more_vert
ANNOUNCED in November 2016, a 3-year trial of publicly funded homebirth is to be offered to low-risk expectant mothers living in Canberra.
This initiative sees the ACT join the Northern Territory and almost all states in the provision of publicly funded homebirth services. Only Queensland is yet to offer this choice.
However, despite the number of Australian public homebirth programs increasing nearly four-fold over the past decade – from four in 2005 to 15 in 2016 – the number of individual women choosing to have their baby at home is not increasing.
In 2013, fewer than 1000 women had a planned homebirth in Australia, representing only 0.3% of all births, exactly the same rate as in 2005. This is starkly dissimilar to our friends across the Tasman. In 2014, 3.4% of women in New Zealand gave birth at home – more than 10 times the rate in Australia. In Canada and the UK, the rate of homebirth, at about 2%, is also much higher than in Australia. Even across Australia, there is an 8-fold difference in the rate of homebirths, with the lowest rates (0.1% of all births) in ACT and Queensland, and the highest rates (0.7% and 0.8% respectively) in Victoria and the NT.
So why is there such variation in practice?
The Australian Commission on Safety and Quality in Health Care identifies the principal drivers of variation as being related to supply, demand or patient need. They highlight that supply and demand drivers are often embedded in cultural and organisational traditions. In particular, medical opinion is usually the major influence over supply decisions.
In essence, doctors choose what they want to offer and do. Sadly, all too often those choices are not evidence-based, as appears to be the case with homebirth.
There certainly does not seem to be a problem with demand. Most submissions to the national Maternity Services Review were related to homebirth and most of them were from women seeking better access to, and more equitably funded, homebirth services.
No, it would appear that lack of supply underlies the stubbornly low rate of uptake of homebirth in Australia, and the root cause of that low supply is prevailing medical opinion. While homebirth is supported by federal, state and territory governments the peak medical body in the specialty, the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG), remains firmly opposed to it.
In response to the announcement of the new ACT public homebirth program, Professor Michael Permezel, Immediate Past President of RANZCOG, was quoted as saying that homebirth posed unacceptable dangers.
Currently, RANZCOG recommends that “planned homebirth [should not be] endorsed” and “should not be offered as a model of care”. Contrast that with the UK, where the National Institute for Health and Care Excellence recommends to “advise low-risk multiparous women that planning to give birth at home … is particularly suitable for them”.
This recommendation comes from a guideline developed by the National Collaborating Centre for Women’s and Children’s Health at the Royal College of Obstetricians and Gynaecologists (RCOG) in the UK. It is likely that these diametrically opposed opinions of the two colleges – RANZCOG and RCOG – contribute, at least in part, to differing supply planning for homebirth services and so to the near 10-fold variation in homebirth rates between the two countries.
The report of the national Maternity Services Review reminds care providers and health planners alike that maternity care should be evidence-based and women-centred. Care should be responsive to an individual woman’s needs and preferences and provide her with access to high quality evidence on which she can make decisions that are right for her. Therein lies the challenge for Australian women and health planners.
Unfortunately, the leading expert medical opinion in Australia, that of RANZCOG, is not evidence-based, but “consensus opinion”. Or what Isaacs and Fitzgerald humorously called “eminence-based medicine”.
Yet the evidence is clear. For carefully selected low-risk multiparous, but not nulliparous, women who live in close proximity to a hospital maternity service, the risks of adverse maternal and perinatal outcomes are similar or lower to like women giving birth in hospital, but with much lower rates of intervention. In this regard, the criticism by the Australian College of Midwives CEO, Ms Ann Kinnear, that the new ACT program was unreasonably restrictive in being limited to multiparous women also appears to be eminence-based, rather than evidence-based.
The question is, therefore, not whether homebirth is safe or not – it’s safe – but rather how can we increase supply (access) to meet demand.
Changing lead medical opinions, including those of RANZCOG and the Australian Medical Association, to better reflect the evidence and be more women-centred would be a good first step. Doing so will liberate hospital management from the anxiety of not having peak professional body support.
In turn, this will facilitate the growth of publicly funded programs. A key attraction of such public programs is that the intrapartum care at home is provided by skilled midwives who are embedded in the hospital’s clinical governance framework. This ensures safer care and better quality assurance.
It is time to stop the homebirth debate. The continued lack of widespread provision of publicly funded homebirth choices is unreasonable, inequitable and, we argue, unsafe. It is forcing some women – those with certain risk factors who choose to birth at home even if it is more appropriate to do so in hospital, for example – to make less safe choices, the outcomes of which we read about all too often in coroners’ reports.
It is time for the leading professional groups to put personal prejudices and opinions aside. A continued eminence-based stance, unsupported by evidence, may be seen by some as being complicit in driving women to less safe care, such as choosing not to transfer to hospital, or choosing not to have a midwife attend them at home.
We look forward to the day in Australia when all low-risk multiparous women have the choice of publicly funded home or hospital birth. A day when supply meets demand and when women-centred, safer care is accessible to all.
Professor Euan Wallace is the Carl Wood Professor of Obstetrics and Gynaecology at Monash University, the Director of Obstetric Services at Monash Health and the newly appointed CEO of Safer Care Victoria, Victorian Department of Health and Human Services.
Dr Miranda Davies-Tuck is an NHMRC Early Career Fellow at the Ritchie Centre, Hudson Institute of Medical Research and the Department of Obstetrics and Gynaecology, Monash University. She is also a visiting Research Fellow to the Victorian government Consultative Council for Obstetric and Paediatric Mortality and Morbidity.
Latest news from doctorportal:
- Autism diagnoses leap 10 percent in a year
- A sugary drinks tax could recoup some of the costs of obesity while preventing it
- Sugar tax report met with sour opposition
- Four dead in Victoria asthma crisis after storm
Loading ...
I find the recent article by Euan Wallace and Miranda Davies Tuck somewhat offensive not only to practicing obstetricians, but also to hospital midwives and the pregnant population who CHOOSE not to take the extra risk to both mothers and babies inherent in home birthing.
The third paragraph states that despite the four fold increase in home birth programs in the last 10 years, the numbers of home births in Australia had remained static. Pregnant women are voting with their feet, but of course doctors are to blame!
I am not sure how much hands on obstetrics is being currently performed by the two authors, but childbirth is very dynamic and can go from ” low risk” to life threatening very quickly and unpredictably, hence the inherent extra risk in home birthing.
We are not allowed to drive a motor vehicle without a seat belt, or a bicycle without a helmet, so it is up to the decision makers in healthcare to decide whether the extra risk involved in home birth is acceptable and if it is publicly funded. To imply that we are somehow behind others countries because of a lower home birth rate is a fallacy .
I totally agree with the response from Professor Robson that the RANZCOG statement opposing home birth is well considered and based on the best available evidence.
Having had some involvement in the Maternity Services Review (as quoted by the authors) some years ago, it is important to realise that this review clearly stated that the outcomes for Australian women and their babies are amongst the best in the world yet approximately 50% of submissions to the review were from disaffected home birth advocates, with home births only representing 0.3% of maternity services.
The ideology here is choice and autonomy but this needs to be balanced against cost and safety. It is disappointing that the AMA would publish such an opinion piece and can’t be left unchallenged.
Midwives frequently trumpet their statistics, suggesting that they are as safe as those in a hospital birthing suite.
As a radiologist (with a DDU), I performed untold obstetric ultrasound studies, initially myself (holding the ulrasound tranducer and doing the whole study) for many years and then in conjunction with a succession of very talented sonographers. As freelance midwides gradually entered the scene, it became obvious that they would cherrypick their cases, selecting only those with unblemished clinical histories and normal serial ultrasound findings AS THEY SHOULD! Thus it is arrant nonsense to compare the 2 sets of statistics as anyone with half a brain can clearly see. Even with this huge filter, tragedies occur, including death resulting from deficiencies clearly visible in a home birth. Major complications can suddenly appear during even the most initially straightforward-looking confinement, requiring skilled IMMEDIATE intervention, if mother and child are to have the best chance of survival….sadly lacking in the average suburban bedroom/lounge room. Try saving a deeply-shocked mother whose simple cephalic presentation suddenly turned into a transverse lie leading to a ruptured uterus! I feel sorry for those poor hospital obstetricians suddenly thrown an impossible situation in an ambulace coming from a home birth “gone wrong”. It’s about time mention was made of this to women looking at what type of confinement to choose. Perhaps this is one of those ultra-subtle Darwinian situations? Wish he was still here to comment…same with those anti-vac flat-earthers etc etc.
This is mostly economics-based. In New Zealand, when independent midwives became entitled to [equal] payment for midwifery services, wherever they occurred, within a few short years 80% of all deliveries were facilitated by midwives, not doctors.
There are multiple studis of home birth in countries – such as the UK and Netherlands – that find excess neonatal and maternal mortality at home, despite experienced midwives and a well-integrated system. Primips are at greatest risk, with most studies showing a three-times excess risk of neonatal death (and morbidity is not even reported). This was shown in the UK Birthplace Study, and the study of publicly-funded Home Birth in Aus (MJA).
No matter how low-risk a pregnancy appears to be, mechanical and bleeding complications can and do occur without warning. Transfer can never be the same as having an operating theatre on standby down the corridor.
Women who are told that Homebirth is equally safe for low-risk pregnancies are not being adequately informed. Low-risk hospital birth can be midwife-managed with minimal intervention until needed, but with help just seconds away.
It’s hard to imagine why a group of health care practitioners would want to work towards less safe conditions for birth. We have come a long way from stirrups and twilight sleep – low-risk birthing suites are calmer, more domestic and access to midwives is automatic.
“Traumatic” births are not confined to hospital – labouring away at home in agony, then having a late transfer to hospital, can be more traumatic than starting there.
I want my appendicectomy done at home please. Can the government please provide an operating theatre in my house? According to the above patients can demand anything they want and doctors have to acquiesce.
And while we’re on the topic of demands, I only want a consultant surgeon to do my hip replacement and I want it tomorrow!
Clearly we do not allow patients to make decisions that consume resources over and above others in other parts of medicine and home birthers shouldn’t be able to ask for infinite resources at the expense of others.
I am a GP with 20 years experience in GP obstetrics during which time I was actively involved with back up for homebirths. My experience and personal statistics is that by selection of low risk pregnancies, good antenatal care, experienced midwives and clear guidelines for early transfer to hospital (not waiting for foetal distress) resulted in a 10-15% transfer rate, many of which delivered safely in hospital without further intervention. Over the 20 years and around 2000 births my safety statistics exceeded those of low risk hospital births. I did have a couple of still births at home but these were of infants known to have serious chromosomal abnormalities incompatible with life where the parents had chosen to birth and greive in the privacy of their own home.
The homebirth debate is full of rhetoric and emotion on both sides of the argument and it is frequently forgotten that homebirth statistics include high risk pregnancies, pregnancies with no antenatal care, unsupervised deliveries, deliveries by unqualified attendants and deliveries by experienced midwives who will not walk away from a woman who is determined to give birth at home despite the risks.
I fully support the establishment of homebirth birthing services (which are not hugely expensive compared to hospital births) which address these issues. These services need to be complemented with appropriate in hospital facilities with a homelike atmosphere and continuity of midwifery care to encourage women to transfer early when requested and to encourage women who for one reason or another are afraid to give birth in a hospital to do so.
This report itself undermines the major professional body of obstetricians and gynaecologists by suggesting that both the immediate past president Professor Michael Permezel and RANZCOG have cast aside “evidence-based medicine” in favour of “eminence-based medicine” based on “personal prejudices and opinions.”
Potentially an article on such a contentious topic should focus more on what the “evidence” is and less on undermining confidence in RANZCOG’s statements.
If you were to apply a Bayesian analysis to the data, it would be unlikely the evidence is strong enough to overcome the “skeptics” of the program. Therefore it seems the authors themselves may be limited by their own personal prejudices.
The NICE recommendation is based on a small number of low quality studies. If you actually read it is clear that it is not based on any reliable evidence, but on the opinion of the group that wrote it.
Unfortunately Professor Wallace and Dr Tuck abuse the term “evidence-based medicine”, and impugn the reputation of Professor Permezel and RANZCOG. It is ironic that Professor Wallace as the new CEO of Safer Care Victoria is promoting a method of maternity care that in practice in Australia has been very far from safe.
Even if a home-birth woman lives close to a hospital and the home-birth mid wife decides that her patient needs to be admitted to a hospital for active treatment, not all hospitals have a stand-by theatre, theatre team, and obstetrician on tap if a forceps delivery or caesarian section is required urgently.
As an anaesthetist when working in suburban hospitals, it was not unusual for me to see a frantic midwife wanting to interrupt a surgical list so that her patient can be attended to. If all theatres are occupied with long cases, it is not difficult to imagine the friction which results.
I must admit that I have been retired for some years now, but I would think that the pressure on theatres and staff is now worse than in my day.
Thank you to the authors for a refreshing approach.
I agree – time to stop putting our heads in the sand. Some women want homebirth, some midwives want to provide homebirth, some doctors will support homebirth – homebirth is not going away and can be safe … time to come together and stop marginalizing it and ensure it can be available to women in a safe and equitable way.
I look forward to the next stage.
Caroline Homer
Shyria,
do you want a law against CS?
I’d suggest you leave such critical decisions to those who are competent to make them.
There is a definite place for home birth but there must be support and integration into the system.
The appalling rate of CSections must also be addressed. It is not acceptable to blame a 35% general CS rate on maternal age and obesity, as Michael Permezel says. Most of my patients are neither old nor obese yet the rate of CS remains high. Nobody takes responsibility. It’s just not good enough.
https://www.ncbi.nlm.nih.gov/m/pubmed/25204886/?i=2&from=/26716916/related
Dear Euan,
with all due respect- for you as a staunch defender of Forceps to criticise a conservative, cautious RANZCOG statement with the term ’eminence based care’ is a bit strong.
If one wanted to improve the care that women get in Victoria (or elsewhere) one could start by reducing the number of Forceps births. I’d estimate that would have the potential to HALVE maternal pelvic floor trauma at your institution. The effects of home birth on maternal and child health would be a mere blip on the horizon in comparison, whether positive or negative- but of course the effect would likely be negative as stated by RANZCOG.
Could I also suggest that we stop accepting UK natural childbirth propaganda as ‘evidence’ or ‘data’? The results of that approach have been neatly summarized in the Morecambe Bay Report, and in the Wernham study from NZ, published just a few months ago.
What’s ‘unreasonable and inequitable’ is the enormous variation in the risk of maternal trauma due to our obsession with CS rates, the variation in Forceps rates and other forms of ‘offensive obstetrics’ , a trend which has been triggered in Australia by the unquestioning acceptance of overseas trends I’m happy to qualify as ‘toxic’.
I’m all for patient autonomy- but that requires informed consent, the provision of accurate and up to date information. That’s where the problem lies in antenatal and intrapartum care. We need to start treating our patients like adults- and we’re often failing to do that. An increased reliance on home birth is guaranteed to make matters worse, not better.
HP Dietz
Professor of Obstetrics and Gynaecology
University of Sydney
Planned Out-of-Hospital Birth and Birth Outcomes.
Snowden JM, Tilden EL, Snyder J, Quigley B, Caughey AB, Cheng YW
N Engl J Med. 2015 Dec;373(27):2642-53.
BACKGROUND: The frequency of planned out-of-hospital birth in the United States has increased in recent years. The value of studies assessing the perinatal risks of planned out-of-hospital birth versus hospital birth has been limited by cases in which transfer to a hospital is required and a birth that was initially planned as an out-of-hospital birth is misclassified as a hospital birth.
METHODS: We performed a population-based, retrospective cohort study of all births that occurred in Oregon during 2012 and 2013 using data from newly revised Oregon birth certificates that allowed for the disaggregation of hospital births into the categories of planned in-hospital births and planned out-of-hospital births that took place in the hospital after a woman’s intrapartum transfer to the hospital. We assessed perinatal morbidity and mortality, maternal morbidity, and obstetrical procedures according to the planned birth setting (out of hospital vs. hospital).
RESULTS: Planned out-of-hospital birth was associated with a higher rate of perinatal death than was planned in-hospital birth (3.9 vs. 1.8 deaths per 1000 deliveries, P=0.003; odds ratio after adjustment for maternal characteristics and medical conditions, 2.43; 95% confidence interval [CI], 1.37 to 4.30; adjusted risk difference, 1.52 deaths per 1000 births; 95% CI, 0.51 to 2.54). The odds for neonatal seizure were higher and the odds for admission to a neonatal intensive care unit lower with planned out-of-hospital births than with planned in-hospital birth. Planned out-of-hospital birth was also strongly associated with unassisted vaginal delivery (93.8%, vs. 71.9% with planned in-hospital births; P<0.001) and with decreased odds for obstetrical procedures.
CONCLUSIONS: Perinatal mortality was higher with planned out-of-hospital birth than with planned in-hospital birth, but the absolute risk of death was low in both settings. (Funded by the Eunice Kennedy Shriver National Institute of Child Health and Human Development.).
As far as I remember, home confinements in U.K.were backed up by an emergency “flying squad,” comprising ambulance, an obstetrician, anaesthetist and supporting staff, such that any obstetric emergency could be dealt with in the home.Without this level of domiciliary support, I think the college is right not to support home delivery.
Evidence-based care is vital, but what about law-based care?
International human rights law places all decisions regarding where and with whom a woman gives birth with the woman.
Clinicians are obliged to give evidence based information and care (as opposed to ’eminence-based care’ – great term). This is how we know that a woman has given her informed consent.
If however a woman makes a decision against the evidence provided by her carer, the law also requires that her carers support her decisions.
Clinicians and health services are contravening women’s rights when they force women into models of care and places of birth that are not of their choosing.
In regards to making homebirth safe, if a publicly funded model was adopted, the same women would still adopt unsafe care by choosing not to transfer to hospital against best advice from Obstetrician or midwife. Without such a service, the women who would transfer from home when required would still have safe deliveries at a hospital regardless. So, on balance I would support the current model and not waste money funding an expensive program for such a small minority where the total gain is in a perceived level of personal satisfaction versus a defined level of baby wellbeing from consistent obstetric and paediatric care.
A cohort study from England (http://www.bmj.com/content/343/bmj.d7400) found 45% of nulliparous woman planning to deliver at home (i.e., already a low-risk group) required transfer to hospital.
Even for multiparous women, the rate was still 12%.
That is a lot of women who need transfer to hospital. And in at least some of those cases, it will be an urgent transfer where every minute counts.
If you live in a quiet town that’s a 5 minute drive from the local hospital, that may be a reasonable risk to take.
But the vast majority of Australians live in major metropolitan centres with overstressed road networks.
Think about an Australian mother living in the inner city of Sydney or Melbourne. If she’s one of the unlucky mothers and her baby becomes distressed, what are her chances of getting to hospital in under 10 minutes?
And if you know that a large proportion of women will need transfer to hospital, but you can not guarantee how long it will take them to get to hospital, then is it really a good idea to have thousands of mothers trying to deliver at home?
It is time the number of unnecessary caesarians and instrument deliveries were reduced. Low risk nulliparous women must be offered this alternative. The high rate of induced deliveries and elective caesars delivering children below 38 weeks of age is a major national concern.
This debate has raged for AT LEAST 30 years in this country, with no real progress over that time for the reasons given clearly in the article. The cause has NOT been helped by the actions, at times fatal to mother, baby or even both, of those medicos and/or midwives who have persistently offered home birth support to women who are NOT in the low-risk group – MULTIPAROUS WOMEN WITH NO KNOWN ANTE-PARTUM RISK FACTORS who MUST still reside within RAPID emergency vehicle access of a HOSPITAL-BASED MATERNITY CARE CENTRE! Those are the criteria already demonstrated to support SAFE home-birth practices, in countries with more concentrated population densities and, apart from New Zealand, safe, well-made roads in the relevant areas. (I would NOT regard even some of the shorter road trips in some parts of NZ to meet such requirements, and it would be interesting to review their radius/distance/time limits in the home-birth qualification arena!) We all remember the Home-like Birthing Centres set up by many hospitals in the past, which allowed many women to have a less-intrusive natural birth, while also having IMMEDIATE access to emergency support for mother AND baby if required. It seems such facilities have fallen out of favour, and I was disappointed during my tour of our new hospital last week to see that this option was no longer available. I am also surprised to see that the home-birth option is being offered in NT settings, but I must assume that some of these will only be occurring in residential settings in (?mainly) Darwin and Alice Springs, given the sparsity of Obstetrics in that region!