Right: the "ideal" of home birth is illustrated in this photo, but recent deaths of babies and mothers have led to a coroner branding home birthing as unsafe.
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Arguments against home births
1. Home births have a greater mortality rate for unborn babies and neonates than births in clinical settings
Critics of home births argue that they pose a higher mortality rate for babies. A study released in 2010 confirmed the high safety risks and higher death rates associated with home births in Australia compared to hospital births.
The study of home and hospital births in South Australia between 1991 and 2006, published in the Medical Journal of Australia, shows that planned home births had a sevenfold higher risk of intrapartum death (occurring during delivery) and a 27-fold higher risk of death from intrapartum asphyxia (loss of oxygen supply during delivery) than planned hospital births. This was despite the finding that women with recognised risk factors, such as null parity, Indigenous status, lower occupational status, and residence outside metropolitan areas, were less likely to plan a home birth. That is, death rates were higher despite the fact that the maternal population under consideration had lower rates of other risk factors normally associated with death in childbirth.
Dr Andrew Pesce, the president of the Australian Medical Association (AMA), has claimed that the study sends a strong signal to the Government that any policy decisions around maternity care must be evidence-based.
Dr Pesce stated, 'The AMA does not support home birth because of the safety concerns for mother and baby, and this latest independent study backs our concerns.'
There have been a number of recent coroners' findings which have similarly stressed the dangers of home birth. On June 28, 2012, Deputy New South Wales's state coroner, Scott Mitchell, concluded that in the early hours of March 27, 2009, a girl died of suffocation from a cord entanglement during delivery in an inflatable pool.
The coroner further concluded that the child's father and a family friend both present at the birth 'lacked the necessary medical, nursing or midwifery qualifications to deal with the complications'. Mr Mitchell stated, 'There's a public interest in ensuring the public knows, particularly the vulnerable members of the public know, this risk exists.'
In June 2012 a South Australian coroner found that three babies who died during or after home births would have survived if born in hospital by caesarean section. All three births involved complications, one was a large baby, one a breech birth and the third was one of twins.
2. There is inadequate regulation of those who assist at home births
It has been claimed that current regulations regarding home birth do not ensure that the birth is managed by qualified midwives.
Concern has been expressed that in most states it is possible to plan to give birth at home without making provision for the assistance of a qualified midwife.
Following the death of a child, home delivered in 2009, without the aid of a midwife, the New South Wales coroner concluded that the unassisted birth was like driving blindfolded. The coroner stated, 'It's a bit like getting into a car. It's possible the steering will fail, but the chances of survival are better than if you get into the car blindfolded.'
Medical experts told the inquest that if a qualified midwife had attended the birth, the child's chance of life would have been much more favourable. The coroner concluded, 'As it was, her mother chose to rely on her own socio-political views about birthing and [the child's] chance of life was deferred to that decision.'
It is also possible for unregistered midwives to assist at home deliveries. In 2010 health practitioner regulation laws were nationally developed and agreed upon by the Australian Health Ministers Council. However, there is a loophole in the regulations which makes it possible to practise midwifery without registration and avoid prosecution.
A South Australian state coroner has called for the prosecution of unregistered midwives following an inquest into what he judged were the 'preventable' deaths of three babies during homebirths. The babies died during or soon after three separate deliveries, each attended by the same former midwife, who claimed that she had attended the births as a 'birth advocate' not a midwife. The claim was rejected by the coroner who judged that regardless of her change in title, she continued to perform the clinical tasks of a midwife. The coroner found that the midwife had withdrawn her registration to dodge the national safety guidelines.
3. If something goes wrong there is often insufficient time to get expert assistance
It has been claimed that even when a mother and unborn child have been judged safe for a home birth, it is still possible that unforeseen complications can arise that need more than the assistance of a midwife. Where such emergencies occur, the distance between where the home birth is occurring and the nearest available hospital facility can prove fatal.
In an opinion piece published in The Herald Sun on January 31, 2012, commentator Susie O'Brien stated, 'Around 700 women across Australia give birth at home and in my opinion that's 700 too many. The problem is that fit, healthy women can still have traumatic, problematic births where things go wrong, and the time it takes to get to an emergency ward can be the difference between life and death.'
Explaining the extent of the threat, O'Brien further stated, 'Up to half of all first-time mothers attempting a home birth have to be transferred to hospital due to complications, according to Dr Ted Weaver, president of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists.'
It has been noted that home birth problems are even more likely to have dire consequences in rural areas where the distances to be travelled to an appropriately equipped clinical birthing centre are longer.
An Australian College of Midwives literature review stated, 'Maternity services in rural and remote areas of Australia have particular problems. The National Rural Health Alliance Inc. (NRHA) released a report (2006) outlining the particular difficulties in these areas of Australia. The closure of many regional maternity units often necessitates women in remote areas to travel great distances to hospital...'
Similar problems occur in New Zealand. 'The Midwifery and Maternity Providers Organisation (2008) provide annual reports on quality and safety relating to maternal and neonatal outcomes.
This report stated 7.4 per cent of babies were born at home, with almost half of all homebirths occurring in rural or remote areas. Transfer rates to hospital from home were 22.9%, which is higher than most reported international rates, and may reflect issues with distance to hospital and preventive strategies.'
Critics of home birth argue that the frequency with which such births require hospital intervention make these births inherently dangerous, as the distance between the home birth site and the hospital is often too great to allow treatment to be given in time.
Comparisons have been made with the system operating in the Netherlands where the low death rate associated with home births has been linked to the country's capacity to quickly transfer to a hospital births that go wrong at home.
On July 6, 2012, The XXFactor published an opinion piece by y Lindsay Beyerstein in which she sought to explain why home birth was so much more successful in the Netherlands than in many other apparently comparable counties. Beyerstein stated, 'Unlike the United States [or Australia], the Netherlands is a small, densely populated country where a large percentage of residents live close to a hospital. In Holland there is an advanced transfer system in place to get labouring women to a hospital should things go wrong at home.' Critics of home birth argue that the distances that often have to be travelled to get a woman in labour to hospital and the lack of an integrated system linking the mid-wife attended home birth to a clinical birthing centre in the event of an emergency make home birthing in countries like Australia inherently more dangerous.
4. The wishes of the mother should not take precedence over the safety of the baby
Critics of home birth argue that the preferences of the mother should not be allowed to put the life of a child at risk.
At a recent coronial hearing into the death of a child during a home birth, a doctor testified that the mother had indicated that she was willing to put her child's life at risk in order to have a delivery in her own home.
The doctor stated she had met the baby's mother when she had presented at hospital with gastro. The doctor said she had warned the mother about the risks of delivering twins in a home birth but that the expectant mother had made up her mind.
The doctor testified, 'She [the mother] said she did understand there was a possibility either twin might die, but she was willing to accept that risk.'
Critics of home birth argue this is not a choice that the mother should be able to make as what is for her merely a preference as to the manner in which birth occurs, could become for the child a question of life and death. They argue that the birthing preferences of the mother should not be allowed to endanger the life of the child.
In an opinion piece published in The Herald Sun, Susie O'Brien stated, 'To expectant mothers thinking of getting out the incense sticks and the tambourine in preparation for a home birth, I would simply say: it's one thing to risk your own life, but it's an altogether different thing to be risking the life of your unborn baby.'
Dr James Harvey, an obstetrician practising in Port Adelaide, South Australia, has asked, 'Morally, doesn't the mother have a duty of care to avoid putting her child at increased risk? The unborn child has no voice; if its mother will not stand up for its best interests, who will? Should society act and be a voice for these children?'
An editorial published in The Lancet on July 31, 2010, stated, 'Women have the right to choose how and where to give birth, but they do not have the right to put their baby at risk. There are competing interests that need to be weighed carefully.'
5. It is possible to have a low intervention birth in a clinical setting
Some critics of home birth argue that the case against hospital deliveries has been exaggerated. They claim that although the intervention rate is far higher in a hospital setting, it is possible to give birth in a hospital in a way that respects the mother's autonomy and only results in a caesarean or other intervention should such procedures be strictly necessary. It has been noted that birthing centres attached to hospitals can provide congenial, relatively non-clinical settings for the mothers giving birth, while at the same time allowing easy access to advanced medical technology, should such intervention be required.
Susie O'Brien noted in an opinion piece published in The Herald Sun, 'I appreciate many women may want a natural, low-intervention birth. But this can be achieved in birthing centres attached to hospitals.
The same point has been made more aggressively by Sarrah Le Marquand in the parenting magazine Mamamia in an opinion piece published on March 14, 2012. Sarrah Le Marquand states, 'Scenarios peddled by home-birth lobbyists, wherein hospital patients are routinely bullied by unsympathetic surgeons, sit at odds with the dominant presence of midwives and the happy medium of birthing centres...
Despite the feel good platitudes parroted by home-birth champions, women in this country already enjoy a good deal of choice regarding where and how to deliver. And rightfully so.' Le Marquand goes on to argue that hospitals offer women enough choice, without them having to take up the potentially hazardous option of home birth.
Some hospitals provide what have claimed are virtually ideal circumstances under which to give birth. Maralyn Foureur, Professor of Midwifery at University of Technology, Sydney has praised the new award-winning Toowoomba Birth Centre.
Foureur noted, 'The design principles of low stress birth spaces were used as the basis of their design. This included the use of noise reducing building materials so that each room is as sound proofed as possible, flexible lighting with adjustable lighting levels, comfortable domestic furniture, large, low beds and deep, wide, circular baths in each room.'
Foureur went on to describe, 'There is ample room to walk around in privacy or to sit, stand, kneel or lie down. There is also a kitchen for preparing food and drink during the many hours of labour, storage for the belongings of the woman and her family or birth supporters, and a domestic feel to the interior d‚cor.'