tag:theconversation.com,2011:/au/topics/home-birth-1874/articlesHome birth – The Conversation2024-02-20T05:26:29Ztag:theconversation.com,2011:article/2238522024-02-20T05:26:29Z2024-02-20T05:26:29Z‘Free birthing’ and planned home births might sound similar but the risks are very different<figure><img src="https://images.theconversation.com/files/576666/original/file-20240220-28-49adlz.jpg?ixlib=rb-1.1.0&rect=22%2C143%2C2973%2C1850&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/couple-prays-together-wife-labors-birthing-477573283">In The Light Photography/Shutterstock</a></span></figcaption></figure><p>The death of <a href="https://protect-au.mimecast.com/s/mdtqCvl1EwSp8GrOUQvN9o?domain=dailymail.co.uk">premature twins</a> in Byron Bay in an apparent “<a href="https://www.naturalbirthandbabycare.com/wild-pregnancy/">wild birth</a>”, or free birth, last week has prompted fresh concerns about giving birth without a midwife or medical assistance.</p>
<p>This follows another case from <a href="https://www.theguardian.com/australia-news/2024/jan/06/baby-in-critical-condition-in-victoria-after-being-delivered-in-freebirth">Victoria</a> this year, where a baby was born in a critical condition following a reported free birth. </p>
<p>It’s unclear how common free birthing is, as data is not collected, but there is some evidence <a href="https://theconversation.com/during-covid-19-women-are-opting-for-freebirthing-if-homebirths-arent-available-and-thats-a-worry-142261">free births</a> increased during the COVID pandemic. </p>
<p>Planned <a href="https://pubmed.ncbi.nlm.nih.gov/32994144/">home births</a> also became more popular during the pandemic, as women preferred to stay away from hospitals and wanted their support people with them.</p>
<p>But while free births and home births might sound similar, they are a very different practice, with free births much riskier. So what’s the difference, and why might people opt for a free birth? </p>
<h2>What are home births?</h2>
<p><a href="https://raisingchildren.net.au/pregnancy/labour-birth/birth-environment/homebirth-pregnancy-care-birth">Planned home births</a> involve care from <a href="https://midwives.org.au/Web/Web/About-ACM/Whats_a_midwife.aspx">midwives</a>, who are <a href="https://www.health.gov.au/topics/nurses-and-midwives/in-australia#:%7E:text=The%20Australian%20Health%20Practitioner%20Regulation,(NMBA)%20regulates%20nursing%20registrations.">registered</a> experts in childbirth, in a woman’s home. </p>
<p>These registered midwives work privately, or are part of around 20 <a href="https://www.uts.edu.au/about/faculty-health/school-nursing-and-midwifery/collective-midwifery-child-and-family-health/research/key-research-areas/publicly-funded-homebirth/national-publicly-funded-homebirth-consortium#:%7E:text=The%20National%20Publicly%2Dfunded%20Homebirth,and%20help%20sustain%20these%20models">publicly funded home birth programs</a> nationally that are attached to hospitals. </p>
<p>They provide care during the pregnancy, labour and birth, and in the first six weeks following the birth.</p>
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Read more:
<a href="https://theconversation.com/explainer-what-are-womens-options-for-giving-birth-55133">Explainer: what are women's options for giving birth?</a>
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<p><a href="https://pubmed.ncbi.nlm.nih.gov/29727829/">The research</a> shows that for women with low risk pregnancies, <a href="https://pubmed.ncbi.nlm.nih.gov/31709403/">planned home births</a> attended by competent midwives (with links to a responsive mainstream maternity system) are <a href="https://www.thelancet.com/pdfs/journals/eclinm/PIIS2589-5370(19)30142-7.pdf">safe</a>. </p>
<p>Home births result in <a href="https://pubmed.ncbi.nlm.nih.gov/32280941/">less intervention</a> than hospital births and women perceive their experience <a href="https://pubmed.ncbi.nlm.nih.gov/32636161/">more positively</a>.</p>
<h2>What are free births?</h2>
<p>A <a href="https://theconversation.com/for-some-women-unassisted-home-births-are-worth-the-risks-5179">free birth</a> is when a woman chooses to have a baby, usually at home, without a registered health professional such as a midwife or doctor in attendance. </p>
<p>Different terms such as <a href="https://aucontemplativelife.wixsite.com/unassistedhomebirtha">unassisted</a> birth or <a href="https://www.naturalbirthandbabycare.com/wild-pregnancy/">wild pregnancy or birth</a> are also used to refer to free birth.</p>
<p>The parents may hire an <a href="https://pubmed.ncbi.nlm.nih.gov/29803611/">unregulated birth worker or doula</a> to be a support at the birth but they do not have the training or medical equipment needed to manage emergencies.</p>
<p>Women may have limited or no health care antenatally, meaning risk factors such as twins and breech presentations (the baby coming bottom first) are not detected beforehand and given the right kind of specialist care. </p>
<h2>Why do some people choose to free birth?</h2>
<p>We have been studying the reasons women and their partners choose to free birth for <a href="https://www.routledge.com/Birthing-Outside-the-System-The-Canary-in-the-Coal-Mine/Dahlen-Kumar-Hazard-Schmied/p/book/9780367506605">more than a decade</a>. We found a previous <a href="https://bmcpregnancychildbirth.biomedcentral.com/articles/10.1186/s12884-020-02944-6">traumatic birth</a> and/or feeling coerced into choices that are not what the woman wants were the main drivers for avoiding mainstream maternity care. </p>
<p>Australia’s childbirth <a href="https://theconversation.com/too-many-healthy-women-are-having-their-labour-induced-for-no-identified-medical-reason-our-study-shows-161281">intervention rates</a> – for induction or augmentation of labour, episiotomy (cutting the tissue between the vaginal opening and the anus) and caesarean section – are comparatively high.</p>
<p>One in ten women <a href="https://theconversation.com/1-in-10-women-report-disrespectful-or-abusive-care-in-childbirth-186827">report disrespectful or abusive care in childbirth</a> and some decide to make different choices for <a href="https://theconversation.com/more-than-6-000-women-told-us-what-they-wanted-for-their-next-pregnancy-and-birth-heres-what-they-said-211435">future births</a>. </p>
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Read more:
<a href="https://theconversation.com/more-than-6-000-women-told-us-what-they-wanted-for-their-next-pregnancy-and-birth-heres-what-they-said-211435">More than 6,000 women told us what they wanted for their next pregnancy and birth. Here's what they said</a>
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<p><a href="https://pubmed.ncbi.nlm.nih.gov/32636161/">Lack of options</a> for a natural birth and birth choices such as home birth or <a href="https://theconversation.com/having-a-baby-at-a-birth-centre-is-as-safe-as-hospital-but-results-in-less-intervention-125732">birth centre</a> birth also played a major role in women’s decision to free birth.</p>
<p><a href="https://www.uts.edu.au/about/faculty-health/school-nursing-and-midwifery/collective-midwifery-child-and-family-health/research/key-research-areas/publicly-funded-homebirth/national-publicly-funded-homebirth-consortium#:%7E:text=The%20National%20Publicly%2Dfunded%20Homebirth,and%20help%20sustain%20these%20models">Publicly funded home birth</a> programs have very strict criteria around who can be accepted into the program, excluding many women.</p>
<p>In other countries such as the <a href="https://www.nhs.uk/pregnancy/labour-and-birth/preparing-for-the-birth/where-to-give-birth-the-options/">United Kingdom</a>, Netherlands and <a href="https://info.health.nz/pregnancy-children/labour-and-birth/where-to-give-birth/">New Zealand</a>, publicly funded home births are easier to access. </p>
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<img alt="Newborn baby holds their parent's finger" src="https://images.theconversation.com/files/576700/original/file-20240220-26-l9zg5j.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/576700/original/file-20240220-26-l9zg5j.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/576700/original/file-20240220-26-l9zg5j.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/576700/original/file-20240220-26-l9zg5j.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/576700/original/file-20240220-26-l9zg5j.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/576700/original/file-20240220-26-l9zg5j.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/576700/original/file-20240220-26-l9zg5j.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">It can be difficult to access home birth services in Australia.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/newborn-baby-holds-onto-their-fathers-1519293962">Ink Drop/Shutterstock</a></span>
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<p>Only around 200 midwives provide private midwifery services for home births nationally. Private midwives are yet to obtain insurance for home births, which means they are risking their livelihoods if something goes wrong and they are sued.</p>
<p>The cost of a home birth with a private midwife is not covered by Medicare and only some health funds rebate some of the cost. This means women can be out of pocket A$6-8,000. </p>
<p>Access to home birth is an even greater issue in rural and remote Australia.</p>
<h2>How to make mainstream care more inclusive</h2>
<p>Many women feel constrained by their birth choices in Australia. After years of research and listening to thousands of women, it’s clear more can be done to reduce the desire to free birth. </p>
<p>As my co-authors and I outline in our book, <a href="https://researchdirect.westernsydney.edu.au/islandora/object/uws:58756/">Birthing Outside the System: The Canary in the Coal Mine</a>, this can be achieved by:</p>
<ul>
<li><p>making respectful care a reality so women aren’t traumatised and alienated by maternity care and want to engage with it</p></li>
<li><p>supporting midwifery care. Women are seeking more physiological and social ways of birthing, minimising birth interventions, and midwives are the experts in this space </p></li>
<li><p>supporting women’s access to their chosen place of birth and model of care and not limiting choice with high out-of-pocket expenses</p></li>
<li><p>providing more flexible, acceptable options for women experiencing risk factors during pregnancy and/or birth, such as having a previous caesarean birth, having twins or having a baby in breech position. Women experiencing these complications experience pressure to have a caesarean section</p></li>
<li><p>getting the framework right with policies, guidelines, education, research, regulation and professional leadership.</p></li>
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<p>Ensuring women’s rights and choices are informed and respected means they’re less likely to feel they’re left with no other option.</p><img src="https://counter.theconversation.com/content/223852/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Hannah Dahlen receives funding from NHMRC, ARC and MRFF</span></em></p>A free birth is when a woman chooses to have a baby, usually at home, without a registered midwife or doctor in attendance. It’s much riskier than a planned home birth.Hannah Dahlen, Professor of Midwifery, Associate Dean Research and HDR, Midwifery Discipline Leader, Western Sydney UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2178032023-12-18T23:18:02Z2023-12-18T23:18:02ZWomen want to see the same health provider during pregnancy, birth and beyond<figure><img src="https://images.theconversation.com/files/566233/original/file-20231218-17-b7lsjp.jpg?ixlib=rb-1.1.0&rect=8%2C146%2C5742%2C3578&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/mid-adult-female-nurse-comforting-tensed-228783766">Tyler Olson/Shutterstock</a></span></figcaption></figure><p>In theory, pregnant women in Australia <a href="https://theconversation.com/explainer-what-are-womens-options-for-giving-birth-55133">can choose</a> the type of health provider they see during pregnancy, labour and after they give birth. But this is often dependent on where you live and how much you can afford in out-of-pocket costs. </p>
<p>While standard public hospital care is the <a href="https://www.aihw.gov.au/reports/mothers-babies/maternity-models-of-care/contents/about">most common</a> in Australia, accounting for 40.9% of births, the other main options are: </p>
<ul>
<li>GP shared care, where the woman sees her GP for some appointments (15% of births)</li>
<li>midwifery continuity of care in the public system, often called <a href="https://theconversation.com/call-the-midwife-playing-catch-up-with-australias-maternity-care-22544">midwifery group practice</a> or caseload care, where the woman sees the same midwife of team of midwives (14%)</li>
<li>private obstetrician care (10.6%)</li>
<li>private midwifery care (1.9%). </li>
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<p>Given the choice, which model would women prefer?</p>
<p>Our <a href="https://bmcpregnancychildbirth.biomedcentral.com/articles/10.1186/s12884-023-06130-2">new research</a>, published BMC Pregnancy and Childbirth, found women favoured seeing the same health provider throughout pregnancy, in labour and after they have their baby – whether that’s via midwifery group practice, a private midwife or a private obstetrician. </p>
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Read more:
<a href="https://theconversation.com/more-than-6-000-women-told-us-what-they-wanted-for-their-next-pregnancy-and-birth-heres-what-they-said-211435">More than 6,000 women told us what they wanted for their next pregnancy and birth. Here's what they said</a>
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<h2>Assessing strengths and limitations</h2>
<p>We surveyed 8,804 Australian women for the Birth Experience Study (BESt) and 2,909 provided additional comments about their model of maternity care. The respondents were representative of state and territory population breakdowns, however fewer respondents were First Nations or from culturally or linguistically diverse backgrounds.</p>
<p>We analysed these comments in six categories – standard maternity care, high-risk maternity care, GP shared care, midwifery group practice, private obstetric care and private midwifery care – based on the perceived strengths and limitations for each model of care.</p>
<p>Overall, we found models of care that were fragmented and didn’t provide continuity through the pregnancy, birth and postnatal period (standard care, high risk care and GP shared care) were more likely to be described negatively, with more comments about limitations than strengths. </p>
<h2>What women thought of standard maternity care in hospitals</h2>
<p>Women who experienced standard maternity care, where they saw many different health care providers, were disappointed about having to retell their story at every appointment and said they would have preferred continuity of midwifery care. </p>
<p>Positive comments about this model of care were often about a midwife or doctor who went above and beyond and gave extra care within the constraints of a fragmented system. </p>
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<img alt="Baby being cleaned after birth" src="https://images.theconversation.com/files/566239/original/file-20231218-29-ls16h5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/566239/original/file-20231218-29-ls16h5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=397&fit=crop&dpr=1 600w, https://images.theconversation.com/files/566239/original/file-20231218-29-ls16h5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=397&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/566239/original/file-20231218-29-ls16h5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=397&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/566239/original/file-20231218-29-ls16h5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=499&fit=crop&dpr=1 754w, https://images.theconversation.com/files/566239/original/file-20231218-29-ls16h5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=499&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/566239/original/file-20231218-29-ls16h5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=499&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Sometimes midwives and doctors in the public system exceeded expectations.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/baby-being-cleaned-assessed-by-paediatrician-1118249573">Inez Carter/Shutterstock</a></span>
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<p>The model of care with the highest number of comments about limitations was high-risk maternity care. For women with pregnancy complications who have their baby in the public system, this means seeing different doctors on different days. </p>
<p>Some respondents received conflicting advice from different doctors, and said the focus was on their complications instead of their pregnancy journey. One woman in high-risk care noted:</p>
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<p>The experience was very impersonal, their focus was my cervix, not preparing me for birth.</p>
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Read more:
<a href="https://theconversation.com/1-in-10-women-report-disrespectful-or-abusive-care-in-childbirth-186827">1 in 10 women report disrespectful or abusive care in childbirth</a>
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<h2>Why women favoured continuity of care</h2>
<p>Overall, there were more positive comments about models of care that provided continuity of care: private midwifery care, private obstetric care and midwifery group practice in public hospitals. </p>
<p>Women recognised the benefits of continuity and how this included informed decision-making and supported their choices.</p>
<p>The model of care with the highest number of positive comments was care from a privately practising midwife. Women felt they received the “gold standard of maternity care” when they had this model. One woman described her care as:</p>
<blockquote>
<p>Extremely personable! Home visits were like having tea with a friend but very professional. Her knowledge and empathy made me feel safe and protected. She respected all of my decisions. She reminded me often that I didn’t need her help when it came to birthing my child, but she was there if I wanted it (or did need it).</p>
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<p>However, this is a private model of care and women need to pay for it. So there are barriers in accessing this model of care due to the <a href="https://doi.org/10.1016/j.wombi.2020.06.001">cost</a> and the small numbers working in Australia, particularly in <a href="https://www.ruralhealth.org.au/sites/default/files/publications/fact-sheet-midwives.pdf">regional, rural and remote areas</a>, among other barriers.</p>
<p>Women who had private obstetricians were also positive about their care, especially among women with medical or pregnancy complications – this type of care had the second-highest number of positive comments. </p>
<p>This was followed by women who had continuity of care from midwives in the public system, which was described as respectful and supportive. </p>
<p><iframe id="iRWBu" class="tc-infographic-datawrapper" src="https://datawrapper.dwcdn.net/iRWBu/2/" height="400px" width="100%" style="border: none" frameborder="0"></iframe></p>
<p>However, one of the limitations about continuity models of care is when the woman doesn’t feel connected to her midwife or doctor. Some women who experienced this wished they had the opportunity to choose a different midwife or doctor. </p>
<h2>What about shared care with a GP?</h2>
<p>While shared care between the <a href="https://raisingchildren.net.au/pregnancy/health-wellbeing/tests-appointments/gps-shared-care-pregnancy">GP</a> and hospital model of care is widely promoted in the public maternity care system as providing continuity, it had a similar number of negative comments to those who had fragmented standard hospital care. </p>
<p>Considering there is strong evidence about the <a href="https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD004667.pub5/full">benefits of midwifery continuity of care</a>, and this model of care appears to be most acceptable to women, it’s time to expand access so all Australian women can access continuity of care, regardless of their location or ability to pay. </p>
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Read more:
<a href="https://theconversation.com/birthing-on-country-services-centre-first-nations-cultures-and-empower-women-in-pregnancy-and-childbirth-170641">Birthing on Country services centre First Nations cultures and empower women in pregnancy and childbirth</a>
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<img src="https://counter.theconversation.com/content/217803/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Hazel Keedle is affiliated with the Australian College of Midwives. Funding for this study was from a School of Nursing and Midwifery Partnership Grant through Western Sydney University, The Qiara Vincent Thiang Memorial Award and Maridulu Budyari Gumal SPHERE Maternal, Newborn and Women’s Clinical Academic Group funding.</span></em></p><p class="fine-print"><em><span>Hannah Dahlen has received funding from the National Health and Medical Research Commission, the Australian Research Council, the Medical Research Future Fund (funding and for this study and funding from a School of Nursing and Midwifery Partnership Grant through Western Sydney University), The Qiara Vincent Thiang Memorial Award and Maridulu Budyari Gumal SPHERE Maternal, Newborn and Women’s Clinical Academic Group funding.</span></em></p>Women favour seeing the same health provider throughout pregnancy, in labour and after they have their baby – whether that’s via midwifery group practice, a private midwife or a private obstetrician.Hazel Keedle, Senior Lecturer of Midwifery, Western Sydney UniversityHannah Dahlen, Professor of Midwifery, Associate Dean Research and HDR, Midwifery Discipline Leader, Western Sydney UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1559332021-03-01T14:29:56Z2021-03-01T14:29:56ZHow COVID-19 has changed the way we give birth<figure><img src="https://images.theconversation.com/files/386169/original/file-20210224-15-1fhokmn.jpg?ixlib=rb-1.1.0&rect=98%2C8%2C4914%2C3170&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/doctor-nurse-pulling-new-born-baby-633855362">LittleDogKorat/Shutterstock</a></span></figcaption></figure><p>COVID-19 has changed how we give birth, where we give birth, and who is present when we give birth. The effects of these changes are yet to be fully understood, and while the experience of childbearing has become more difficult in many ways during the pandemic, there may also be some benefits in the long term.</p>
<p>Childbirth is a time when women can feel particularly vulnerable. But they can find comfort in having capable and reassuring figures to provide them with support and motivation, and never more so than when labour takes a long time or is more complicated than usual.</p>
<p>Midwives play a key role in this, but often their workload is such that they cannot always offer the level of one-to-one personal contact an expectant woman may require. Throughout the coronavirus crisis, midwives have been under increased pressure, dealing with <a href="https://www.theguardian.com/society/2020/mar/29/midwife-shortage-doubles-as-nhs-staff-diverted-to-tend-covid-19-patients">chronic levels of understaffing</a> exacerbated by rates of sickness or enforced isolation. Many are exhausted and have low morale, but they work as hard as ever to ensure a birth is the positive experience it should be for parents.</p>
<p>Birth is naturally a shared experience, but <a href="https://www.nhs.uk/conditions/coronavirus-covid-19/people-at-higher-risk/pregnancy-and-coronavirus/">restrictions arising from the crisis</a> have left many women unable to have anyone other than the midwife present until the final stages. For some, it feels that we are going back to the days when fathers were not permitted in the birthing room until everything was over.</p>
<p>As a result, some women have been left feeling that they have been forced to <a href="https://www.bbc.co.uk/news/stories-52098036">go it alone</a>, with birth partners who risk missing out on all or most of the experience also feeling guilt and anger at the thought of not being there to support their loved one at such a time. Partners might also worry that not being present at and after the birth could affect their bond with their new born infant.</p>
<p>The opportunity to learn the skills of baby care and infant feeding together in the first few days also risks being lost, leaving women being sent home to fend for themselves initially. <a href="https://doi.org/10.1136/bmj.m3973">Limits on visitors</a> can also increase <a href="https://www.bbc.co.uk/news/uk-england-55810079">feelings of isolation</a>.</p>
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<img alt="A woman cradles a newbord baby in hospital." src="https://images.theconversation.com/files/386173/original/file-20210224-23-411i5v.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/386173/original/file-20210224-23-411i5v.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/386173/original/file-20210224-23-411i5v.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/386173/original/file-20210224-23-411i5v.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/386173/original/file-20210224-23-411i5v.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/386173/original/file-20210224-23-411i5v.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/386173/original/file-20210224-23-411i5v.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Many women have felt alone while giving birth during the pandemic.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/asia-chinese-mother-holding-her-newborn-1750611116">Alan Thien/Shutterstock</a></span>
</figcaption>
</figure>
<p>Worse still, if the birth doesn’t go as planned, a woman may end up grieving separately from her family. While midwives fill the void as best they can, and as valuable as the crucial care they provide is, their presence can’t make up for the absence of family and friends at these key moments.</p>
<p>There is recognition of these issues within the health service and <a href="https://www.england.nhs.uk/coronavirus/wp-content/uploads/sites/52/2020/12/C0961-Supporting-pregnant-women-using-maternity-services-during-the-coronavirus-pandemic-actions-for-NHS-provi.pdf">guidance</a> published at the end of 2020 sets out the steps hospitals should take to enable women to receive support from a partner, relative, friend or other when receiving maternity care during the pandemic. </p>
<h2>A shift to home birth?</h2>
<p>While the current situation is presenting challenges for women giving birth and for maternity services, there could be some benefits arising from the measures put in place as a result of the pandemic. </p>
<p>In my conversations with clinicians at number of hospitals over the past year, it has been notable how many have cited a notable reduction in women coming into maternity units in the early stages of labour, partly because they want to be with their partners but also because of the fear of being exposed to COVID-19. </p>
<p>This may not be a bad thing: comforting surroundings of home and family can lead to a reduction in <a href="https://www.sciencedirect.com/science/article/pii/S0266613807000514">anxiety levels</a>, which in turn aids higher production of <a href="http://www.childbirthconnection.org/maternity-care/role-of-hormones/">oxytocin</a>, the hormone which enables contractions.</p>
<p>While this should be viewed as a positive development, there needs to be further investigation into mothers’ perception of the experience and the longer term impact they felt from not having the clinical support provided within a birth centre or in hospital.</p>
<p>Before COVID, the <a href="https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/livebirths/bulletins/birthcharacteristicsinenglandandwales/2017">home birth rate</a> in the UK was just 2% – <a href="https://blogs.bmj.com/bmjsrh/2020/04/02/home-birth-covid-19/">the pandemic may result in an increase in these figures</a>. Hopefully women will have gained more confidence in their ability to labour and give birth in their own environment if that is what they want, and this could be further aided by the current restructuring of maternity provision.</p>
<p>But there also risks to staying home during childbirth. We are all aware of reports from the pandemic of people being afraid to attend hospital during the pandemic and their health <a href="https://www.theguardian.com/society/2020/may/08/more-people-dying-at-home-during-covid-19-pandemic-uk-analysis">suffering as a result</a>. This is especially dangerous for pregnant women, as such fear can stop them seeking help, for example when their baby doesn’t move. We do not yet know if there has been an increase in pregnancy loss due to non-attendance at hospital during the pandemic.</p>
<figure class="align-center ">
<img alt="A woman is held by her partner in a birthing pool." src="https://images.theconversation.com/files/386172/original/file-20210224-15-1foc7q8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/386172/original/file-20210224-15-1foc7q8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/386172/original/file-20210224-15-1foc7q8.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/386172/original/file-20210224-15-1foc7q8.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/386172/original/file-20210224-15-1foc7q8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/386172/original/file-20210224-15-1foc7q8.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/386172/original/file-20210224-15-1foc7q8.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">It’s possible the pandemic will lead to a rise in the number of home births.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/beautiful-african-american-woman-labors-peacefully-444550261">In The Light Photography/Shutterstock</a></span>
</figcaption>
</figure>
<p>The shift towards “<a href="https://www.england.nhs.uk/ltphimenu/maternity/targeted-and-enhanced-midwifery-led-continuity-of-carer/">continuity of carer</a>” models – the key principles of which include ensuring women see the same people throughout their pregnancy and empowering them to make their own choices – is intended to improve outcomes for women, wherever they choose to give birth.</p>
<p>It is clear that COVID-19 has had a significant impact on the childbearing experience. If it has a positive overall effect with an increase in normal birth for women at low risk of complications, and a balance of greater availability of staff to provide the additional care required by high-risk cases, then the changes that have been introduced as a result of the pandemic are to be welcomed.</p>
<p>But if there is found to be an increase in poor outcomes then care provision and restrictions currently in place will need to be reviewed. We do not yet know the full story of how COVID-19 has affected maternity care, but there will be lessons we can learn for the future of childbearing once the pandemic is over.</p><img src="https://counter.theconversation.com/content/155933/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Alison Edwards does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>There will be lessons we can learn for the future of childbearing once the pandemic is over.Alison Edwards, Visiting Lecturer, Midwifery, Birmingham City UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1495872021-01-07T19:09:32Z2021-01-07T19:09:32ZA history of childbirth in the UK – from home, to hospital, to COVID-19<figure><img src="https://images.theconversation.com/files/374265/original/file-20201210-23-d78vxn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://unsplash.com/photos/ux53SGpRAHU">Freestocks/Unsplash</a>, <a class="license" href="http://artlibre.org/licence/lal/en">FAL</a></span></figcaption></figure><p>My daughter was pregnant, and gave birth, in 2020. She attended every antenatal appointment and scan alone. Her partner sat on a chair on an empty hospital corridor while she was in early labour on the ward. Hers is now a normal experience for women. The COVID-19 pandemic has challenged assumptions about the childbearing year. Some features of this change are very clear. Others will take much longer to see and to understand.</p>
<p>In the UK, the first thing to be impacted in the spring lockdown was where women gave birth. In over <a href="https://blogs.bmj.com/bmjsrh/2020/04/02/home-birth-covid-19/">a third</a> of areas, home births were suspended at a time when women were looking at giving birth at home as <a href="https://www.patientsafetylearning.org/blog/home-births-fears-and-patient-safety-amid-covid-19">a safer option</a> than hospital. Some women resorted to “<a href="https://www.theguardian.com/lifeandstyle/2020/dec/05/women-give-birth-alone-the-rise-of-freebirthing">freebirthing</a>” – giving birth without any medical professionals present – as a result. </p>
<p>Decisions about whether to continue offering home birth depended on local staffing levels but also local beliefs about the types of care which were vital to maintain. Some areas preserved choices around place of birth, others centralised care in larger maternity units.</p>
<p>There is some anecdotal evidence that more women gave birth <a href="https://www.maternityandmidwifery.co.uk/covid-19-lockdown-and-the-emerging-impact-on-pregnancy/3666/">at home</a> during the first wave, but also that more opted to have <a href="https://www.bbc.com/news/uk-wales-54263166">planned caesarean births</a>. Birthing partners – who had gradually been welcomed into labour rooms from the late 1960s – suddenly found themselves <a href="https://www.thetimes.co.uk/article/covid-rules-on-pregnancy-have-gone-too-far-335lkbnbv">shut out</a> on the grounds of safety. Women have been expected to manage antenatal appointments, scans and early labour on their own. Maternal mental health has taken a back seat to physical health: the focus has been on providing a bare minimum of safe service. </p>
<p>The pandemic will affect birth rates, types of care and social beliefs about reproduction in the longer term. Some of these features are not yet clear, but debates about what the experience of pregnancy and birth should look like in the future have been reignited. There will be long term effects on the relationship between midwives and women, with <a href="https://www.rcog.org.uk/globalassets/documents/guidelines/2020-10-21-guidance-for-antenatal-and-postnatal-services-in-the-evolving-coronavirus-covid-19-pandemic-v3.pdf">cuts</a> to face-to-face antenatal care. There will also be impacts on both maternal and paternal mental health.</p>
<p>Some of these issues have been the subject of debate for decades. Birth is both a private experience and one on which society has always taken a view. The biology of reproduction does not fundamentally alter but society, medicine and technology affect how birth is experienced.</p>
<h2>All change</h2>
<p>Prior to the first world war, antenatal care did not exist. Women called for a midwife or their GP when they were in labour and most gave birth at home. Midwives attended over 75% of births, usually working alone. </p>
<p>In the 1920s, antenatal care began to develop in response to growing national concern about rising rates of maternal death in childbirth. The goal was to identify problems before women went into labour, although there was often little that could be done to manage issues. Alongside this, the medical speciality of obstetrics developed in the 1930s to offer emergency care, including instrumental and operative deliveries. Specialists believed that GPs did not have the skill to manage complex situations at home and numbers of babies born in hospital began to creep up in the years prior to the second world war. </p>
<p>Midwives focused on care in uncomplicated situations and their training, which had started in 1905, became longer and more medically focused. Maternal deaths <a href="https://oxford.universitypressscholarship.com/view/10.1093/acprof:oso/9780198229971.001.0001/acprof-9780198229971?rskey=K9hkoH&result=6">reduced dramatically</a> from the late 1930s, with the development of antibiotics and later with the availability of blood transfusions and improvements in general health. There is <a href="https://www.springer.com/gp/book/9781489929754">little evidence</a> to say that antenatal care or hospital birth had significant impacts.</p>
<p>Nevertheless, medical involvement and antenatal surveillance continued to grow after the second world war and was given momentum with the increasing use of hospitals for birth. Birth in hospital has been justified since the 1960s on the grounds of safety. By 1970, over 80% of births took place in hospitals and a <a href="https://discovery.nationalarchives.gov.uk/details/r/C289661">government report</a> called for there to be enough beds for all women to have hospital births. </p>
<p>But the evidence for the greater safety of hospital is <a href="https://pubmed.ncbi.nlm.nih.gov/24418202/">weak</a> and <a href="https://www.npeu.ox.ac.uk/birthplace/results">has been challenged</a> in the last 20 years. This has meant that home births have continued to be offered to women, but the proportion of women considered “low risk” enough to be eligible for birth outside hospital has got smaller over time. In 2019, only <a href="https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/livebirths/bulletins/birthcharacteristicsinenglandandwales/2019#place-of-birth">2.1%</a> of births were at home in England and Wales.</p>
<h2>Medicalisation of care</h2>
<p>Before the 1960s, women giving birth at home were supported by family, friends and midwives. The move to hospital care meant that they now found themselves alone in cold, clinical hospital rooms. The Association for Improvements in Maternity Services (AIMS) was set up in 1960 following one woman’s experience of hospital birth (she originally called the group “The society for the prevention of cruelty to pregnant women”).</p>
<p>AIMS and other consumer groups such as the National Childbirth Trust (NCT) called for partners to be allowed into labour rooms to offer support to women. More and more hospitals allowed this during the 1970s and since the early 21st century it has become more unusual for partners not to be present. COVID-19 has reminded us that the importance placed on social support and the role of partners is fragile. </p>
<p>Of course, many women welcomed the medicalisation of childbirth – after all, it included effective pain relief in labour, foetal heart rate monitoring and the growing safety of caesarean births. Others, from the 1970s onwards, fought back. Midwives were forced to straddle the different views of birth – believing that it was a normal process, but also being alert to complex and dangerous situations developing.</p>
<p>The COVID-19 pandemic has inevitably forced maternity services to offer support in different ways, with technology playing a central role. Much less attention has been paid to the experiences of women. It remains to be seen whether the pandemic will eventually usher in new and creative ways of providing maternity care – or whether minimal services will become the new normal.</p><img src="https://counter.theconversation.com/content/149587/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Tania McIntosh does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The pandemic will affect types of care and social beliefs about reproduction in the longer term.Tania McIntosh, Principal Lecturer in Midwifery, University of BrightonLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1347452020-03-28T14:44:00Z2020-03-28T14:44:00ZPregnant in a time of coronavirus – the changing risks and what you need to know<figure><img src="https://images.theconversation.com/files/323712/original/file-20200327-146699-12m3w45.jpg?ixlib=rb-1.1.0&rect=49%2C32%2C5365%2C3558&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A pregnant woman walks past a street mural in Hong Kong on March 23, 2020. With the coronavirus pandemic moving quickly, pregnant women are facing a changing health care system.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com">Anthony Wallace/AFP via Getty Images</a></span></figcaption></figure><p>“So, being pregnant and delivering in a pandemic … what’s that gonna look like?”</p>
<p>That question, sent to me by a colleague who is both a registered nurse and an expectant mother, stopped me in my tracks. <a href="https://health.tamu.edu/experts/hector-chapa.html">As an OB-GYN physician</a>, I naturally focus on the science of health care. Her email reminded me of the uncertainty expectant mothers now face as health risks and the health care system around them change amid this coronavirus pandemic. </p>
<p>While knowledge about the new coronavirus disease, COVID-19, is rapidly evolving and there are still many unknowns, <a href="https://www.acog.org/">medical groups</a> and studies are starting to provide <a href="https://www.cdc.gov/coronavirus/2019-ncov/prepare/pregnancy-breastfeeding.html">advice</a> and answers to questions many expecting families are asking.</p>
<h2>Do pregnant women face greater risk from COVID-19?</h2>
<p>So far, the data on COVID-19 does not suggest pregnant women are at higher risk of getting the virus, according to the <a href="https://www.acog.org/clinical/clinical-guidance/practice-advisory/articles/2020/03/novel-coronavirus-2019">American College of Obstetricians and Gynecologists</a>. However, as we have seen from <a href="https://medlineplus.gov/ency/article/007443.htm">the flu</a> they are at greater risk of harm if they get respiratory infections. Pregnancy causes a variety of changes in the body and results in a slight immunocompromised state which can lead to infections causing more injury and damage. </p>
<h2>Does having the coronavirus create a greater risk of miscarriage or preterm labor?</h2>
<p>Studies have not yet been done to show if having COVID-19 during pregnancy increases the chance of miscarriage, but there is some evidence from other illnesses. During the SARS coronavirus epidemic in 2002-2003, women with the virus were found to have a slightly higher risk of miscarriage, but only those who were <a href="https://www.ncbi.nlm.nih.gov/pubmed/15295381">severely ill</a>. </p>
<p>Having respiratory viral infections during pregnancy, such as the flu, has been associated with problems like <a href="https://www.ajog.org/article/S0002-9378(12)00722-3/pdf">low birth weight and preterm birth</a>. Additionally, having a <a href="https://www.cdc.gov/ncbddd/birthdefects/features/kf-birthdefects-maternal-fever-during-pregnancy.html">high fever</a> early in pregnancy may increase the risk of certain birth defects, although the overall occurrence of those defects is still low.</p>
<h2>Can a mother with COVID-19 pass the virus to her baby in the womb?</h2>
<p>This data is evolving fast. Two papers published March 26 describe finding <a href="https://jamanetwork.com/journals/jama/fullarticle/2763854">coronavirus antibodies</a> in three newborns of mothers with COVID-19. That could suggest they had been exposed to the virus in the womb, though the virus itself was not detected in their umbilical cord blood and researchers have <a href="https://jamanetwork.com/journals/jama/fullarticle/2763851">raised questions</a> about the type of test used. Researchers in an <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)30360-3/fulltext">earlier study</a> found no evidence of COVID-19 in the amniotic fluid or cord blood of six other infants born to infected women. While the research papers include only a small number of cases, a lack of vertical transmission – from the mother to child in utero – would be consistent with what is seen with other common respiratory viral illnesses in pregnancy, such as influenza. </p>
<p>There have been <a href="https://www.theguardian.com/world/2020/mar/14/newborn-baby-tests-positive-for-coronavirus-in-london">a few reports</a> of newborns as young as a few days old with infection. But in those cases, it is believed that the mother or a family member transmitted the infection to the infant through close contact after delivery. The virus can be transmitted through a cough or sneeze, which could spread virus-laden droplets on a newborn. </p>
<h2>How are prenatal checkups changing?</h2>
<p>Prenatal care may look different for a while to control the spread of COVID-19 among patients, caregivers and medical staff. </p>
<p>Typically, a pregnant woman has about 14 prenatal visits. That may be <a href="https://s3.amazonaws.com/cdn.smfm.org/media/2272/Ultrasound_Covid19_Suggestions_(final)_03-24-20_(2)_PDF.pdf">reduced by approximately half</a>, with telemedicine playing a larger role. Telemedicine is already endorsed by the American College of Obstetricians and Gynecologists for <a href="https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2014/02/health-disparities-in-rural-women">patients in rural settings</a>. Now, the pandemic is making virtual care solutions an indispensable tool. Pregnant women are able to do some at-home monitoring, such as for high blood pressure, diabetes and contractions, and telemedicine can even be used by pregnancy consultants, such as endocrinologists and genetic counselors.</p>
<p>The frequency of sonogram appointments may also change. The Society of Maternal Fetal Medicine says it is <a href="https://www.kff.org/womens-health-policy/issue-brief/telemedicine-and-pregnancy-care/">safe to reduce “routine” ultrasounds</a> at this time without jeopardizing the health and safety of the pregnancy. Of course, some patients with specific conditions like twins or babies with suspected birth defects may require more traditional follow up.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/323711/original/file-20200327-146689-g6zsjp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/323711/original/file-20200327-146689-g6zsjp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/323711/original/file-20200327-146689-g6zsjp.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/323711/original/file-20200327-146689-g6zsjp.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/323711/original/file-20200327-146689-g6zsjp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/323711/original/file-20200327-146689-g6zsjp.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/323711/original/file-20200327-146689-g6zsjp.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">As the coronavirus pandemic spread through Wuhan, China in early 2020, pregnant women faced new risks as hospitals began to run short of supplies. In the U.S., some hospitals started limiting visitors during delivery to reduce the chance of spreading the disease.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com">Getty Images</a></span>
</figcaption>
</figure>
<h2>What should I expect during delivery?</h2>
<p>Hospitals are doing what they can to minimize person-to-person transmission, and that may mean delivery looks different, too. Some hospitals are screening all medical staff, including with <a href="https://www.vumc.org/coronavirus/latest-news/mandatory-covid-19-screening-employees-begin-wednesday">temperature checks</a>, at the start of shifts.</p>
<p>Visitors are also being restricted. Recently, a hospital in New York enforced a <a href="https://www.nyp.org/coronavirus-information/coronavirus-visitor-policy-change">no visitor policy</a>, including partners, for patients about to give birth, citing coronavirus risk. This is definitely not what laboring women envision for their delivery, but in times of widespread communicable disease, it is reality. </p>
<h2>If I have COVID-19, will I need a cesarean section?</h2>
<p>No. Having COVID-19 is not a reason for a cesarean. There’s <a href="https://www.ncbi.nlm.nih.gov/pubmed/32196655">no evidence</a> that either method, vaginal birth or cesarean, is safer when it comes to COVID-19. Although data is still limited, other coronavirus infections have not been known to pass to the child from vaginal birth. </p>
<p>Both the American College of Obstetricians and Gynecologists and the Society of Maternal Fetal Medicine believe, in most cases, the timing of delivery should not be dictated by the mother’s COVID-19 diagnosis. Women infected early in pregnancy who recover should see no change to their delivery schedule. For women infected later in pregnancy, it is reasonable to attempt to postpone the delivery, as long as no other medical reason arises, until the mother receives a negative test result.</p>
<h2>How long will I be in the hospital after I give birth, and what if I have COVID-19?</h2>
<p>Expect a faster discharge from the hospital. To limit the risk of inadvertent exposure and infection, the ACOG says <a href="https://www.acog.org/clinical-information/physician-faqs/covid-19-faqs-for-ob-gyns-obstetrics">discharge may be considered</a> after 12 to 24 hours, rather than the usual 24 to 48 hours for women with uncomplicated vaginal births, and after two days for women with cesarean births, depending on their health status. </p>
<p>For mothers with confirmed COVID-19, the Centers for Disease Control and Prevention advises that <a href="https://www.cdc.gov/coronavirus/2019-ncov/hcp/inpatient-obstetric-healthcare-guidance.html">infants be isolated from them</a>, which understandably is not ideal. That could mean drawing a curtain between the mother and newborn and keeping them at least six feet apart. The CDC suggests continuing that separation until 72 hours after the mother’s fever is gone. If no other healthy adult is present in the room to care for the newborn, a mother who has confirmed or suspected COVID-19 should put on a facemask and practice hand hygiene before each feeding or other close contact with her newborn.</p>
<h2>Is home birth safer than a hospital right now?</h2>
<p>If a woman chooses to have her baby in a hospital or birthing center, she will have a dedicated team of health care providers trained to protect her and her baby from COVID-19 and handle any unforeseen complications. There is some concern regarding person-to-person exposure with COVID-19 in a home birth setting due to fewer restrictions on visitors. Although the ACOG has not made a statement specifically on this risk, the <a href="https://www.rcm.org.uk/media/3800/2020-03-21-covid19-pregnancy-guidance.pdf">United Kingdom’s Royal College of Obstetricians and Gynaecologists</a> has a statement advising against home birth for women who have been exposed to COVID-19. </p>
<h2>Can I breastfeed my baby if I have COVID-19?</h2>
<p>In <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)30360-3/fulltext">limited cases</a> reported to date, no evidence of virus has been found in the <a href="https://www.cdc.gov/breastfeeding/breastfeeding-special-circumstances/maternal-or-infant-illnesses/covid-19-and-breastfeeding.html">breast milk of women infected</a> with COVID-19; however, precautions are still recommended. Breastfeeding is encouraged and is a potentially important source of antibody protection for the infant. The CDC recommends that during temporary separation, women who intend to breastfeed should be encouraged to pump their breast milk to establish and maintain milk supply. The mother should wash her hands before touching any pump or bottle parts. If possible, it is also <a href="https://www.acog.org/clinical/clinical-guidance/practice-advisory/articles/2020/03/novel-coronavirus-2019">recommended</a> to have someone who is healthy feed the infant.</p>
<p>Having a child is a momentous occasion that should be celebrated, including during a pandemic. Do your part to keep yourself healthy. Wash your hands, maintain social distance and keep in close contact with your health care providers throughout the pregnancy. It may not be what you envisioned, but you will have quite a story to tell your children.</p>
<p>[<em>You need to understand the coronavirus pandemic, and we can help.</em> <a href="https://theconversation.com/us/newsletters?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=upper-coronavirus-help">Read our newsletter</a>.]</p><img src="https://counter.theconversation.com/content/134745/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Hector Chapa does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>As the COVID-19 pandemic spreads, pregnant women are facing new health risks and a health care system that’s changing around them by the day.Hector Chapa, Clinical Assistant Professor, Director of Interprofessional Education, College of Medicine, Texas A&M UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1338662020-03-22T12:21:18Z2020-03-22T12:21:18ZDuring coronavirus hospital surge, a midwife recommends home birth<figure><img src="https://images.theconversation.com/files/321067/original/file-20200317-60879-d01hck.jpg?ixlib=rb-1.1.0&rect=77%2C46%2C5078%2C3385&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A woman holds her newborn son right after giving birth; they are still in the birthing pool after labour at home.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>For many health-care providers who worked through the 2003 SARS epidemic, especially in epicentres, like Toronto, the COVID-19 pandemic is a reminder of the many lessons health-care providers <a href="https://www.ncbi.nlm.nih.gov/pubmed/12925421">learned at that time.</a> Social distancing measures are the most effective way to “<a href="https://www.nytimes.com/2020/03/11/science/coronavirus-curve-mitigation-infection.html">flatten the curve</a>” and minimize the spread of the epidemic. </p>
<p>However, as a midwife working in Toronto for over 20 years, I can also speak about another important lesson learned during SARS that is often forgotten or overlooked: <a href="http://doi.org/10.1624/105812410X482329">the importance of home birth and the role of midwives during an epidemic</a>. </p>
<p>There is ample evidence from high-income countries like Canada, the United States and the United Kingdom <a href="https://doi.org/10.1016/j.midw.2018.03.024">to demonstrate the safety of home births for healthy people who have a trained midwife</a>. In fact, research shows that <a href="https://doi.org/10.1111/j.1523-536X.2009.00322.x">home birth may even be beneficial in terms of rates of unnecessary interventions, complications and associated cost to the system</a>. </p>
<p>The evidence is so compelling that in 2014, U.K.’s NICE, the National Institute for Health and Care Excellence — the main body responsible for setting guidelines for health care in the U.K. — <a href="https://www.nice.org.uk/guidance/cg190">recommended home births for all low-risk healthy pregnant people</a>. Since the selection criteria for home birth is <a href="https://doi.org/10.1016/j.jogc.2018.08.008">vitally important to safety</a>, being a low-risk pregnant person is an important factor. For people with <a href="https://www.ontariomidwives.ca/sites/default/files/CPG%20supplemental%20resources/Choice%20of%20birthplace.pdf">high blood pressure, diabetes, preterm labour and other health issues</a>, home birth would not be the safest option.</p>
<p>However, despite these recommendations, mainstream perception has not greatly changed regarding hospital as the preferred place of birth for the large majority. The reasons for this are numerous and complicated, and highly related to <a href="https://doi.org/10.17615/4yqp-tc63">social norms, preferences and perceptions of risk</a>.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/321425/original/file-20200318-1982-alqy28.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/321425/original/file-20200318-1982-alqy28.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/321425/original/file-20200318-1982-alqy28.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/321425/original/file-20200318-1982-alqy28.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/321425/original/file-20200318-1982-alqy28.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/321425/original/file-20200318-1982-alqy28.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/321425/original/file-20200318-1982-alqy28.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A husband and a midwife both congratulate a new mother, moments after birth, placing their hands on her shoulder and the back of the newborn’s head.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>I have seen many news articles, targeted campaigns, TV shows and even movies supporting home births. But in all my 20 years as a regulated midwife, nothing in my recollection came close to changing people’s minds about place of birth than SARS. </p>
<p>For midwives, this was not necessarily surprising, as we know the safety of a home birth. But it was one of the first times mainstream public perception was greatly altered.</p>
<h2>Home births during a pandemic</h2>
<p>During a pandemic, people quickly remember that hospitals are, and should be, for sick people; that is, those needing medical care. Ironically, however, in Canada and the U.S., health-care systems the <a href="https://www.cihi.ca/en/hospital-stays-in-canada">No. 1 reason people are admitted to hospital is for childbirth</a>. </p>
<p>During a pandemic it soon becomes apparent what a bad idea it is to have healthy women and newborns in the same places and spaces as those who are unwell, and increasingly so as more get infected.</p>
<p>Suddenly — our high tech, bells and whistles “for the normal” starts to seem like a really poor idea. In fact, research shows all those bells and whistles lead to more intervention — more episiotomies, more use of forceps and vacuum, and more severe vaginal tearing — <a href="https://www.ontariomidwives.ca/sites/default/files/CPG%20supplemental%20resources/Choice%20of%20birthplace.pdf">with no better outcomes for either the pregnant woman or newborn</a>.</p>
<p>As soon as that babe is here, it becomes even more apparent what a bad idea it is to have a vulnerable new human in a place with lots of sick people.</p>
<p>Home birth starts looking better every second.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/321426/original/file-20200318-1926-jjyqyk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/321426/original/file-20200318-1926-jjyqyk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/321426/original/file-20200318-1926-jjyqyk.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/321426/original/file-20200318-1926-jjyqyk.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/321426/original/file-20200318-1926-jjyqyk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/321426/original/file-20200318-1926-jjyqyk.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/321426/original/file-20200318-1926-jjyqyk.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A woman being examined at home by her midwife.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
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</figure>
<p>I fully appreciate all the bells and whistles — when they are needed. But, like many of my colleagues, I personally prefer a home birth for low-risk births with a healthy uncomplicated pregnancy and normal labour. Not just because it can be very beautiful — <a href="https://www.ontariomidwives.ca/home-birth">quiet, intimate, family oriented</a> — but also because it is actually safer for healthy people — at least during a pandemic. </p>
<p>Although I could talk about the great benefits of home births in general, I’m specifically advocating for home births, or out-of-hospital births, during a pandemic. So, as our health resources and hospital beds become more scarce, I hope we remember the importance of home birth.</p>
<h2>Lessons from SARS</h2>
<p>SARS was one of the rare times in my career that I had both obstetrical and pediatric colleagues openly supporting the idea of home births and encouraging people to stay out of hospital. At that time, we understood hospital care should be saved for those who were high risk. This was even more clear as the situation worsened during the SARS epidemic.</p>
<p>There were many other important lessons learned during SARS, particularly for Canadian midwifery — although there is almost no academic literature on this subject. However, I do have some anecdotal experience to share as a front-line care provider during that time.</p>
<p>If there is one essential service that we know must continue during a pandemic, it is the business of birthing.</p>
<p>Midwives are an important part of the health force that is often overlooked. Our speciality is low-risk normal birth: this is where we have the most expertise and where we can be most effective. </p>
<p>This is a time when other birth attendants — mainly obstetricians — will be called on for their clinical and surgical speciality skills to manage those pregnant people who have complications, have COVID-19 or are unwell for other reasons.</p>
<p>Midwives can be divided into those who work within the hospital setting and those that work outside within the community. This would help prevent movement in and out of people’s homes and health-care settings. </p>
<p>Midwives have a lot of crossover skills between nurses and physicians. We can stitch and prescribe, like a physician, but also start an IV and take blood, like a nurse. There are many things we can use our skills for beyond birthing.</p>
<p>Some midwives have more advanced skills such as being able to assist during surgery, perform bedside ultrasounds and conduct vacuum deliveries. These skills could be important as the health force declines.</p>
<p>Birth centres, or other out-of-hospital birth locations, should be considered and opened as places for low-risk people to give birth and for healthy newborns to stay.</p>
<p>Finally, the needs of those who are pregnant are often overlooked. Home birth has many potential benefits, but most importantly in a pandemic, we need healthy people to give birth with the best chances of staying healthy — which doesn’t always mean hospital.</p><img src="https://counter.theconversation.com/content/133866/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Manavi Handa does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>During a pandemic, a home birth starts looking better every second. Midwives with their specialized skills in low-risk normal birth can be of great service.Manavi Handa, Associate Professor, Midwifery Education Program, Toronto Metropolitan UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1257322019-10-29T19:24:15Z2019-10-29T19:24:15ZHaving a baby at a birth centre is as safe as hospital but results in less intervention<figure><img src="https://images.theconversation.com/files/299082/original/file-20191029-183136-1d1i2sm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Birth centres are a good option for women with low-risk pregnancies, but availability is limited.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/516261340?src=3JsVAt37Eq-SeAqziSP12g-1-78&size=huge_jpg">Lolostock/Shutterstock</a></span></figcaption></figure><p>Having a baby at a birth centre is as safe as giving birth in hospital, according to our research, published today in the journal <a href="https://bmjopen.bmj.com/content/9/10/e029192.full">BMJ Open</a>. </p>
<p>Women who give birth in a birth centre are also less likely to undergo unnecessary interventions such as caesarean sections, <a href="https://theconversation.com/from-barber-surgeons-to-car-mechanics-the-technologies-of-vaginal-birth-20474">forceps or vacuum</a> deliveries, which come with increased risks for <a href="https://americanpregnancy.org/labor-and-birth/cesarean-risks/">mothers</a> and <a href="https://theconversation.com/how-birth-interventions-affect-babies-health-in-the-short-and-long-term-93426">babies</a>. </p>
<p>Some women are advised to give birth in a hospital labour ward. This includes women expecting twins, having a breech baby (coming bottom-first instead of head-first), with medical complications such as high blood pressure, diabetes, or if they have had a previous caesarean section. </p>
<p>However, women with uncomplicated pregnancies should have the option to give birth in a birth centre with the right services around them.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/how-birth-interventions-affect-babies-health-in-the-short-and-long-term-93426">How birth interventions affect babies' health in the short and long term</a>
</strong>
</em>
</p>
<hr>
<h2>Our study</h2>
<p>In the largest Australian study of its kind, we used routinely collected data from across the country, from 2000 to 2012, and grouped women according to where they planned to give birth: in a hospital labour ward, birth centre or at home.</p>
<p>We carefully selected healthy women with uncomplicated pregnancies who gave birth to a single baby in a head-down position at term (between 37 and 41 weeks of pregnancy) and without any known major medical or obstetric risk factors. </p>
<p>We tracked 1.25 million births, most of which were planned in hospital labour wards (1.17 million or 93.6%), with just over 5% in birth centres (71,505 or 5.7%) and a small proportion at home (8,212 or 0.7%).</p>
<p>We found women who planned a hospital birth were almost three times less likely to have a vaginal birth without an epidural than those who gave birth at a birth centre. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/299114/original/file-20191029-183136-1d03o4l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/299114/original/file-20191029-183136-1d03o4l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=411&fit=crop&dpr=1 600w, https://images.theconversation.com/files/299114/original/file-20191029-183136-1d03o4l.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=411&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/299114/original/file-20191029-183136-1d03o4l.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=411&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/299114/original/file-20191029-183136-1d03o4l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=517&fit=crop&dpr=1 754w, https://images.theconversation.com/files/299114/original/file-20191029-183136-1d03o4l.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=517&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/299114/original/file-20191029-183136-1d03o4l.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=517&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Women who give birth in hospital are more likely to have an epidural.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/1143044708?src=h2CpXdg3HJvcCnx4fdd-JQ-1-6&size=huge_jpg">Kipgodi/Shutterstock</a></span>
</figcaption>
</figure>
<p>Women who gave birth in hospital were more likely than women who gave birth in a birth centre to have: </p>
<ul>
<li>a caesarean section in labour (7.8% vs 4%)</li>
<li>forceps birth (4.6% vs 2.5%)</li>
<li>vacuum extraction (7.3% vs 3.5%)</li>
<li>an epidural (13.8% vs 6.5%)</li>
<li>labour sped up with the drug oxytocin (16.5% vs 8.1%).</li>
</ul>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/how-forceps-permanently-changed-the-way-humans-are-born-125701">How forceps permanently changed the way humans are born</a>
</strong>
</em>
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<p>Rates of complications were similar among women who gave birth in hospitals and birth centres, including severe postpartum haemorrhage (bleeding) and readmission to hospital. </p>
<p>The number of stillbirths and baby deaths up to four weeks of age was stable across hospitals and birth centres. However, babies born in birth centres were slightly more likely to need admission to intensive care for more than 48 hours. </p>
<h2>What about home births?</h2>
<p>Around 0.7% of the women we tracked gave birth at home. But this didn’t include women who planned to give birth at home and transferred to a hospital during the pregnancy. Nor did it include women who gave birth at home with no health professional in attendance (known as <a href="https://theconversation.com/for-some-women-unassisted-home-births-are-worth-the-risks-5179">freebirthing</a>). </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/pushing-home-birth-underground-raises-safety-concerns-6825">Pushing home birth underground raises safety concerns</a>
</strong>
</em>
</p>
<hr>
<p>Based on the available data, the proportion of baby deaths during home births (nine of 8,182 births or 1.1 per 1,000 births) was similar to hospitals (880 of 1,171,050 births or 0.8 per 1,000 births). </p>
<p>First-time mothers had a slightly higher risk of death during a home birth than those who had previously given birth, although the numbers were too small to make firm conclusions. </p>
<h2>What happens at birth centres?</h2>
<p>Birth centres are typically co-located with hospitals, though a small number are standalone facilities. The centres typically provide midwife-led care to women with uncomplicated pregnancies in a home-like environment.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/299115/original/file-20191029-183151-65jz0j.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/299115/original/file-20191029-183151-65jz0j.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/299115/original/file-20191029-183151-65jz0j.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/299115/original/file-20191029-183151-65jz0j.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/299115/original/file-20191029-183151-65jz0j.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/299115/original/file-20191029-183151-65jz0j.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/299115/original/file-20191029-183151-65jz0j.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Birth centres provide a more home-like environment than hospital.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/1033088542?src=gHLH_Z_gSvndcDGnIrYJ-A-1-17&size=huge_jpg">KieferPix/Shutterstock</a></span>
</figcaption>
</figure>
<p>Care at birth centres is usually provided by midwives that the woman knows. This is known as <a href="https://www.cochrane.org/CD004667/PREG_midwife-led-continuity-models-care-compared-other-models-care-women-during-pregnancy-birth-and-early">midwifery continuity of care</a>, and results in lower rates of intervention. </p>
<p>Birth centres are a more relaxed environment than a hospital labour ward; they’re usually less clinical, with a normal double bed, access to a birthing pool or bath, with soft lighting and equipment hidden out of sight. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/explainer-what-are-womens-options-for-giving-birth-55133">Explainer: what are women's options for giving birth?</a>
</strong>
</em>
</p>
<hr>
<p>Different birth centres have different criteria about who can give birth there, but usually women must be having only one baby, in a head down position, and be keen to have a medication-free birth. Higher risk women, such as those who have had a previous ceasarean section, are excluded.</p>
<p>If complications in labour do arise, women in birth centres transfer to the hospital labour ward. If the birth centre is located away from the hospital, there are clear protocols on how this should happen – usually in an ambulance. </p>
<h2>Reducing unnecessary intervention</h2>
<p>The rates of intervention across Australia are generally high compared to similar countries. </p>
<p>Our national caesarean section rate, for example, is at <a href="https://www.aihw.gov.au/reports-data/population-groups/mothers-babies/overview">35%</a> – much higher than the World Health Organisation’s ideal rate of 10-15%. And there is considerable variation <a href="https://www.safetyandquality.gov.au/our-work/healthcare-variation/atlas-2017/atlas-2017-3-womens-health-and-maternity">across the country</a>. </p>
<p>Increasing women’s access to birth centres can help reduce our high rate of caesarean sections. </p>
<p>And it won’t cost the health system more: our <a href="https://www.womenandbirth.org/article/S1871-5192(19)30689-4/fulltext">past research</a> found <a href="https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0149463">birth centre and hospital births</a> both cost around A$2,100.</p>
<p>Yet currently, few Australian women have the option to have their babies in birth centres; even those who live close to a birth centre may not get a spot because many are oversubscribed and resort to waiting lists. </p>
<p>It’s time to increase access to birth centres and home birth for low-risk women.</p>
<hr>
<p>
<em>
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Read more:
<a href="https://theconversation.com/so-your-birth-didnt-go-according-to-plan-dont-blame-yourself-89155">So your birth didn't go according to plan? Don't blame yourself</a>
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<img src="https://counter.theconversation.com/content/125732/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Caroline Homer receives funding from NHMRC. She is a Life Member of the Australian College of Midwives and the immediate Past President. </span></em></p><p class="fine-print"><em><span>David Ellwood was a Chief Investigator on the NHMRC Birthplace in Australia project.</span></em></p><p class="fine-print"><em><span>Hannah Dahlen receives funding from NHMRC and ARC. I also work in a private practice in Sydney and attend hospital and home births.</span></em></p><p class="fine-print"><em><span>Vanessa Scarf works as a midwife in a hospital on a casual basis. She also worked on the NHMRC funded Birthplace in Australia Study as the Project Coordinator.</span></em></p>Compared to women who give birth in a birth centre, those who give birth in hospitals are much more likely to have interventions – from epidurals, to labour augmentation and caesarean deliveries.Caroline Homer, Co-Program Director: Maternal and Child Health, Burnet InstituteDavid Ellwood, Professor of Obstetrics & Gynaecology, Griffith UniversityHannah Dahlen, Professor of Midwifery and Higher Degree Director, Western Sydney UniversityVanessa Scarf, Lecturer in Midwifery, University of Technology SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1202102019-08-07T22:36:01Z2019-08-07T22:36:01Z25 years on: What midwifery in Canada has achieved and what it still needs<figure><img src="https://images.theconversation.com/files/285756/original/file-20190725-136759-p6acls.jpg?ixlib=rb-1.1.0&rect=215%2C5%2C3778%2C2586&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Demand for midwifery services across Canada is now much greater than midwives can currently provide.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>On Jan. 1, 1994, <a href="https://www.ontario.ca/laws/statute/91m31">The Midwifery Act in Ontario</a> was implemented. This was a historic event as Canada was, at that time, the only developed nation in the world without a system of regulated midwifery. </p>
<p>Over the past 25 years, all the other Canadian provinces and territories have followed Ontario by legalizing and funding midwifery — except <a href="https://www.whitehorsestar.com/News/midwifery-rules-on-track-for-year-s-end">Yukon</a> and <a href="https://www.cbc.ca/news/canada/prince-edward-island/pei-midwives-regulation-application-1.4976724">Prince Edward Island</a>, which are planning to do so. </p>
<p>The number of midwives practising across the country has grown remarkably — from 60 in 1994 <a href="https://canadianmidwives.org/category/maps/">to around 1,700 in 2019</a>. They attend nearly 11 per cent of births in the country.</p>
<p>I am a registered midwife in Ontario, as well as an assistant professor in the midwifery education program at McMaster University. I also used midwifery services in the era before legislation and lobbied the Ontario government in the 1980s to include midwifery in the health-care system. And I was accepted into the first class of midwifery students at McMaster in 1993. </p>
<p>I have been a witness to the changes and advances in midwifery over the past 25 years. During this time, there has been great progress in the profession. At the same time, midwives have been on the sidelines of policy decisions. This has made midwives more vulnerable to the whims of governments than those in older, more established health professions, like nurses and physicians. </p>
<h2>From home to hospital births</h2>
<p>Of course, in 1994, we had no way of knowing how much midwifery would grow and how the practice would change. Midwives at that time attended many births at home, while also working to integrate into the hospital setting. </p>
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<p>Each midwife was on-call 24 hours a day, seven days a week, providing care under the principles of continuity of care, informed choice and choice of birth place. Many had to transfer care to an obstetrician if their client needed an induction of labour or wanted an epidural for pain relief.</p>
<p>Now, in the 21st century, midwives manage both inductions and epidurals, and most of the births they attend take place in the hospital. </p>
<p>Many have moved to “shared care” models of care so that midwives can have more time off-call to spend with their families. Some are participating in “collaborative care” projects to serve diverse populations, such as the longstanding <a href="https://www.scbp.ca/">South Community Birth Program</a> in Vancouver.</p>
<h2>Renewal of Indigenous midwifery</h2>
<p>Midwives in Markham Stouffville Hospital in Ontario have developed the <a href="https://www.msh.on.ca/clinics-departments/stollery-family-centre-childbirth-children/alongside-midwifery-unit-amu">new and exciting Alongside Midwifery Unit</a> — the first space of its kind in Canada, offering specially designed birthing rooms for women expecting a normal birth with a midwife. </p>
<p>Other midwives work in freestanding birth centres <a href="http://www.torontobirthcentre.ca/">such as the Toronto Birth Centre</a>. </p>
<p>In Hamilton, a <a href="https://www.thespec.com/living-story/9277470-new-programs-sees-hamilton-midwives-offer-set-it-and-forget-it-birth-control-method/">group of midwives is providing expanded services</a> that include medical abortion and contraception. </p>
<p>Across the country, there has been <a href="https://indigenousmidwifery.ca/">a renewal of Indigenous midwifery</a>, with Indigenous midwives providing care <a href="https://indigenousmidwifery.ca/audio/">rooted in their culture and traditions</a>. </p>
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<figcaption><span class="caption">Spirit of Birth. Produced by MAAIINGAN Productions and Frog Girl Films. Directed by Rebeka Tabobondung.</span></figcaption>
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<p>Regardless of location, demand for midwifery services is much greater than midwives can currently provide.</p>
<h2>Lack of pay equity</h2>
<p>Although midwifery has made great progress, not all news about midwifery is positive. Midwifery services in many parts of Canada are limited and not adequately funded. </p>
<p>A <a href="https://doi.org/10.1016/j.wombi.2018.10.002">recent study of midwives in Western Canada</a> showed high rates of burnout and mental and physical health problems, causing many to consider leaving the profession. </p>
<p>Many midwives, especially those who are aging or who have young families, struggle with the on-call demands of providing care in a continuity of care, or caseload, model. Evidence suggests that <a href="https://doi.org/10.1016/S0140-6736(13)61406-3">this model results in better outcomes for clients</a> — creating a dilemma for midwives who want to provide the best care but also desire better work-life balance.</p>
<p>In Ontario, lack of increases in pay over the past decade led midwives <a href="https://www.tvo.org/article/the-uncertain-future-of-midwifery-in-ontario">to take the government to the Ontario Human Rights Tribunal</a>, arguing that lack of pay equity had led the almost exclusively female profession to fall behind.</p>
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<p>Although the tribunal ruled in favour of the midwives, the <a href="https://www.nationalobserver.com/2019/07/11/news/new-human-rights-challenge-ford-government-says-workload-not-gender-justifies?utm_source=National+Observer&utm_campaign=d20290dad2-EMAIL_CAMPAIGN_2019_07_12_12_22&utm_medium=email&utm_term=0_cacd0f141f-d20290dad2-276861289">current government is seeking to quash the decision</a>. </p>
<p><a href="https://www.cbc.ca/news/canada/windsor/college-of-midwives-ontario-funding-cut-1.4946081">Funding cuts to the College of Midwives</a>, to which midwives must belong, mean that membership fees have increased, further reducing compensation and morale.</p>
<h2>More investment in midwifery needed</h2>
<p>Evidence worldwide shows the <a href="https://www.who.int/workforcealliance/media/news/2013/midwifecochrane/en/">benefits of midwifery-led care for women and babies</a>. </p>
<p>Although midwives in Canada have accomplished many things since 1994, much more needs to be done to make midwifery a sustainable profession that offers the care women wish to receive.</p>
<p>Integrating midwives into decision making and planning for reproductive care, adequately compensating those who do this work and developing flexibility in models of care and scope of practice: these are all paths to building a strong midwifery profession in the years to come.</p>
<p>[ <em>Deep knowledge, daily.</em> <a href="https://theconversation.com/ca/newsletters?utm_source=TCCA&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=deepknowledge">Sign up for The Conversation’s newsletter</a>. ]</p><img src="https://counter.theconversation.com/content/120210/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Kathi Wilson is an assistant professor in the midwifery education program at McMaster University, Hamilton ON. She has previously received research funding from CIHR and is a member of the New Democratic Party of Canada.</span></em></p>The benefits of midwifery for women and babies globally are clear. In Canada, innovations in midwifery centres and services are tempered by low pay and high rates of burnout.Kathi Wilson, Assistant Professor, Department of Midwifery, McMaster UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1190452019-07-18T11:20:27Z2019-07-18T11:20:27ZHome birth may start babies off with health-promoting microbes<figure><img src="https://images.theconversation.com/files/281472/original/file-20190626-76738-16veuf2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">What are the differences between planned assisted childbirth with midwife at home versus delivery with obstetrician at a hospital?</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/hospital-home-birth-traffic-sign-two-471601175?src=jaaoc93ZxlMSXNoDAVr2ow-1-2&studio=1">M-SUR/Shutterstock.com</a></span></figcaption></figure><p>For all of human history, babies have been born where their mothers lived – whether in a house, hut or cave. Only in the last century has birth moved out of the home and into the hospital. How has that changed the types of microbes that live in and on our bodies – collectively known as the microbiome – which we know are vital to human health?</p>
<p>To find out, our group of researchers from New York University, University of California San Francisco and Sejong University in Seoul, South Korea compared different kinds of fecal bacteria from babies born at home to babies born in the hospital. Our results suggest that <a href="https://doi.org/10.1038/s41598-018-33995-7">hospital births can change the gut microbiome of newborns</a>, perhaps placing these babies at higher risk for certain immune or metabolic disorders. So how do we respond? And why do I, as a hospital-based midwife, care? </p>
<p>Starting with the midwife part: There is a bas relief at Angkor Wat in Cambodia that depicts a woman giving birth. She is supported from behind, a midwife kneels in front and a newborn lies across her chest. It looks just like many midwife-attended births today, despite the fact it comes from halfway around the world and is 800 years old. </p>
<p>I like to think about what it means to do the same work that midwives did centuries ago. Whether by necessity (then) or by choice (now), the midwives’ philosophy of care is pretty much the same. Namely, to support an undisturbed birth – where interventions are used only when absolutely necessary. Increasingly, <a href="https://doi.org/10.1038/d41586-018-02480-6">research suggests this is a good approach to care</a>. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/284106/original/file-20190715-173351-oakrwz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/284106/original/file-20190715-173351-oakrwz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=397&fit=crop&dpr=1 600w, https://images.theconversation.com/files/284106/original/file-20190715-173351-oakrwz.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=397&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/284106/original/file-20190715-173351-oakrwz.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=397&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/284106/original/file-20190715-173351-oakrwz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=499&fit=crop&dpr=1 754w, https://images.theconversation.com/files/284106/original/file-20190715-173351-oakrwz.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=499&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/284106/original/file-20190715-173351-oakrwz.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=499&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A bas relief on a temple at Angkor Wat shows a woman giving birth with the help of a midwife.</span>
<span class="attribution"><span class="source">Robin Hayes</span>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span>
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<h2>Babies’ first inheritance</h2>
<p>In the last decade, researchers have discovered many ways <a href="http://dx.doi.org/10.1136/gutjnl-2018-317503">our health depends on the trillions of bacteria</a> and other microorganisms that reside in and on our bodies. Exposure to vaginal bacteria at birth starts an important colonization process in the newborn. In the beginning, bacterial colonies on different parts of babies’ bodies are similar and tend to match their mothers. Over time, different body habitats, like the skin, mouth and gut, develop their own distinct microbial communities. </p>
<p>The baby’s intestinal microbiome plays a key role in initiating immune and metabolic function. That is why we wanted to investigate how hospital factors might shape the early gut microbiome. We compared feces from healthy, breastfed babies who were born vaginally at home to similar babies born in the hospital. Then we determined which microbes were most likely to flourish in which babies during the first month of life. </p>
<p>Here is what we found: Babies born at home were more likely to <a href="https://doi.org/10.1038/s41598-018-33995-7">be colonized with “beneficial” microbes</a>, the kinds associated with normal immune, metabolic and digestive functioning. Babies born in the hospital were more likely to be colonized with microbes associated with interventions like cesarean section, antibiotic treatment and formula feeding even though none of those things happened to the babies in our study.</p>
<p>Then we wanted to see if these differences in the microbiome made epithelial cells – which line the colon – behave differently. </p>
<p>So we exposed these epithelial cells to fecal material – which contains a sample of the baby’s microbiome. We found that cells exposed to material from hospital-born babies were more likely to show an inflammatory response when the baby was one month old. While inflammation is an important defense mechanism, chronic inflammation at the cellular level can also contribute to inflammatory diseases later in life.</p>
<p>To be clear, we observed this only in the lab, not in a living baby, so we can’t speculate on the significance of this finding for the long-term health and well-being of babies. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/284148/original/file-20190715-173325-1vwadpt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/284148/original/file-20190715-173325-1vwadpt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/284148/original/file-20190715-173325-1vwadpt.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/284148/original/file-20190715-173325-1vwadpt.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/284148/original/file-20190715-173325-1vwadpt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/284148/original/file-20190715-173325-1vwadpt.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/284148/original/file-20190715-173325-1vwadpt.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A midwife examines her patient preparing for a home birth.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/pregnant-woman-being-examined-home-by-432161725?src=VQ_E5NDVZPJntx_jor88cw-2-2&studio=1">Monkey Business Images/Shutterstock.com</a></span>
</figcaption>
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<h2>Undisturbed birth</h2>
<p><a href="https://doi.org/10.1038/d41586-018-02480-6">Research suggests that babies benefit</a> from undisturbed exposure to their mother’s bacteria, including vaginal and fecal bacteria at birth, then ongoing exposure to the mother’s milk and skin bacteria while breastfeeding during the first year. Disruptions in early mother-to-baby transmission are associated with changes in the infant microbiome which, in turn, have been <a href="http://doi.org/10.1016/j.molmed.2014.12.002">associated with health problems later in life.</a> Thus, supporting an undisturbed birth process makes sense. </p>
<p>But, undisturbed birth isn’t always possible. Complications arise, and microbiome-altering interventions – like antibiotics or cesarean section – can save a mother or baby from life-threatening emergencies. These interventions may impact the baby’s microbiome, but no one would recommend any other course of care. </p>
<p>However, what about interventions performed without medical necessity? For example, one in three babies in the U.S. is delivered by cesarean section. That’s around <a href="http://doi.org/10.1186/s12978-015-0043-6">double the rate we would expect</a> if responding to medical need alone. Women in the U.S. frequently experience many <a href="https://doi.org/10.1016/S0140-6736(16)31472-6">interventions while giving birth</a>. <a href="https://doi.org/10.1016/S0140-6736(16)31472-6">Too much intervention used too soon</a> doesn’t help, and in many cases <a href="https://doi.org/10.1016/S0140-6736(16)31472-6">may harm, mothers, babies and their microbiomes</a>.</p>
<p>The mothers of the babies in our study did not experience overt interventions at birth. All mothers who had antibiotics, a cesarean delivery or a water birth were left out. That meant our study was small, only 10 babies in the hospital and 10 babies at home. Yet a large study of over 1,000 babies came to the same conclusion: full-term, breast-fed babies born vaginally at home had the most “beneficial” microbiomes. That is, they were colonized with microbes that have been <a href="https://doi.org/10.1542/peds.2005-2824">associated with normal health and development</a>. Further research is needed to understand the implications, but thinking through a typical hospital birth may suggest areas to study further.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/284146/original/file-20190715-173355-16s9r58.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/284146/original/file-20190715-173355-16s9r58.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=399&fit=crop&dpr=1 600w, https://images.theconversation.com/files/284146/original/file-20190715-173355-16s9r58.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=399&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/284146/original/file-20190715-173355-16s9r58.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=399&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/284146/original/file-20190715-173355-16s9r58.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=502&fit=crop&dpr=1 754w, https://images.theconversation.com/files/284146/original/file-20190715-173355-16s9r58.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=502&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/284146/original/file-20190715-173355-16s9r58.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=502&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Are hospital births too sterile?</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/newborn-child-hospital-516260941?src=Ix8Km2-pMoruh5WE5t0ERQ-1-17&studio=1">Lolostock/Shutterstock.com</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span>
</figcaption>
</figure>
<h2>Birth in the hospital: Too clean?</h2>
<p>One reason hospital births differ from those at home is that hospitals prioritize cleanliness. Hand washing, bactericidal scrub and frequent cleaning limit the spread of germs. As the baby nears delivery, a sterile drape may be placed underneath the woman and sometimes over her legs and abdomen to create a “sterile field” around the baby. </p>
<p>In some hospitals a bactericidal soap may be used to wash the vagina before delivery, destroying almost all the bacteria. This practice reflects just how little we value the robust microbial habitat of the mother’s vagina which, interestingly enough, <a href="http://doi.org/10.3389/fmed.2018.00181">changes during pregnancy to promote an abundance of healthy flora</a>. There may also be frequent vaginal exams performed during labor that carry small amounts of antiseptic lubricant into the vagina. </p>
<p>After birth, the baby may be taken to a semi-sterile warmer instead of having contact with the mother’s skin. Antibiotic ointment is usually applied to the baby’s eyes. A full-body bath to “clean” the baby is also common, constituting another source of potential damage to microbial colonies on the newborn’s body. </p>
<p>But even for babies who “room in,” contact with the outside world is limited compared to home where a baby might get licked by the family dog or passed around to an array of visitors. The “hygiene hypothesis” suggests that we, as humans, <a href="https://doi.org/10.2147/ITT.S61528">need early and frequent exposure to diverse organisms</a>. We tend to restrict this in the first few days of life in the hospital. Is that the right approach? </p>
<p>In the U.S. only 1% of births occur at home. Our research suggests a previously unrecognized benefit of home birth. Might this information also lead to a redesign of hospital care? When we start to value the power of babies’ first inheritance – bacteria from their moms – we may end up with a different view of what “best practice” really is. </p>
<p>[ <em>Deep knowledge, daily.</em> <a href="https://theconversation.com/us/newsletters?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=deepknowledge">Sign up for The Conversation’s newsletter</a>. ]</p><img src="https://counter.theconversation.com/content/119045/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Joan Combellick received funding from the Gerber Foundation.</span></em></p>Evidence suggests that microbes play a vital role in health. But what microbes we get depends whether we were born in a hospital versus at home. That could impact our health decades later.Joan Combellick, Assistant Clinical Professor of Midwifery, Yale UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1160562019-05-02T21:54:14Z2019-05-02T21:54:14ZRoyal baby: Did Meghan Markle have a home birth?<figure><img src="https://images.theconversation.com/files/272103/original/file-20190501-113855-cw2e0y.jpg?ixlib=rb-1.1.0&rect=23%2C29%2C3957%2C2620&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Meghan, Duchess of Sussex, arrives for her baby shower at the Mark Hotel on Feb. 19, 2019, in New York. She was rumoured to want to deliver her baby at home rather than in hospital. </span> <span class="attribution"><span class="source">(AP Photo/Kevin Hagen)</span></span></figcaption></figure><p>The Duke and Duchess of Sussex — Prince Harry and Meghan Markle — have <a href="https://nationalpost.com/news/world/buckingham-palace-says-prince-harrys-wife-meghan-has-gone-into-labour-with-their-first-child">announced the birth of their first child</a>, a baby boy. </p>
<p>While the world has waited anxiously for <a href="https://www.nytimes.com/2019/05/06/world/europe/meghan-markle-baby-boy.html">news of this British royal birth</a>, there has been intense speculation about where Meghan Markle, the Duchess of Sussex, would deliver her baby. </p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1125396713777156097"}"></div></p>
<p>Reports that she wished <a href="https://www.elle.com/culture/celebrities/a27097980/meghan-markle-home-birth-report/">to deliver her baby at home</a> for reasons of <a href="https://www.dailymail.co.uk/news/article-6904657/Meghans-home-birth-plan-Duchess-Sussex-wants-baby-home.html">privacy and comfort</a> have renewed debates about the safety of home birth. </p>
<p>While some media reports were positive about the idea, <a href="https://www.theguardian.com/commentisfree/2019/apr/13/meghan-markle-home-birth-should-not-blind-us-to-risks-for-most-women">others warned about the risks</a> of childbirth in general and, in particular, when it takes place at home.</p>
<h2>A home birth is a safe choice</h2>
<p>In the United Kingdom, <a href="http://www.historyandpolicy.org/policy-papers/papers/choice-policy-and-practice-in-maternity-care-since-1948">most women gave birth at home until the 1960s</a>. After the National Health Service was established, <a href="https://www.ncbi.nlm.nih.gov/books/NBK328267/">the Peel Report</a> of 1970 recommended universal hospital birth. By 1975, only five per cent of women still gave birth outside of hospital. </p>
<p>The <a href="https://vanierinstitute.ca/context-understanding-maternity-care-canada/">story in Canada is similar</a>, with a sharp move away from home birth occurring in the middle of the 20th century. Safety for both mother and child has been declared the reason for this shift. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/272108/original/file-20190501-117598-1h25p4i.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/272108/original/file-20190501-117598-1h25p4i.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/272108/original/file-20190501-117598-1h25p4i.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/272108/original/file-20190501-117598-1h25p4i.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/272108/original/file-20190501-117598-1h25p4i.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/272108/original/file-20190501-117598-1h25p4i.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/272108/original/file-20190501-117598-1h25p4i.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Research in Canada shows that women who planned a home birth had lower rates of obstetrical intervention, such as pain medication and fetal monitoring, and lower rates of caesarean section.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>However, there is little evidence that hospitals have made birth safer for women who are experiencing normal, healthy pregnancies.</p>
<p>I am a registered midwife in Ontario and an assistant professor in the midwifery education program at McMaster University. My colleagues and I take great pride in providing evidence-based care to the pregnant women who choose midwifery care. We know that good evidence supporting the safety of home birth has been lacking in the past. </p>
<p>Recent research from several countries, however, has shown that for those with low-risk pregnancies, giving birth at home is a safe choice.</p>
<h2>Lower rates of caesarean section</h2>
<p>In Canada, three studies — one from <a href="https://doi.org/10.1503/cmaj.081869">British Columbia</a> and <a href="https://doi.org/10.1503/cmaj.150564">two</a> from <a href="https://doi.org/10.1111/j.1523-536X.2009.00322.x">Ontario</a> — have looked at the outcomes of more than 21,000 planned home births. </p>
<p>The planned home birth group included women who were transferred to hospital. They were compared to the outcomes for low-risk women having hospital births attended by midwives or family physicians. </p>
<p>These studies all showed that the outcome for newborns was the same. But the women who planned a home birth had lower rates of obstetrical intervention, such as pain medication and fetal monitoring, and lower rates of caesarean section.</p>
<p>Similarly, in England, a <a href="https://europepmc.org/articles/pmc3223531">study of place of birth</a>, including home birth, concluded that, overall, outcomes for the newborn did not differ by place of birth. </p>
<p>The newborns of first-time mothers, however, did have a slightly higher chance of a poor outcome. On the other hand, in the Netherlands, where home birth is more common, <a href="https://doi.org/10.1111/j.1471-0528.2009.02175.x">a study of 529,688 births</a> showed no differences in newborn outcomes between home and hospital births, even though more than 40 per cent of women in the study had planned a home birth.</p>
<h2>Publicly funded midwifery is essential</h2>
<p>A key component that promotes the safety of a planned home birth is the existence of regulated and well-trained midwives who are integrated into the health-care system. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/272111/original/file-20190501-117607-1332qqk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/272111/original/file-20190501-117607-1332qqk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/272111/original/file-20190501-117607-1332qqk.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/272111/original/file-20190501-117607-1332qqk.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/272111/original/file-20190501-117607-1332qqk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/272111/original/file-20190501-117607-1332qqk.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/272111/original/file-20190501-117607-1332qqk.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">The Society of Obstetricians and Gynaecologists of Canada recently released a statement supporting home birth for healthy, low-risk women.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>In Canada, the U.K. and the Netherlands, midwives receive university-level education. Midwifery care, regardless of birthplace, is publicly funded, and access to emergency services and hospital birth is readily available. Smooth transfer to hospital, when needed, is an important part of safe home birth services.</p>
<p>In Canada, <a href="https://doi.org/10.1111/jmwh.12896">approximately 20 to 25 per cent of planned home births</a> are transferred to hospital. Most of these transfers are for non-emergency reasons such as prolonged labour or need for pain relief. In many cases, midwives continue their care for the woman in the hospital.</p>
<p>Currently <a href="https://www.ontariomidwives.ca/home-birth">in Ontario</a>, about 4,000 or three per cent of the 140,000 births that occur per year are planned to take place at home. </p>
<h2>A long tradition of royal home births</h2>
<p>Over the past few years, planned home birth has increasingly gained acceptance by obstetricians. The Society of Obstetricians and Gynaecologists of Canada recently released <a href="https://doi.org/10.1016/j.jogc.2018.08.008">a statement that supports the choice of home birth for healthy, low-risk women</a>. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/272101/original/file-20190501-113861-iqakxn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/272101/original/file-20190501-113861-iqakxn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=448&fit=crop&dpr=1 600w, https://images.theconversation.com/files/272101/original/file-20190501-113861-iqakxn.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=448&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/272101/original/file-20190501-113861-iqakxn.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=448&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/272101/original/file-20190501-113861-iqakxn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=564&fit=crop&dpr=1 754w, https://images.theconversation.com/files/272101/original/file-20190501-113861-iqakxn.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=564&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/272101/original/file-20190501-113861-iqakxn.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=564&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Britain’s Meghan, the Duchess of Sussex, leaves King’s College, London, after joining a panel discussion to mark International Women’s Day on March 8, 2019.</span>
<span class="attribution"><span class="source">(AP Photo/Frank Augstein)</span></span>
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</figure>
<p>In the United Kingdom, the National Institute for Health and Care Excellence <a href="https://www.nice.org.uk/guidance/cg190/chapter/Recommendations#place-of-birth">recommends that healthy women with uncomplicated pregnancies consider out-of-hospital birth, including home birth</a>, to reduce rates of intervention, especially caesarean section.</p>
<p>If the birth of Baby Sussex did, indeed, take place at Frogmore Cottage, it will become part of <a href="https://www.goodhousekeeping.com/life/a27113224/meghan-markle-home-birth/">a long tradition of royal babies born at home</a>. </p>
<p>And, no doubt, a royal home birth would spark an increase in this choice of birth place in the United Kingdom and elsewhere.</p><img src="https://counter.theconversation.com/content/116056/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Kathi Wilson has previously received funding from the Canadian Institutes of Health Research.</span></em></p>A professor of midwifery education reviews the research evaluating the safety of home versus hospital births.Kathi Wilson, Assistant Professor, Department of Midwifery, McMaster UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/842812018-03-14T18:57:05Z2018-03-14T18:57:05ZWhat to do when the baby is born before you get to hospital<figure><img src="https://images.theconversation.com/files/197479/original/file-20171204-5399-1nf3v92.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The most important thing is to keep the baby warm – put her on your chest covered with a warm towel.</span> <span class="attribution"><span class="source">from www.shutterstock.com</span></span></figcaption></figure><p>Women often express a fear of giving birth en route to the hospital, and these fears have some basis. <a href="https://www.youtube.com/watch?v=WXEZ6g2WLoM">Dramatic videos</a> do the rounds on social media of women giving birth to babies in cars, on their <a href="http://www.abc.net.au/local/stories/2013/02/20/3694162.htm">front lawn</a>, or as recently happened, <a href="http://www.dailymail.co.uk/news/article-5067703/Mom-gives-birth-car-keeps-driving-hospital.html">in the car alone</a> and then driving themselves to hospital.</p>
<p>In <a href="https://www.aihw.gov.au/getmedia/728e7dc2-ced6-47b7-addd-befc9d95af2d/aihw-per-91-inbrief.pdf.aspx?inline=true">Australia</a>, around four to five in 1,000 births are recorded as “other”, meaning the birth didn’t occur in hospital, in a birth centre, or as a planned home birth. The birth may occur in the woman’s home, en route to the hospital or in ambulances where a midwife or doctor is not in attendance. More babies are born as unplanned out of hospital births than as planned home births in Australia. We often refer to these births as “born before arrival”.</p>
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<iframe width="440" height="260" src="https://www.youtube.com/embed/2Tpt1fJlnIA?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Videos of women giving birth en route to hospital go viral.</span></figcaption>
</figure>
<p>Babies born before arrival are <a href="http://doi.org/10.1136/bmjopen-2017-019328">more likely to be premature</a> (12.5% compared to 7.3%), be smaller, and most likely be a second baby, and a girl (possibly because they are smaller).</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/balancing-hope-and-fear-for-babies-born-at-24-weeks-gestation-1402">Balancing hope and fear for babies born at 24 weeks gestation</a>
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<p>In a <a href="http://doi.org/10.1136/bmjopen-2017-019328">new study</a> looking at ten years of births in NSW, we found women more likely to deliver early are women of low socioeconomic status, those living in rural or coastal areas and those living in areas with high rates of planned home birth.</p>
<p>This may be due to some women having poor levels of engagement with health services, or needing to drive big distances to get to hospital. Another factor to consider though is some of these births could be “<a href="https://www.ncbi.nlm.nih.gov/pubmed/22300611">freebirths</a>” – giving birth at home intentionally without a midwife or doctor.</p>
<p>While <a href="http://doi.org/10.1136/bmjopen-2017-019328">we showed</a> babies born unexpectedly before arrival have poorer outcomes, this is probably due mostly to prematurity which increases the risk for all babies. We also know babies born before arrival are more likely to be cold and this is even more likely to happen when they are small in size, such as when they’re premature.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/birthing-on-country-could-deliver-healthier-babies-and-communities-31180">Birthing on Country could deliver healthier babies and communities</a>
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</em>
</p>
<hr>
<h2>What to do if the baby is coming early</h2>
<ul>
<li><p>Call an ambulance and someone will be able to talk you through the birth until the ambulance arrives</p></li>
<li><p>Get down low and put a towel under you so the baby has a soft landing. Don’t sit on the toilet</p></li>
<li><p>If you have a heater put it on and get some towels on it or in the dryer to warm</p></li>
<li><p>As soon as the baby is born, put her straight on your chest and rub dry with a towel. Get whoever is there to put a second warm dry towel over the baby removing the now damp one. Your skin is the best way to warm a baby up</p></li>
<li><p>If the baby is not breathing try blowing in her face as the cold air can make her gasp and take a breath. If that doesn’t work rub the baby’s back up and down with the towel as this can stimulate her to breathe.</p></li>
<li><p>If the baby doesn’t respond to these initial steps you may need to <a href="http://raisingchildren.net.au/articles/pip_cpr_babies.html">resuscitate</a> her using <a href="https://www.youtube.com/watch?v=avYRvVHAvfM">CPR</a>, but this is rare</p></li>
<li><p>Keep the baby warm at all times and especially cover the head as this is where a lot of heat is lost</p></li>
<li><p>Do not cut the cord or attempt to tie it with string or shoelaces or anything else, just leave it attached to the baby</p></li>
<li><p>Do not pull on the cord and try to deliver the placenta as you may cause heavy bleeding or even pull the uterus out which is then a serious emergency</p></li>
<li><p>Try to stay warm and calm, and maintain skin-to-skin contact with your baby, as help will arrive soon.</p></li>
</ul>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/childbearing-hips-dont-make-the-difference-in-childbirth-15685">'Childbearing hips' don't make the difference in childbirth</a>
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<hr>
<p>Some other things to be aware of is that liquid (amniotic fluid) will come out as the baby is born. Be prepared – there will be some blood loss and up to a certain point this is a normal part of the process. Most importantly try not to panic – birth is a normal process.</p>
<p>It’s hard for women to always get the timing just right when making the decision to go to hospital or the birth centre, or to call the midwife for a home birth. </p>
<p>We know going to hospital too early will increase your chances of <a href="https://www.ncbi.nlm.nih.gov/pubmed/29054342">interventions</a> such as a synthetic oxytocin hormone to speed labour up, forceps or caesarean sections. These lead to more bleeding and pain for the mother, longer length of stay in hospital and a greater chance of the baby needing to be admitted to the neonatal intensive care unit. </p>
<p>Be aware if you had a reasonably quick first birth. Chances are it will be even quicker second time around.</p>
<p>It’s really important women don’t worry too much about this happening as the chances are small, and even if it does happen it usually turns out fine. Once the shock wears off, you have an entertaining birth story! </p>
<p>If you follow the steps above you can dramatically reduce the risk of problems for the baby.</p><img src="https://counter.theconversation.com/content/84281/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Hannah Dahlen receives funding from NHMRC and ARC. She is affiliated with the Australian College of Midwives. </span></em></p><p class="fine-print"><em><span>Charlene Thornton receives funding from the NHMRC and NSW Health.</span></em></p>Women often express a fear of giving birth en route to the hospital, and these fears have some basis.Hannah Dahlen, Professor of Midwifery, Western Sydney UniversityCharlene Thornton, Post-doctoral Fellow in the School of Medicine, Western Sydney UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/658132016-09-22T16:17:41Z2016-09-22T16:17:41ZRise in ‘freebirthing’ suggests women feel midwives and doctors are ignoring their needs<figure><img src="https://images.theconversation.com/files/138852/original/image-20160922-22521-1qnx9fo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Going it alone.</span> <span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-474985237/stock-photo-an-african-american-mother-cradles-her-newborn-daughter-after-giving-birth-at-home-in-a-birthing-pool-of-water.html?src=IhZlpOctqEAyGFUKwz1kZw-1-27">Shutterstock</a></span></figcaption></figure><p>Freebirthing, where women choose to give birth without medical assistance from midwives or doctors, is mired in controversy. Healthcare workers harbour deep concerns for the health of mother and baby. But its growing popularity suggests that when it comes to childbirth there is a widening gap between what women want and what they are offered.</p>
<p>Maternity professionals recognise that sometimes events occur during labour that require timely intervention to ensure the safety of mother and baby. On the other hand, ethically and legally a woman’s right to autonomy regarding her own body includes the right to decline medical advice or treatment should she wish it, whether or not that runs counter to the recommendations of midwives or doctors. In Britain, this is at the heart of <a href="http://www.birthrights.org.uk/">respectful maternity care</a> and is <a href="http://www.birthrights.org.uk/library/factsheets/Consenting-to-Treatment.pdf">enshrined in law</a>.</p>
<p>There is now a growing body of research from Sweden, Holland, Australia, Canada, the US and UK that explores the freebirthing phenomenon, including the <a href="http://www.midwiferyjournal.com/article/S0266-6138(16)30010-9/abstract">mother’s motivations for choosing this way</a> and their <a href="http://www.midwiferyjournal.com/article/S0266-6138(16)30123-1/pdf">subsequent experiences</a>. Despite the countries’ differing approach to offering maternity care and homebirthing services, it’s interesting to find the studies reveal recurring themes. </p>
<h2>Why would you?</h2>
<p>The most obvious recurring theme drawn from mothers’ comments to researchers is that they chose freebirthing as a way of resisting the biomedical model of birth. Both midwifery and obstetric care were rejected as for many, they were <a href="https://theconversation.com/its-no-wonder-women-opt-for-caesareans-over-natural-birth-when-they-are-not-given-a-real-choice-63736">synonymous, reflecting wider criticisms of maternity services</a>. This decision stemmed primarily from their own risk assessment, of where the harms of excessive interventions often carried out in hospitals were deemed riskier than carrying out a freebirth. </p>
<p>Where homebirth services were available, some women did not want the routine care that is provided by midwives. This was largely due to the belief that routine care practices would cause interference that would get in the way of their ability to birth safely. Additionally, they were concerned that they may face coercion should they decline aspects of care provided by the midwives, therefore they did not want care imposed upon them during childbirth. The researchers’ findings across all studies agreed that women sought to retain full control and autonomy throughout their experience of giving birth, a need they felt maternity services were unable to meet.</p>
<p>It must be recognised that many of the women who chose to freebirth had previously had negative or even traumatic experiences of maternity care – these experiences had led to their decision to do things differently. This shows a great loss of trust and faith in healthcare services, and these women embody the <a href="http://whiteribbonalliance.org/campaigns2/respectful-maternity-care/">link between disrespectful care and the experience of traumatic childbirth</a>. The same rationale is also found in women who following a traumatic childbirth who <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1595139/">request an elective caesarean</a>, or even forgo future pregnancies and children. </p>
<p>On the other hand, other women were keen to point out that their decision to freebirth stemmed not from a negative perception of maternity care, but from a positive perception of the natural, physiological and instinctual processes of giving birth in which they placed their trust, making the need for maternity care redundant. </p>
<p>The decisions made at both ends of this spectrum challenge the basis on which our current healthcare provision around childbirth is offered.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/138853/original/image-20160922-22527-1rru9re.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/138853/original/image-20160922-22527-1rru9re.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/138853/original/image-20160922-22527-1rru9re.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/138853/original/image-20160922-22527-1rru9re.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/138853/original/image-20160922-22527-1rru9re.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/138853/original/image-20160922-22527-1rru9re.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/138853/original/image-20160922-22527-1rru9re.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Some women prefer to give birth at home among family, rather than in front of maternity professionals - and that’s their right.</span>
<span class="attribution"><span class="source">In The Light Photography/shutterstock.com</span></span>
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</figure>
<h2>The challenges midwives face</h2>
<p>In the UK, NHS <a href="https://www.nice.org.uk/news/press-and-media/midwife-care-during-labour-safest-women-straightforward-pregnancies">maternity policies</a> strongly recommend an approach of individual care that offers equitable access to midwife-led homebirth services or birth centres as well as doctor-led hospital birth. However, two studies from the UK that explored freebirthing reveal that this may not always happen in practice.</p>
<p>One study revealed a “<a href="http://www.midwiferyjournal.com/article/S0266-6138(16)00047-4/abstract">pervading mood of fear</a>” created by midwives, where mothers experienced midwives’ risk-averse approach to maternity care as manipulative in order to encourage conformity to guidelines, regardless of the mothers’ wishes. This suggested that their midwives prioritised the institutional requirements over the needs as expressed by the mothers-to-be. Consequently, this led women to avoid maternity care altogether. </p>
<p>A second study found that some women found <a href="https://bmcpregnancychildbirth.biomedcentral.com/articles/10.1186/s12884-016-0847-6">access to homebirth services obstructed</a>, leading them to choose to freebirth. Some women even <a href="http://www.midwiferyjournal.com/article/S0266-6138(16)30123-1/abstract">faced opposition from maternity providers</a> to their decision to freebirth, leading in some cases to negative and distressing repercussions including referrals to social services. It’s important to note that this occurred despite the legislation in the UK that assures a woman’s right to bodily autonomy. </p>
<p>The women in both studies recognised that British midwives currently work in a <a href="http://hea.sagepub.com/content/13/6/589.short">technocratic, litigious, and deeply risk averse</a> environment, and that this inevitably shapes how midwives approach their role. But evidently this runs contrary to the rhetoric of <a href="http://www.publications.parliament.uk/pa/cm200203/cmselect/cmhealth/796/796we04.htm">“individualised” woman-centric care</a> that is supposed to underpin maternity care.</p>
<p>Overall, these illuminating studies reveal a resistance to the dominant medical approach to childbirth that is not meeting some women’s needs. Criticism of an overly medical approach is not unique to discussions of freebirthing: a <a href="http://www.sciencedirect.com/science/article/pii/S0140673616314726">study published in The Lancet</a> indicated that the overuse of maternity interventions is associated with increased psychological and physical harms. </p>
<p>Of course there are occasions when timely medical interventions can be the difference between life and death, but what these studies highlight are the lengths some women will go to avoid what they feel as intrusive, over-medicalisation of giving birth.</p>
<p>For some women, the decision to freebirth stems from a philosophical belief that an unassisted birth is safer, and is their right to carry out. For others it reveals a <a href="http://www.womenandbirth.org/article/S1871-5192(10)00082-X/abstract">“broken system”</a> that is failing them, and points to the need for a collective response to find a fix.</p><img src="https://counter.theconversation.com/content/65813/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Claire Feeley received funding from The Wellbeing of Women, in conjunction with the RCM and the Burdett Trust (grant number ELS505) to carry out the study 'Why do some women choose to freebirth?' (Feeley and Thomson, 2016).
</span></em></p>Does the growth of ‘freebirthing’ mean that women are rejecting professional advice? Or is there something else going on?Dr Claire Feeley, Midwife and PhD Researcher, University of Central LancashireLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/462992015-09-09T05:02:37Z2015-09-09T05:02:37ZAre we overscheduling our kids from the moment they’re born? The real ‘labor’ economics<figure><img src="https://images.theconversation.com/files/93342/original/image-20150828-19918-s99d7x.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Hurry up! We're on the clock. </span> <span class="attribution"><span class="source">Baby birth via www.shutterstock.com</span></span></figcaption></figure><p>Are we overscheduling our children even from the moment of their birth? </p>
<p>We live in an on-demand world. Movies are shown on request, food is delivered on call and drivers arrive when beckoned. As an economist, not a medical doctor, I was surprised to find new data that suggest more babies are showing up when scheduled rather than on their own time frame.</p>
<p>Numerous writers have suggested that <a href="http://parenting.blogs.nytimes.com/2013/10/11/10-signs-your-parent-is-overscheduled/">parents</a>, <a href="http://www.washingtonpost.com/wp-dyn/content/discussion/2008/07/09/DI2008070901910.html">teenagers</a> and <a href="http://www.nytimes.com/2013/10/13/fashion/over-scheduled-children-how-big-a-problem.html">children</a> are all <a href="http://www.cnn.com/2013/03/08/living/overscheduled-busy-children/">overscheduled</a>. Should birth be scheduled too?</p>
<h2>The baby boom</h2>
<p>In the early 1970s, an influential <a href="http://www.karger.com/Article/PDF/155472">review</a> of when women gave birth found that “[m]ore human births occur between 1:00 and 6:00 am than at other times of day.” Today, this no longer happens, since most babies in the US are born midafternoon in the middle of the week.</p>
<p>Not only does this issue set the tone from the very beginning of our lives, but it also is occurring on an enormous scale. Currently, the US has about four million births each year. To put that number in context, <a href="http://www.statcan.gc.ca/tables-tableaux/sum-som/l01/cst01/demo02a-eng.htm">Canada</a>, our northern neighbor, has a population that is almost 36 million people. This means every decade more babies are born in the US than all the people living in Canada! </p>
<p>Not only are large numbers born, but childbirth is a big business since the “<a href="http://www.nytimes.com/2013/07/01/health/american-way-of-birth-costliest-in-the-world.html">cumulative costs</a> of approximately four million annual births is well over US$50 billion.”</p>
<h2>When are babies born?</h2>
<p>Starting in 2003, states across the US began switching to a new standardized birth certificate that gathers much more information than the old birth certificate. Part of the extra information is the exact time of day when each child was born. The below table shows the time and day when babies were born, taken from the five most recent years of publicly released information.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/92577/original/image-20150820-7225-98w4z7.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/92577/original/image-20150820-7225-98w4z7.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/92577/original/image-20150820-7225-98w4z7.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=126&fit=crop&dpr=1 600w, https://images.theconversation.com/files/92577/original/image-20150820-7225-98w4z7.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=126&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/92577/original/image-20150820-7225-98w4z7.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=126&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/92577/original/image-20150820-7225-98w4z7.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=158&fit=crop&dpr=1 754w, https://images.theconversation.com/files/92577/original/image-20150820-7225-98w4z7.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=158&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/92577/original/image-20150820-7225-98w4z7.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=158&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">This table shows the time and day when babies in the US are born, from 2009 to 2013.</span>
<span class="attribution"><span class="source">Author's calculations</span></span>
</figcaption>
</figure>
<p>There is no reason to expect that babies prefer leaving the womb on any particular day of the week. This means that births should be roughly evenly spaced out throughout the week. However, the table’s shaded gray bottom row shows this even spacing doesn’t happen. Instead, only 20% of all babies are born on Saturday or Sunday. If births were evenly distributed, about 29% (two days out of seven) of all births should occur on the weekend.</p>
<p>Babies are also not born randomly throughout a particular day in the US. If babies were born evenly spaced during the day, each of the table’s four time slots should have about 25% of all births. However, the shaded gray far right column shows far more babies than expected are born between noon and 6:00 pm. Interestingly, the midnight to 6:00 am time frame is now the least likely period for a baby to be born, capturing only 16.4% of all births. This is a far cry from the <a href="http://www.karger.com/Article/PDF/155472">1972 review</a> quoted above that found the early morning hours were the most likely time for women to give birth.</p>
<p>The yellow numbers in the center of the table show the most likely time for a baby to be born is Tuesday afternoon, closely followed by Wednesday and Thursday afternoons. The least likely time for a baby to be born, shaded in green, is very early Sunday or Monday morning.</p>
<h2>Why the change?</h2>
<p>There are primarily three ways to give birth: vaginal delivery, induced delivery and Cesarean section. Looking at the time of day when births occur using each method shows very different patterns (see graph <a href="http://www.cdc.gov/nchs/data/databriefs/db200.pdf#fig2">here</a>).</p>
<p>Vaginal births happen more or less evenly spaced out during the day, with a slight bump in the early morning hours. C-section births typically happen either around 8:00 am or noon. Induced deliveries typically happen around 3:00 pm.</p>
<p>Why are so many babies now born on Tuesday afternoons instead of early in the morning, like the data from the 1970s showed? Births today are more likely by <a href="http://www.ncbi.nlm.nih.gov/pubmed/17011400">C-section</a> or induction. </p>
<p>The percentage of women who give birth by C-section has dramatically increased over time (see graph <a href="http://www.cdc.gov/nchs/data/databriefs/db35.pdf#fig01">here</a>). In 1991, about 23% of all women giving birth had a C-section, but by 2010 this was almost <a href="http://www.cdc.gov/nchs/data/nvsr/nvsr61/nvsr61_01.pdf#tab21">33%</a>. Since only about one-quarter of all women who undergo a C-section did a trial of labor, this indicates many C-sections are scheduled (see table 14 <a href="ftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Dataset_Documentation/DVS/natality/UserGuide2013.pdf">here</a>). C-sections may be scheduled by the doctor, or by the mother, or as emergency procedures. Unfortunately, birth records don’t indicate why a C-section was performed.</p>
<p>The same trend occurred for births that were induced (see graph <a href="http://www.cdc.gov/nchs/data/databriefs/db155.pdf#fig01">here</a>). In 1990, about 10% of all women giving birth were induced, but by 2010 the share had more than doubled to almost 24%. </p>
<p>There are many potential <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3751192/">reasons</a> for the increases in C-sections and inductions. Examples range from improved medical imaging that lets doctors determine with more accuracy uterine and fetal conditions during the last few weeks of pregnancy to a desire by doctors to avoid any type of problem to either mother or unborn child. </p>
<h2>Is scheduling a reason?</h2>
<p>Scheduling to meet the convenience of doctors and other medical staff is likely one factor driving this shift in birth times. <a href="http://www.bls.gov/opub/ils/pdf/opbils68.pdf">Data on when</a> doctors and other medical professionals work show the vast majority are currently on the <a href="http://businessmacroeconomics.com/">job</a> from 8:00 am to 4:00 pm. Relatively few work during the wee hours of the night and early morning.</p>
<p>The shift from vaginal childbirth to C-section or induction has moved more babies from being born in the middle of the night to times more closely aligned with health care workers’ daily <a href="https://www.jstage.jst.go.jp/article/bst/5/4/5_2011.v5.4.139/_pdf">schedules</a>. Research suggests that when doctors and patients have an opportunity to decide when to schedule a birth, the <a href="http://papers.ssrn.com/sol3/papers.cfm?abstract_id=907406">doctor’s preferences win</a> out about three-quarters of the time, possibly because doctor’s value their <a href="http://www.sciencedirect.com/science/article/pii/0167629695000399">leisure</a>.</p>
<p>Scheduling by mothers might be a contributing factor in a small number of cases. Research has found that some Chinese mothers appear to be <a href="http://www.sciencedirect.com/science/article/pii/S1570677X15000404">scheduling their sons’</a> births to avoid unlucky days and ensure a lucky birthday. <a href="https://www.aeaweb.org/articles.php?doi=10.1257/pol.20130243">Tax implications</a> also have a small impact on births around New Year’s Eve. </p>
<p>The <a href="http://www.marchofdimes.org/mission.aspx">March of Dimes</a>, a non-profit devoted to preventing birth defects, is concerned about scheduling; it runs a <a href="http://www.marchofdimes.org/pregnancy/why-at-least-39-weeks-is-best-for-your-baby.aspx">campaign</a> asking mothers to wait until 39 weeks before giving birth. The National Institutes of Health convened an expert panel that estimated <a href="http://www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Obstetric-Practice/Cesarean-Delivery-on-Maternal-Request#2">2.5%</a> of all births in the United States are cesarean deliveries done on maternal request, but cautioned that it has “<a href="https://consensus.nih.gov/2006/cesareanstatement.pdf">little confidence in the validity of these estimates</a>.”</p>
<h2>Does it matter?</h2>
<p>So what does this trend mean for the health of the baby and the mother? </p>
<p>There is research that suggests it is more <a href="http://onlinelibrary.wiley.com/doi/10.1111/j.1471-0528.1986.tb07863.x/abstract;jsessionid=E648C1C7FE957E4C63597282E3788CE6.f03t01">dangerous</a> to have a baby in the <a href="http://link.springer.com/article/10.1186%2F1471-2393-12-92">middle of the night</a>, when less medical staff is available. But the <a href="http://www.acog.org/Resources-And-Publications/Obstetric-Care-Consensus-Series/Safe-Prevention-of-the-Primary-Cesarean-Delivery">actual riskiness</a> of vaginal childbirth, C-section or induced delivery is affected by a whole host of factors depending on the mother’s, child’s and hospital’s characteristics.</p>
<p>This shift from unscheduled births to setting birth times is unparalleled in history. There is a clear benefit to scheduling a birth when there is a medical need. However, when there are no medical concerns, there are <a href="http://www.sciencedirect.com/science/article/pii/S0167629613001458">advantages</a> to being flexible and spontaneous.</p>
<p>As a middle-aged male, I will never give birth. However, I think our lives are diminished when every event is scheduled, starting from the moment of birth. What do you think?</p><img src="https://counter.theconversation.com/content/46299/count.gif" alt="The Conversation" width="1" height="1" />
Are we overscheduling our children even from the moment of their birth? We live in an on-demand world. Movies are shown on request, food is delivered on call and drivers arrive when beckoned. As an economist…Jay L. Zagorsky, Economist and Research Scientist, The Ohio State UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/450032015-07-27T14:13:21Z2015-07-27T14:13:21ZHospitals are safer than home births – but only if you’re poor<figure><img src="https://images.theconversation.com/files/89182/original/image-20150721-24282-188flh9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Medical support is one of the things that makes birth safer.</span> <span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-202121116/stock-photo-midwife-checks-newborn-baby-heart-beat.html?src=G16_p9IkpuIKk_NObz4b6w-1-45">Baby by Shutterstock</a></span></figcaption></figure><p>Over the past few decades, many developed countries have experienced sharp rises in home birth rates. While the number of home births in most of these countries remains low, the trends are striking. For example, home births in the US increased by almost <a href="http://www.ncbi.nlm.nih.gov/pubmed/20575315">30% between 2004 and 2009</a>. Similarly, the fraction of home births in the UK <a href="http://www.ncbi.nlm.nih.gov/pubmed/18847065">almost tripled between 1990 and 2006</a> and out-of-hospital births in Canada <a href="http://www5.statcan.gc.ca/cansim/a26?lang=eng&id=1024516">more than quadrupled between 1991 and 2009</a>. </p>
<p>Despite these trends, there is still a lot of controversy among scientists and the media on the risks associated with home births. This prompted us to investigate the impact of home births on the short-term health of newborns. We <a href="http://dx.doi.org/10.1257/app.20120359">found evidence</a> that hospital births were significantly safer in terms of infant mortality but only for those women in the poorer half of the population. For richer women, giving birth at home was just as safe.</p>
<p><a href="http://www.meltemdaysal.com/research/NL_Homebirths_Manuscript.pdf">Our study</a> used data on 356,412 Dutch women deemed to be in the low-risk pregnancy category who delivered between 2000 and 2008. The Netherlands is an ideal setting to study this question because it is the only developed country where home births are widespread: between 2000 and 2008, about 25% of births took place at home. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/89184/original/image-20150721-24266-m9c0i.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/89184/original/image-20150721-24266-m9c0i.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/89184/original/image-20150721-24266-m9c0i.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/89184/original/image-20150721-24266-m9c0i.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/89184/original/image-20150721-24266-m9c0i.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/89184/original/image-20150721-24266-m9c0i.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/89184/original/image-20150721-24266-m9c0i.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Home births on the up.</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-200198798/stock-photo-mother-rest-with-her-newborn-baby-in-bed-immediately-after-a-natural-water-birth-labour-concept.html?src=pd-same_model-200198861-nJcu-syHHq1e09LuNgNpIA-1">Birth by Shutterstock</a></span>
</figcaption>
</figure>
<p>In addition, the Dutch institutional setup allows us to investigate place-of-birth effects (home versus hospital) independently from provider-effects (obstetrician versus midwife). This is because Dutch maternity care is based on a system of risk selection where low-risk women can choose between a home or a hospital birth and in both cases the delivery is supervised by a midwife without a doctor being present. In contrast, high-risk women are always required to give birth in a hospital under the supervision of an obstetrician. </p>
<p>The Netherlands is a country where the childbirth system is a major policy issue because the Dutch mortality rate within the first seven days of life (seven-day mortality) <a href="http://www.bmj.com/content/337/bmj.a3118">is one of the highest in Europe</a> and the contribution of home births to this is hotly debated.</p>
<h2>The problem in the raw data</h2>
<p>Location of delivery and newborn health outcomes are related in the raw data. Historical data shows that seven-day mortality declined from 4.25 deaths per 1,000 births in 1980-85 to 2.42 deaths in 2005-09, while the share of hospital births increased from 61.25% to 72.06%. In addition, most of the mortality decline between 2000–2008 comes from newborns weighing more than 2,500g, who are more likely to be low-risk and so eligible for home births. </p>
<p>However, these raw correlations can be misleading: even among low-risk women, those who give birth at home or in a hospital may have different risk factors, with riskier deliveries usually taking place in a hospital. Therefore, babies born in a hospital often have more health problems than babies born at home and simple comparisons of these two groups are misleading.</p>
<p>Our study has an innovative solution to circumvent this problem. We noticed that some women end up giving birth at home or in a hospital depending on how far they live from the nearest obstetric ward. For example, women living within 2-4km of a hospital are almost 10% more likely to deliver in a hospital than those living at least 11km away. </p>
<p>Using this observation, we compared two groups of low-risk women who are identical, except that the women in one group have a higher probability of delivering in a hospital only because they live closer to a hospital.</p>
<h2>Hospitals reduce infant deaths for some people</h2>
<p>We found that giving birth in a hospital leads to large reductions in infant mortality. Our calculations suggest that the rise in hospital births explains roughly 46%–49% of the reduction in infant mortality in the Netherlands between 1980 and 2009. However, these findings do not equally apply to all low-risk women. </p>
<p>All the mortality reduction we find is driven by births from the poorer half of the Dutch population while in the richer half home births seem as safe for the child as hospital births. It’s not clear why, but it may be because risk selection is more difficult and less precise for women with lower socioeconomic status, for example due to more difficult communication with the midwife. </p>
<figure class="align-left ">
<img alt="" src="https://images.theconversation.com/files/89183/original/image-20150721-24286-t8fisk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/89183/original/image-20150721-24286-t8fisk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/89183/original/image-20150721-24286-t8fisk.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/89183/original/image-20150721-24286-t8fisk.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/89183/original/image-20150721-24286-t8fisk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/89183/original/image-20150721-24286-t8fisk.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/89183/original/image-20150721-24286-t8fisk.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Home birth is as safe if you’re more well off.</span>
<span class="attribution"><span class="source">Pool by Shutterstock</span></span>
</figcaption>
</figure>
<p>There are many reasons why a hospital birth may reduce infant mortality, such as: the availability of better facilities and equipment, potentially better hygiene (sterility) or the proximity to other medical services. In our data we cannot pinpoint the precise reason but we do find that infant mortality is even lower among births in a hospital with a neonatal intensive care unit. We cautiously interpret this as evidence that access to medical technologies may be an important channel in explaining the lower infant mortality among hospital births.</p>
<p>One policy implication of our work is that ensuring access to a hospital birth may improve newborn outcomes even among low-risk women living in a developed country. Specifically, our results caution against policies that encourage home births for all low-risk women. </p>
<p>The Netherlands is a country where maternity care is provided using a rigorous process of risk selection based on both past medical history and the current health status and development of the mother and the foetus. The Dutch maternity system is explicitly geared toward home births. Yet, even with a relatively sophisticated model of risk selection, we find that some women classified as low risk benefit from a hospital birth and their babies would have been saved if their mothers had delivered in a hospital. </p>
<p>Low-income women benefit especially from a hospital birth, which may be related to risk assessment. If so, having a good understanding of risk selection must go hand-in-hand with crafting policies about home births. </p>
<p>While home births are less expensive on average, we cannot just mandate home births for all apparently low-risk women because our study shows that hospitals provide valuable services that translate into lower infant mortality. A second policy implication of our work is that low-risk women, particularly the lower-income ones, should be informed about the potential risks of home births.</p><img src="https://counter.theconversation.com/content/45003/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Home births are on the up but hospitals still matter.N. Meltem Daysal, Associate Professor of Economics, University of Southern DenmarkMircea Trandafir, Associate Professor of Economics, University of Southern DenmarkReyn van Ewijk, Professor of Statistics and Econometrics, Johannes Gutenberg University of MainzLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/291952014-07-15T04:38:28Z2014-07-15T04:38:28ZRisks versus rights in home birthing: a legal view<figure><img src="https://images.theconversation.com/files/53844/original/nmm8s54k-1405391996.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The legal landscape around rights and responsibilities for home births is growing increasingly complex.</span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/tom_focus/6381797933/in/photolist-aHWobR-MK25L-mv4XZv-fduoqb-94EcJg-iNpH9k-AwHaw-cZCJSu-6t4Hnw-9f7aPF-bvghrw-bJb4Fx-nhbGtv-iMfqi-7GjUsg-7GjVe6-5PL3xc-6BkEdN-Gdg8U-Gdkzz-bQYotr-6hr9nQ-7fPNHM-adeUNC-9DiuSn-b5EYdK-emy9z-8CptUB-fAdFfB/">Flickr: Thomas</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc-sa/4.0/">CC BY-NC-SA</a></span></figcaption></figure><p>The ongoing and sometimes emotive debate about risks and rewards of giving birth in hospital or at home is nothing new. What is new is the attention being given to the legal rights and responsibilities of parents and health practitioners.</p>
<p>Consider <a href="http://www.sapolicenews.com.au/component/content/article/4-news/25742-police-probe-babies-death.html">this recent news</a>: South Australian police have announced criminal investigations of the deaths of two babies in home-birth deliveries. Detectives are said to be closely examining evidence given by witnesses during an earlier inquest to determine if perjury was committed or evidence was withheld or concealed. Charges, including manslaughter, may be laid.</p>
<p>This is a highly unusual development.</p>
<p>As a general rule, few health practitioners are subject to criminal charges in Australia, although the number has perhaps been growing in recent years. The <a href="http://www.austlii.edu.au/au/cases/vic/VSC/2013/93.html">imprisonment of Dr James Peters in Victoria</a> is a recent, albeit unusual, example.</p>
<p>Australia has not yet seen the prosecution of a midwife or doctor following a home birth – though we have seen cases come before disciplinary tribunals, coroners’ courts if the child has died, or civil courts if the child or mother is said to have suffered injury for want of reasonable care.</p>
<p>So how do parents wanting home births and their health-care providers now navigate the legal landscape?</p>
<h2>Risk assessment</h2>
<p>Central to legal arguments about home births is the assessment of risks and the provision of accurate information. The latter is crucial to the question of whether a mother’s decision about where she gives birth is well informed.</p>
<p>Only a few weeks ago, a <a href="http://www.coronerscourt.vic.gov.au/resources/d6ca3578-3cc8-4271-a13d-f576090c82ba/thomasfreemantle_420110.pdf">Victorian coroner reported</a> in relation to the death of a child, Thomas Freemantle, following a home birth. The birth was complicated by cephalo-pelvic disproportion, a condition whereby the baby’s head or body is too large to fit easily through the mother’s pelvis. </p>
<p>The parents agreed that medical practitioners had told them of the risks of a home birth given aspects of the mother’s medical history, but argued they were “not sufficiently firm in their advice that Thomas should be born at hospital”.</p>
<p>The coroner’s view was bluntly stated: “high-risk pregnancies demand birth occur in the safest setting – namely, a hospital which can provide emergency and timely, medical support”. He went on to say that “the safety of the child is paramount and … the wishes of the parents always secondary to ensuring the safest birthing process”. </p>
<p>But it may not be entirely true, in the legal sense, to say the wishes of parents are always secondary to ensuring the safest birthing process. While the coroner spoke in favour of unambiguous communication, that does not guarantee a mother will always simply accept the given advice (whether by doctors or midwives).</p>
<h2>The rights of mothers</h2>
<p>An example of advice being given but not accepted can be found in a <a href="http://www.austlii.edu.au/au/cases/vic/VCAT/2014/771.html">decision earlier this month</a>, where a hospital had declined to provide a mother with home birth services under its program because of medical concerns – namely, her age and the number of her earlier pregnancies. </p>
<p>The mother argued the hospital’s refusal was discriminatory and in breach of her human rights, but the Victorian Civil and Administrative Tribunal found the medical advice was sound. Neither argument by the mother, as to discrimination or breach of human rights, succeeded. </p>
<p>This returns us to the earlier suggestion (by the Victorian coroner) that the wishes of parents are always secondary to ensuring the safest birthing process. The mother (having been refused participation in the hospital’s home birth program) simply chose to deliver at home without a midwife in attendance, as she appears to have done on five prior occasions. </p>
<p>The law recognises that a mother, when not clearly lacking the capacity to make decisions, is able to decide where to give birth freely, regardless of advice about the safest birthing process.</p>
<p>Further complications for mothers may arise in assessing the quality of advice provided to them. Not all advice is good advice, not all care is good care. <a href="http://billmaddens.wordpress.com/2014/03/11/home-births-permanent-prohibition-on-provision-of-midwifery-services/">Disciplinary case examples</a> highlight that unfortunate reality.</p>
<h2>Making sense of it all</h2>
<p>So what are the emerging legal trends? While this area of law seems under constant development, perhaps the following can be safely said:</p>
<ul>
<li><p>health practitioners should give clear and sometimes robust advice about the risks of home birth in the context of known medical history, so mothers can make informed choices.</p></li>
<li><p>a mother has the right to choose where to deliver her child, but that does not extend to forcing a health-service provider to allow a home birth service it has decided is unsafe for her or her unborn child, in accordance with accepted clinical practice.</p></li>
<li><p>for those health practitioners and providers who offer services unsafe for the patient or the unborn child, existing civil and disciplinary action precedents may soon be followed by criminal charges.</p></li>
</ul><img src="https://counter.theconversation.com/content/29195/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Bill Madden does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The ongoing and sometimes emotive debate about risks and rewards of giving birth in hospital or at home is nothing new. What is new is the attention being given to the legal rights and responsibilities…Bill Madden, Adjunct Fellow, Western Sydney UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/287532014-07-04T04:57:09Z2014-07-04T04:57:09ZBirthing pools recalled after case of Legionnaires – so, should you be worried?<figure><img src="https://images.theconversation.com/files/52956/original/tzbsx2b7-1404385938.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Home or away?</span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/eyeliam/7167903447/sizes/l">Jason Lander</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span></figcaption></figure><p>The <a href="http://www.theguardian.com/society/2014/jul/01/home-birthing-pools-recalled-nhs-public-health-england-after-baby-falls-ill-legionnaires-disease">recall of hired home-birthing pools</a> after a baby contracted Legionnaires’ disease will inevitably lead some women to worry about having a water birth at home. While the incidence is rare, it is worth keeping in mind some clear guidelines about how to best use a water pool.</p>
<p>Home birth is an option for women who are at low risk of complications, but it is certainly not widespread. In the UK, the percentage of women who have their baby at home is very low – only <a href="http://www.ons.gov.uk/ons/datasets-and-tables/index.html">2.3% in 2012</a> (included in this figure are many home births that are unplanned). Others who plan home births initially labour at home using water, but <a href="https://www.npeu.ox.ac.uk/birthplace/publications">then transfer to hospital</a> for additional pain relief.</p>
<p>But about <a href="http://www.biomedcentral.com/1471-2393/14/60">half of women who planned home births</a> use water birth pools, as immersion in water <a href="http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD000111.pub3/abstract">helps relieve pain</a>. </p>
<p>In the case of the baby with Legionnaires’, it was born in a pool that was pre-filled and kept heated for several days before. The recommended water temperature for water birth pools is 36-37°C so that during labour the baby is not overheated or shocked by cold water. But this is also an ideal temperature for many bacteria to flourish in, including the Legionnelle bacteria, which <a href="http://www.nhs.uk/conditions/Legionnaires-disease/Pages/Introduction.aspx">cause a severe lung infection</a>. So the recommendation is that home birth pools should never be pre-filled and kept warm. This is the reason that hot tubs that aren’t cleaned and looked after <a href="http://www.bbc.co.uk/news/health-19097187">have also been implicated</a> in cases of Legionnaires’ disease.</p>
<p>Some women may be tempted to pre-fill the pool when they know they could go into labour so that they don’t have to wait while it fills up when labour starts, or to try it out beforehand. But a good idea is to fill it with cold water to see how long it takes to fill – most only take 10-20 minutes – before emptying, cleaning and drying the pool until it’s actually needed, which will also give you an idea of when to start the process. This would prevent the unusual Legionnaire bacteria but also more common bacteria.</p>
<h2>Hiring a pool</h2>
<p>Not all women buy pools because they are for a one-off use or because buying one may be too expensive. Some NHS Trusts provide a rigid shell and women can then purchase a disposable liner, although many are hired privately. These hired pools come in a variety of types, usually free standing, and can have inflatable or rigid frames with disposable liners. Most come with pumps and pipes to aid filling and draining and most companies provide advice about safety and hygiene which should be read and adhered to. Even so, it’s ideal to discuss the pool, how and when to fill it and ensure it’s clean and safe with a midwife. </p>
<p>While an investigation into how the baby contracted Legionnaires’ is carried out, certain types of birthing pool have been banned by the NHS and Public Health England (PHE) until further notice. Heated pools from the particular supplier in this case have been recalled and a further six companies that hire out pools are being questioned over whether they carry out the right risk assessments. </p>
<p>Concerns about infection are not new. But a Cochrane review I lead that looked at the evidence to date <a href="http://www.ncbi.nlm.nih.gov/pubmed/19370552">showed no difference</a> in the incidence of infection in mothers or babies using a variety of pools, both plumbed in and free-standing. Importantly, however, all were filled at the time of use, were carefully maintained, with strict cleaning regimes, or with one time use only liners. </p>
<p>The concept of a pool that is pre-filled and kept warm is a new phenomenon but not one that is recommended in any NHS facility. The risk of infection is well recognised and all NHS facilities have policies and processes that include birth pools being filled at the time they are needed, are thoroughly cleaned and dried after every use and monitored for potential infections. Most good companies would recommend similar precautions. </p>
<p>All midwives are also very aware of the risk of infection and any woman considering birth at home or using water during birth should speak to her midwife about her plans. Advice in local waterbirth workshops for expectant parents also now explicitly includes not using pre-filled/heated pools because of the rare but possible infection risk.</p>
<p>There are important advantages for women giving birth at home, such as a sense of well-being from being in their own environment. The use of water during labour and birth is likely to be a contributing factor to this, so it is vital that women have all the information they need to safely birth at home and use water immersion during labour if they wish. </p>
<p>So the key message must be that any infection is unusual – and legionnaires extremely rare – but good practice when it comes to birthing pools, and under the guidance of a midwife, will contribute to a positive birth experience for all. </p><img src="https://counter.theconversation.com/content/28753/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Elizabeth Cluett was lead reviewer on the Cochrane review into outcomes from immersion in water during labour and birth</span></em></p>The recall of hired home-birthing pools after a baby contracted Legionnaires’ disease will inevitably lead some women to worry about having a water birth at home. While the incidence is rare, it is worth…Elizabeth Cluett, Director of Programs for Family, Child and Psychosocial Health. Lead Midwife for Education., University of SouthamptonLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/68852012-06-24T20:40:40Z2012-06-24T20:40:40ZHome birth is a viable and safe option for most women<figure><img src="https://images.theconversation.com/files/10588/original/vwfy4c29-1336955893.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The perceived dangers of home birth are overstated.</span> <span class="attribution"><span class="source">krzyboy2o</span></span></figcaption></figure><p>In response to a recent South Australian coroner’s finding that <a href="http://www.skynews.com.au/local/article.aspx?id=759002&vId=">three babies died from preventable causes</a>, Health Minister Tanya Plibersek has said she will close a loophole in national health laws that allowed a former midwife to practice home birth without regulation. This case and its tragic consequences should not be confused with the quality service provided by experienced midwives. </p>
<p>Opinion in Australia is divided on the safety of planned birth at home. Supporters of women’s right to give birth at home view it as a normal, natural process and understand that the majority of pregnant women will give birth safely and with minimal need for intervention. Supporters of birthing in hospitals (and the safety that goes with that), on the other hand, view birthing as fraught with risk and danger. </p>
<p>The weight of numbers supporting hospital births as safest <a href="http://www.biomedcentral.com/1471-2393/11/47">reflects the “no-risk” society</a> in which we live. Technology-intensive childbirth is equated with high standards of care and as being in the best interest of mothers and babies. </p>
<p>In such a society, responsible parents are those who understand that a perfectly healthy child is more important than a perfect birth. They place trust in their care providers to keep them safe, willingly doing whatever they believe helps ensure the birth of a healthy baby. </p>
<p>It’s interesting to note, then, that a large proportion of women who seek to give birth at home are refugees from a previous, traumatic hospital birth experience. <a href="http://www.biomedcentral.com/1471-2393/11/53">Many report</a> obstetric practices that are insensitive and a maternity service that is inflexible and incapable of meeting their needs. </p>
<p>A 2008 <a href="http://www.biomedcentral.com/1471-2393/11/53">survey of 2,792 mothers</a> through the <a href="http://fairfax.com.au/fdnetwork/essential-baby-network/">Fairfax Essential Baby website</a> highlighted traumatic and unsatisfactory experiences of women giving birth in an overstretched system. A particularly alienating feature of this system is its “one-size-fits-all” service, which dismisses the special needs of individual women. </p>
<p>Other features of current maternity services include conflicting information and advice, which result from staffing arrangements that cannot secure a known caregiver once the woman is admitted to a hospital. A constant stream of unknown carers undermines the trust women have in the care received and decisions being made.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/10584/original/s377ks2f-1336955226.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/10584/original/s377ks2f-1336955226.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/10584/original/s377ks2f-1336955226.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/10584/original/s377ks2f-1336955226.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/10584/original/s377ks2f-1336955226.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/10584/original/s377ks2f-1336955226.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/10584/original/s377ks2f-1336955226.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Women tend to over-estimate the risks associated with childbirth.</span>
<span class="attribution"><span class="source">courosa/Flickr</span></span>
</figcaption>
</figure>
<p>Despite the very remote chance of a woman dying during childbirth in Australia, pregnant women are <a href="http://www.biomedcentral.com/1471-2393/11/53">reported to be more fearful</a> of the birthing process than ever before. These high levels of fear are being sustained because of the perception of their own birth risk, which is out of proportion with medical risk, because the maternity service treats every pregnancy with suspicion. This process has been described in the <a href="http://www.theage.com.au/victoria/hard-labour-20100619-yo2p.html">media as an “antenatal scare”</a>. </p>
<p>In response to 832 submissions to the 2008 National Review of Maternity Services from women, health services, maternity care professionals and a range of other key stakeholders, the government announced a <a href="http://www.health.gov.au/internet/main/publishing.nsf/Content/maternityservicesreview-report">major program of reform</a>. The program recognised the need to reach a balance between safety and improving women’s birthing experience. </p>
<p>Pregnant women are now actively encouraged on a number of government <a href="http://www.health.wa.gov.au/havingababy/home/">information-based websites</a> to make informed choices about the maternity care they receive. These same women now find themselves <a href="http://www.biomedcentral.com/1471-2393/11/47">labelled by maternity care professionals</a> on whom they rely as “difficult” or “untrusting” if they question the the decisions being made on their behalf. </p>
<p>Those who dare to seek more control in the process of giving birth or who choose to give birth naturally are being <a href="http://www.smh.com.au/opinion/society-and-culture/when-push-comes-to-shove-home-births-dont-deserve-to-be-demonised-20111213-1ot0e.html">demonised</a>. </p>
<p>In announcing the change to how maternity care is provided, the government said it was sufficiently convinced by evidence supporting the safety of healthy women who choose to birth at home in the care of registered midwives with appropriate support services in place. </p>
<p>Problems arise when <a href="http://summaries.cochrane.org/CD000352/home-versus-hospital-birth">guidelines ensuring the safety of home birth</a> are not adhered to. These guidelines preclude pregnant women having twins or a breech baby at home. </p>
<p>Sadly, these circumstances have resulted in highly publicised deaths of babies born at home. The death of a baby is a tragedy no matter whether birth was at home or in hospital. And having a baby in hospital doesn’t guarantee life, as many bereaved parents will attest. </p>
<p>There’s now <a href="http://summaries.cochrane.org/CD000352/home-versus-hospital-birth">sufficient international evidence</a> to support the conclusion that there’s no difference in the safety of healthy mothers who give birth in hospital or at home when they are in the care of qualified midwives working within rigorous guidelines. </p>
<p>Despite excellent safety outcomes for healthy mothers and babies associated with giving birth at home, uninformed debate continues to undermine confidence and generate fear.</p><img src="https://counter.theconversation.com/content/6885/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Meredith McIntyre does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>In response to a recent South Australian coroner’s finding that three babies died from preventable causes, Health Minister Tanya Plibersek has said she will close a loophole in national health laws that…Meredith McIntyre, Senior Lecturer in Midwifery, Monash UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/68252012-05-28T20:38:21Z2012-05-28T20:38:21ZPushing home birth underground raises safety concerns<figure><img src="https://images.theconversation.com/files/11060/original/dj8qzmng-1337914391.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Home birth isn't going away – and time is running out to solve the insurance dilemma.</span> <span class="attribution"><span class="source">Flickr/hubeRsen</span></span></figcaption></figure><p>Women have the right to determine what happens to their bodies; and this includes where and how they give birth. But from July 2013, private midwives may not be able to legally provide their services to women who choose to give birth at home. This means that without government intervention, Australian women will lose access to safe, supported home births. </p>
<p>Officially, only a small proportion of women choose to give birth at home in Australia, around 0.3%. But this figure doesn’t take into account the increasing number of planned births at home without a midwife present – this is known as <a href="https://theconversation.com/for-some-women-unassisted-home-births-are-worth-the-risks-5179">free birthing</a> and is inherently risky. </p>
<p>There is no <a href="http://www.medicareaustralia.gov.au/">Medicare rebate</a> for home birth and virtually no private health insurance rebates, so women and their partners foot the bill of around $3,000 to $6,000 for their midwife’s care. (A handful of health services also offer publicly funded home births to a limited number of very low-risk women). </p>
<p>Privately practicing midwives haven’t had access to affordable insurance since 2002, following the <a href="http://www.smh.com.au/articles/2003/03/14/1047583693489.html">collapse of insurance giant HIH</a>. Since then, many midwives have ceased practising, making it difficult for women to access this service. Others risk practicing without insurance, but if anything goes wrong, there is no recourse for negligence and the midwife can face financial ruin. </p>
<p>The issue of funding and insurance came to a head in 2009, following the release of the Commonwealth government’s <a href="http://www.health.gov.au/internet/main/publishing.nsf/content/maternityservicesreview">Maternity Services Review</a> (MSR). </p>
<p>Despite receiving hundreds of submissions to the review from consumers who talked of the benefits of home birth, and the barriers to receiving this type of care, the government decided to exclude funding and insurance for home births from the reform process. This decision is perplexing, but the <a href="http://www.health.gov.au/internet/ministers/publishing.nsf/Content/tr-yr09-nr-nrsp040909.htm?OpenDocument&yr=2009&mth=09">reason</a> given was, essentially, that it was too hot to handle and insurance could not be found. </p>
<h2>National registration</h2>
<p>At the same time as reforms from the MSR were being implemented (2010), Australia moved from a system of state- and territory-based health registration schemes to the implementation of a <a href="http://www.ahwo.gov.au/natreg.asp">National Registration and Accreditation Scheme</a>.</p>
<p>Under this scheme, all health professionals registered by the <a href="http://www.ahpra.gov.au/">Australian Health Practitioner Regulation Agency</a> (AHPRA) are required to have insurance for every area of their practice. This presents a problem for private midwives who <a href="http://www.health.gov.au/internet/main/publishing.nsf/Content/Maternity+Services+Review-Indemnity_insurance_FS">aren’t insured</a> for home births. </p>
<figure class="align-left ">
<img alt="" src="https://images.theconversation.com/files/11061/original/5gqjh8ng-1337916982.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/11061/original/5gqjh8ng-1337916982.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=840&fit=crop&dpr=1 600w, https://images.theconversation.com/files/11061/original/5gqjh8ng-1337916982.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=840&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/11061/original/5gqjh8ng-1337916982.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=840&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/11061/original/5gqjh8ng-1337916982.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1056&fit=crop&dpr=1 754w, https://images.theconversation.com/files/11061/original/5gqjh8ng-1337916982.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1056&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/11061/original/5gqjh8ng-1337916982.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1056&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Midwife-supported home births are as safe as hospital births for low-risk women.</span>
<span class="attribution"><span class="source">Asus</span></span>
</figcaption>
</figure>
<p>Realising this was a safety issue, the Commonwealth government gave midwives a two-year and then additional one-year <a href="http://www.google.com.au/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&ved=0CFEQFjAA&url=http%3A%2F%2Fwww.nursingmidwiferyboard.gov.au%2Fdocuments%2Fdefault.aspx%3Frecord%3DWD11%252F4423%26dbid%3DAP%26chksum%3Di5LeZen3YBVhNMkcRKDBtQ%253D%253D&ei=E_PCT6LeH-uaiAf9hsygCg&usg=AFQjCNFxnq0JroDfJ9AwUCLh0WQfnpAblw">exemption</a> on the insurance requirement. But this exemption will expire on June 30, 2013 and a midwife could then be disciplined and potentially lose her registration for attending a birth at home if a solution is not urgently found. </p>
<p>This leaves two options for home birth: for women to give birth without the care of a midwife, or for midwives to go underground and drop their registration. Neither option is safe or feasible.</p>
<h2>Evidence-based practice</h2>
<p>The <a href="http://www.ncbi.nlm.nih.gov/pubmed/19624439">scientific evidence</a> is clear that where registered midwives are present, home birth for <a href="http://3centres.com.au/guidelines/what-is-low-risk/">low-risk women</a> is just as safe as hospital birth. And it’s gradually becoming a more acceptable option via mainstream maternity services throughout Australia. </p>
<p>However, <a href="https://www.mja.com.au/journal/2010/192/2/planned-home-and-hospital-births-south-australia-1991-2006-differences-outcomes?0=ip_login_no_cache%3Db0c9adf8bfd575a7c90f2ab25a3d6a89">scientific evidence and health policy data</a> show that intentionally birthing at home without a health professional (free birthing) and planning a home birth if you have a high-risk pregnancy is less safe.</p>
<p>So what’s the solution to Australia’s home birth insurance problem? </p>
<p>We just need to look to Canada, the United Kingdom and New Zealand for options. What protects midwives in these countries is duty-of-care legislation, or clinical pathways that carefully balance the rights of women with the professional responsibilities of midwives. </p>
<p>In the United Kingdom, for example, <a href="http://www.bcf.nhs.uk/our_services/maternity_services/supervision_of_midwives">supervisors of midwives</a> (experienced midwives) support and guide midwives to ensure they’re practising safely. In this case, women’s informed choice is respected and midwives are not hung out to dry for supporting this choice. </p>
<h2>Australian reform?</h2>
<p>Australia’s state and territory health ministers were presented with an options paper at last month’s Australian Health Workforce Ministerial Council (AHWMC), which proposed, among other things, insurance for midwives caring for low-risk women at home. </p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/11120/original/gk7k2km7-1338185445.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/11120/original/gk7k2km7-1338185445.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=901&fit=crop&dpr=1 600w, https://images.theconversation.com/files/11120/original/gk7k2km7-1338185445.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=901&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/11120/original/gk7k2km7-1338185445.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=901&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/11120/original/gk7k2km7-1338185445.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1132&fit=crop&dpr=1 754w, https://images.theconversation.com/files/11120/original/gk7k2km7-1338185445.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1132&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/11120/original/gk7k2km7-1338185445.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1132&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption"></span>
<span class="attribution"><span class="source">Sean Dreilinger</span></span>
</figcaption>
</figure>
<p>Insuring midwives to provide home birth services for low-risk women is based on <a href="http://www.ncbi.nlm.nih.gov/pubmed/19624439">evidence</a> and deserves government support. But the ministers postponed the discussion and elected to revisit the issue at their next meeting in August.</p>
<p>If the decision is made to support home birth, some procedural challenges will follow. For instance, will midwives be uninsured if women develop risk factors and choose to pursue a home birth? Imagine a situation where a midwife is forced to walk out during a birth because it is no longer deemed “low risk” and the woman refuses to go to hospital? This won’t enhance safety.</p>
<p>We have 13 months to find a solution that protects women’s rights to choose their place of birth and enlist the services of skilled, regulated midwives. The alternative is to regulate women’s choice indirectly by regulating midwives and forcing them to choose between women and their livelihood.</p>
<p>One thing is clear: home birth is not going away and government denial won’t resolve this issue. Governments must act quickly to resolve this issue to ensure Australian women have access to safe and supported home births. </p><img src="https://counter.theconversation.com/content/6825/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Hannah Dahlen is a practicing midwife. She receives funding from the NHMRC and is affiliated with the Australian College of Midwives (national spokesperson).</span></em></p>Women have the right to determine what happens to their bodies; and this includes where and how they give birth. But from July 2013, private midwives may not be able to legally provide their services to…Hannah Dahlen, Professor of Midwifery, Western Sydney UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/44522011-12-15T19:33:44Z2011-12-15T19:33:44ZThinking about giving birth at home? Look at the evidence on safety<figure><img src="https://images.theconversation.com/files/6452/original/zqv23wns-1323837892.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The frequently cited Netherlands study doesn't show it's safe to give birth at home in Australia.</span> <span class="attribution"><span class="source">Assy</span></span></figcaption></figure><p>We’re fortunate to live in a society where robust evidence forms the basis of the information health-care professionals provide to patients – and home birth should be no exception. But the evidence about the risks of home births and the relative safety of hospital-based births is too often <a href="https://theconversation.com/comfortable-safe-and-in-control-why-women-should-have-the-option-to-give-birth-at-home-4065">ignored by home birth advocates</a>. </p>
<p>Women need clear and accurate information about the risks of different birthing environments. As an obstetrician of 30 years, I have these discussions with pregnant women and their partners every week. And many are surprised to learn that giving birth at home is far more risky for their baby than a planned hospital birth.</p>
<h2>Stark reality</h2>
<p>A <a href="http://www.ncbi.nlm.nih.gov/pubmed/20078406">2010 study</a> by Kennare and colleagues confirmed <a href="http://www.bmj.com/content/317/7155/384.full">previously published Australian evidence</a> that giving birth at home increases the risk of a baby dying during childbirth. </p>
<p>The authors reviewed the outcomes of 1,141 planned home births in South Australia from 1991 to 2006 and found they were associated with a seven-fold increase in the child or fetus dying compared with a planned hospital birth. The risk of fetal death due to asphyxiation was 27 times higher. </p>
<p>The same study noted that in the period 1991 to 2006, the incidence of fetal death in labour due to asphyxia halved in South Australian hospital births compared with the <a href="http://www.ncbi.nlm.nih.gov/pubmed/2246989">outcomes recorded for 1976 to 1987</a>. But there was virtually no improvement for planned home births over the same study period.</p>
<p>Rates of interventions such as caesarean section and instrumental delivery were lower in the planned home birth group. But this isn’t surprising, given that women who are higher risk of complications are more likely to require interventions and will therefore have a planned hospital birth. This wasn’t accounted for in the study. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/6466/original/d2vyqzs2-1323920983.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/6466/original/d2vyqzs2-1323920983.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=392&fit=crop&dpr=1 600w, https://images.theconversation.com/files/6466/original/d2vyqzs2-1323920983.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=392&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/6466/original/d2vyqzs2-1323920983.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=392&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/6466/original/d2vyqzs2-1323920983.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=492&fit=crop&dpr=1 754w, https://images.theconversation.com/files/6466/original/d2vyqzs2-1323920983.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=492&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/6466/original/d2vyqzs2-1323920983.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=492&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption"></span>
<span class="attribution"><span class="source">cindalee</span></span>
</figcaption>
</figure>
<h2>Safety claims</h2>
<p>Despite the evidence of the risks of home birth, advocates continue to cite international evidence of its comparative safety.</p>
<p>A <a href="http://www.ncbi.nlm.nih.gov/pubmed/19624439">2009 Netherlands study</a> led by de Jonge, examined 321,307 women who planned to give birth at home and 163,261 who intended to give birth in hospital. The study concluded there were no significant differences to perinatal mortality (the risk of the child dying) between either group – and this is the message promulgated by home birth advocates. </p>
<p>But when you closely examine the study you see that in the self-selected home-birth group, more of the women were: 25 years and older, of Dutch origin, of medium to high socioeconomic status, more likely to have had two or more children previously and more likely to give birth at 41 weeks gestation. Given these factors put the women in this group at low risk of complications, you’d expect this group to have better outcomes than the hospital birth group, who were at higher risk. </p>
<p>The authors reported that the number of babies who died or were admitted to a neonatal intensive care unit was the same in both groups: seven for every 1,000 births. The equivalent <a href="http://www.ncbi.nlm.nih.gov/pubmed/7639843">Australian statistics</a> for low-risk women delivering in hospital is between 2.2 and five for every 1,000 births – this is quite a contrast and hardly an endorsement of obstetric practice in the Netherlands.</p>
<p>It must also be noted that maternity services in the Netherlands are set up to meet the demands for home births. Transport is good and distances are short if women need an emergency transfer to hospital. The same advantages are not available in all places in Australia. And if local services aren’t available for quick transfer, the risks of home birth increase. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/6469/original/pz63wp7j-1323922583.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/6469/original/pz63wp7j-1323922583.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/6469/original/pz63wp7j-1323922583.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/6469/original/pz63wp7j-1323922583.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/6469/original/pz63wp7j-1323922583.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/6469/original/pz63wp7j-1323922583.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/6469/original/pz63wp7j-1323922583.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Almost half of first time UK mothers planning to give birth at home were transferred to an obstetric unit.</span>
<span class="attribution"><span class="source">AAP</span></span>
</figcaption>
</figure>
<h2>Comparing risk</h2>
<p>Last month, the Royal College of Obstetricians and Gynaecologists released the long-awaited findings of the <a href="http://www.bmj.com/content/343/bmj.d7400">National Perinatal Epidemiology Unit’s Birthplace in England</a> cohort study.</p>
<p>This study compared the safety of birth planned for healthy women with straightforward pregnancies in four settings: home, freestanding midwifery units, “alongside midwifery units” (midwife-led units on a hospital site with an obstetric unit) and obstetric hospital units. All the women were classified as having a <a href="http://www.nice.org.uk/CG055">low risk</a> for complications.</p>
<p>The overall incidence of adverse outcomes during childbirth was 4.3 for every 1,000 births. For first-time mothers planning to give birth at home, there were 9.3 adverse events for every 1,000 births and a 45% transfer rate to an obstetric unit.</p>
<p>For women having their second baby there was no significant difference in adverse outcomes between all sites but of the women planning to have home births, 10% to 12% were transferred to other sites. </p>
<p>So my advice to women planning to give birth is – look at the evidence. Even if you fall within the low-risk category, home births pose an increased risk to your baby, particularly in your first pregnancy. </p><img src="https://counter.theconversation.com/content/4452/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>I am a Fellow of The Royal Australian and New Zealand College of Obstetricians and Gynaecologists which does not endorse home birth</span></em></p>We’re fortunate to live in a society where robust evidence forms the basis of the information health-care professionals provide to patients – and home birth should be no exception. But the evidence about…John Svigos, Consultant Obstetrician and Gynaecologist & Associate Professor , University of AdelaideLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/40652011-11-22T03:03:43Z2011-11-22T03:03:43ZComfortable, safe and in control: why women should have the option to give birth at home<figure><img src="https://images.theconversation.com/files/5473/original/methyl_lives.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Government restrictions on midwife-led care make it difficult for women to have a home birth.</span> <span class="attribution"><span class="source">Methyl lives</span></span></figcaption></figure><p>Choosing where to give birth – whether in a public hospital, private facility or in the home – is a fundamental human right that should be available to all Australian women. But despite the Commonwealth Government’s supposed reforms to the maternity care system in 2009, new regulations make it difficult for women to opt for a home birth. </p>
<h2>Who chooses home births?</h2>
<p>Women planning home births value their right to choose a safe and familiar birthing environment. They want to form a partnership with a trusted midwife who will respect them throughout their pregnancy and work with them to achieve their birth plan. </p>
<p>The <a href="http://www.aihw.gov.au/publication-detail/?id=6442472399">average age</a> of women birthing at home is 32 years, with almost a third (30.5%) aged over 35 and almost two thirds (62.5%) living in a major city. Only 0.4% of births at home (in 2008) were by women of Aboriginal and Torres Strait Islander descent. </p>
<p>Past experience of birthing in a hospital may have been traumatic or unpleasant for these women. Of the 1,000 women who gave birth at home as planned in <a href="http://www.aihw.gov.au/publication-detail/?id=6442472399">2008</a> (accounting for 0.3% of all births), three quarters already had at least one child. </p>
<p>The average weight of babies born at home was a healthy 3,700 grams (8.2 pounds) and 99.4% of babies were born alive. The overall average birth-weight for live births in Australia in 2008 was 3,377 grams (7.4 pounds). </p>
<figure class="align-left ">
<img alt="" src="https://images.theconversation.com/files/5474/original/Dra_sick_Love.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/5474/original/Dra_sick_Love.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=904&fit=crop&dpr=1 600w, https://images.theconversation.com/files/5474/original/Dra_sick_Love.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=904&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/5474/original/Dra_sick_Love.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=904&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/5474/original/Dra_sick_Love.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1135&fit=crop&dpr=1 754w, https://images.theconversation.com/files/5474/original/Dra_sick_Love.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1135&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/5474/original/Dra_sick_Love.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1135&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption"></span>
<span class="attribution"><span class="source">Flickr/Dra sick Love</span></span>
</figcaption>
</figure>
<h2>Why opt for a home birth?</h2>
<p>A <a href="http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD004667.pub2/abstract">2008 systematic review</a> published in the Cochrane Library, shows women who go through their pregnancy and birth in the care of an experienced midwife are more likely to feel in control and achieve spontaneous vaginal birth, than women who choose other models of care. </p>
<p>These women are less likely to require anaesthesia, the use of instruments to aid the birth or to undergo an <a href="http://www.babycenter.com.au/pregnancy/labourandbirth/labour/episiotomy/">episiotomy</a>. And their babies are likely to have a shorter length of hospital stay, with fewer complications. </p>
<p>Perhaps the most important benefit the authors found was a reduced risk of losing a baby before 24 weeks gestation. They concluded that all women should be offered midwife-led models of care and be encouraged to take up this option. </p>
<h2>Insurance restrictions</h2>
<p>Midwives wanting to provide maternity care to women who choose to give birth at home are currently in a state of precarious limbo. Since the <a href="http://www.ahwo.gov.au/natreg.asp">introduction of national registration</a> for health professions in Australia, midwives have had to hold professional indemnity insurance. Midwives can’t practice without this, or they risk action by the <a href="http://www.nursingmidwiferyboard.gov.au/">Nursing and Midwifery Board of Australia</a> (NMBA) under the new national legislation. </p>
<p>While hospital employers grant midwives medical indemnity insurance, under vicarious professional liability cover, there are currently only two insurance options for self-employed midwives and neither provide cover for birth at home. One covers pregnancy and postnatal care at home, with birth in a “clinical setting” (hospital or birthing centre); the other cover is for pregnancy and postnatal care only. </p>
<p>In September 2010, the Health Ministers’ Council granted a <a href="http://www.aph.gov.au/library/pubs/bd/2010-11/11bd091.htm">two-year exemption</a> for private practising midwives involved in home birth to hold indemnity insurance. But they must still hold insurance for pregnancy and postnatal care. And they must inform all women seeking their care for a home birth that they are not insured for labour and birth care, meaning compensation can’t be claimed if something goes wrong. </p>
<p>Midwives must also provide data on the health of the mothers and babies they support in birth to their state/territory perinatal data agency. In future, they will have to ensure they can demonstrate that they comply with all the NMBA’s (yet to be determined) safety and quality requirements.</p>
<p>These decisions to restrict midwives’ insurance aren’t based on evidence of increased risk – they may have been influenced, however, by the <a href="http://www.aph.gov.au/library/pubs/bd/2010-11/11bd091.htm">obstetric industry’s history of litigation</a>. Nevertheless, choice for midwife-led care is restricted.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/5475/original/willem_velthoven.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/5475/original/willem_velthoven.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=398&fit=crop&dpr=1 600w, https://images.theconversation.com/files/5475/original/willem_velthoven.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=398&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/5475/original/willem_velthoven.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=398&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/5475/original/willem_velthoven.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=501&fit=crop&dpr=1 754w, https://images.theconversation.com/files/5475/original/willem_velthoven.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=501&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/5475/original/willem_velthoven.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=501&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption"></span>
<span class="attribution"><span class="source">Willem Velthoven</span></span>
</figcaption>
</figure>
<h2>Collaborative care restrictions</h2>
<p>Midwives are required to work collaboratively with doctors. These requirements mean highly skilled midwives have to seek approval to provide care they’re already capable of giving, so women can claim a Medicare rebate. The doctor can withdraw this approval at any time, and for any reason, regardless of the stage of care. </p>
<p>The arrangements transfer accountability for the birthing process, which should be between the midwife and the woman, to the doctor. They don’t ensure safety, better outcomes or reduce the risk of death or injury. In fact, there is no evidence to date that shows hospital-based, doctor-led care is safer for the mother and baby than home births led by midwives.</p>
<h2>Regulation and safety</h2>
<p>The Federal Government’s insurance and collaborative care requirements are unlikely to improve outcomes for these babies and their mothers. They may actually motivate women to seek alternative, unregulated options for giving birth. </p>
<p>The rate of free-birthing (electing to give birth at home without any care-provider and/or support) in Australia appears to be increasing, as does the trend for women to opt for non-professional care providers to support them and their families during the birthing process. </p>
<p>Women choosing to give birth at home are becoming increasingly marginalised, with fewer options for quality care than those who give birth in other settings. These restrictions only serve to further diminish their confidence in the health system, which they see as working against them. </p>
<p>We need to intelligently and safely accommodate women who want to give birth in their home into the mainstream maternity care system and provide them with safe and varied options. We can and must do better.</p><img src="https://counter.theconversation.com/content/4065/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Heather Hancock does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Choosing where to give birth – whether in a public hospital, private facility or in the home – is a fundamental human right that should be available to all Australian women. But despite the Commonwealth…Heather Hancock, Adjunct Associate Professor, University of AdelaideLicensed as Creative Commons – attribution, no derivatives.