Hospital or home? Where to give birth should be a woman’s fundamental choice, but alternatives to hospital birth are rarely mentioned in Australia. Homebirth is frequently discouraged by a number of factors, including newspaper headlines, advice, and economics.
Since the 19th Century, birth has been an area of contention between obstetricians and midwives – two groups whose approaches to birthing differ.
The obstetrician is a medical doctor who generally views birth as a risk to be managed. In Australia, male obstetricians predominate, outnumbering females in a 6:4 ratio. Midwives, 99 per cent all of whom are female, are birth professionals without some specialist medical skills.
HOSPITAL BIRTHS
The hospital is an environment in which doctors are in control. This is characterised by interventions, all of which carry some level of risk. In today’s litigious society, doctors are nearly always sued for using too little technology, therefore a cautious, defensive attitude dominates.
In a medicalised birth, a common experience is the “cascade of intervention”, where one procedure creates the need for more. One such cascade starts with an epidural block in the spine, which can slow the birth process and increase the likelihood of a forceps or vacuum delivery.
About 40 per cent of Australian birthing women are given a spinal epidural for pain relief. Disengaging the woman from actively participating in the birth, this is liable to be associated later with a diminished level of satisfaction about the experience. Some studies also point to an association between epidural use and an increased likelihood of children developing a drug addiction later in life.
An episiotomy is a surgical intervention where an incision is made from the vagina in the direction of the anus to widen the birth canal. This is painful, and takes a while to heal. It is carried out on 17 per cent of women giving birth in Australia.
For caesarean sections, the Australian rate has steadily risen to 32 per cent, and far exceeds the World Health Organization’s maximum benchmark of 10 to 15 per cent.
Non-medical reasons for this high rate can include:
- Financial incentives, in the form of Medicare payments.
- Avoiding risky vaginal births, and lawsuits.
- Speeding up safe births that are taking longer than normal.
- Women who choose elective caesareans to avoid the pain of labour, or because of their busy lives.
Obstetricians largely drive our rise in caesarean birth numbers, and only a minority of women make an informed choice. Where such a choice exists, a wide range of elevated risks to mothers and infants needs to be taken into account.
Rates of all interventions are more common in private hospitals. Taxpayers are unwittingly supporting these practices through a subsidy of obstetricians’ insurance premiums, Medicare rebates covering unnecessary caesareans, and the private health insurance rebate that ranges between 10 and 39 per cent.
Some women have good hospital experiences that match their expectations, but at the other end of the scale, procedures carried out without consent can result in post-traumatic stress disorder, and a deep-seated fear of hospital birth.
HOW IS HOMEBIRTH DIFFERENT?
While the latest 2011 data shows about 97 per cent of Australian women giving birth in a hospital, the homebirth rate was 0.4 per cent, although it would probably have been higher if adjusted for under-reporting. And this figure is following an upward trend. Women choosing homebirths were generally better educated and older than the average.
For a homebirth, the woman is in control of the process, and feels empowered by making her own decisions. She is in a familiar environment where she feels safe. Her partner is likely to be around to offer support, and other family members may be present. She can choose soft music, essential oils and dim lighting. One option for homebirthing mothers is a water birth in a special birthing pool. This offers a shorter labour, pain relief during labour, easier relaxation, and a greater ease in changing positions.
Woman-centred birth, aided by a midwife, is focused away from technology. Interventions are limited to cases where they are considered necessary, and the caesarean rate is a very low five to ten per cent. Natural birth works with four “ecstatic” hormones (oxytocin, beta-endorphin, epinephrine-norepinephrine and prolactin) that encourage ease of labour, curb or prevent pain, enhance bonding with the baby, and help avoid postnatal depression.
Holding the baby following birth helps to avoid postnatal depression, aids bonding, and helps with breastfeeding. Unmedicated babies who are not separated from the mother at this time find it far easier to attach to the nipple. Active participation in the birthing process tends to result in greater satisfaction and fulfilment.
Another option for woman-centred natural birth is a birthing centre. At the latest count, 22 of these are found in Australia, most being attached to hospitals. Usually run by a team of midwives, these facilities often provide one-on-one midwife care. In 2011, they represented 2.2 per cent of Australian births.
OPTIONS AND COSTS
In the UK, Netherlands, New Zealand and Canada, midwives are the primary carers and one-on-one midwife care is provided through the public health system. Midwives have the advantage of offering continuity of care through pregnancy, birth, and the postnatal period.
With an expected cost ranging from $3500 to $6000, Australian homebirth via a midwife is more often restricted to more affluent families, which further reduces its incidence. Midwives who meet a range of criteria can attract Medicare rebates ranging from $1000 to $2000 for antenatal and post-natal care.
Another 12 publicly funding homebirth outreach programs are running through hospitals in New South Wales, South Australia, the Northern Territory and Western Australia. For women with private health insurance, some funds cover certain aspects of homebirth.
Although homebirth-only midwife numbers have been dropping, because of a range of unresolved deterrents and issues, the number of private practice midwives working in hospitals and at homebirths is growing.
HOMEBIRTH MIDWIVES UNDERMINED
The primary unresolved issue for homebirth midwives is a lack of professional indemnity insurance. Australia’s two midwife insurance policies, offered by MIGA and Vero, exclude homebirth practitioners. The government’s response to this predicament is to provide homebirthing midwives with a temporary exemption from requiring coverage. These exemptions have been repeatedly extended, most recently to 2015. A lack of coverage has persuaded some of these midwives to cease practicing, while those who remain face the risk of financial ruin.
Over time, Australia’s independent midwives have been steadily marginalised in favour of obstetricians. Contributing factors have been lack of appropriate training for independent practice, lack of systems for peer support and supervision, and difficult liaison and professional relationships with hospitals. In hospital settings, a hierarchy has been established where midwives are considered subordinate to doctors.
In an uneven playing field with obstetricians, midwives can have their registration suspended for accusations of having committed the slightest lapse, or may be restricted to hospital birthing units. In WA, one midwife was suspended for successfully delivering a homebirth following an earlier caesarean.
Ungrounded complaints from hospital staff can be taken seriously, and the midwife is treated as guilty until proven innocent. Investigations can take more than a year. The real-world impact is that a homebirth-only midwife in this predicament can lose her livelihood.
WHEN MIDWIFERY BECOMES ILLEGAL
While Australia is far from being a champion of homebirth and independent midwifery, there are worse places overseas. In Hungary, Croatia and Russia, homebirth is illegal or heavily restricted, and perhaps it is no coincidence that for decades they suffered under Communism.
In Hungary, an obstetrician named Ágnes Geréb was imprisoned in 2010 in a maximum-security facility, then held under house arrest without charge for a total of three years, for supporting homebirthing women. More encouragingly, a homebirthing mother attended by Geréb won a case at the European Court of Human Rights, which creates a legal precedent allowing women throughout the European Union the chance to homebirth.
HOMEBIRTH IN THE MEDIA
When homebirth is mentioned in the Australian media, the context is usually negative. If something goes wrong with a homebirth, it gets attention, yet similar problems with hospital births are generally considered unworthy of comment. While negative stories involving homebirth midwives are covered, obstetricians generally evade the same scrutiny. Most of these stories focus on problems that occurred when a family opted for a homebirth in higher-risk circumstances for which a hospital birth would probably have been a better choice.
This media bias builds up a simplistic picture of homebirth midwives as negligent and irresponsible. Homebirthing parents can be seen in a similar light, and may be likened to those who choose not to vaccinate their children. This contrasts with the United Kingdom, where negative stories are the exception, and a woman’s right to a government-funded homebirth is accepted.
In the polarised homebirth safety statistics debate, different studies are quoted by both sides to reaffirm arguments. Accusations of small sample sizes, cherry picking and flawed methodologies abound. However, it is fair to say that homebirth is safe for a low-risk pregnancy with a midwife attending the birth, preferably not far from civilisation, and with a hospital transfer option.
WOMEN AND TECHNOLOGY – AUSTRALIA’S BLINDSPOTS
The Australian Medical Association and Royal Australian and New Zealand College of Obstetricians and Gynaecologists take a negative position on homebirth. In the UK, their equivalent bodies are supportive. Such a wide gulf in cultural attitudes is remarkable.
Australia has certain biases that it finds hard to recognise. We love technology. As it continues to infiltrate our lives, our society is becoming become more intolerant of low-technology practices, considering them old-fashioned or inferior. At another level, hospital birth represents centralisation and control, which will probably endear it to those with an authoritarian streak.
In various ways, Australia exhibits negative attitudes to women, their birth choices, and their ability to safely give birth outside a hospital. Homebirth Australia believes that Australia is in violation of the CEDAW women’s rights convention through its restriction of homebirth choice.
On other counts, this misogynistic bias is clearly visible:
- Unrestricted abortion is fully legal only in Victoria and the ACT, despite majority public support.
- At last count, only 21 per cent of Coalition state and federal MP’s are women.
- When a paid maternity leave system was introduced in 2011, we were the second-last developed country to implement one.
HOW CAN THE SYSTEM BE MENDED?
Currently, government policies offer little support for homebirthing women and their midwives, therefore keeping homebirth levels low, while stopping short of an outright ban. Demand continues to outstrip supply.
If homebirth were prohibited, it would go underground, and there are worrying signs that this is already happening. The practice of free birth, where no midwife is present, is rising. Despite it being inherently dangerous, some women feel pushed in this direction by various factors, including the social stigma attached to homebirth here.
What would it take for every Australian woman who would like a homebirth to be able to access one? Boosting midwife numbers through more supportive policies is an important aspect. If homebirth midwives were a sufficiently large group, insurance companies would be far more likely to offer professional indemnity coverage.
The Australian lobby group Maternity Choices (formerly Maternity Coalition) sees midwife-focused care as better value for money than the current high-technology, high-intervention system, where over-servicing is the norm. In some parts of the world, homebirth is associated with major cost savings; in the US for example, an uncomplicated vaginal birth costs three times less at home than it would in a hospital.
Ultimately, a strong grassroots birth choice movement is the best asset for expanding the rate of homebirth in Australia, but its voice needs to be heard and understood by mainstream society.
RESOURCES
Homebirth Australia
www.homebirthaustralia.org
Maternity Choices (formerly Maternity Coalition)
www.maternitycoalition.org.au
Martin Oliver is a writer and researcher based at Lismore, Northern NSW.
