Homebirths data unreliable

LEADING obstetricians have called for more research into the longer-term outcomes of children born at home in Australia, saying that currently, no reliable data were available.

Dr Andrew Pesce, a Sydney-based obstetrician and gynaecologist and former AMA president, said scant data existed on homebirths in Australia because there was no systematic collection.

“We just don’t know what the outcomes of homebirths are other than a crude estimate of relative perinatal mortality”, he said.

He was commenting on a letter published in the MJA calling for the homebirth debate to refocus on long-term injuries to children born at home. (1)

In their letter, Professor Lachlan de Crespigny and Professor Julian Savulescu, of the University of Oxford, and Professor Susan Walker, of the University of Melbourne, wrote that the risks to the future child of morbidity associated with birth outside a hospital setting, which had largely been ignored, needed to be better quantified and communicated.

They wrote that recent perinatal deaths related to homebirths in Australia were just “the tip of the iceberg”.

“Blanket respect for maternal autonomy overlooks the risk to the health of any future child who might survive damaged”, they wrote.

“Clinicians and pregnant women have an ethical obligation to minimise risk of long-term harm to a future child.”

The letter authors used findings from two high-profile coronial inquests held this year to back their call for more data. One inquest looked at three fatal homebirths in South Australia supervised by the same midwife, and another into a fatal “free birth” (ie, one without supervision) in NSW.

Dr Pesce said evidence to date indicated a threefold increased risk of an otherwise healthy term baby dying in a homebirth compared to hospital birth.  (2)

“Without data people can say whatever they want. We need a paradigm shift in the policy debate from no-evidence-based homebirths to evidence-based medicine and then design clinical care around it”, Dr Pesce said.  He said longer term injury risks were unexplored territory, with the only states that regularly published figures on homebirth outcomes (WA and SA) focusing on perinatal mortality rates.

Professor Caroline de Costa, professor of obstetrics and gynaecology at James Cook University School of Medicine, said she was in total support of the opinions expressed in the letter.

“I think that if homebirth is going to be an option, the results should be assessed in the same way that the results of hospital birth are, so that we have good evidence on which to base future decisions about the provision of care”, she said.

However, Professor Hannah Dahlen, associate professor of midwifery at the University of Western Sydney, said the premise relied on by the letter’s authors was flawed because the fatalities it cited were all high-risk homebirths or free births.

“Now nobody is saying that is a good idea — there are problems when women have babies at home when they have risk factors. A hospital is a very good place to be when you need extra medical intervention”, Professor Dahlen said.

“The evidence we have is that for low-risk women who are attended at home by competent midwives who are well networked into a responsive health service, homebirth is safe — as safe for the baby and safer for the mother in terms of morbidity [compared with hospital births].”

Professor Dahlen said about 0.3% of births in Australia were homebirths and this figure was on the rise because “more women are fleeing highly interventionist obstetric models in hospitals”. (3)

“What is it about our health services and the systems and options that we give women that make them feel so unsafe that they are willing to take that risk”, she asked. “That is a lens we never place upon ourselves.”

The letter authors wrote that “harm to people who will exist is a clear and uncontroversial morally relevant harm”.

However, Dr Pesce said maternal autonomy could not be overridden and women, on balance, made decisions in the best interests of their babies.

He warned that any move to a prescriptive system for homebirths would push the practice “underground, beyond our reach and make things worse rather than better”.

“In my interactions they [pregnant women] won’t do something if they are advised it is going to harm their baby”, Dr Pesce said.

- Amanda Saunders

1. MJA 2012: 197: 551
2. BMJ 1998; 317: 384
3. AIHW Australia’s mothers and babies 2006

Posted 19 November 2012

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