03 Aug 2010

Homebirth…again

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Well its 5 45 am on Good Friday and I can’t sleep. The reason is I’ve just attended a wonderful birth. One of my patients began her first labour at about 2 this morning and then had a perfectly natural birth at about 5 am.

No complications, no stitches, all perfectly natural with the father virtually doing the delivery himself. (I have told her that many women will be very envious of her experience).

So my mind wandered to all of the stuff in the SMHthis week about homebirth, including the inevitable – er – piece by Miranda Devine.

Some leading Doctors and midwives have explained that hospitals are so unfriendly that it is inevitable that women will “go underground” and choose risky homebirths. They argue that if we can provide continuity of midwifery care and be generally more welcoming in the hospital system they will not take such risks. I’m not so certain about these arguments and in some cases they are a little self serving in that they suit the various protagonists agendas for reform of the Australian maternity system (reform that I support, too, by the way).

There are two problems with these arguments:

1. From time to time women do come to hospital to have their babies yet refuse monitoring and intervention such that they place their babies at what seems to most doctors and midwives as an unacceptable risk. In other words you can have a risky birth in hospital,too.

2. There are some women for whom a hospital – no matter how friendly and accommodating it may be – is ismply an unacceptable place to give birth. This group of women will give birth at home no matter how accomodating the health system may be.

And of course this is the rub. Australia has proven to the world – via the scientific literature – that homebirth is unsafe because the women and caregivers who are involved in homebirths perform high risk births (breech births, previous caesareans and twins) at home. Little wonder independent midwives struggle to find indemnity insurers.

However in some countries planned homebirth has been shown to be a reasonably safe option for women.

My view is that home birth should not be discarded because of the activities of zealots and – in some cases – the inexperienced and ill informed. I believe that home birth should be an option for women as much as I believe that elective caesarean should be. Seriously. I think that if a womn has absolutely no obstetric risk factors and no medical problems she should be entitled to consider a homebirth. While my midwifery colleagues might disagree I would strongly prefer such a woman to have previously given birth normally because we know that women having their first baby face up to a 30 percent likelihood of some medical intervention in labour or at the time of birth while women having their second or third vaginal birth have much lower risks (a less than 5 % risk of a caesarean or instrumental birth if they labour spontaneously). Adverse events for babies are much less frequent in women having their second or third baby when compared to their first.

Also for me home as a place of birth has an important positive. It does not masquerade as a health facility. I would prefer a homebirth in Coogee to giving birth in – say – the Ryde “freestanding low risk” matenity unit. If you’re going to have your baby in a hospital it might as well be one that can perform an emergency caesarean and have a neonatal paediatrician resuscitate your baby should you need it.

So I don’t think that the issue of homebirth should derail the important matter of reform of Australia’s maternity system. Realistically even under optimum circumstances it will be an option taken up by relatively few women. I do believe however that women’s choice surrounding child birth should include access to a well structured and organised homebirth service provided by practitioners with appropriate training and experience in the important relevant areas. Clear criteria for abandoning a homebirth or transfer to hospital should be provided and adhered to.

What the zealots do is a side issue.

I’m off to bed

R

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