In Australia Homebirth is a contentious issue. For many years now we have heard of the increased risk to babies and mothers of homebirth, and read stories of homebirth tragedy splashed on newspaper billboards. We have also seen reports of the protests of pro-homebirth midwives, women and their families fighting for a woman’s right to choose where they give birth.
Meanwhile halfway around the world in the Netherlands, homebirth is an integral part of the public funded medical system with 30% of low risk women birthing at home. Across the ditch in New Zealand 11% of women give birth annually in publically funded homebirth programs. Even in the United Kingdom, of which Australia is a dominion, publicly-funded homebirth accounts for 2.9% of low risk births.
With the debate polarised by starkly differing views about the safety of homebirth, it’s not surprising that only 0.9% of Australian women give birth at home. But how accurate and relevant are those statistics on safety? While the homebirth opposition, including the Australian government, call for sanity in a debate which they claim unduly costs the lives of women and babies, their pro-homebirth opponents question the validity of the research upon which these claims are based.
There are a number of limitations to the research conducted to date. Many homebirth studies have included in their sample, women who planned a homebirth in their first trimester. The planned place of birth can change during pregnancy due to the development of pregnancy complications and other personal factors. Including women who originally intended but ultimately decided against a homebirth skews research results about the number of women who succeed in a homebirth.
In addition, in examining rates and outcomes of homebirth nationally, studies have included women considered both high and low risk. Debates about what should and should not be considered ‘high risk’ aside, including both these groups does not provide an accurate assessment of the safety of homebirth for low risk women.
An additional issue is the inclusion in rates of infant death of babies known prior to birth to have no chance of survival. When women are delivered the devastating news during pregnancy that their baby has physical or chromosomal defects which make survival impossible, they may plan a homebirth rather than a hospital delivery to make the most of what little time they may have with their baby. Including these babies in mortality rates again skews research data by increasing the rate of neonatal death attributed to homebirth. To be clear we are referring here to babies which no amount of modern medical science can save.
Despite studies claiming increased risks to babies and mothers attempting a homebirth, in the recent Australian national Maternity Services Review over 60% of submissions were about homebirth. The vast majority of these were from women who wanted access to homebirth. In an attempt to meet this need, publicly funded homebirth has been introduced by some Australian health services in NSW, VIC, SA, WA and NT. These programs cater for women who are at low obstetric and medical risk, providing midwifery continuity of care on a caseload basis. Professional indemnity insurance is provided to the midwives by the hospital out of which they are employed.
Recently Australia’s National Publicly-funded Homebirth Consortium undertook a national evaluation of outcomes for women and their babies in 12 publicly funded Australian homebirth programs. The research examined data collected for six years from January 2005 to December 2010 for women intending a homebirth at the onset of labour. To avoid skewing of statistics, women who initially planned but ultimately withdrew from the programs during pregnancy were excluded, and mortality rates were examined to determine the percentage of infant death which could be conclusively attributed to physical or chromosomal factors incompatible with life.
Data that was examined related to demographics, mode and place of birth, perineal trauma, management of the third stage of labour, and postpartum haemorrhage greater than 500 ml. Maternal and neonatal transfer to hospital, birth weight, maternal and neonatal morbidity and mortality, admission to a special care nursery and breastfeeding rates were also examined. Of the 1807 women on which data was collected:
Of the 1807 babies born 99% had a birth weight greater than 2500 g with only 3% admitted to the special care nursery. The rate of stillbirth and early neonatal death was low at 1.7 per 1000 births when the expected deaths of babies with foetal anomalies were excluded. Nearly all women initiated breastfeeding with 69% still breastfeeding at 6 weeks. Only 3% of women had an episiotomy and only 1% sustained a third degree tear. Postpartum haemorrhage occurred in only 2% of women even though three quarters chose a physiological management of the third stage (delivery of the placenta without assistance or medication). There were no maternal deaths.
The results of this research are similar to the largest prospective cohort study on place of birth for women at low risk of complications – The Birthplace in England study – and are promising in terms of determining the comparative safety of hospital and homebirth for low risk women. In particular the high rate of vaginal birth and low rate of caesareans are of note. Also the role played by a high rate of water births in the avoidance of interventions is also worth considering, keeping in mind the starkly lower availability and use of water for birth in hospitals where invention rates are much higher.
However while promising, this study is too small to draw robust conclusions about the safety of homebirth. In addition, the guidelines by which women are admitted to public funded homebirth programs are stringent. As such outcome rates of women homebirthing within publicly funded homebirth programs cannot be accurately compared to those choosing to homebirth outside these programs and away from the controls they enforce. This study does however provide support for the continuation of publicly funded homebirth programs and for ongoing research over time into the benefits of these programs, and ultimately homebirth generally, to women and babies.
Published on 29/07/2013