Tate Spencer-Koch lived for the briefest of moments after a tragic homebirth.
Jahli Jean Hobbs suffered a similar fate, passing away after another homebirth, complicated by the fact she was a breech baby.
Similarly, Tully Oliver Kavanagh died soon after delivery, partly because he was the second of twins his mother planned to deliver at home.
But as awful as their deaths were, some believe that the bigger tragedy is that all three infants could have possibly survived had they been born in hospital.
Some advocates of homebirthing may not share that view, and it's a view that has also raised concerns for the Australian College of Midwives (ACM).
The answer to all this is not to demonise women for their choices, but to stop and consider our responsibility as a society to mothers and babies
But it was the clear finding of South Australian deputy coroner Anthony Schapel this week, who ruled that it was a "matter of certainty" that all three infants would have lived had they been born by caesarean section.
Mr Schapel said even without such surgical intervention, the babies may have survived if their births had occurred in hospital rather than at home.
The deputy coroner investigated the three deaths, partly to examine the regulatory framework surrounding homebirths and partly because they all involved former independent midwife Lisa Barrett.
The deaths of Tate in 2007, Jahli in 2009 and Tully in 2011 have also been referred to SA's director of public prosecutions, to determine if any offences have been committed.
Potential risks and benefits
The issues involving homebirths are certainly complicated. On one hand, most people - from health ministers to senior medical officers - defend the right of the mother to choose how and where she delivers her baby.
On the other hand are the risks inherent in some homebirths, especially when there are complications.
The ACM has guidelines in relation to homebirths which identify some of those risks and make recommendations. For instance, it recommends a breech delivery, where the baby is coming out bottom first, shouldn't be attempted at home.
But college spokeswoman Hannah Dahlen said the final decision still rested with the mother, and that the reason many opt for home deliveries lay with the attitudes of some health professionals. In addition, the skyrocketing rates of intervention during childbirth over the past 10 years had left many women traumatised and fearful, she said.
"A woman wanting to have a vaginal breech birth in hospital will often have to fight hard and search far and wide to find a doctor to support her choice," Professor Dahlen said at the time of the inquest.
"A woman wanting to have twins in hospital without being forced into having an epidural or having the second twin virtually extracted from her body will also have to fight hard to have her choices respected. So when these women seek care outside our mainstream system, whose fault is it really?
"The answer to all this is not to demonise women for their choices but to stop and consider our responsibility as a society to mothers and babies."
In his findings, Mr Schapel presented a series of recommendations, including more education on the risks associated with homebirths and the need to dispel some notions associated with complicated births in hospitals.
He called on authorities to consider the establishment of alternative birthing centres and for legislation to make it an offence for anyone to act as a midwife without being registered.
He also suggested that midwives be required to report the intention of a mother to deliver at home where the pregnancy involved complications, including a breech delivery or twins. South Australian Health Minister John Hill and federal Health Minister Tanya Plibersek have agreed to consider the recommendations.
The ACM supported the coroner's calls for all midwives to be registered under national law, as a way of ensuring accountability and safety. But it was disappointed greater emphasis was not placed on ways to prevent tragedies such as the three investigated deaths.
The college said it had grave concerns over the recommendation to report women who wanted a homebirth where there were risks involved, fearing it would push some women underground and make them determined not to engage with health services or support of any kind.
In his final submissions at the inquest, counsel for Ms Barrett, Mark Twiggs, made similar arguments that women who chose to give birth at home shouldn't be considered uneducated or naive.
"They have studied and made a choice and they should always have that free choice," he said, adding that more regulation surrounding homebirths would take away that choice.
"They need help, but heavy regulation is going to push these people underground."
Arguments against homebirth
In his evidence, the then-South Australian president of the Australian Medical Association, Andrew Lavender, said in some cases the risks to the baby weren't properly taken into account, and the focus appeared to be on the need to enhance the experience of the mother.
He also said there was a small group in the community whose support for homebirthing had taken on an almost "religious mantra".
Even further opposed to homebirthing was the Royal Australian and New Zealand College of Obstetricians and Gynaecologists. Its 2009 statement, presented to the inquest, asserted that there was an unacceptably high rate of adverse outcomes associated with homebirths.
In his findings, Mr Schapel said that, in short, the college "did not support homebirths in any circumstances, even low-risk births".
The coroner said the deaths of Tate, Jahli and Tully highlighted the divide between the supporters and the critics of homebirths, especially where there were complications involved.
"It is said that in the context of homebirthing the management of these risks is unacceptably difficult," Mr Schapel said.
"An opposing philosophy involves the notion that, although no person wants to see their unborn child die, the mother has a complete and unfettered choice of venue of birth. Underpinning this philosophy is the seemingly unshakeable dogma that an adverse outcome in the homebirth setting would inevitably have occurred in a hospital setting in any event."
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