In many countries, home births are commonplace - and generally regarded as safe. So why in Australia, where such births are rare, is the Government discouraging the practice? John van Tiggelen investigates.
"Midwives are the experts in normal births. Obstetricians are the experts in abnormal births. Leave a normal birth in the hands of an obstetrician, and it's more likely to end up abnormal." - independent midwife Jennie Teskey
Whenever you say to women, 'Thou shalt not do this', you end up with an element that becomes fanatical. That's the nature of oppression: it brings about rebellion.
Farmer Hayden Ewart and his partner Alice Cunningham live in Murchison, on the lower Goulburn, 160 kilometres north of Melbourne, in a red-brick bungalow fronting a highway humming with trucks. Last Anzac Day weekend, on Friday night, a heavily pregnant Alice retired to bed with cramps, sure she would awake in labour. Instead, she woke up disappointed, and spent Saturday morning painting the bathroom. Meanwhile, Hayden, having inflated the birthing pool in the lounge room, remained a chance to line up for Murchison in the local football league the next day. It was an away game, against Avenel, and Alice joked the team needed a safe pair of hands, too.
Late that afternoon, her contractions returned in earnest. Alice rang her private midwife, Helen Sandner, and told her she didn't feel great. Something seemed skewiff; the baby felt out of position. Sandner, who lives in Bendigo, an hour's drive west of Murchison, alerted the backup midwife, Mary-Anne Richardson, and drove off with the four carry-cases containing the tools of her trade: foetal heart rate monitors, suture materials, bags of fluids, drugs, catheters, bedpans, oxygen tanks and suction apparatus. The only thing missing from her mobile birth ward - the only crucial thing, give or take an obstetrician to boss her around - was insurance because, since the indemnity crisis of 2001, insurers have refused to cover midwives who attend home births.
"It was a classic dark and stormy night," recalls Sandner. "There was lightning and thunder and terrible wind. I thought, 'This should push it along.' " Sandner arrived at the house before eight, in time for a tuna casserole prepared by Hayden. Alice's contractions had waned, and she was having a bath in the freshly painted bathroom. In the lounge room there were candles burning, a log fire, acoustic music. By the pool lay a waterproof torch. Alice's sister Jess arrived with a bag of treats, then Richardson. "It just felt really nice," says Sandner. "You know, cosy." The two midwives constructed a sling and gently rocked Alice in an attempt to position the baby more favourably. They drank tea. They played board games. At one stage, Alice and Hayden retired for a lie-down. Outside, semitrailers rumbled on through the rain.
Alice went into serious labour just on midnight. Five hours later she gave birth in the pool to Angus Patrick Ewart, without painkillers and with little fuss. The placenta took its time, another hour, during which Alice and Angus, snuggling on top of her, connected via Skype to her parents in England. Then everyone, midwives included, had a catnap in their armchairs, with Hayden cuddling Angus by the fire. Sandner packed up around eight as family began arriving with Angus's toddler sister, Lucy, who'd spent the night with her grandmother. "It was very beautiful, very relaxed, all things considered," says Sandner. "But you know, most of them are like that."
In 10 months' time, Helen Sandner will cease to assist home births. By then the federal Minister for Health, Nicola Roxon, will have engineered changes in private midwifery practice that restrict midwives to providing continuity of care within the hospital system. The carrot is access to Medicare provider numbers for eligible independent midwives from July 10, 2010. The stick is the denial of professional registration should they remain without indemnity insurance: i.e., should they continue to attend home births.
Roxon's backdoor assault on home births came as a shock to Sandner and her colleagues. Although a long-awaited maternity service review had recommended against supporting home births, few anticipated Roxon would go further. As Hannah Dahlen, the spokeswoman for the Australian College of Midwives, saw it, the idea of a feminist Labor Health Minister limiting women's birth choices seemed about as likely as Peter Garrett giving the go-ahead to a uranium mine.
From an international perspective, Australia's lack of sympathy for women who want a home birth is curious, to say the least. Demand for home births nation¬wide, about 700 a year, is already suppressed because parents must bear the full cost themselves (about $3000 in midwifery fees) - unlike, say, in New Zealand, where hospital and home births are funded without bias, and demand is 20 times higher. The vast majority of modern nations support planned home births (i.e., those attended by midwives with hospital backup) for low-risk pregnancies. The weight of evidence, including studies in Sweden, Switzerland and Canada, shows these are as safe as hospital births.
But in Australia, the argument prevails - and Roxon evidently accepts - that the practice is dangerous. "The risks are unacceptable, because the only data we have in this country indicate that," says Andrew Pesce, the newly elected president of the Australian Medical Association who previously headed the Royal Australian and New Zealand College of Obstetricians and Gynaecologists. "As a doctor I cannot support home births."
Pesce cites a 1998 review of births showing that, in Australia, a child is up to three times more likely to die during a planned home birth than during a planned hospital birth. The study also explained that most of the extra deaths could be attributed to higher-risk pregnancies such as twins and breech presentation, which might elsewhere have been referred to hospital. But Pesce is adamant that all expectant mothers are better off birthing in hospital, preferably under the direction of a doctor. Home birth in this country, he says, is a counter-cultural phenomenon that women pursue at their own risk.
"The 0.25 per cent [of Australian women who have a home birth] have such a strong commitment to choosing a home birth that they either don't understand or they ignore emerging warning signs [of foetal distress]," he says. "They cling on too long and delay a timely transfer to hospital ... What I'm saying is the priority [of these women], more than most people would accept, seems to be based on avoiding going to hospital. And that leads to bad outcomes."
Pesce blames the more radical advocates of natural birth for "demonising mainstream maternity services". His ultimate argument, then, is as much about ideology as it is about safety: that it is feminist point-scoring, rather than merely location, that compromises the safety of a home-born baby.
"I actually agree with him on that," says Hannah Dahlen, from the Australian College of Midwives, albeit with the caveat that she finds insulting the suggestion that women who opt for a home birth are either gullible or irresponsible. "Wherever you take rights away, whenever you say to women, 'Thou shalt not do this', you end up with an element that becomes fanatical. That's the nature of oppression: it brings about rebellion.
"Birth should not be a political act. It should be an important, intimate, family event - whether that occurs at home or in hospital. Midwives don't support home births for everybody; what we support is women's choice.
"We have the highest caesarean rate in the world, but I would never take away a woman's choice to have an elective caesarean, which involves major abdominal surgery, is costly and is associated with a greater incidence of complications and stillbirths in subsequent pregnancies. So why should we prevent women from choosing to have a birth that is safe, natural and cheap?"
Dahlen believes Pesce is escalating a turf war against midwives. "If it is about safety, then how can he condone pushing home births underground? I've seen how the independent midwife who transfers a home-birth client to hospital at the first sign of trouble is treated vilely, is almost elbowed out of the way [by the attending doctor]. This is not about safety, it is about control, because in this country we have a large private medical industry that has a strong investment in keeping its power over a market. That is the bottom line in all of this argument. Doctors save women when it's needed, but when women say, 'Thanks, but no thanks, we'd like to do this on our own', they feel threatened. Doctors want women to need them. Some women do need them, and that's fine, but some don't, and that should be okay, too."
Two months ago, a landmark review of half a million births in the Netherlands found no difference in survival rates between hospital births and home births for low-risk pregnancies. One in three babies is born at home in Holland, compared to one in 400 in Australia. There are tangled reasons for the high rate - Holland's provision of post-natal home care is second to none, for one - but essentially the Dutch have resisted the medicalisation of birth that began sweeping the West in the '50s, with its promises of pain relief, sterile rooms and around-the-clock doctors, and clung to the pre-war notion that midwives knew what they were doing. Today, births in Holland remain midwife-led, in hospital as well as at home, with an obstetrician assuming responsibility only if there are complications. (Not coincidentally, the Dutch rate for caesarean sections is half that of Australia's.)
I should divulge some background here. My mother was born at home, as were her 13 brothers and sisters. My sisters were born at home. My cousins in Holland - there are 50 of them - are giving birth at home. It's not so much a cultural thing as a non-thing; call us stubborn, but the Dutch figure you go to hospital when things go wrong, and you stay home when they don't.
As it happens, I live in a pocket of Australia where the home-birth rate is 20 times that of the rest of the country. Around Castlemaine, in central Victoria, tree-changers in particular seem to have a thing for it, with the town's independent midwife, Sally McCrae, delivering up to 25 babies a year. In comparison, the local hospital, which deals only with low-risk pregnancies and refers all others on to Melbourne or Bendigo, delivers about 70 babies a year.
One of the duty doctors at the local maternity ward is Ronnie Moule. Curiously, despite having delivered hundreds of babies in hospitals around the country, she chose to have each of her own four children at home, attended by a midwife. "The key thing for me [in choosing a home birth] was that I wanted a good experience," says Moule. "I've seen a huge variety of births, and witnessed an equal variety of birth experiences. In hospital, a woman's experience of birth depends very much on who will be assisting her. The busier the hospital, the less control she will have over that. Some birth attendants bring a sense of calmness, some bring anxiousness, some are disinterested, some are respectful, some are jittery and impatient."
Moule is talking to some extent about midwives as well as doctors, but adds, "If you want a doctor who is calm and patient, the system doesn't accommodate that very well.
"As a woman, once you know you're physically safe, you want your vulnerability taken care of. After all, what is birth? It's pooing in front of someone, having it cleaned up, then stretching and burning your vagina. Some women are going to want to do that in a place where they feel emotionally safe as well as physically safe. If you want a private, intimate birth, for you and for the baby, then that's more likely to happen at home."
Earlier this year, McCrae invited me to a "home-birthers' picnic" in Castlemaine's botanic gardens. McCrae organises these twice a year for past clients. She is no-nonsense, generous and warmly regarded; some 50 adults have turned up with their broods. She's also slightly wary; perhaps she has sensed my unease with the way home-birthing has become a movement in this country. People here wear it like a badge, alongside cloth bags, reconciliation and anti-fluoridisation. And all that placenta planting - my grandma might have fertilised a whole orchard had she gone in for that.
The question, frankly, is: are the type of people who choose home birth in this country the type who do not immunise their children? After all, it's one thing to avoid hospital, but quite another to shun public health. The answer, I can report, is no. Or mostly no. I do meet a mum who breastfed her child for four years, and a dreadlocked woman who appears to have named her eight children after weather conditions. But for the most part, extreme earth-mother types tend not to be able to afford an independent midwife. Instead, I run into a number of people I know: friends of friends, neighbours, the local mayor. These aren't hippies. They aren't even particularly earnest. They are intelligent, professional people who, to a couple, have done the research and realised that if they are to optimise their chances of having a safe, vaginal birth, then, statistically, the best place is at home.
Sent on by McCrae, one mother after another tells me her birth stories, good and bad. Overwhelmingly, these begin with either herself, or a best friend or a sister having a disappointing birth experience in hospital. Typically, she would be admitted to a birthing suite in labour, only for the contractions to ease. The attending midwife reassures her this is normal, but a doctor decides things need to get moving and puts her on a drip of labour-inducing drugs. Over ensuing hours the dose is steadily increased until the doctor returns, probes the cervix for dilation and announces something like, "We're not going anywhere here, are we?" He or she then strongly recommends an epidural, for the pain and in the event a caesarean is called for. There's no mention that the epidural may leave the woman too drugged to push effectively. A few hours later, utterly spent, she is wheeled into theatre. In the lingo of the natural birth lobby, this is called the "cascade of intervention".
"I went into hospital for my first birth without any complications, fully planning to give birth myself," one woman tells me. "But everything seemed geared to the doctor doing it for me. Then, with my second pregnancy, I was told the hospital didn't do VBACs [vaginal birth after caesarean]. That's when I thought, 'Enough', and had it at home."
Over the past 20 years, maternity services have undergone profound contractions in response to the rise of personal injury law. GPs no longer deliver babies because they can't afford the insurance. Maternity wards in rural Australia are closing apace, including 40 in Victoria in the past 13 years. Specialist obstetricians are shying away from techniques that require excellent personal skills, such as the use of forceps in assisting troublesome vaginal births, or the vaginal delivery of twins and breech births.
In contrast, caesarean rates have doubled in the past 10 years. Caesareans are pretty much litigation-proof because they are performed by a team, come with an established level of risk and are the technique of last resort. Now the surgery is becoming the technique of first resort, with one in six babies extracted by elective caesarean. Another one in six is born by so-called emergency caesarean. In some private hospitals, the total caesarean rate is as high as 50 per cent.
"Obstetricians are becoming more and more wary about being sued," says Dr Andrew Bisits, the head of obstetrics at John Hunter Hospital in Newcastle. "A lot of decisions [about baby delivery] are dictated by, 'What will I say in court when I get it wrong?' I've noticed this sort of reasoning insidiously increasing and it becomes a very negative, defeatist position."
Bisits is one of the last remaining obstetricians to deliver breech babies naturally. The technique is perceived as inherently dangerous by some colleagues, but Bisits points out the practice is only unsafe in the hands of those who have not been allowed to develop the necessary skills. In other words, says Bisits, he's in much the same boat as midwives assisting home births: with support, the practice is safe. Marginalise it, and it becomes risky.
"We [doctors] have a prevailing obsession with risk, and as a result the medical approach to birth is a very fearful approach," he says. "The cascade of intervention is very real. There's pressure on us to intervene all the time, because we're always looking to prevent things from going wrong. Also we're in a hospital, we're busy, there's a pre¬mium on bed space, we're multitasking, so it's difficult not to unwittingly exert pressure on labouring women to get on with it. And it is so easy, as the doctor, to talk a woman into a caesarean, before or during labour. Because it's not only doctors who are risk-averse, it's the expectant mother, too, and at this point she is profoundly hypersensitive to anything that is said to her."
Bisits believes the medicalisation of birth needs to be wound back. He points out medicine doesn't advance without fail; recent medical history is full of modish surgical procedures that turned out to be ill-advised, including routine circumcision, spinal fusion and tonsillectomy, to name a few. Home birth may seem a backwards step to some, but then, not so long ago, infant formula was being hailed by the medical profession for putting paid to the primitive practice of breastfeeding.
Midwifery is a very old, archetypal tradition of care, and from a purely human, clinical perspective, it makes sense," says Bisits. "Birth is women's business, if I can use a cliché. Midwives have a different perspective to doctors: they don't let risk rule the day. They will focus on the positives and put the risk in perspective.
"What has been trivialised to date is the value of the vaginal birth. Labour is a very finely orchestrated event that allows the baby to say, 'I'm ready', which triggers a series of hormonal changes in the mother ultimately geared to benefit the bonding between mother and baby. I can tell you that the difference between the high of a mother who's had a vaginal birth and the response of a mother who's had a caesarean ... well, they are worlds apart."
In june, a coroner investigating the death of a baby in an amateurishly planned home birth in northern NSW urged Roxon to reconsider her refusal to indemnify private midwives. Although the birth, near Nimbin, was attended by a local midwife, she had attended solo and had failed to organise transport in case of an emergency, to monitor the baby's heart rate adequately and to seek professional medical help when it became clear the baby might be in distress. Despite this "series of shortcomings", the coroner, Nick Reimer, said the midwife could not be held responsible for the death. Instead, he reminded authorities that the practice of home-birthing was a mother's inherent right, was here to stay and should be available as a safe option. He implored Roxon to take "great care" in drafting legislation that could drive the practice underground, with "disastrous ramifications".
Lareen Newman, a public health academic from Adelaide, says the lack of government support is already pushing women to extremes. Several independent midwives, for instance, now offer free assistance to women who vow to otherwise go it alone. In fact, two of the mothers at the home-birthers' picnic told me they had considered giving birth at home without a midwife. "My husband lost his job and we were having real trouble finding the $3000 [in midwifery fees]. So I almost became a reluctant free-birther," said one, in a reference to the radical movement that contends childbirth is a deeply sexual experience that should only be shared between lovers.
Opponents of home births like to conflate free-birthing, which regards medical intervention as "birth rape", with midwife-led care, which includes arranging backup bookings in hospital (about one in six planned home births ends up there). Earlier this year, Janet Fraser, a prominent Sydney advocate of free-birthing, gave a phone interview as she went into labour. She told The Sunday Age's John Elder she had not undergone a single test, scan or consultation in the previous nine months. She also told him she'd previously had an emergency caesarean, a serious risk factor in any subsequent birth. After publication, it transpired the baby had not survived, and purveyors of opinion such as Miranda Devine, Andrew Bolt and Fiona Connolly wasted no time in using the tragedy to denounce the selfishness of women who choose to give birth at home.
Commentators will have another opportunity for disapproval this week. On Monday, mothers and babies from around the country will be staging a rally in defence of home births in Canberra. Alice Cunningham, the farmer's wife from Murchison, will be there, along with little Angus. She's flying up partly in support of Sandner and Richardson, her midwives, who have home-birthing duties. "When Hayden and I decided to have a home birth, it just felt right," she says. "I didn't see it as a women's rights issue. But I do now."
Sandner and co may not be out of a job come July 10 next year. With the low demand for home births, many midwives in private practice also work part-time in the hospital system. Roxon has promised them a bigger role by allowing access to Medi¬care provider numbers, which will allow them to bill the government for ante- and post-natal care, as well as for assisting births in hospital. It should mean that expectant mothers who crave continuity of care, rather than rotating shifts of midwives and doctors, will finally be able to afford it.
In addition, a few progressive hospitals, in tacit acknowledgement of the danger of pushing home births underground, have announced they will expand their maternity services to offer midwife-led home births for low-risk pregnancies. More are expected to follow, but it's clear the vast majority won't without a government directive.
"Home births will still happen. It's just that from mid-next year, they are going to be less safe," says Sandner. "What the Minister's decision means for me is that if I wish to continue calling myself a midwife, then I have to give up that part of the job that I find most satisfying and that I am specifically trained to do, which is birthing babies naturally. Basically, I am being told that all my training and experience is best served by carrying out an obstetrician's orders in hospital, and as we all know, that leads to more intervention."
Says Richardson: "At some point in every labour, a woman is going to say, 'I don't want to do this any more.' As a midwife hearing this, you're powerless to know what she really wants unless you've been caring for her from the outset. But if you're in a hospital, and there's a doctor present - whooshka, the cascade begins, there's no way you can challenge the doctor. It happens all the time."
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