Tuesday, October 25, 2011

Head on the chopping block – HOMEBIRTH:

Homebirth the hot topic: combine that with autonomy, women’s choice of place of birth no matter what the risk factor and you have an explosive cocktail and a subject that will divide a nation. There has been much written on this subject and sadly what is bringing it to the forefront again is term foetuses (babies) dying at home, with or without a health professional.

In 2009 there were 30,760 women giving birth in WA and the average age was 29.5yrs, the majority of women (98.8%) gave birth in hospital. Non Hospital births 1.2% including Born Before Arrival (BBA) (0.4%) and babies born at home (0.8%). The caesarean section rate was 33.3% (10,241) of the women recorded as having had a previous caesarean section 87.1% had a repeat section. What we need to be doing is reducing the caesarean section rate and concentrating on is promoting normal birth.

In 2010 WA had 245 homebirths, 203 occurred with the Community Midwifery Program and 42 homebirths with private practice midwives. We have 19 private practice midwives registered with the Health Dept and 5 eligible midwives.

This debate about homebirth revolves around less than 1% of women, not that I am suggesting that their views are not important; however there are 99% of women that need midwifery input to improve their birth experiences. It seems that a disproportionate amount of time is spent on homebirth in relation to the work that needs to be done to improve maternity services for all women.

I will start with my position as a midwife on the subject in the current Australian context;

Do I believe that women have the right to choose where and how to give birth? YES.

Do all women need a midwife throughout the continuum of pregnancy, birth and postnatal period? YES.

Should homebirth be an option for all women? The evidence shows that homebirth is safe for uncomplicated pregnancies.

Should all women have a midwife? YES

Should high risk women birth at home supported by a midwife? This is the six million dollar question; professionally and personally I would answer NO, based on the lack of protection for the midwife to facilitate this choice. However it is not that simple; usually women who are choosing homebirth for high risk pregnancies have experienced some sort of birth trauma, are extremely fearful of hospital and usually have knowledge of the associated risks, each case needs to be evaluated individually. It is unfair to label all these women as zealots or radical. What needs to happen is to listen to what the issues are and find more flexible ways to support these women providing continuity of midwifery care, collaboration with an obstetrician within a safe health system.

What is a problem is if midwives / or de-registered midwives keep supporting high risk homebirth without collaboration and health service support. Recently there have been several high risk homebirth deaths. If the term fetus (babies) keeps dying in the homebirth setting we will be endangering homebirth for uncomplicated pregnancies. Worse still women will lose their autonomy because the term foetus will be afforded more rights similar to what has happened in the USA. Currently in Australia a foetus has no rights under law until born alive, but this concept is being challenged.

What needs to happen is that health services need to be more flexible, by having visiting rights for private practice midwives allowing them to bring their women into hospital and continue to caring for them. When fearful women present they should be facilitated to birth in a low risk setting such as a secondary hospital or birth centre supported by the tertiary hospital. Specialist obstetricians could travel to see the women and support the secondary hospital – it is about being flexible – considering the psycho-social issues of the women. Having all high risk women being herded into a hospital like cattle is giving them no choice or options therefore creating more fear. Remembering there is established legal principle that a mentally competent woman can refuse treatment. It is no wonder that these women choose to birth at home or freebirth. Freebirth is an unsafe and unacceptable practice and Health Services are failing women if this is the only option they feel they have.

We as midwives need some sort of supervision or mentoring system to support us in difficult clinical situations therefore allowing us to support these women. We need legislative changes to protect the midwife to stay with women no matter what the risk and where she chooses to birth, we need health services to be more flexible and supportive. We need women to be demanding that Health Services and Doctors be flexible, it’s about open communication and negotiation.

Three questions:

What do you think about the homebirth debate?
Would you have a high risk birth at home?
Would you freebirth?

Ref: WA Mothers and Babies 27th Annual Report – Midwives Notification System
photo credit: http://offthebroiler.wordpress.com/2006/11/21/death-of-a-turkey/

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