convince an underwriter to manage the risk without the millions of dollars currently being spent by the government to prop up the system.

  7. Tony Blackmore

    Home birth may be a nice idea for some; but take heed of this:

    My daughter had a totally normal pregnancy and everything went normally until a few moments after the birth. Partner and mother were smiling and my daughter had the baby in her arms and then it came – a massive hemorrhage and unconsciousness.

    Fortunately it was in a maternity hospital, a crash team arrived within the minute and my daughter survived.

    A home birth and we would have had a death.

    Tony Blackmore

  8. james mcdonald

    Greg and MD: If what Justine says is true that “the Government has supported the insurance premium payments for her obstetrician and will reimburse the obstetrician’s insurer for the costs of high claims. The cost nearing the billion dollar mark”, then do you have any suggestions how to to “convince” the insurers to cover midwives outside hospitals? Easy, just set up a co-op with all the millions they have lying around and tell the insurers that if a payout is really high they won’t have to pay it. Great, that’ll work!

  9. Evan Beaver

    Yes it was a good article. Clear and rational.

    Some of the commenters would do well to remember that ‘the plural of anecdote is not data.’

  10. Monica Kane

    Justine thank-you for providing a balance to Bernard’s article. I was disappointed in reading his polemical piece. I normally enjoy his work.

    Through a holistic approach women and families must have the right to choose where they birth. I do not feel the need to lecture others on the benefits of homebirthing. I trust that people can weigh up the information and access suitable medical advice in deciding their place and plan for birth. I expect society to allow me the same right.

    As Justine pointed out the government framework ensures the insurance (as it should,) of professionals in this field. Except midwives operating from home. This exclusion is potentially creating discrimination.

    Justine you have provided a well informed argument and I hope Bernard acknowledges your contribution to this discussion. However if information or balance was his objective, he would have asked an agency spokesperson in the first place.

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