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I WAS interested to read the article by Professor Euan Wallace and Dr Miranda Davies-Tuck, Homebirth in Australia: Eminence- versus evidence-based care. The authors make a comparison of the proportion of births undertaken in home settings in Australia (about 0.3%) with the rate in New Zealand (3.4%) and look at this from the perspective of clinical variation.
They attribute this difference to “cultural and organisational traditions”. They go on to say that: “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.”
The authors attribute “blame” for this apparent “problem” to the Royal Australian and New Zealand College of Obstetricians and Gynaecologists, of which I have just taken over from Professor Michael Permezel as President. I take strong issue with the authors’ contention that the College opinion is “not evidence-based, but ‘consensus opinion’ … Or what Isaacs and Fitzgerald humorously called “eminence-based medicine”.
In contrast to the opinion presented by the two authors, the College statement C-Obs 2 was reviewed by a multidisciplinary committee that included two community representatives, midwifery representation, and members from New Zealand – the statement is extant for both countries. The recommendation is not based on “prejudice” but on the available large international studies that show increased rates of perinatal death and adverse neonatal outcomes for what should be a very low-risk group of women. I would encourage all women contemplating homebirth, and those providing care to them, to read the statement.
As the peak professional body for obstetrics and gynaecology in Australia and New Zealand, the College puts an enormous effort in developing guidance that takes consideration of all available evidence, not simply throwing in the towel when randomised trials are unavailable and resorting to personal opinions.
Professor Steve Robson is President of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists. He is also both a Fellow of Royal College of Obstetricians and Gynaecologists (London) and a Fellow of the Royal Society of Medicine of the UK.
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The reality is that, in Australia, most public hospital births ARE managed by midwives, with medical collaboration as required. Hospital clinics are generally also run by midwives. Australia has no lack of access to midwifery care,
On the other hand, we know from worldwide data that home births result in worse outcomes for both mothers and babies than risk-matched hospital births. This is because, no matter how low-risk a pregnancy appears to be, unforseen mechanical and bleeding complications can, and do, occur intra-partum. The widest study of publicly-funded homebirths in Australia showed an excess neonatal mortality, and didn’t even measure morbidity.
Australian women can have free hospital births, attended by midwives, without medical intervention unless needed, in public hospitals.
Unfortunately most of the home birth disasters in Australia have resulted from women with high risk pregnancies birthing at home. Obstetricians and midwives need to look at ways to make hospital birth more appealing to this group of women, as they have often had a previous traumatic hospital experience. Shared care between obstericians and midwives would help. All pregnant women need access to a midwife, midwifery care is cheaper than obstetric care and thus the important area of time spent listening and explaining is cheaper.
Working as a midewife in a rural setting for 20 years i never looked at any labouring woman as if nothing would go wrong. I found that there was minimal interference from doctors,withou there being very good reason to do so. People forget every birth is different. A friends recent fourth vaginal delivery resulted in a very sick baby with meconium aspiration,which resulted in a nicu admission. Might have been a very different story if it had been born at home.