December 01, 2003

The debate about home birth services

There is a lot of debate on the Australian ozmidwifery mailing list regarding establishing a home birth service for women the State of NSW. One of the Sydney metropolitan Area Health Services has been investigating the setting up of a home birth service that would work in conjunction with their Birth Centre programs, offering women a choice of birth place. Two hospitals are involved: St George Hospital and The Royal Hospital for Women. Both have excellent Birth Centres staffed by midwives who are experienced in normal births and they are keen to extend their services to the community.

The advantages of this proposal are that for the first time, home births would be available for free in NSW, as part of our Medicare system, and midwives would have the opportunity to work outside the hospital, facilitating birth in home settings. Many of the midwives currently employed as part of the Birth Centre teams have extensive home birth experience, either in Australia or overseas (especially New Zealand and the UK). No doubt some would prefer working as independent practitioners but are unwilling to take legal risks due to the lack of professional indemnity insurance at this time. Others may prefer the collegiate atmosphere that comes with working in a small team of dedicated midwives who share a common philosophy and the back-up that such a system provides.

The debate seems to hinge on whether this kind of hospital based home birth service will give women true choice, because it is feared that the doctors will be setting down such strict criteria that many women will be excluded. These fears are based on the assumption that the midwives will not be able to exercise professional judgements of their own but will have to apply rigid protocols that have a medical orientation.

Also, why is it always assumed that the doctors have a strong bias against home birth? I agree that many are ignorant of birth in any setting apart from a regulation labour ward and that many are fearful of the strength and popularity of independent midwives. Whilst some doctors would see a midwifery service as threatening and attempt to block it any way they could, there have always been some, with different experience, who have supported women choosing home births and have provided midwives with the necessary back up. There may not be many of these enlightened medicos, and they are fairly invisible (often due to unwelcome pressure from their own colleagues to “toe the party line”) but they deserve recognition and support from the community for their stand. Some of these doctors are behind the present moves to broaden maternity services to incorporate a community based element.

An assumption is also being made that home birth midwives are willing to “bend the rules” to accommodate women’s wishes even if the best advice, based on evidence, suggests that home birth might not be a safe option in a specific case. Any midwife who was willing to stick her neck out and support a woman wanting a home birth when there were clear medical risks would be foolish in the extreme and would deserve censure for her lack of professionalism. It could be argued that in the present climate of a litigeous society, independent practitioners might need to be extra vigilant (read: screen more carefully) about the women they accept, given the lack of protection they have and this might also lead to a lack of choice for women.

Home birth is not a popular choice for women in Australia, due to ignorance about this option, fear of censure if a woman decides to take this path, perceptions of lack of safety and cost. If we can get a home birth service established as part of the regular health services this will be a wonderful move forward, for women, midwives and our community. Making it a free service will attract women who can’t afford to pay for private midwifery care. Midwives and students will be able to gain valuable experience that will broaden their skills and increase their visibility within the community. Home birth may again be seen as a mainstream, rather than a “fringe” activity. Birth might have a chance to become normal and natural again.

This debate is healthy and necessary if we are to clear the air, establish common goals and get home birth back on the agenda with politicians and health bureaucrats. Success breeds success and this first attempt to offer a community service is a bold move that deserves praise and support. The “purists” who only want a home birth service based on midwives working in solo, independent practice risk shooting themselves in the foot if their efforts torpedo these first attempts to establish a hospital based service fail. The last thing we want is for the politicians and hospital administrators to get the message that home birth, and especially a service based in a hospital is not needed or is, perhaps, “not good enough”. What they need to hear is that lots of women want this service and are willing to use it, and soon.

The National Maternity Action Plan is a wonderful document that I whole heartedly support. However, we need all kinds of models of midwifery care, and that includes services such as this hospital based home birth option. I am sure that everyone can see the significance of these proposals and I hope they will lobby strongly for these new programs at St George and The Royal Hospital for Women to be implemented speedily.

Posted by andrea at December 01, 2003 03:28 PM

Comments

At Blue Mountains Hospital we have been attempting to set up a Midwifery Model of Care that may well include 'unexpected' homebirths, due to the care we want to offer for women.
There seems to be no mention of this in your papers.
We are continuing in this process with minimal support from the system. Everything is 'too hard.' Then next comes with infiltration of fear that is not only 'dumped' on the women who are birthing, but also the midwives.
The 'unit' at Blue Mountains is exceptional in the support of women birthing. This needs to be seen on a broader perspective.
Thank you Vita

P.S. the midwives are very tired!

Posted by: Vita Rinks on December 27, 2003 12:54 PM

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