Dr Andrew Pesce, a Sydney obstetrician and gynaecologist and former president of the Australian Medical Association, writes:
Croakey readers will recall the controversy surrounding the publication of a review of planned home births in South Australia between 1991 and 2006. The study was published in the Medical Journal of Australia in January 2010.
At the time, the presentation of data which indicated a statistically significant increase in the numbers of babies dying following a planned home birth led to significant debate and even hostility from readers who claimed it gave a distorted view the risks of home birth. The corresponding author, Marc Kierse, reinforced the main message of the paper that, in the absence of proper risk assessment and limiting planned home birth to low risk pregnancies, home births in Australia led to higher rates of perinatal death.
Since that study, the two States which publish their perinatal statistics in ways which identify outcomes in planned home births separately to all other births have published their latest reports.
The Perinatal and Infant Mortality Committee of Western Australia published its review of perinatal outcomes from 2005-2007 in December 2010. It found:
“Of the 658 planned home births in the period, the Committee reviewed seven deaths, six of which occurred at term or post-term gestational ages. From the information available, three of these deaths were considered to be possibly avoidable. The perinatal death rate for term home births was 3.9 times higher than for hospital term births”. All of the deaths in the planned home births occurred under the care of registered midwives.
In June 2011, the South Australian Maternal, Perinatal and Infant Mortality Committee published its review of pregnancy outcomes for 2009. Of the 160 planned home births that year, there were 5 perinatal deaths, a perinatal death rate of 3.1%. This compared to an overall perinatal mortality rate of comparable weight babies weighing more than 1500g of 3/1000. So in 2009, the chance of a baby dying in a planned home birth was more than 10 times the state average. All of the home births included in the statistics were cared for by registered midwives.
On the above evidence, it remains clear that planned home birth in Australia as currently practiced is leading to the deaths of a number of babies who would otherwise have survived if their birth was planned in a hospital maternity unit. This is occurring in pregnancies cared for by registered midwives, as well as during “freebirths” where women give birth at home without any medical or midwifery care.
It is likely that a large part of this excess perinatal mortality is due to women with high risk pregnancies choosing to plan a home birth. In the South Australian report, this view is reinforced by the following new recommendation:
“All home births should be conducted in accordance with the ‘Policy for Planned Birth at Home in South Australia’; specifically that the mother should be transferred for hospital care when a planned home birth is complicated by the presence of meconium stained liquor…”
There is also a restatement of recommendations from previous reports which “remain pertinent”:
“Planned home birth for twins, breech presentations and post-term infants is associated with unacceptably high risks. A previous caesarean section is a contraindication for home birth.”
It is noteworthy that in the Netherlands, a country with the longest history of a well developed health system supporting planned home birth, such high risk pregnancies are not considered eligible for planned home birth and women are transferred to hospital when risk factors emerge in pregnancies previously classified as low risk.
The Australian College of Midwives published a position for planned home birth in August 2011, reinforcing the importance of limiting planned home birth to low risk pregnancies.
“At – or prior to – booking, the midwife must advise the woman of situations where homebirth cannot be supported. At any time, the midwife is not obliged to participate in a homebirth that the midwife considers will increase the risk of harm to the woman or her baby.”
This position statement was endorsed by the Nursing and Midwifery Board.
The result of this quite reasonable statement was the opposition to, and often vilification of, the ACM and N&MB by individuals and home birth lobby groups advocating support for women’s choice of home birth notwithstanding the risks this might pose.
Similarly, the South Australian Coroner, and SA Health Minister John Hill – a reasonable man who has been sympathetic to low risk women seeking planned home birth – have recently been publicly savaged for seeking to investigate the causes of deaths of babies during home births.
No Minister will consider funding a system of maternity care which supports unsafe clinical practice. Until those individuals and groups which advocate for publicly funded home birth unambiguously and publicly state home birth is unsuitable for high risk pregnancies, their advocacy will remain at the fringes of the maternity system.
If they can cross that Rubicon, they might find that they have broader support than they realise.
For previous related Croakey posts