In a recent post, Dr Andrew Pesce, a Sydney obstetrician and gynaecologist and former president of the Australian Medical Association, raised concerns about the safety of current home birth practices.

In the article below, Hannah Dahlen, Associate Professor of Midwifery, University of Western Sydney, and national media spokesperson for the Australian College of Midwives, suggests the need for a more wide-ranging debate whose ultimate goal should be making all births – whether they take place at home or in hospitals – as safe as possible.


Broadening the discussion about home births

Hannah Dahlen writes:

Once again the home birth debate rears its ugly head in public, and we spin the well-worn wheels of argument in the ever deepening intellectual (or not so intellectual) rut, hoping that somehow we will gain traction with one more scientific study or State mortality report and move the debate forwards in the direction that subscribes to our particular belief system.

After more than 20 years of reading, researching and being engaged in clinical practice I have come to the conclusion that the answer to this debate is not statistics but a shared responsibility. It is time to work together on what we agree on, whilst learning to compromise or accept that which we don’t agree on.

The principles we tend to agree on include respecting the right of women to choose where and how they give birth; making sure the best evidence is provided to women making this choice; ensuring that the practitioners attending women who choose home birth are skilled, regulated and networked into a responsive system that has women at the centre and not professional self interest.

Home birth has always been a choice women have sought in every country in the world and in every epoch in history. The numbers of women having a home birth have doubled in the USA and Australia in the past four years.

Home birth will not go away, it is here to stay, so let us all share the responsibility for making it safe and satisfying, as should be our goal with all maternity care options.

The paradigm of risk in much of the developed world is one that holds home birth as risky and hospital birth as safe.

The assumption (not entirely wrong) is when things ‘go wrong’ home is not the best place to be; however conversely we could argue when things are ‘going right’, hospital is not necessarily the best place to be and can be the cause of things going wrong as women enter what has been described as the cascade of intervention.

The reality is there are advantages and disadvantages with both places of birth, therefore we are left with a couple of options – we recognise women’s choice as valid and try to reduce the disadvantages and improve the advantages of all options of care (shared responsibility), or we obstinately put our heads in the sand and hope if we ignored it long enough home birth will go away (the current attitude to home birth in Australia).

Never in history and in no country on earth has this ever happened but in some countries concerted efforts to cater for women’s choice means hospital birth and home birth have been made safer.

The continued focus on the safety of home birth in research (primarily perinatal mortality) often leads us up a blind ally – not that perinatal outcomes are not important – but they hide agendas and underlying discourses and will not end the debate.

Handpicking research to prove your point is something we are all expert in and sadly the public who trust us to provide an ethical and objective lense remain ever more confused.

So I will begin by agreeing with Dr Pesce (I think). While home birth advocates often cite research which is supportive of the safety of home birth and home birth critics cite papers that show a lack of safety, the studies examining the safety of home birth have consistently found comparable perinatal mortality among low risk women giving birth at home with a midwife, and low risk women giving birth in hospital, but lower intervention rates and maternal morbidity.

Likewise, studies have shown that when women with high-risk pregnancies give birth at home the perinatal mortality is increased. In fact, the evidence is now substantial enough that we can identify where the greatest risk lies; for example, women giving birth to twins (especially the second twin) and breech babies.

Looking at small State reports of 160 births, where one or two deaths will alter the perinatal mortality rate dramatically, is not a sensible approach.

Any statistician will tell you when events are rare, large numbers are needed to make sure statistical errors are not made. However, we should never dismiss any evidence that may help us improve our practice and we must always be willing to learn and improve.

So, if we are agreed (mostly) that homebirth for women with risk factors in their pregnancy leads to an increase in adverse outcomes compared to hospital birth, where to next?

Well this is where we must move from the current kindergarten approach of beating one another up with handpicked statistics, to the adult approach in the debate and towards a shared responsibility.

Keeping in mind the well-founded assumption that home birth is here to stay, there are three issues we need to consider. Firstly, why do women undertake a birth at home with risk factors? Secondly, how do we define safety? Thirdly, do we really want to take away a woman’s right to self-determination.

Why do women undertake a birth at home with risk factors?

The intervention rates during childbirth have skyrocketed over the past ten years in Australia, leaving many women traumatised and fearful.

A first time mother in Australia now has a greater chance of having surgical intervention during her birth than of not having it. This is not safe, either physically or psychologically. It is expensive, has many consequences and is counterproductive to optimising normal birth and healthy mothers and babies. The ramifications of these issues are: more traumatised women due to interventions during birth; fewer options of care – especially continuity of midwifery care; fewer experienced, networked midwives available to attend women privately; and limited to no access for women to a hospital birth under a private midwife.

A woman wanting to have a vaginal breech birth in hospital will often have to fight hard and search far and wide to find a doctor to support her choice. A woman wanting to have twins in hospital without being forced into having an epidural or having the second twin virtually extracted from her body, will also have to fight hard to have her choices respected. A woman wanting to have a vaginal birth after caesarean in a birth centre may find she is ‘banned’ from this option and has limited choices available to her.

So when these women seek care outside our mainstream system, whose fault is it really?

The answer to all this is not to demonise women for their choices but to stop and consider our responsibility as a society to mothers and babies.

It is time we made our maternity care system accountable and really listened to what women are telling us and how in fact we are failing them. When a woman chooses to have a homebirth with risk factors present, the question we need to ask is not ‘what is wrong with her’ but rather ‘what is wrong with a maternity care system that provides such limited options and inspires such fear that she would take on the added risk’?

These women do not love their babies less, they fear mainstream care more and this is a terrible indictment of our care.

How do we define safety?

When health professionals, and in particular obstetricians, talk about safety in relation to homebirth, they usually are referring to perinatal mortality. While the birth of a live baby is of course a priority, perinatal mortality is in fact a very limited view of safety.

With suicide during pregnancy and the postnatal period now one of the leading causes of maternal death in Australia, the UK and USA, we are very remiss to not consider safety in a much broader context.

Cultural, emotional, social, psychological and spiritual safety rarely appear in the mainstream debates about the safety of homebirth, yet qualitative research would indicate this dominates in women’s decision making regarding choice of place of birth. Not only does it dominate women’s thinking, research indicates ignoring its importance is potentially deadly.

Do we really want to take away a woman’s right to self-determination?

Women’s right to control what happens to their bodies during pregnancy and birth may be enshrined in law but this right is frequently violated in practice. I find it ironic that the same professionals who fight for the right for a woman to terminate her pregnancy will fight against her right to give birth at home. The law in this country is on the side of women and self-determination.

To step into this and attempt to regulate a woman’s body has serious ramifications and undoes hard won battles our feminist forbears fought for with such vigor. The unintended consequences of regulating the ‘pregnant uterus’ should give us cause for sober reflection. Where do we stop once we start and who controls what is acceptable behavior and what is not?

I genuinely believe that most health professionals are united in the belief that a woman’s right to self-determination should be protected and is protective. There have been attempts of late to regulate midwives more closely to try and indirectly regulate women.

Midwives are being reported to their registering body AHPRA with increasing frequency and some of the reports are highly vexatious. This also is concerning because when midwives are forced to abandon women who step outside accepted guidelines, then freebirth (birth at home with no health professional in attendance) – which is rising in our country – becomes an even worse option with regards to safety.

The home birth is about more than safety

It is becoming increasingly apparent when midwives and obstetricians stop warring over the safety of home birth that the argument is far more complex.

The debate around home birth is about more than place of birth or associated perinatal mortality, it raises deeper and more complex issues: the right of women to have control over their bodies during childbirth, the rejection of the prevailing medical model and risk paradigm of pregnancy and childbirth, societies’ belief that they have an investment in the product of childbirth and therefore should determine what is considered safe, the culture of childbirth in a country and the position and status of women within a society.

Home birth also represents starkly the different philosophical frameworks held by midwifery and medicine, and hence the debate over this issue is ideological, contested, longstanding and circumscribed by relationships of power.

Sadly it is rarely about women and women’s voices are often dismissed or denied in the debate.

It is time to stop talking about the statistics and start working together to make home birth and hospital birth as safe (physical, cultural, emotional, social, psychological and spiritual) as it can be.

Perhaps then the right women will give birth in the right place at the right time and with the right health care provider and have outcomes that are both safe and satisfying.

This endpoint is something we all agree on, now let’s work together to get there.

Note: The Australian College of Midwives (ACM) Position Statement on Homebirth Services and Guidance for Midwives Regarding Homebirth Services along with a comprehensive ACM Homebirth-Literature Review that Dr Pesce referred to were interim guidelines out for consultation and have since been altered. The final documents were released last week by ACM. As you will see the right for women to choose their place of birth and care provider is strongly upheld.