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Federal

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.

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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 comments

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Kathryn McCallum
Member

Thanks Justine for telling it like it is.

JaneShaw
Guest

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.

Whistleblower
Member
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… Read more »
MD
Member
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… Read more »
Kindred
Member

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.

Ann Jorgensen
Member

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.

Tony Blackmore
Member

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

MaxwellsDemon
Member

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!

Eponymous
Member

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.’

Monica Kane
Member
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… Read more »
Karl Fitzgerald
Member
As someone who has enjoyed the benefits of midwifery with the birth of our first child, I’m shocked at this development. One wonders what the new President of the National Association of Specialist Obstetricians and Gynaecologists (NASOG), Dr Hilary Joyce has to say about this? As the forst woman elected as the head of this peak body, will she stand up for the rights of women to choose? Did her predecessor allocate a % of funds towards lobbying for enhanced monopolistic control of this very private issue? The <a href=”http://www.crikey.com.au/2008/11/19/maternity-health-reform-has-harmed-women-but-not-obstetricians/”profits delivered per baby are assured to raise eyebrows. One wonders… Read more »
Nadia David
Member
Thanks Justine for making the points I imagine a few people would like to in response to Bernard’s article. Home birth as an option clearly isn’t about just settling in and having your baby at home without any consideration of your personal situation, your pregnancy, your baby and the risk factors those three things throw up. You would be mad, and so would any midwife/practitioner, to support and attend the home birth of a woman with risk factors. I have never heard any home birth proponent suggest such a thing. And that is where you’re going a bit astray MD.… Read more »
corbie68
Member

I find it disturbing that nothing is being done to support women’s options in this matter, I’m not a wingnut hippy either Nadia and if I ever got pregnant I doubt I would go the home birth option, but still to deny women the right to that option over a bunch of technicalities is a serious health policy oversight at best.

Chris Johnson
Member

Thanks Justine for your article. One question before I comment – where does Joyous Birth fit into the home birth process?

hozozco
Member
My wife and I planned a home birth last year. In the end we needed to transfer to the hospital and narrowly avoided a caesarian. So I’ve managed to see both sides (from the male perspective anyway). Our privately employed midwives (we had 2), were competant and professional (if totally uninsured). We also encountered an excellent obstetrician who worked hard to facilitate a ‘natural’ (non-caesarian) birth. I’m a Nurse and I can appreciate how dangerous hospitals are. They’re full of over-worked, often very tired Nurses/Midwives/Doctors that can really do some nasty things to you if you’re not careful (I’m now… Read more »
Pete WN
Member

Thanks Justine – good article.

I’m in favour of less hospital resources for mothers who don’t want or need them; done safely of course. There were good arguments as to why that should happen.

Justine Caines
Member
Dear MD Thanks for your considered comments. I acknowledge that comparing total obstetric data with midwifery data is not comparing like with like, but I used it because the difference was so huge. The NZ incident data alone assists us to argue midwifery and homebirth risk. Yes as total volunteers we do brief insurers. This is a difficult proposition when the largest Australian based insurer is owned by Dr’s. Regarding the comments that we are asking for special treatment. Currently the Premium Support Scheme covers private practice medicine. The High Cost of Claims Scheme provides further assistance for the high… Read more »
Chris Johnson
Member
I’m assuming Roxon’s National Registration and Accreditation Scheme for home birth industry professionals is designed to ensure equal treatment for women and their unborn in addition to providing both with maximum protection. Registering midwives in accordance with the Scheme’s criteria promotes opportunities for the same insurance indemnity offered to other allied health professionals such as pharmacists, psychologists etc. The US home birth guru Marsden Wagner says “midwives take care of normal pregnant women, while hospital-based obstetricians take care of complicated, high-risk pregnancies.” Regulation of the home birth industry would establish guidelines for healthy and high-risk mums including those with extreme… Read more »
KerryMcG
Member
Dear Bernard Your standard of journalism has been a delight. You’ve been switched on enough to see what’s really going on in ALP Qld and other areas when most journalists have been recycling press releases. But you’ve been sold a pup on the homebirth issue. Arne Garborg explains it nicely when she said: “It is said that for money you can have everything, but you cannot. You can buy food, but not appetite; medicine, but not health; knowledge, but not wisdom; glitter, but not beauty; fun, but not joy; acquaintances, but not friends; servants, but not loyalty; leisure, but not… Read more »
gef05
Member

@ Chris Johnson

Awesome. That site you linked to is quoting Andrew Bolt.

Game Over.

Damien
Member
No-one has yet given me a convincing reason why midwives for homebirths should be exempt from holding professional indemnity insurance. O&Gs do indeed have government assistance to subsidise their insurance, but as a non-procedural GP, I get no subsidy at all. Picture this possibility: One day in my consulting room a flustered midwife rushes in asking for help. I run across the road to attend a woman in labour, whom I’ve never met, with a severe unexpected birth complication. An ambulance is called and I help as much as I can with my limited resources, but a disabled infant results.… Read more »
Chris Johnson
Member

Apologies to GEFO5. Here’s the link that disturbed me. http://www.joyousbirth.info/articles/janetsfreebirth.html

john2066
Member
Good article. Lets not forget the real reason home births/midwives are being banned – the greedy medical profession. They will stop at nothing to make sure all medicare rebates go to themselves, and make sure that everything has to go through their hands. Despite all the evidence home births are safe. Naturally there are chronic shortages at all levels of medical specialists – because they keep it that way. Recently it emerged of obstetricians taking 2 million dollars a year – yes 2m a year -out of medicare. As usual the media slobbers all over the doctors. And as for… Read more »
Dom
Member
When “home births are good” hits my ears I normally hear “modern scientific medicine is rubbish”. That annoys me, of course. One, because there are good reasons that the average lifespan of a human has almost double in the last 120 years or so (in western society, anyway), and it’s not due to the rise of alternative medicine. Two because it got rid of smallpox and almost got rid of polio. Three because my wife and I are certainly only alive today due to scientific medicine, so I take it personally. Four because by then I’m not really listening, as… Read more »
Angie
Member
It’s really surprising to me that you can choose to have an elective c-section in this country whic costs thousands of dollars, but you can’t choose to have a planned and supervised homebirth. Obviously hospitals are equipped with every medical convenience, but the realilty of childbirth is that for many women, these medical conveniences are not wanted or needed to safely deliver their babies. I say this too as a mother of two who has had 2 c-sections. So while I personally wouldn’t have been able to have a homebirth for medical reasons, I strongly support the rights of women… Read more »
petethegeo
Member

I still hold that it should be the right of the patient to sign away rights to litigation in the event of a misshap (except in the case of gross negligence) we had such forms for hangliding instruction and they saved a sport that the insurance companies were going to shut down due to denial of service….
Hm. Interesting that we could even get insurance, let alone a right to sign a waiver, I would think there are fewer hanglider pilots in Aus than home-birth advocates and I’m sure the miss-hap rate (per capita) in hangliding is a lot higher.

Venise Alstergren
Member
MONICA KANE: Bernard Keane did ask for an agency spokesperson prior to writing his article. If you had taken the trouble to read his comment properly you would have seen words to the effect that on Monday Justine Caines of Homebirth will be putting the official point of view. It is a shame that it was necessary to wait until Monday before a well reasoned and calm comment was to be made. Frankly, I was appalled by the tone of so many of the comments, especially those coming from the supporters of home birthing. Seldom have I heard/read so many… Read more »
rmacfarl
Member

A well-reasoned and welcome response. I have a question though… Are there guidelines for homebirth which would stipulate when a transfer to hospital is mandatory to protect the health of mother and/or baby (e.g. pre-37 weeks gestation, pre-eclampsia, breach birth, complications during labour, etc.)? And if not, wouldn’t it be best to establish such, and clearly communicate these to all. I repeat my earlier comment: ultimately, whatever the means, the end we all want is both a healthy mother and a healthy baby…

Justine Caines
Member
Dear Venise Bernard asked for no such comment. I called him on Friday afternoon to discuss the inaccuracies of his piece and it’s overall tone. Bernard challenged me to a response, to prove to him I was not a ‘wing-nut’. I provided the published response and also a critique of the Maternity Services Review outlining the inaccuracies of it, as Bernard had quoted data from it. Venise currently OUR taxes fund a very expensive obstetric dominated maternity system. Despite a rising caesarean and other intervention rate, the perinatal death rate has remained fairly static, the cerebral palsy rate has not… Read more »
Monica Kane
Member
Justine thank-you for your clarification regarding an opportunity to respond to Bernard’s article. Venise, your right, I didn’t ‘take the trouble’ to read all the comments as at the time I read Bernard’s piece there were no comments. I did not look again until reading Justine’s piece on Monday. Regardless, Bernard could easily have sourced a balanced response. There are many options aside from a youtube video. It appears either purposeful or lazy. Either is not the writing I expect when reading something by Bernard. In regards to the tone in many of the comments, I agree. At times the… Read more »
Kate
Member
There comes a time when the benefit of technical ‘improvements’ is outweighed by the iatrogenic harm produced. Childbirth is at risk of being caught at this tipping point. Has the pendulum swung too far? At beginning of the 20th century, there was widespread concern about the physical deterioration of the British people. One in 10 infants died before they were a year old, and many of those who survived reached adult life in poor health. During 1902, reports in the British national press claimed that up to two thirds of the young men who volunteered to fight in the Boer… Read more »
Venise Alstergren
Member
Monica Kane: Nevertheless BK DID say The Home Birthing Association will be commenting on Monday. You merely had to scroll through the piece to find it in comment form. If, as it sounds, you are a spokesperson for this organization you should not only have gone to the trouble to research anything I may have said, far more important to have researched something the author of the piece may have said. I’m disappointed that you didn’t enjoy my calling some of your organization’s madder commenters as being po-faced, if anyone personified that description it was the dolorous and tasteless woman,… Read more »
Monica Kane
Member
Venise, firstly I would like to clarify that I am not a spokesperson for the organisation. Had I been, I would have declared this. I believe in women’s rights and I am a homebirth advocate (based on experience). This does not mean I think all women should have homebirth nor do I believe it to be a superior choice. There is a huge difference, as I am sure you understand, between advocacy and religion. Although your comments were not directed at me, I don’t feel the comparison is accurate, in fact it is merely reductionism. I agree with your point… Read more »
Alison Croggon
Member
Venise, I can’t but notice that you don’t offer others the same courtesy that you demand from them. I have to say the various women who were – quite reasonably – objecting to their being characterised as “wingnuts” for choices they made with care, deliberation and after rational research didn’t seem holier-than-thou to me. Anyone who researches pregnancy and childbirth is acutely aware that many things can go wrong in the best of circumstances. Tragically, mothers and babies die in childbirth (as often in hospital as in homebirth situations) and nobody wants that outcome in any circumstance. That should be… Read more »
Veronica
Member
It disturbs me that deciding whether to have your child in a hospital or at home has become an issue about ‘women’s rights’. It is so perverse as to be stupid. Surely what every woman wants, first and foremost, is to deliver their child safely – that is, deliver the child in a manner that is safe for both mother and baby. Now when someone has an acute illness such as pneumonia for example, we do not argue about whether the person should be treated at home or in a hospital. We accept the logic that the hospital is most… Read more »
greg wood
Member
I only saw this today but really had to comment. I’ll be a Dad soon, my beautiful wife and I have discussed the choices we have and are choosing a home birth with an independent midwife. We thought through it all carefully, spoke with friends who have had home births and hospital births and made an informed decision. We are funding it ourselves and are really happy with our decision. What I don’t get is the people that harp on about ‘tax payers money’ if a transfer to hospital is necessary? How inconsiderate and inhuman. We all deserve the right… Read more »
Gender-Equity
Member
Readers I thank the earlier evidenced based comments regarding the topic of Home Births and Maternal Care. I would like to see more competition, choice and time series research on maternal care in Australia. I would also like to see the debate widened, as the current maternal care environment in Australia is too restrictive, outdated, expensive and not of world’s best practice. Pregnancy: More choice and competition amongst obsteticians. The choice to be cared for by a dedicated midwife for the term and birth. Greater flexibility in work practices for parents to be. Birth: bring back water births and baths… Read more »
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