The Homebirth debate: I want to pull my hair out!

Some arguments presented; I am working through some thoughts and decided to blog it!

I will start with the role and scope of a midwife; the midwife is the specialist in dealing with the 'normal' pregnancy & birth and recognising when things become abnormal and then refer to an obstetrician. All medium and high risk pregnancy should be seen by an obstetrician, you could have shared care or good collaborative care so that the woman can have continuity of care with her midwife whilst seeing the obstetrician.

I can see some independent/private midwives totally disagreeing with my definition of what a midwife's role or scope of practice is. However this is determined by the ANMC competency standards / Ethics / Conduct and the ANMC decision making framework. The scope of practice for a midwife is clear; that is dealing with what is 'normal'. The ACM referral guidelines are also used to guide midwives in private practice - there are recommended conditions of which women should be referred (evidenced based) and when to refer women. this document protects the midwife if followed.

The government funds a small percentage of homebirths through the CMPWA programme, therefore women can claim through medicare - this is for approx 450 women per year. The program accepts healthy low risk women and the demand is greater than what is available.

As far as I am aware there are no Midwifery Group practices in WA, which really is a tragedy, as most other states have several MGP both private a publicly funded.
I do wonder if the women who choose independent midwives know the scope of practice of a midwife and to what extent she/he can practice? and do independent midwives ever say to the women this is out of my scope of practice I am not qualified to do this? however I will support you in the hospital setting?

There are a number of independent/private midwives who practice in WA, these are separate from the government funded midwives. Independent/private midwives will have a fee for service for which women cannot currently claim through medicare. This can be limiting for women and expensive.

Interestingly like private obstetricians private midwives are not required to follow public/government policy because they are privately employed. However they are responsible to the regulatory body which for midwives is the Nursing and Midwifery Board of Australia (from October for WA).

I do understand and empathise with the woman that has been so traumatised that she just cannot face going to hospital or even seeing a doctor due to her mis-treatment, this is very real and happens all too often. Recently this was evident in the 750 submissions made by women/men when asked about maternity services in Australia. Who cares for these women? The women are so fearful they would rather freebirth.... this is a terrible reflection of the state of maternity care in Australia. We are letting these women down.

I am frustrated with the homebirth debate; on one hand you have the independent midwife who at all costs will defend the right to support a woman of her "choice" to birth at home whether she is medium or high risk (and rightly so otherwise who looks after them). They believe that the woman has the right to choose homebirth because she is well informed and knows all the associated risks with birthing at home with a risk factor, therefore has the right to self determination and the right to refuse treatment. There are health professionals who do believe the midwife should walk away from this woman in other words abandon her in labour because your registration is at risk. There are obstetricians who believe that women do not have the right to choice when they are high risk......that it is the obstetricians professional right to make the correct decision in the 'best interest of the woman and baby'.

The law in Australia does not protect this midwife when she/he works outside of the scope of practice. Unlike the UK where the midwife is protected by legislation and is not allowed to abandoned the woman..... We need this type of protection in Australia for the midwife. Currently the independent midwife works out on a limb and is not supported and alienated by the hospital system.

The problem I have with the above scenario is that the midwife is not qualified to care for the high risk woman she/he would be working out of the scope of practice, because this is not within the role of the midwife and this worries me. I am not saying our role as a midwife is not to support this high risk woman, it is to support and provide collaborative care for the risk factor associated with the pregnancy, however often doctors will not collaborate unless the woman does as the doctor suggests.......this is a lose - lose situation.

The trouble as I see it is that fundamentally women are not being heard by health professionals, they feel pressured, bullied and are often scared into submission by the health professional, therefore choose an alternative model of care this may include freebirthing (birthing without a trained health professional present). Hospitals are not flexible, they are rigid and not prepared to meet the woman half way.... it appears that's its the hospital way or the highway...and women will choose the highway.

So what is the answer?
If I sound frustrated I am?
Please tell me how we move forward?
How do we stop women from feeling alienated and force independent midwives to work outside their scope of practice?

Homebirth Study: creates furore in the press

The Maternity Services Review has sparked a debate about Homebirth and independent midwives or private practice midwives. By refusing to indemnify this group of health professionals and which virtually outlaws homebirth.
Instead of bringing the obstetricians and midwives together the decision by the Government not to indemnify private practice midwives has created a war between the AMA and Midwifery Profession.

The newspapers are all sprouting the new SA Homebirth study "New Study Confirms High Risks Of Home Births" which is not supportive of Homebirth, however skewed the study may be... here are a few headline examples as a result of the study: Tightening Of Homebirth Laws Recommended: and

Women warn they'll risk birth without midwives

MANY future mothers say they will give birth at home without any medical assistance if proposed changes to maternity services proceed.

It is interesting that Dr Pesce quotes
"But, given the accumulated evidence from Australia spanning 30 years, facilitating and funding home birth in an autonomous setting would be contrary to the principles of evidence based health administration".

Now that is a farce......this study clearly is not accurate, there is no evidence that these planned homebirths were under the care of a registered midwife between 1991-2006 (fifteen years) and it is a retrospective population based study, that is low evidence. Why is it that evidence is not used by our learned colleagues in relation to our high cesarean section rate.... or why has the AMA not taken any notice or even commented on this newspaper article "Cesarean births risk mums' lives"
maybe it has something to do with the fact midwives have nothing to do with the increase in the cesarean section rate and we are not threatening their income in this instance...... however it is a different matter when it comes to homebirth even though less than 1% of the population have a homebirth.
It is rather funny that this evidence is being manipulated to suit the AMA......

At the end of the day it comes down to power and living in a patriarchal society. It is every woman's right to choose where and how to birth her baby, given informed choice and free from coercion.

Is this the future for Australian women......Why did hospital send the police to my door? The hospital wanted this woman to be induced....she was not quite sure and not ready so she missed her appointment...the woman was being cared for by a private practice midwife and was a planned homebirth.... so the hospital sent the police to ensure she was safe and not birthing at home......what is happening to Australian women's autonomy?

Here is a story of a "Freebirth" I found on mystic wick forum, if you don't think Freebirth happens read this story....And this is the birth story of Marley, born Feb this year
There are many stories like this one, the Australian Maternity system is letting women down, it needs to change......

Homebirth is not a crime, it is a choice!

another post relating to Freebirth......

I am wondering is the rise of Freebirthing or unattended childbirth two fold... one women are not being heard... and secondly they are taking matters into their own hands, that is making their own decisions... without medical advice. This may be because once they seek medical advice they are bullied or made to feel guilty that they choose to do it alone.....
Unfortunately it is when things go wrong that everyone sits up and takes notice..... I can blog till the cows come home as to how unsafe Freebirthing or unattended childbirth is.... but until something goes wrong... no one is really going to listen or do anything.... and that is the tragedy....every thing seems easy and 90% of the time it is.....however life is not that clear or easy....

I have to agree with Regina's post on The Fun Times Guide Pregnancy site.... where she intimates the Freebirth figures are pretty scary.

No one has answered my question as to how do we fix the problem? is there a solution? or do we wait for infant and maternal mortality to rise first then act?

An interesting perspective on Freebirth:

Basil from my garden:

Surfing the net as I do, I often come across some very interesting stories...this one made me think more about how some women feel about Freebirth...(birthing without any health professional present) however even though I can understand the choice these women have made... I still can not comprehend the fact that women will choose to birth without a midwife.

this quote was taken from: Women giving birth at home without midwives

When Jennifer Margulis went into labor with her fourth child, she sent her husband off to take the kids to school, then waited at home for her body to do what she felt confident it had evolved over millions of years to do on its own.
There was no rushing to the hospital, no midwife, no EMTs. Just Jennifer and her husband, home alone, giving birth.
"I think a lot of people think a woman who would want to have an unassisted birth would be a little bit crazy," said Margulis, who holds a Ph.D. in literature, and is a contributing editor for Mothering Magazine. "I think I may have had that reaction as well. I am definitely not a crazy person. I am a very educated, thoughtful and caring person. I am not a person who takes a lot of unnecessary risks. The whole point is it is not risky if you do your homework."

I would really like to know what 'homework is done' I am sure that there is a lot of information.... but if it takes a Bachelor of Midwifery student 3 years to learn how to be a competent Midwife and a Registered Nurse a further 12 months as a post graduate course or 18 months if in Europe to be a competent midwife - how is it that women think all it takes is a bit of homework to be able to recognise when things are going wrong with a birth where medical intervention may be required for both the woman and baby......

I appreciate that many women may have fallen foul of medical intervention which has scared them.....however I firmly believe that Freebirthing is not the answer.... a more collaborative approach is required with more flexibility from our health professionals and hospital system.... rather than a fear factor or paternalistic approach.

I would like introduced into Australian legislation the clause that is in British legislation which makes it illegal for a midwife to refuse to care for a woman....so women who choose to have a homebirth and they may be considered "high risk" are supported by a midwife... and the midwife is protected by the legislation and has support from her supervisor of midwives ( we would have to introduce a similar system here) and all care is clearly documented if required for legal reasons, therefore protecting the woman, baby and midwife...

I have been practicing midwifery for many years... and I have to say that every birth is unique, special and at times unpredictable.... however I am so acutely aware of what is normal that when things begin to become abnormal it is like a sixth sense for me.... how do women who are freebirthing understand this or even begin to think they know when often times it can be a total surprise.... the difference being that if recognised early enough help can be close at hand....Yes I also am a firm believer of a woman's body knows what to do and how to do it.... but as we all know this doesn't always go the way it is meant to do... years ago we had a much higher childbirth morbidity and mortality rate and why was that, in a nutshell, women hemorrhaged and infection was high on the list. This has been reduced why, because we are better educated, we know more (through research) and have better treatments. This brings with it higher expecations.... that everything will be normal.... and yes 90% of the time it is.... but I would not want to be in that 10%.

A sad reflection is that Freebirth is on the increase, although it is difficult to prove this fact. This therefore means as health professionals we are failing women and not respecting their choice, we need to re think this whole position....

Please help me understand why some women think it is best to have a freebirth...

Why is it so hard for Doctors to accept working in partnership with Midwives

January 10 The Australian published a story "Doctors firm against role of midwives".
We are all eagerly waiting for the release of the federal health minister Nicola Roxon's report on Maternity Services in Australia. During the process of review the obstetricians have stepped up their campaign against the MIDWIFE.
Lets look at the facts: Midwives want to look after low risk women - Midwives want to offer midwifery-led-care, which is a midwife-focused, woman-focused model of care for low-risk-women.
Women with medical problems, or in a higher risk category will see an obstetrician or the midwife will refer the women if it is required.
Is this so hard to understand?

Why are obstetricians so determined not to work collaboratively with midwives?

Dahlen (Australian College of Midwives) says obstetricians are incorrectly claiming or implying that midwives are seeking to be in sole charge of births.

‘‘We are not asking for midwives to be out there on their own — we don’t want that,’’ Dahlen said.

‘‘What we want, what we have always wanted, is collaborative models of care, where women can have a midwife who cares for her through her pregnancy and postnatal period.

‘‘It’s not about being ‘independent’ — this is about doing what midwives are best at, caring for women, particularly low-risk women, and having support from obstetric colleagues when that’s needed.

‘‘Part of the reason we have such a high intervention rate is because normal, low-risk women are being cared for by highly specialised surgeons trained in surgery.

‘‘We are not saying midwives are not going to work with obstetricians — we are asking for more choice, not less.’’ Dahlen says women are ‘‘marching with their feet’’ to seek better access to midwifery services, based on the number of women prepared to attend rallies and on the number of submissions from individual women to the federal Government’s review.

In December the Government revealed over 900 submissions to the review had been received, most of them from individual consumers.

It is about time someone started listening to what women want.....our maternity services are failing women and this is evident by the number of women who freebirth.
Also the submissions from women indicate that our maternity system has become to focused on medical intervention.

It will be very interesting to see the outcome of Nicola Roxon's report.....we are waiting with baited breath.

RANZCOG - the need to support Midwifery- Led Care - give women informed choice!

It is the 21st century and whenever we discuss midwifery, nursing and medicine it is usually in relation to evidenced based practice - the latest research - how to move forward within the professions looking at the research. I do find it ironic that when Obstetricians have good evidence to show that homebirths have a place in Maternity Care they fail to acknowledge this.

I came across this site called 6 minutes.com.au - and there was an article written by Michael Woodhead - click on the link to find the full article.

Doctors 'in denial' about safe home births The medical profession has been accused of encouraging the trend for dangerous unattended ‘freebirths’ by failing to support safe homebirths.

Obstetricians and state bureaucracies are reluctant to acknowledge that there is good evidence to support the safety of planned attended homebirths for low risk women, says a public health researcher and member of the Australian Maternity Coalition.

.... in this month’s Australia and New Zealand Journal of Obstetrics and Gynaecology (48: 450-52) she says the Royal Australian and New Zealand College of Obstetrics and Gynaecology opposes home birth, even though the balance of evidence shows that planned home births for low risk women have no greater mortality or morbidity than hospital births if attended by a qualified health professional.

This is a tragedy for women and midwives: why are obstetricians so opposed to midwifery led care? in the face of good evidence. One has to ask, what is the point of research if we do not use it?
In recent years there appears to have been an increase in popularity in freebirth, I wonder why?

The professions need to be working in collaboration with each other, respecting the knowledge, skills and ability to care for women and refer to obstetricians when we need to. Let midwives look after low risk women, that is what we do best.

UK concern over 'Freebirth'

Following on from my earlier blog....Freebirth seems to be reaching epidemic concern - this article "Pregnant women are opting for risky 'freebirths' in the UK Telegraph states that

Advocates of the freebirth approach claim that it is "more natural" than giving birth surrounded by midwives and doctors. It would usually take place at home.

Freebirth involves giving birth without medical assistance, which has led to concerns that women could find themselves in dangerous situations if something goes wrong.
The Royal College of Midwives suggest that

Mothers-to-be are making the radical choice because ministers have failed to deliver their pledge to let them have their babies where they want.
Some women aren't certain about homebirths and others want them but the service can't provide..... "The worry is that women will do it themselves. If you're not offering women choice then that is the danger."

I have noticed over the last 6 months that the topic of Freebirth has become more topical and anecdoteally there have been a number of women choosing this option.

Freebirthing is a trend that is becoming increasingly popular in America. It is not known how many freebirths take place in Britain or Australia, however it is becoming of concern. Off course America's Medical Association (AMA)adopted a resolution at its annual meeting last weekend (June 08) to introduce legislation outlawing home birth -

"It's unclear what penalties the AMA will seek to impose on women who choose to give birth at home, either for religious, cultural or financial reasons-or just because they didn't make it to the hospital in time," said Susan Jenkins, Legal Counsel for The Big Push for Midwives 2008 campaign. "What we do know, however, is that any state that enacts such a law will immediately find itself in court, since a law dictating where a woman must give birth would be a clear violation of fundamental rights to privacy and other freedoms currently protected by the U.S. Constitution."
This is an interesting concept happening in America, apparently this motion is a swipe at Ricki Lakes documentary The Business of being Born on homebirth - The Big Push for Midwives are an organisation of midwives fighting for the rights of midwives and women. "Our goals are to fully integrate the Midwives Model of Care into the health care systems of our states, to highlight the importance of family health care choices and to defend the ability of CPMs to provide legal and safe prenatal, birth and postpartum care to families in every state".

It does seem to be a worldwide trend that midwives and women are constantly fighting for the right to choose the model of care and birth they want. Why is this so difficult? This is the 21st century, we as women have the right to autonomy, the right to choose whatever model of care we desire.
It is interesting to note that America is pro-fetus, Britain pro-woman, Australia & New Zealand have not had many test cases, but tends to follow the UK, however can be swayed by the USA.
I am so pleased I do not live in America.

If you know any freebirth stories please share them.

Is our Maternity system failing? A Freebirth gone wrong.

In NSW a newborn baby dies, after the mother birthed at home with her husband and no health professional, a freebirth. The woman attended a hospital three days prior to the birth and was told the baby was fine however that she was at high risk of complications, including the rupture of a scar from previous caesarean. They wanted to induce her labour immediately. The woman refused and return to her home in the Blue Mountains where she gave birth to a stillborn baby several days later.

Two doulas, who are not medically trained but provide emotional support for women before and during childbirth, and a qualified independent midwife were called but arrived too late.

The baby's father told The Sun-Herald the doulas had told him the baby was stillborn due to an infection contracted inside the womb.

This tragedy confirms the fears of maternity experts who are alarmed at the growing trend of women evading the health system in favour of unsupervised home births.
This begs the questions, what information did the hospital doctors give this woman to scare her away and make the decision she did? Why do women make these choices? Was this woman suspicious that she may be coerced into something she did not want, and made a hasty decision? did she feel she had "no choice"
The Australian College of Midwives supports homebirth for low risk women. Midwives are trained in the 'normal' and can recognise the 'abnormal' therefore refer when necessary to an obstetrician. However the College does not support "freebirthing" its too risky.

Associate professor Dahlen said in this case the woman had been traumatised by a previous hospital experience and fears she might be forced into induction or a caesarean. Against medical advice, she made a last-minute decision to leave the hospital and go home and soon after the baby died in the womb.

If we fix the system we won't have women resorting to a last-minute panicked decision like this......... The increase in women freebirthing is a symptom of a system that does not give women choice. We're seeing more and more of these concerning incidents in the last two years. It has to be addressed, and urgently.

The NSW Health Department spokesman said;

Patients have the right to decline medical intervention or treatment, as as the freedom to choose where, when and from whom they will receive medical advice and assistance

It is suspected that this baby died of Group B streptococcus, not as a result of the homebirth. This case is currently with the coroner, so watch this space........

As a midwife I have to say, that there are enormous risks associated with 'freebirthing' and it is not advisable. I am an advocate for homebirth in low risk women, that is with no risk factors. However it is important to talk about your concerns and collaboration is the key. I urge any woman considering the option of Freebirth to seek advice, from your doctor, midwife, someone who can give you appropriate advice.

Look at all your options carefully, be fully informed in the risks associated with your condition and your babies condition before you make a decision. Write the risk and benefits down so that the facts are clear and there can be no mistakes, get a health professional to read your list so you have a balanced view and you have not left something out, then make a decision.

Remember to act on the FACTS not the EMOTION, after all it is your life, dreams and aspirations that your are considering. Take the time to make that decision, there are always consequences to actions.

Ref: http://www.smh.com.au/articles/2008/09/13/1220857899000.html?feed=fairfaxdigitalxml

National Caesarean Awareness Day (NCAD)

"Getting clear about fear"

I attended the NCAD conference yesterday and what a sensational day it was. It never ceases to amaze me the endurance of women. I was fortunate to meet many amazing women but in particular a women who had dreamed of having a vaginal birth, but unfortunately had quite the opposite. Amber shared her journey of first the joy of being pregnant then the horrendous pain of being rail-roaded into a caesarean, not once but twice and why, for the perceived ‘risk’. Amber for her third pregnancy employed an independent midwife to achieve the dream she wanted. ‘
This begs me to ask the question?
Why is our medical system failing these women?
This has been the theme of a few of my recent blogs and I have come to the sad conclusion that Obstetricians have what they perceive as the women’s best interest in mind, historically this comes from the Hippocratic Oath, however, they fail to hear or listen to what women want. They hide behind the fear of litigation and work in a defensive manner (consent forms for vaginal birth, refusal of epidurals etc).This also is a result of a perceived loss of medical power, in times gone by it was always ‘doctor knows best’ however now with ready technology and ‘google’ the consumer, woman is armed with information and therefore asking more questions. We fear risks that are hard to understand: doctors find it hard to understand why women make the choices they do. This then leads to the power struggle and the ‘fear’ tactic to regain the power and so the cycle continues. If the medical model continues to not listen to women, instead of women caving in to the ‘fear’ or the doctors pressure, they will seek help from other sources, be it, independent midwives or freebirth, they will do it alone.


Approximately 77 people attended the conference, what was exciting to see was women breastfeeding their young babies. It was sad to see that there were no Obstetricians at the NCAD conference, last year there were several and it made for good conversation and debate. Why did the doctors not attend? They would benefit from hearing Ambers story!
The word ‘RISK’ is communicated in many different ways and changes the birth plan enormously if communication is not a two way street. Maybe a solution is that we need to start at medical school to change the mindset of doctors, have consumer groups talk to medical students, about listening and informed choice.
Doctors are forgetting that most women are well informed and make choices. Autonomy is the single most denied option given to women who are pregnant. Women have the right to choose the care that they desire, despite the doctor not agreeing with them, as long as the women are fully aware of the implications of their actions. It is important to let go of control, develop a trust relationship and do not manipulate. “Listen more & insist less”.
I have to acknowledge the great presenters of the conference, Amber her story, The VBAC Dilemma: What the Evidence Tells Us - Henci Goer; Risk and Fear: The Best of Friends - Heather Hancock, Birth Beyond Fear - Lorraine Hale, Next Birth after Caesarean - Tracy Martin, Moving on after a challenging Birth - Lynne Staff and Initiating Change in the Operating Theatre – Caroline Dufton & Sara Bayes.

NCAD have achieved many things over the last year, more awareness regarding the rising rate of caesarean sections, the enormous help they provide to traumatised women resulting in caesarean section. Government recognition of the caesarean rate and the need to reduce this rate (through lobbying), advice on the National Maternity Plan, also the assistance with NVBAC (Next Vaginal Birth After Caesarean) clinic at a major tertiary hospital, and too much more to mention here.



This is only the tip of the iceberg; Birthrites do a fantastic job and continue to do so. They are a group of dedicated people who work very hard, a job well done.
If you require any further information regarding Vaginal Birth after Caesarean section: visit Birthrites - Healing After Caesarean Section http://www.birthrites.org/

The planing committee: Congratulations an Excellent program and day.

What is Free birthing? please help answer the question!

In recent months I have heard this term used more frequently. This is a new phenomena for me, "Free birth" or "Free birthing". I am guessing it is the same as an unattended birth, meaning that there is no health professional present. Is this a correct assumption?

These are open questions in an effort to get some answers from the women who choose this option so that i can understand what freebirthing is, you don't know if you don't ask.

What is freebirthing?

What makes women decide to have a freebirth?

How common is freebirthing? Is it becoming a more favourable choice for women?

Are our midwives and obstetricians not meeting the needs of women?

How many women do you know who have had a free birth? or contemplating a free birth?

If anyone knows the answers to these questions, please feel free to comment.