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.
Who chooses home births?
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.
The average age 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.
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 2008 (accounting for 0.3% of all births), three quarters already had at least one child.
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).
Why opt for a home birth?
A 2008 systematic review 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.
These women are less likely to require anaesthesia, the use of instruments to aid the birth or to undergo an episiotomy. And their babies are likely to have a shorter length of hospital stay, with fewer complications.
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.
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 introduction of national registration 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 Nursing and Midwifery Board of Australia (NMBA) under the new national legislation.
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.
In September 2010, the Health Ministers’ Council granted a two-year exemption 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.
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.
These decisions to restrict midwives’ insurance aren’t based on evidence of increased risk – they may have been influenced, however, by the obstetric industry’s history of litigation. Nevertheless, choice for midwife-led care is restricted.
Collaborative care restrictions
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.
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.
Regulation and safety
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.
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.
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.
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.