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The Homebirth Debate

Is a minority of hijackers misrepresenting major advances in Australian Midwifery?  Two edited takes debate the point

On 24 June this year, Nicola Roxon introduced three bills in the House of Representatives that proposed major changes to midwifery in Australia. Midwives have been able to access some limited Medicare items since November 2006, but Roxon’s bills would extend Medicare and Pharmaceutical Benefits Scheme funding to midwifery and nurse practitioner services.

The bills resulted from a review earlier in the year by Rosemary Bryant, Commonwealth Chief Nurse (a position established by Roxon), which concluded what Australian women by and large have been saying for years, that unless you’re privately-insured there’s not enough choice when it comes to giving birth, especially in a regional community. Roxon’s bills also added to the growing push for collaborative care, making midwives more central in maternity care as part of a team-based approach. It needs to be said, however, that doctors are not over-keen about the reforms.

If Roxon thought this major reform would get support from those who support choice in “birthing”, she was wrong. The bills upset many homebirth advocates who wanted Medicare funding for midwives outside clinical settings like planned home births, and ‘homebirth midwives to have professional indemnity cover.

Roxon’s bills established a publicly-funded professional indemnity scheme for midwives, but didn’t extend to services provided outside clinical settings where risks are much higher. Private insurers won’t provide indemnity cover for homebirth midwives because there’s too few of them to provide a premium pool, and homebirths are too high risk.
This hasn’t stopped some women suing after bad outcomes.

As Ms Bryant’s report notes, if one practitioner can’t be sued [and many homebirth midwives strip themselves of assets and require tight contracts against litigation, then some clients will try to sue other practitioners who were involved, e.g. obstetricians called in at the last minute when a homebirth has gone badly wrong. Other medical professionals are reluctant to become involved now for fear of becoming ‘the litigee of choice’.

The reaction from many homebirth advocates has been extreme and Nicola Roxon has been vilified across the blogosphere and deluged with letters and emails.

Many claim that the Government is seeking to ban homebirths, when it is doing no such thing, and claim – against considerable contrary evidence – that homebirths are as safe    or safer than deliveries in clinical settings, including birthing centres.

The missing fact in the virulent attacks on Roxon and her reforms — which the Coalition have eagerly taken up in Parliament — is that only a tiny fraction of Australian women choose homebirths – 0.22% of all births in Australia, according to Bryant’s report. Even in New Zealand, where taxpayers fund homebirths, the rate is only 2.7%. Moreover the rate was declining rapidly in Australia even in the 1990s, when homebirth-midwife insurance was available.

No one is stopping Australian women who want homebirths from choosing them. Nicola Roxon’s bills merely continue the current approach of not providing Medicare funding for homebirths and require that midwives are either part of a professional, accredited, indemnified, collaborative care model.

What should have been hailed as a major midwifery step forward in the Australian health system – long characterised by a maternity care approach dominated by obstetricians (usually male) has been drowned out by ideological attacks from a tiny unrepresentative minority.

AGAINST THE ABOVE [midwife author]

The issue of homebirth divides the community into those who think it is OK and those  who don’t. Often, no amount of evidence, opinion, or research will convince either side.
The above view is based on two incorrect pieces of information. The first is that “no one is stopping Australian women who want homebirths from choosing them”. The second is that there exists ‘considerable evidence’ that home births are dangerous.

To start with the first. As of July next year it will no longer be legal to have a homebirth attended by a registered private midwife in Australia. This is a fact, the reason being that the state and Commonwealth governments are implementing a National Registration and Accreditation Scheme for health professionals.

As part of this scheme a health professional must hold professional indemnity insurance in order to register to practise. Private midwives are presently unable to obtain such insurance because there is no insurance product available for them to purchase: they form too small a collective to make it worthwhile for an insurer to provide that product.

The legislation currently before Parliament proposes indemnity insurance to some midwives. It is not at all clear who these midwives will be only that they are “eligible” and that they will work “collaboratively” and that they won’t attend homebirths. Extending this legislation to cover homebirth midwives is the only realistic way that homebirth with a registered private midwife will remain an option for Australian women after July 2010.
This is why so many have written to Nicola Roxon, visited their local MPs and made submissions to the recent Senate inquiry concerning this legislation.

The second piece of incorrect information is that home birth is an inherently dangerous and high-risk option. There is a body of evidence regarding the safety of homebirthing. The most recent published study (only a few months ago), of over half a million low risk births showed that women and their babies were as safe at home as they were in hospital. Even the Australian homebirth study published over a decade ago found that low-risk women were no less safe at home giving birth.

That study did point out that the practices of unregistered midwives versus registered practitioners was the issue of concern. The fact is that flawed research from the 1970s which falsely concluded homebirths were not safe has misinformed government policy for decades.

The UK Department of Health website states that “for a healthy woman experiencing a normal pregnancy with no major complications anticipated during the birth, studies have shown that it is equally safe to be attended by midwives in the comfort of your own home as to have your baby in hospital.” The Department of Health in the UK has made one of its priority targets for 2009/10 to give more mothers-to-be the opportunity to choose to give birth at home.

One could write many pages setting out the breadth of evidence that supports homebirth as an option for women but would distract from the fact that at its heart this debate is not about safety or risk or insurance. It is not a turf war about whether obstetricians or midwives should be the most important care provider for pregnant women. It is about whether all Australian women have the autonomy to make their own choices about how they will give birth — a fundamental choice about a fundamental life experience.

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