Issue 45 / 19 November 2012

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

Sorry, there are no polls available at the moment.

55 thoughts on “Homebirths data unreliable

  1. Dr M says:

    I don’t think the costs are the point, although that might be an effective deterrent. What value do you place on a human life? It is sad to see prospective mothers who are so protective of their unborn that they won’t eat soft cheese or touch alcohol for 9 months, and then risk it all on a homebirth. Sure, some get away with taking that chance, but for the ones that don’t, the results can be catastrophic – and the worst part is that hypoxic damage may not show up for months or even years. A primup should by preference be delivered in a hospital setting – you never know what can go wrong until you try.

  2. Rose says:

    If proponents of home births cannot provide evidence-based data on cost-effectiveness of home births, then let them pay the costs of transfer, emergency treatment, mortality, and morbidity from their own pockets rather than burden others with the Medicare, PBS , medical indemnity, and Centrelink costs of their choice.

  3. Greg the Physician says:

    I have been following this discussion with interest but have not commented until now as I do not work in the obstetric field myself. However I must take issue with Dr Rassaby’s latest comment. With any management decision, we actually do have a responsibility to not just present the treatment options and discuss the benefits and short and long term risks of each, but to advise the patient which option we would recommend and our reasons for doing so. Most patients do not have medical degrees or years of clinical experience, and those that attempt to educate themselves on a medical topic from the internet often pick up very unorthodox ideas, to put it mildly. Sometimes more than one treatment option is quite reasonable, but at other times there is a clear best treatment option which we should do our utmost to persuade our patient to accept. If patients make all the decisions without input from their doctor, who just uncritically accepts this decision and facilitates its implementation, then we don’t need medical practitioners and we don’t need to have prescription medications – let the patient obtain whatever they want OTC! And a surgeon should always operate on a patient if the patient wants the operation, even if it’s against the surgeon’s judgement and advice?! Patients are NOT medical experts, full stop. Dr Rassaby, I would very much like to know from which medical school you graduated!

  4. Dr Lewis Rassaby says:

    Sue Leraci asks ‘……don’t we have a duty to counsel….’. Well no, you do not! This idea of a clinician’s role comes straight out of the 1950s . The medical expert/deferential patient paradigm is really defunct. Clinicians nowadays share information with their patients, listen to them, respect their choices and rarely tell them what to do. As if we would know!

  5. Sue Ieraci says:

    Dr K – I don’t see us “saving the patient from themselves” so much as correcting the mountains of misinformation that lead people to make decisions they might not otherwise make. The true picture of intra-partum mortality at HB is not presented by the HB proponents – not to mention the morbidity from hypoxia. There is also misinformation about how quickly the hospital can mount a rescue when things go wrong – from the time of calling the ambulance to getting to theatre or blood transfusion. What I see in the HB world is ideology that leads to expectations and ways of viewing the world that tend to direct choices along a certain line. These expectations are not immutable – I’ve read the opinions of many women who were attracted to HB, but rescued by some good information and insight. IF we counsel patients about their smoking and diet, and get them to take cholesterol-lowering agents long term, don’t we have an even greater duty to counsel families (not just mothers) about the risks of childbirth?

  6. Dr Lewis Rassaby says:

    RANZCOG should support homebirth for the reason that endorsement will assist in developing services that are as safe as possible. Marginalizing alternative birth practices will make them unsafer.

  7. Dr K says:

    Sue – I agree entirely with your interpretation of the data and would not plan a homebirth myself, because that level of risk is not one that I am willing to take. However, I also understand and respect the families who look at that data and decide that they are willing to trade that increase in risk for the benefits of a homebirth as the absolute risks are low.
    I think as people who work in obstetrics we need to be mindful that we have alienated many people whose priorities are different from ours. I am always taken by how different my understanding of a birth is to my patients (low risk, easy liftout for me is wonderful, but for some women is a “disaster” vs crash LSCS which was very challenging for me is “just so wonderful” to the parents).
    Ultimately I see my role as one of educator, risk manager and invited guest into a family’s birth – I will argue vehemently for what I believe is the lowest risk decision, but recognise that to some women I am talking rubbish because they see the tripling of a low risk as still a low risk!
    I don’t think RANZCOG should support homebirth, but I also think our dialogue around the issue needs to improve considerably. We need to stop seeing ourselves as “saving the patient from themselves” and start seeing ourselves as a source of expertise and information which can help them make good decisions. As mentioned by previous posts, litigation despite our best efforts and our own emotional response to difficult situations don’t help.

  8. david mountain says:

    Just to point out some of the fallacies raised by some of the homebirth advocates in this forum.

    Birth may be a physiological process (so is death, which is a 100% programmed physiological certainty) BUT it is also an an extremely difficult process for human beings. This is because we pay for our v large brains/ heads (and hopefully some rationality) by being the only creatures who routinely require assistance during delivery and having very high rates of injury and mortality relative to other animals as those in developing countries can still attest to.
    Those who try to conflate the risk of children being in car accidents miss the point (because they don’t really get statistics?). Children spend almost every day of their lives in cars e.g. they have a very large exposure to the risk. To generate the same level of risk (which is what happens during a “physiological” low-risk delivery at home), takes 1 exposure of 1-48 hours e.g. the actual risk of a delivery is about 1000 x higher than getting in a car for a long journey for a child. This is not surprising as delivery is statistically the most dangerous day of any person’s life (except of course the day of their death).
    Finally as always the homebirth backers distort the arguments and try to portray any information in a highly biased way. The article and arguments are that a) better research looking at all outcomes from homebirth (short and long term) be compared with other methods of delivery AND that mothers contemplating homebirth should have a balanced and informed view of the risks to them, and their unborn child before making this most important decision for their child’s potential future welfare. Neither of these things should be a problem for those with open minds and with children and mothers best interests at heart.

  9. Sue Ieraci says:

    “Why not focus on a team approach to positive lifestyle education, healthy diet, exercise prior to, during and after pregnancy and childbirth…?” That’s what teams of midwives, doctors and allied health do in hospital maternity services. No amount of exercise or healthy eating will guarantee that there won’t be an intra-partum mechanical emergency, such as a cord accident, shoulder dystocia or harmorrhage – and there are no teams to collaborate to mitigate these at home. There is already Australian research, from both WA and SA, which confirms the general finding that homebirth, for first time mothers, at least triples the intra-partum mortality.

  10. Rose says:

    Scrap the poll now- do the research in this country.
    “Harm to people who will exist..a. morally relevant harm” may result from antenatal, intrapartum, post-partum factors, but I am not aware of any evidence that imposed interventions historically such as burning witches (some were midwives) to prevent stillbirths, wet-nursing royal babies, removing Hitler youth from their parents, have reduced harm.
    Why not focus on a team approach to positive lifestyle education, healthy diet, exercise prior to, during and after pregnancy and childbirth, while doing the research suggested in the article?

  11. Sue Ieraci says:

    Dr K – the recent study that is most relevant to our AUstralian conditions is the UK Birthplace Study. That study evaluated a system where there was close cooperation between the midwives and the hospital, with a tight risk-out rate and a 40% transfer rate. IN spite of all this, the intra-partum mortality for the babies of first-timers was three times higher than for hospital births. They only counted deaths, not disability from hypoxia. The NEtherlands is now starting to move away from their liberal HB model, as their perinatal outcomes are not ideal. The risks of out-of-hospital birth might be uncommon, but they can be catastrophic. Most drink-drivers don’t die or kill people, but the vast majority of people accept that they shouldn’t take that risk.

  12. Jeanette M says:

    For those of you who continue to state that planned homebirths for low risk pregnancies with midwifery care present have a higher M and M outcome than low risk hospital births, please read the latest Cochrane Review on homebirth, where you will discover than the “facts” you quoted are no longer valid.
    Homebirth, under the circumstances noted above, is as safe as hospital birth, with the ADDED BENEFIT of lower intervention rates.
    Furthermore, I fail to understand why homebirth is so maligned in Australia, given that the UK, New Zealand and the Netherlands all have widely utilised, government funded, SUCCESSFUL homebirth programs, without the associated hysteria and vilification that seems so necessary to so many commenters in Australia.

  13. Dr K says:

    I find it interesting that noone has mentioned the well run, low risk homebirthing programs that exist in collaboration with public hospitals. The data from these programs is collected and analysed extensively and it seems the women and midwives are largely doing well.
    I think these programs work well because those of us working in delivery suite feel we have embarked on a legitimate collaboration with the birthing woman, and feel much less trepidation when asked to assist them after transfer. The therapeutic relationship is much easier to build than it is with a privately homebirthing woman, as we know what discussions our midwives have with their patients and that we all trust each other.
    These programs are expensive and there are questions about justice in health spending, but I’m very pleased to have had the opportunity to offer women a legitimate choice.

  14. jay rao says:

    Potential hazards of homebirth even in the so called “no risk women” includes maternal and/or foetal loss which is devastating to everyone concerned especially to the family, which can happen in a hospital set-up although very rare. In today’s society esp. in Australia when every attempt is made by most maternity units to accommodate family’s requests there is no reason why any woman should risk her life and her unborn child’s life. CHOICE OF A LIFETIME -TRY TO GET IT RIGHT.

  15. Dr Lewis Rassaby says:

    I love it when people say something like ‘thats just a FACT’ . In the real world today’s facts are tomorrow’s fiction. I was a young doctor when cauterizing bladders and painting the cervix with gentian violet were “facts”.

    There are no facts in medical practice just degrees of certainty. People who argue by recourse to “facts” are just trying on an argument from authority, which is always the worst form of argumentation.

  16. Dr M says:

    Maybe it is time to turn the question around. How would you feel if only the homebirth option was available, with no or very limited hospital backup? This is after all the situation of the majority of women worldwide, not the lucky few in Australia and similar countries. Would you be happy if the health services regarded this as the norm?

  17. Stacey says:

    I would quite happily be part of a study into homebirth outcomes. Both my homeborn babies are thriving. Thanks for asking. One is over 5, the other is coming up to 1. Oh, and that question? Loaded! Agree with whoever said life is about risk. I chose to avoid the VERY high risk of a repeat c-section (with its high rate of complication), which would have most likely led to a repeat experience of PND. I did my research, as pretty much all homebirthing women do. We aren’t flippant about our babies, and just because we care about ourselves, doesn’t mean we don’t care about our babies. We’re the ones who’ve conceived, grown, and adored our babies before anyone else ever sees them. I chose homebirth BECAUSE I wanted what was best for my babies and myself.

  18. Sue Ieraci says:

    We live in a society that has minimised risk in so many ways – through vaccination, screening, road safety and so much more. Giving birth in hospital is just one of these measures to mitigate risk to the about-to-be-born person. We know from the UK Birthplace study that first-timers giving birth at home lost three times as many babies as those delivering in hospital. And that was despite a 40% transfer rate. That’s just counting deaths – not hypoxic injury. The real problem is that there isn’t a fail-safe way of “risking out”. No matter how healthy and fit a woman is entering labour, a mechanical complication can unpredictably appear – cord accident, shoulder dystocia, haemorrhage. No matter how good the provider is, there just isn’t an operating theatre of blood bank at home. It’s the intra-partum complications that occur at home that are almost unheard of in hospital. That;s just fact.

  19. Robyn Thompson says:

    Interesting that some doctors continue to pursue the fear tactic on homebirth again! The same data is recorded for the Perinatal Data Unit for all women who give birth in Australia. However, I agree with Dr Andrew Pesce, there should be transparent short, medium, and long term outcome data available, similar to the Australian Wave Study (AIFS, 2007), for all Australian pregnancy, labour and birth outcomes (women and babies) regardless of place of birth. Any trauma or death is a tragedy; no professional wants these events to occur. Babies are conceived and born, so it seems to me it would be far better for the women, their babies, families, and the professionals, to stop asking unprofessional questions like the one in this poll. Our energies and skills would better utilised by collectively providing women with whatever service they require regardless of place and of course based on responsible, well-informed decision making that includes the women and their chosen other(s). After 40 years as a midwife (25 homebirthing with women) it would be far more responsible for us to come to terms with the fact that on one level our professions are independent, and on another interdependent, one profession does not have control over the other. A midwife is continuously present with the pregnant, labouring and birthing woman, except in circumstances of freebirth or the women who birth at home or on the side of the road before arriving at the institution. The presence of the obstetrician is intermittent and her/his advanced skills are appreciated when required. Given the chance most healthy women do not need the services of an obstetrician, they do very well with the midwife and it is much better when accessible consultation and referral arrangements are made with the woman’s chosen GP. The total planned homebirths in 2007 (870) represents 0.3% of all Australian women who gave birth; there were there (0.3%) fetal deaths. Of the women who gave birth at home 24.9% were primipara (first baby), 99.5% had a non-instrumental vaginal birth, 97.6% were cephalic (head) presentation, 99.7% were liveborn, 1.4% were preterm and the mean birth weight of the live births was 3678 g, most homebirths 56.8% were in major cities (AIHW, 2009).

    AIFS. (2007). Australian Institute of Family Studies. In J. Baxter (Ed.), Growing Up in Australia: The Longitudinal Study of Australian Children (pp. 41): Australian Government.
    AIHW. (2009). Australia’s mothers and babies 2007 (pp. 123). Canberra: Australian Institute of Health and Welfare.

  20. Poit says:

    It seems that some of the arguments used by pro-home birthers are similar to those used by the anti-vax brigade – “those evil doctors are trying to stop my right to be ‘natural’ “.
    Most sensible people agree that obs intervention rates are higher than they should be, and that needs to change, but the data is fairly clear that even with these unnecessary high intervention rates, it’s still safer than homebirth. Also, the high epidural and C section rates in private hospitals are largely patient choice, and I’m not aware of anyone cord blood banking unless the mother decides.
    The arguments that women have been successfully having natural childbirth for thousands of years tend to ignore the very high infant and maternal mortality for the majority of those years.
    As for the arguments that being able to fall pregnant somehow means that all women are automatically intelligent and informed enough to fully comprehend the risks/benefits and make a sensible decision in their baby’s best interest, visit any public hospital or read some of the comments on here and you’ll see that’s nonsense. And trying to turn it into a feminist issue is just muddying the waters, as there are females for and against, just as there are males for and against.

    At the end of the day, the baby’s safety (both short and long term, at a population wide level) should be the overwhelmingly consideration (as per vaccination, as per the seatbelt analogy). IF the data does show that homebirth is not as safe, then they should be discouraged.

    Competent adults taking increased risk to themselves to have a “nice natural experience” is fine, passing that increased risk to babies is not.

  21. Concerned2 says:

    The pressure is on for hospital births because it is in hospitals where they can allow the doctors to do hasty cord clamping. This allows the hospitals to harvest the trapped blood in the placenta (and that in the umbilical cord) and sell it after it is extracted into various substances: red cells, white cells, plasma, platelets, and hormones, and enzymes, and even bacteria of viruses or diseases, and certainly genetic information. Most home births, if the midwife is ethical and is not registered in a private blood bank or cord blood bank, allow the baby and not the science or others to get their full placenta blood.
    For weaker babies who were harvested by early cord clamping, do visit, Sure it is not professional written but it is well documented that the governments were fully aware they allowed exploiting babies in medical institutions to obtain placenta blood. They all called it, in willful blindness, a waste product. They sent the babies, or some of them for expensive revival. These weakened babies struggled in school, and some for the rest of their lives. Some died. All cover-ups, in All Nations that exploit babies for their blood by the policies and traditions of doctors.

    These doctors and some midwives and nurses did not review the science evidence that what they thought was reliable science studies on cord clamping were absent of the babies never clamped until after the placenta was birthed, and all pulsation ceased. They did not have the time to give babies that 20 minutes of special care – but their own, of course.
    Blessings, to you all. Donna

  22. Dr Lew Rassaby says:

    Responding tto Cheryl), who said that she observed many births go wrong quite quickly and unpredictably and that unless homes could be fitted with emergency equipment, homebirth is unsafe…..are your observations coming from hospital practice or home birth ?

    You might note that about 40% of planned homebirths in Australia end up as hospital deliveries, most of them as unhurried and relatively seamless transfers thanks to our excellent midwives.

    Things go wrong in hospitals, as we all know, because they are too big, busy and under resourced to always provide one to one care efficiently and well.

    Hospital are just the ticket when you are seriously sick but they are best avoided otherwise. Most contributors agree that birth is not a disease process but sometimes can be complicated and require medical intervention. That is the rationale for birth centres, now an accepted part of hospital services. Its not a huge step from birth centres to home births providing arrangements for transfer in the event of complications are made seamless and midwives are given insurance as independent practitioners and accreditation to local hospitals.

  23. Rose says:

    Please extend the research to include longer-term outcomes for children born at home , by location, by midwife, and extend it to include the outcomes for children born in hospitals, by hospital,public versus private, by midwife, obstetrician, obstetric registrar, VMO GP,ambulance officer, retrieval team, or ?bystander in the increasing number of rural hospitals where the maternity services have been downgraded or closed.

  24. Dr K Stewart says:

    But, Julian Savulescu, the analogy breaks down when applied to homebirth vs hospital birth, because while the wearing of a seat belt may diminish one’s driving pleasure, it generally doesn’t cause serious morbidity in a high proportion of users. It does no harm. The same cannot be said of obstetrician-led hospital birth. The problem is that the rate of medical intervention in birth in a hospital setting is probably too high. But how can one tell whether the medical induction, the Ventouse extraction, the augmentation, the traction on the cord, the decision to operate was justified in each individual case, and whether the intervention actually prevented a worse outcome for baby and/or mother?
    I think that the statistics speak volumes – 50% C-section rates in private hospitals, up to 80 and even 90% epidural rates in some private maternity units, and who knows what the rate of other interventions is. The point is that pregnant women are not told. There is no way of really comparing maternity units or obstetricians and what their rates of intervention are, and certainly no way of finding out what their rates of maternal and perinatal M&M are. And that’s if you are even lucky enough to be able to choose who you deliver with in an hospital.
    Personally I wouldn’t be comfortable with a home birth, FWIW, but the point is that many thinking, intelligent women are choosing it because hospital births feel too risky and frightening to them, and with very good reason. It is almost impossible to escape intervention in a private hospital birth, unless your labour is very short, and those interventions can have lifelong effects on a woman’s body. Instead of spouting analogies and trying to scare or legislate pregnant or aspiring pregnant women out of the home and into a hospital, I just wish that we could all work at trying to make the hospital birth scenario more baby-and-woman centred, trying to maximise every woman’s potential to give birth normally and safely, instead of treating her as a medicolegal risk to be managed and a ‘bed’ to be emptied as fast as possible to make way for the next occupant.

  25. Julian Savulescu says:

    And to refer to everyone’s favourite analogy: driving a car. The risk of being injured in a single trip by not wearing a seat belt is extremely low. Still, we expect people to wear a seat belt to make the risks as low as possible, despite some inconvenience and diminution of driving pleasure. Home birth is like driving a car without a seat belt. Actually, it is like not putting on your child’s seat belt. Most children will be unharmed. Some trips are very safe. And wearing a seat belt won’t remove all risk of injury or death. Nonetheless, if one child is permanently brain damaged because she did not wear a seat belt, that is one child too many.

  26. Julian Savulescu says:

    The risk of a “low risk” homebirth may indeed be low. But if the risk of a hospital birth is lower, then birth should occur in hospital, unless there is a good reason. Imagine I want my daughter to feel the wind in her as she comes mountain biking with me, a sense of freedom and connection with nature. Is the feeling of the wind in her hair worth the small risk of a head injury from not wearing a helmet on a single occasion. The risk of head injury on any one ride is far smaller than the risks of home birth. Still, many people would see it as irresponsible to stop your child wearing a helmet to feel the wind in her hair. If bicycle helmets are mandatory, home birth should be discouraged.

  27. cheryl says:

    As a midwife and mother of 4 I think all women should be responsible for their bodies and their lives. Unfortunately it has been my experience over many years that a low risk birth is very much a retrospective diagnosis. I have seen many deliveries go from low risk to extremely high risk in minutes. No home can be equiped with either enough staff or the equipment needed in a true medical emergency just as no one can quarantee a normal birth of a healthy infant to a healthy mother until after the birth. If women are fully informed of the real risks associated with birthing their babies and proceed with planned home birth why is it that home birth midwives need insurance? I think there is too much focus on the birth experience of the mother to the point of disregarding the birth experience of the baby.

  28. Tim says:

    What an excellent discussion! I am reading a whole lot of very valid viewpoints, despite the often polarizing nature of them all. I agree that better funding of services for and medical interaction wth home births is required, along with a NATIONAL ongoing forum to address all the important issues as they come up. What is most important, is to recognize individual’s right to conduct their lives as they wish, and for all of us to resist quoting the worst case scenario for any opposing viewpoints, and then quoting that as a typical outcome.

  29. KerryMcG says:

    I fully support the question and the subsequent research that Dr Pesce calls for . The morbidity and subsequent health of mother and baby SHOULD be taken into consideration by mothers when choosing their caregiver. And we SHOULD have that information, My mother gave birth to me on Fathers Day, after a five hour labour and a forceps delivery. The “lovely” GP made it home to his family for lunch. My mother’s uterus was torn and she was unable to have any more children. And she didn’t see me for three days, until my bruises faded.
    How many women who have “an emergency cesarean” are surprised to learn they can’t walk without pain for YEARS?
    These factors affect families and relationships and are being ignored. Good on the doctor for calling for this research. I fully support the data being collected and the analysis being made available to young mothers.

  30. Dr Lew Rassaby says:

    Dear Dr W,

    That is a nasty remark. Frightening women, sowing guilt and fear have no place in this debate. Nor do ex cathedra pronouncements about what is important and what is not.

    There is a huge number of studies on home birth with varying methodologies, designs, sample sizes etc… a vast trove of data about which debate can be incredibly productive and interesting IF you can give the sloganeering, the cheap comments, the entrenched positions, the turf wars and the like.

    Get sensible!

  31. Dr W says:

    Dear BS. You were lucky – probably. You won’t really know until your child starts school, will you? The circumstances of the birth are not really about the mother’s comfort, but the child’s best interests.

  32. bs says:

    In one generation women go from being responsible for birthing to being irrirsponsible for birthing – I had a 1.5hr homebirth in 2011 not for ideoligcal reasons – this I find offensive, quite simply I did not need a medical setting/service and nor did my child – I was at more risk in a hospital at the age of 39.5. If the people who are getting financial, status and control benefits from the hospital setting could just simply reduce the risk for women and children in their setting maybe homebirth would not be on the rise! Stop trying to bully women who are healthy, focus on need! not the ideoligcal wants of some women to have unnecessary procedures risking their own lives and their childrens at the hands of wasted medical dollars, beds and practitioners. Only one in five women should need medical help not everyone…………..

  33. Ruth Armstrong says:

    We thank readers for their interest in the poll. In retrospect it is not well worded although we wanted to include the concept of long term risk as discussed in the article. Professor Savulescu’s wording is more in line with our intention: “Should women be discouraged from having a low-risk homebirth?”. We are not suggesting that any third person should override a woman’s choice of where to give birth but at what point should concerns about long term risk override ideology about birth settings?
    Dr Ruth Armstrong
    Medical Editor

  34. Dr Harry Haber says:

    I feel that home births a greater risk to mother and child. Australia is a free country, so that if a mother wishes a home birth, then a legal document between the midwife and the mother should be formulated by mediation so that both parties understand the risks and costs involved.This would make it clear that if anything went wrong, we the community should not have to bear the burden of insurance and maybe the outcome of future health care. Unfortunately even though childbirth a normal event,about thirty five years, a infant was delivered in hospital by a Dr Robert Diamond a very able obstetrician, following a complicated delivery, the infant had severe cerebral palsy. This cost our medical indemnity insurance 21 million dollars.

  35. Kirsten Small says:

    FACT: the risk of a child dying in a motor vehicle accident is three times higher than the risk of perinatal death. (ABS data)

    If we are genuinely concerned about the health of children, why are we not having a discussion about whether people should be allowed to put their ‘lovely and nice’ personal experience of driving ahead of the best interests of their child?

    Lets be honest – the discussion around home birth is about power, thinly veiled behind a smokescreen called ‘risk’.

  36. Julian Savulescu says:

    I agree with Kirsten Small, this is an odd question. We were not suggesting that requests for low risk homebirth be overridden. We were suggesting that they should be informed of the risks accurately and that it is wrong to take on these kinds of avoidable risks. But people should be free to do wrong things in many areas of life, like smoking or engaging in risky sports. The question should have been: “Should women be discouraged from having a low-risk homebirth.” I think the answer to that is yes, unless society can’t afford to provide safer hospital care.

  37. Mike Numan says:


    FACT: “low risk women” having planned homebirth of their first baby in a well-established system (the UK) have twice the death rate than those having hospital birth. Birthplace study 2012, BMJ

    FACT: “low risk women” having homebirth in a very well integrated system in the Netherlands have significantly higher death rates (the worst in Europe) than high-risk women looked after by a Dutch obstetrician. BJOG 2012

    Homebirths should only be allowed for those low-risk women with previous normal births, as these have been shown to have probably no increased risk.

  38. Sarah says:

    Whilst birth in hospitals is associated with ‘medicalisation’ of a physiological process and increased intervention, the fact is:
    1. Perinatal mortality, for both mother and child is HUGE in areas where these interventions are not available. Unexpected complications happen, all the time.
    2. The increasing rate of caesarean sections is ridiculous, but so too it is related to the huge rate of obesity, gestational diabetes and big babies who can’t be delivered vaginally.

    I think having a lovely birthing experience is nice, but not essential; giving my child the best chance of a healthy future, however, is essential. Maybe I’m biased because I work with neonates only.

    As always though, ‘more studies are needed’ to determine the comparative risks.

    I do agree, that poll question was poorly written and unashamedly biased.

  39. Sally says:

    I find it interesting that the spectrum of opinions expressed so far (i.e. mainly pro-home births) stands in stark contrast to the poll result. I wonder why this is so –

  40. Dr M says:

    Pregnancy is definitely a physiological process, but so is passage of a renal stone. The point is that both maternal and fetal mortality rates were much higher when home births were the norm, and are much higher in countries where home births are still the norm. Death is easy to quantify. Damage in terms of mental and physical disability is more difficult to measure, but may be more significant in the long term. In a world environment which is steadily becoming more competitive, should we not give our children every possible advantage?
    The real problem is not the natural home birth, but the fads and gimmicks which have emerged, and I am particularly concerned when I hear about things like water births, particularly because I have also seen some spectacularly bad outcomes. Women opting for these deliveries may not realise the risks they are subjecting their vulnerable infants to.

    The fallout in terms of bladder and bowel pathology from high tears vs episiotomy is also something to consider when having a home delivery – a few nights of rattling bedpans and stress vs a lifetime of incontinence pads would be a major consideration to most people. The costs might even balance over time.

    On a personal level I have experienced both a NVD and a CS (for CRN), and after the first two days my recovery from the CS was both quicker and easier than the normal delivery. Had I had more children, I would have opted for an elective CS, remembering that beforehand I was so keen on a natural birth that I refused so much as a painkiller, and was adamant that I would never have an epidural.

  41. Jeanette M says:

    It’s a shame the so-called medical professionals who contributed to this article (barring the associate professor in midwifery) have failed to do even the most rudimentary research into the existing facts, published research and reports regarding home birth.

    The latest Cochrane Review (as mentioned by another commenter) clearly shows that low-risk women, attended by a midwife at planned home births, have the same safety outcomes as low-risk hospital births, with the ADDED BENEFITS of reduced rates of interventions.

    As any rational and educated person can easily determine, medical interventions have unfortunate short term negative effects on both babies and mothers, including greater risk of PND, lower breastfeeding and maternal satisfaction rates and in the longer term, often devastating effects on the child in question, with, for example, the use of opioids at birth linked to a propensity for addiction later in life.

    Regardless of the statistics, it is a woman’s inalienable right to choose how and where she feels best suited to give birth, and the medical profession’s focus should be on supporting each woman, rather than attending first and foremost to their own convenience and remaining subservient to their insurance companies, often trotting out misleading “facts” to women yet braying to all and sundry that they ensure they receive informed consent. Out of interest, how many hospital professionals tell women that one of the potential side effects of Pitocin is foetal death? Given it’s stated on the medication itself, I trust each and every one telling women that they “need” to be induced state all the associated risks, including this one?

    I find it really unfortunate to read the tired old trope being continued of doctors and obstetricians being anti women’s rights and private practising midwives being supportive of individual women’s rights to birth safely and in a manner of their choosing. As a first time mother to be, I can think of no worse place to birth a low risk baby than a hospital, and nothing better than at home, with the caregiver/s of my choosing, with myself as an empowered and educated mother to be making the best choices for myself and my future child.

    I would also like to remind those trying to treat women as some vessel of a future human, whose rights somehow should trump that of the mother carrying it, that certainly in Victoria, no one is a human until they have been born and drawn breath, and whilst I, like any pregnant woman, want the best for my child, no one has the right to decide that my pregnancy takes precedence over MY human rights. What next? A demand for personhood laws, preventing women from driving whilst pregnant, due to the foetus’ inherent and inalienable rights to not die in a car crash, or banning all pregnant women from eating X, Y and Z?!

    Repeat after me folks:
    A) A pregnant woman has the right to choose how and where she gives birth (certainly according to the European Court of Human Rights);
    B) Those of us who choose to homebirth are likely far more educated on the benefits and risks of all aspects of childbirth than those who choose to blithely abnegate all personal responsibility to the medical profession; and
    C) To imply that women choosing to homebirth are irresponsibly choosing to risk our future child’s safety is just ridiculous.

  42. Dr Lewis Rassaby says:

    I am strongly in favour of home birth and have been all of my professional life. My children and my grandchildren have been born at home. I find the medicalisation of birth generally to be a soulless and mostly unnecessary way of dealing with one of life’s great transitions. I feel the same way about dying and note that many Australians are changing their attitudes to the medicalisation of death.

    There is always a need for good quality research. A lot of research in other countries has been done and much of it is applicable to the Australian context. Unfortunately, in the thirty odd years I have been advocating for home birth statistics have been used like duelling pistols at twenty paces by minds whose prejudices are seemingly incapable of change.

    Openness to change, a sensitivity to the expressed needs of birthing women, a commitment to rational and informed discourse, a respect for difference are all keys concepts that bear on how we consider the great transitions of birth and death.

  43. Tracy Reibel says:

    Once again women’s decisions regarding their place of birth is being used to deride their capacity to know and understand what is best for their baby and themselves. Health professionals, particularly obstetricians, but GPs, midwives and anyone else involved in the care of pregnant women need to all take a step back, ensure that women are well informed, understand their true clinical risk (in the presence of actual risk factors, rather than perceived), and initiate a space where a dialogue can occur with their chosen health carer to make a decision that is safe and secure for them. Stop telling women they don’t know what they are doing when we have been responsible for the continuation of families forever. And don’t start on the women are safer when a medical professional is involved, because there are enough statistics to prove otherwise. Hospital is no safer than home – the skill of the birth attendent in assisting and supporting women in their decision making is the most potent force for ensuring good birth outcomes. Even then, new life will not be perfect and some mothers and babies will suffer. We cannot pretend there is any perfect system, because quite simply, there is not.

  44. Jenna says:

    As a HBA2C mother I feel this statement is one that needs more emphasise: “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.” I will never again trust a doctor after my first two experiences of giving birth. And I agree with some of the commenters that banning homebirth does not serve women or babies, it simply makes it more risky as people will do it anyway. Allow women to birth where they feel is best for them and their babies with plenty of backup and support in case something does go wrong. And stop pulling the dead baby card, every mother wants a healthy baby and usually homebirth mothers do a huge amount of risk assessment, it is not a decision make lightly.

  45. Barbara Cook says:

    Most bizarre question to be asked. As pointed out competent midwives supported by a responsive medical system attending low risk women, women should have informed choice to access midwifery care and a home birth if they choose.
    To do more research is clutching at straws in trying to maintain the control measures of fear and restricting women’s choices. The research has been done overseas and is in Cochrane.
    Those births cited were never low risk and they were done at the request of women so seriously harmed or terrified by the medical system.
    Women like these are seeking midwives in the hope of having a ‘normal’ birth. We need to start looking at why women are so badly harmed by the system and look at ways the system can be improved to prevent harm or make it better for those already harmed.
    Look at ways of working in a collaborative arrangement with an eligible midwife. Stop playing the emotional blackmail.

  46. michelle m says:

    @Phillip Watters – yes the law of the land also says men and women (including pregnant women) have the right to refuse medical care and also the right to give informed consent to any and all medical procedures – so what is the solution? declare all homebirth women to lack competency? forced removal to hospital? Where does it all end? Why not just properly resource the sector and provide women with the midwives they need and the backup services required. It is not that hard.

    Agreed that more co-operation is necessary between all – obviously difficult when RANZCG and the AMA refuse to support homebirth in any way whatsover and continue to promote sensationalist research and headlines to support their position.

    A no fault disability scheme would solve so many problems for the whole sector – maybe something all can agree on.

  47. cate says:

    Giving birth in hospital is a risk – should we allow low risk women and their babies to be routinely subjected to high risk interventions in hospital that can cause long term harm and damage to babies and mothers?

    All birth is risky – it is for the fully informed woman to decide what risk she is willing to bear.

    Most women WANT a midwife with them at a homebirth – the behaviour of researchers and obstetricians who continue demonising homebirth is only making homebirth more risky in this country – it is an absolute disgrace of so called professionals.

  48. Philip Watters says:

    The comments show the usual polarity of opinion. I agree that pregnancy is a physiological process (and that physiology is a fascinating subject in itself) but the fact is, some problems can be predicted and avoided by good antenatal care, and emergencies can develop with alarming rapidity. Carers need to stop the finger pointing and co-operate better. Unfortunately, the “buck stops here” carers still pay high indemnity premiums because of the lack of a “no fault” compensation scheme for disabled babies and mothers,, whether or not their disability is directly due to detectable antecedents. THAT is where “evidence” comes in. Lawyers’ understanding and approach to the the individual case is often quite different to that of the health professions. The law of the land regarding torts in the form of birth damage demands the best levels of evidence available. Perhaps some of the angst expressed here should be directed more to tort law reform than to health carers who, despite popular opinion, do try (and are ethically bound) to act in their patients’ best interests. That includes both individual and population based interests.

  49. Beverley Walker says:

    What a loaded biased question. Where do these questioners get their reasearch education? Now my infromation direct from parents is that the question is put to women in hospitals like this: “Do you want your baby to die?” or Do you want a flourishing baby?” I thought this must be a one off but as a reciever of information it is still being asked in 2012. Why did a young girl who refused a Caesarian birth at 38 weeks because theplacenta was encroaching on the internal os – but declared to be 2 1/2 cms away by ultrasonagrapher. A private hospital female doctor works only from 9-5. Following a normal delivery (admittedly with the woman semisitting up in bed) the doctor who was “very cross” with the mother for refusing caesarian and it was getting near her 5.00 pm deadline pulled on the cord which snapped – result death-threatening haemorrhage. Safe in hospital? No. Chemical and surgical inductions at the rate of 1 in 2 in private hospitals and surgical births are putting the health of our women at risk in 2012.

  50. mira says:

    I wonder whether there is research into the long term risks of common hospital birth interventions, as called for in regard to homebirths? I doubt it. The long terms risks of errors affecting both the mother and the infant from hospital interventions are a part of daily life for many mothers, and more than justify a choice for a homebirth with a supportive and respectful clinical team of our own choosing.

  51. Mark Donohoe says:

    Surely this is a joke story? Please, please tell me this is a joke. Pregnancy is NOT a medical condition. Birth is NOT a disease in need of medical intervention. Birth is necessary and personal part of life that our profession has a long history of interfering with, albeit with good intentions. We do well to look for high risk pregnancy and birth and offer our services. If mothers choose not to take our advice, we would do well to reflect on our failure, not theirs. Mothers are not stupid. They maintain generations, and there is a strong evidence base for that.

    We doctors should be careful of applying the “evidence-based” argument in normal life. How many obstetricians have evidence-based marriages, or even evidence-based children. A recent published study (Raymond, Elizabeth G. MD, MPH; Grimes, David A. MD. The Comparative Safety of Legal Induced Abortion and Childbirth in the United States. Obstetrics & Gynecology. February 2012 – Volume 119 – Issue 2, Part 1 – p 215–219) found evidence for abortion over birth. Their conclusion:

    “CONCLUSION: Legal induced abortion is markedly safer than childbirth. The risk of death associated with childbirth is approximately 14 times higher than that with abortion. Similarly, the overall morbidity associated with childbirth exceeds that with abortion.

    And THAT’s what happens when you start to apply EBM to normal life. I propose enforcement of the findings of this trial to those who are truly and blindly committed to evidence-based medicine. I can confidently predict we can return to sanity within a single generation!

    I am a GP. My wife is a pre-natal yoga teacher. I have listened to the stories and the experiences of the mothers and would-be-mothers with obstetricians. On the lower north shore of Sydney, it is a disgrace, and that utter failure to listen to the mothers now sees half of all births in some of our hospitals done by caesarean, and tens of thousands of women who could have and should have been left alone living with what amounts to abuse of position and power.

    My plea – focus on your own specialty and get your caesarean rates below 20%. Get interventions in birth below 35%. Leave women to birth bravely and successfully and joyfully without your help, and support them in that decision by working with real people outside the profession – the midwives, doolas, yoga teachers and more.

    Birth is not a disease or a medical procedure. The life lived after normal birth by normal mothers in normal environments is none of our business. Once we have fixed our own profession’s tendency to fiddle and intervene unnecessarily, we can ask permission to enter the conversation with women to see what we can offer for them and their soon-to-be-babies to improve birthing.

  52. elizabeth says:

    The question is entirely reasonable and I fail to see the point of the first comment. That women are choosing to take on a risk misses the point that the risk extends to the future health of a child. I cannot see why homebirth advocates are against further studies as this seems entirely reasonable. How can you have a reasoned discussion of the risks if you don’t know them? Are they afraid of what such studies may find? To convert this into some sort of feminist issue is misleading to women in general and I say this as someone brought up in a feminist environment.

  53. Jennifer Cameron says:

    As Hannah has said homebirthing represents about 0.3% of Australia’s births. We need to better measure morbidity , maternal and neonatal,to obtain a real picture of the effects of where birth takes place. Why would pregnant women with no identifiable risk factors benefit from birth in a hospital?

  54. David Knight says:

    I am not a fan of homebirth but some women will elect to do this anyway. Such women need to be encouraged to have a competent home birth midwife in attendance rather than “freebirth”. They should also be encouraged to discuss the risks and potential complications with a midwife or obstetrician. They should provide clinical details to the local hospital in case an emergency transfer to hospital is needed in labour or immediately post natally. You cannot “override” patient autonomy.

  55. Kirsten Small says:

    What an odd poll question to attach to this article. Would your answer be the same if the question where – ‘Should the potential risk of death or injury to a child override a father’s right to drive the child in his car using a properly fitted child restraint?’

    Our society continues to have a strongly gendered discussion around what women can and can’t do with their bodies, in a way that we don’t for men.

    Risk is everywhere, not just with birth. Yet we get so hot under the collar when women choose to take on a risk that in the greater scheme of things is less than the daily commute to work.

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