By Justine Caines

High Risk BirthIn the last 5 years working for Maternity Coalition I have worked tirelessly to help establish one-to-one midwifery care across Australia.  I am passionate that women can choose a midwife in any setting, but especially at home as I have experienced the beauty of homebirth.  I do not at see myself as conservative or someone who ‘sells out’ in my role as an advocate.  In the last year however I have been forced to reassess all of this.  After 4 very normal pregnancies with stunning, intervention-free homebirths I was greeted with the news that I was having twins.  In a split second I plummeted into the category of ‘high-risk’ – but did I really, and who defined it anyway?

Breech birth, vaginal birth after caesarean (VBAC) and twins birth can carry additional risk. The risk must be measured rationally however.  The risk of uterine rupture for example after a primary c/s is not quite 1%.  The vast majority of Obstetricians do not support women to achieve a VBAC.  Many paint a picture of fear and death citing uterine rupture as a compelling reason to elect for a repeat caesarean.  The risk of spontaneous abortion after amniocentesis is 1-2%.  This test is routinely offered to women over 35 without any of the trappings of death and injury.

Before I was aware I was carrying twins I had planned another homebirth.  I very much look forward to it.  My first thought was “My homebirth is out the window’.  Although I resist becoming a prisoner to the language of obstetrics that sees women as deficient beings in need of rescuing, I think some of it had rubbed off.  In our advocacy we spend much of it demonstrating that midwifery care should be a mainstream option, but also accept the obstetric line that breech and twins and VBAC belong within a high-risk category. Now with a label threatening to choke me I sat back and thought, “Where is the individual rights of the woman and her body here?’

Very few women would knowingly put their baby or themselves at risk.  Why then are women with ‘special needs’ granted less insight or knowledge of their body’s capacity or their baby’s wellbeing?  Again we know the answer.  It is because current obstetric practice in Australia is not about women, or even babies.  It is about fear and control, the necessary ingredients in keeping maternity services dominated by the medical profession, and keeping the birthing of babies as big business.

After the huge shock I researched obstetric management of twins.  It seemed at best if I fought hard I could give birth to my babies vaginally, but I would be very likely to be pressured to have an epidural (for the fast removal of twin 2, via c/s or forceps), I would also be pressured to have constant foetal monitoring.  In the event of twin 2 presenting breech I would be likely to have a very managed birth (via forceps).  In the event that I had not given birth by 38 weeks, induction would be strongly recommended. Of course the far more acceptable option would be an elective caesarean section again at 38 weeks.  Despite many twins being born by caesarean section, like many obstetric practices it is not supported by evidence.

“Virtually no data from controlled trails are available to help determine the choice between vaginal birth and caesarean section for women with multiple pregnancy. A single trial has assessed the effect of caesarean section for delivery when the second twin was in a non-vertex presentation. As would be expected, maternal febrile morbidity and need for general anaesthesia was increased with caesarean section. No offsetting advantages in terms of decreased fetal or neonatal morbidity or mortality were found.”  Enkin et al 3rd Ed Guide to effective care in pregnancy and childbirth … p.146

At 38 weeks my babies would be smaller and more likely to need additional care.  In the event of a caesarean section I would need to recover from major surgery and at the same time attempt to breastfeed 2 babies and care for another 4 children.  This was considered a safe option?  I was very fortunate to be sent the now out of print book, “Having Twins’ by Elizabeth Noble (copies can be found on etc).  This text reaffirmed my gut feeling that although a multiple pregnancy required some special care through nutrition and rest there is no reason that twins should be treated as high risk.  The misconception that all twins arrive early was a consistent theme.  Why does one neglect the power of a woman’s mind in determining when and how she gives birth? Currently there are very few practitioners who affirm a woman’s ability to carry twins to term.  In my case I gave birth to two, three-kilogram babies at 40weeks, 1 day.  With the exception of my midwives everyone I spoke to would say “You won’t go full term’  “You’ll have these babies early’  “No –one carries twins to term’.  Interestingly the women I spoke to who had birthed twins at home or at least been cared for by an independent midwife all went very close to term.  Those who birthed in hospital had to fight off the routine 38-week induction but with supportive care they all achieved term babies at 39 to 40 weeks.

This was very welcome news.  I told my babies daily that they would grow to term.  I did not give a thought to the fact that I would birth premature babies.  Living in rural NSW this would have been disastrous for our family and myself.  I would have been hours away from home and our children.  I was fortunate enough to read a fascinating book called Pre-natal Parenting by US Neonatologist, Frederick Wirth.  After 35 years seeing the often tragic consequences of premature birth, Dr Wirth researched how the mind affected the body.  He makes a compelling case for women to focus on positive and loving thoughts throughout their pregnancy; Guiding families to address relationship problems and potential fears to enable not only a healthy pregnancy and birth but also an affirming start to bonding and parenting a new human.  He says:

“Prenatal visits help your healthcare provider recognize complications during pregnancy, and they do an excellent job, but too many patients believe that their pregnancy outcome depends solely on the quality of their medical care. The success of your pregnancy also depends on the psychological and spiritual content of your life.’

I was intrigued; Dr Wirth must be supportive of midwifery care and the option of homebirth (due to the very model of care being holistic blending health care into the social fabric of our lives).  Dr Wirth in fact described the first homebirth he attended as the most beautiful, despite witnessing hundreds in the hospital system.  He felt like an intruder and wanted to leave the couple to do what they were doing so beautifully, creating a safe and loving environment to welcome new life.

I was buoyed by what I read. I progressed full steam with confidence that the only place to have my babies was at home full term.