Friday, December 23, 2011

"homebirthing is a sensitive and controversial issue"

The report said “homebirthing is a sensitive and controversial issue”.
The irony of this statement was clear when it appeared in Improving Maternity Services in Australia – The Report of the Maternity Services Review (2009). Homebirth continues to be both sensitive and controversial today.

Maternity Coalition's Summer 2011 issue of Birth Matters devoted significant space to the extremely sensitive and controversial end of homebirth; "high-risk homebirth". MC President, Ann Catchlove, wrote a deeply personal and moving column referring to the death of a baby in a highly publicised homebirth, that "I hope that we will have realised that the way to respond to "high-risk homebirth" is not by prohibition and persecution but by seeking to understand why women make decisions and giving them real options within the system. Meanwhile, in the here and now, a mother is being treated in a most unfair and unjust manner. We need to stand up and say that is wrong."

In an article published in the (UK-based) AIMS Journal Vol 23 No3 2011, Joy Johnston (who is also the author of this blog) wrote:
The constant recurring theme in Australian and international midwifery regulation is the public interest. The Australian medical profession considers obstetric supervision of all maternity care to be in the public interest, and assesses midwifery as incapable of delivering optimal and safe maternity care in settings outside obstetric surveillance. The issue of home birth is the pimple on the end of the maternity system’s nose. It won’t go away, it hurts when touched, and it’s a real nuisance.
The large 'Birthplace' study [click here for link and comment] looking at place of birth in the UK is to:
effectively be replicated in Australia from 2012 with a NHMRC funded birthplace study led by Professor Caroline Homer from the University of Technology, Sydney. Feeding in to the Maternity Services Review recommendations for more research and national data collection, the study will investigate outcomes from about 45,000 births across public and private hospitals including birth centres, freestanding midwifery units and homebirths, both publicly and privately funded. “We need to continue to grow the evidence and what has to be unpacked are the important pieces of information for women – their chances of a normal birth versus a caesarean section or their chances of good outcomes versus bad,” Homer said. “We haven’t had a big national study which clearly defined intended place of birth at onset of labour, not at 12 weeks. Smaller studies have also been a bit vulnerable because of their low numbers.” (quoted from Nursing Review, 21 Dec 2011)
MIPP is currently undertaking a REVIEW OF PLANNED HOMEBIRTH FOR ‘AT RISK’ WOMEN IN VICTORIA, 1999-2009. The data for this audit is being prepared by the Victorian Perinatal Data Collection team. Women included in this audit are those identified as ‘at risk’, having been recorded as planning to give birth at home in the care of a midwife, and that they have one or more of the following obstetric risk categories: Multiple pregnancy; abnormal presentation (especially breech); preterm labour prior to 37 completed weeks of pregnancy; post term pregnancy 42+ weeks; and previous caesarean birth. It is anticipated that at least one paper for publication in a professional peer-reviewed journal will come out of this review, and it is hoped that valuable information will be highlighted.

Monday, December 12, 2011

Hospital back-up bookings for planned homebirth

Midwives practising privately in and around Melbourne have, for many years, used the booking and emergency referral arrangements provided by the Women's hospital. The process has been simple: the midwife can fax the woman's details to the hospital, and the woman is given a hospital record number confirming the booking. The midwife provides copies of any blood test and other investigations relevant to the pregnancy, and contacts the hospital if and when obstetric referral is required.

In the past two years, after the Women's hospital relocated from the old Carlton site to its present site in Parkville, and, coincidentally as the numbers of births increased with the recent 'baby boom', restrictions have been placed by the hospital on which women are able to make bookings. For women who are experiencing uncomplicated pregnancies (which is usually the case for women planning homebirth), only those who live in the Women's local area are able to make a booking.  The hospital was apparently bursting at the seams.   Midwives who had previously brought women transferring from planned homebirth to the hospital from distant locations are now referring women who need medical attention to the nearest public maternity hospital.

Some midwives objected to the change.  Transferring to the Women's had been a well-managed matter, that the midwife could confidently navigate.  Professional respect between the independent midwife and the hospital staff, and vice versa, was generally upheld.  This of course tends to reassure the (labouring-birthing) woman, who is at the *centre* of the care.  [The good relationship between Midwives in Private Practice (MIPP)s and the Women's has been written about previously in this blog - eg see July 2008]

The Women’s hospital is now undertaking a review of ‘Services provided by the Women’s hospital in relation to women who choose to give birth at home’. A letter to participating midwives states that The Women’s “has identified a number of issues associated with its existing homebirth backup arrangements and, in recent months, significant concern regarding the clinical risks has heightened.” The Women’s Executive “has decided to review the current arrangements in order to clarify the Women’s role and responsibilities in this area and to determine the most appropriate processes for supporting women who choose to give birth at home.”

The fact that "significant concern regarding the clinical risks has heightened" in recent months, in relation to homebirth, is a matter that midwives who attend homebirths care a great deal about. Has there been some change in the way midwives practise, or in the way midwives and women planning homebirth proceed through their decision-making processes?  Is there a problem specific to the Women's, or ...?

MIPP leaders have also been aware of some issues that would come under the heading of 'clinical risk'.  During the past couple of years, with the federal government's Maternity Services Review; the passing of new legislation requiring professional indemnity insurance which was not accessible; the 'exemption' for homebirth; and the Medicare provisions for participating eligible midwives - this has been a time of unprecedented stress and concern for midwives practising privately, attending women for planned homebirth. 

An application was made some months ago to the Victorian Perinatal Data Collection Unit (VPDC) by MIPP for retrospective information on the birth outcomes of women identified as ‘at risk’, having been recorded as planning to give birth at home in the care of a midwife, and that they have one or more of the following obstetric risk categories: 

  • Multiple pregnancy; 
  • abnormal presentation (especially breech); 
  • preterm labour prior to 37 completed weeks of pregnancy; 
  • post term pregnancy 42+ weeks; and 
  • previous caesarean birth. 

  • There has been an unexpected delay in obtaining the data requested, as 2009 data cannot yet be publicly released. We understand that the delay has been related to the change from manual data entry to electronic data entry at some sites.  We will inform our members and readers as soon as something becomes available.  The VPDC publishes data on actual homebirths (and outcome data for each hospital providing data to the system) each year.  The MIPP audit is seeking information on outcomes specific to 'at risk' pregnancies and planned homebirth.

    Thankyou to anyone who has read this far.  We will keep you updated on matters of interest to the private midwifery community, as information becomes available.

    Your comments are welcome.

    Thursday, December 1, 2011

    Safety of home birth - the UK Birthplace study

    Birthplace study 

    Perinatal and maternal outcomes by planned place of birth for healthy women with low risk pregnancies: The Birthplace in England national prospective cohort study. 

    This new cohort study from the UK reports on birth outcomes for healthy women with low risk pregnancies.

    As with all research, statistics can be interpreted differently by different people.  In this post I want to give a general overview of the research, and provide links for those who are interested in reading more.

    The first point to note is that the title 'Birthplace' may be misleading.  The outcome data was sorted according to PLANNED [not actual] place of birth.

    Readers may remember a study from South Australia (Kennare et al 2010) which received considerable press coverage as it claimed huge increases in adverse outcomes for planned homebirths. For more comment and links relating to that study, click here.

    Although there are major differences between planned homebirth in the UK and planned homebirth in Australia, valuable lessons can be learned when we review and critically consider the meaning of results of research.  

    Births at home or in hospital: risks explained is an article at the NHS Choices: your health your choices website.  The explanations given are well considered: compare with the titles and subsequent content of newspaper articles listed and linked at the end of the piece.

    Links to the headlines

    First-time mothers warned over home birth risks. The Daily Telegraph, November 25 2011
    Home births three times more risky than hospital, says study. Metro, November 25 2011
    Women with low-risk pregnancies 'should have birth choices'. The Guardian, November 25 2011
    First-time mothers who opt for home birth face triple the risk of death or brain damage in child. Daily Mail, November 25 2011
    Home as safe as hospital for second births. The Independent, November 25 2011
    Home birth risks up for new mums. The Sun, November 25 2011

    Another commentary worth reading is at the Having a baby  blog.  The writer Marina Colville concludes:
    This study supports government policy to offer choice in place of birth to all women.  However, there remains a severe lack of viable community midwifery services with associated expertise which means most women do not have a realistic choice of where they give birth despite a potential claim to the contrary by a range of Trusts.  This issue should be addressed by NHS managers who have so far largely not implemented this long standing government policy particularly in the face of extensive evidence from this study showing the cost-effectiveness of it.
    Make no mistake, any attempt to change the maternity service following this study will be as tortuous as the previous years of inaction but this study is vital fuel for the fire making the case for better birth experiences for women and babies.

    Your comments are welcome.
    ps: for Sarah Buckley's comments on the question 'Is homebirth safe?' and links to her work, go to