2012/11: Should Australian mothers be discouraged from home births?

What they said...
'Planned home birth for low risk women ... using certified professional midwives was associated with lower rates of medical intervention but similar ... neonatal mortality to that of low risk hospital births....'
Johnson and Daviss 2005 study of 5,000 United States and Canadian women delivered at home by a midwife

'The AMA does not support home birth because of the safety concerns for mother and baby'
Dr Andrew Pesce, the president of the Australian Medical Association (AMA)

The issue at a glance
On June 5, 2012, the South Australian Deputy State Coroner, Anthony Schapel, handed down his findings into the deaths of three babies following complicated homebirths. He recommended all midwives should be registered and those who are not, but continue to perform midwifery duties, should face criminal sanction.
Mr Schapel also asked South Australian Health Minister John Hill to consider making health workers duty-bound to report intended homebirths that have an 'enhanced risk' of complication, including the birth of twins or breech births, to the Health Department. A senior obstetrician would then counsel the parents about the associated risks.
The Australian Medical Association, which is opposed to home birth, has welcomed the recommendations as have others who are concerned about the risks that home birthing cam pose to the health of child and mother.
Supporters of home birth have argued that the South Australian coroner's recommendations will either deny pregnant women the freedom of choice they should be able to exercise, or drive home birth underground where it is more dangerous because detached from any sort of medical support system.

Background
A home birth in developed countries usually takes place in a residence and not in a clinical setting such as a hospital or birth centre. Natural childbirth methods are normally used and the birth is usually attended by a midwife or lay attendant with expertise in managing home births.
Women with access to high-quality medical care may choose home birth because they prefer the intimacy of a home and family-centred experience or desire to avoid the medically-centred experience typical of a hospital or clinical setting. Professionals attending home births can be obstetricians, certified midwives or doulas.
Home birth was, until the advent of modern medicine, the only method of delivery. In developing countries, where women may not be able to afford medical care or it may not be accessible to them, a home birth may be the only option available, and the woman may or may not be assisted by a professional attendant of any kind.
The evidence regarding safety is difficult to interpret. The United Kingdom National Institute for Health and Clinical Excellence reports that mortality in labour or childbirth for booked home births, regardless of their eventual place of birth, is the same as, or higher than for birth booked in obstetric units. The American College of Obstetricians and Gynaecologists advises that 'although the absolute risk may be low, planned home birth is associated with a twofold to threefold increased risk of neonatal death when compared with planned hospital birth.'
A prior caesarean delivery significantly increases the risk of uterine rupture and other dangerous complications and women wishing to attempt a vaginal birth after caesarean are advised do so only in a hospital with ready access to emergency care. Due to a greater risk of peri natal death, the American College of Obstetricians and Gynaecologists advises women who are post term (greater than 42 weeks gestation), carrying twins, or have a breech presentation not to attempt home birth.
A large 2009 study reported that, in the Netherlands, planned home birth led by a midwife at onset of labour 'does not increase the risks of peri natal mortality and severe peri natal morbidity among low-risk women, provided the maternity care system facilitates this choice through the availability of well-trained midwives and through a good transportation and referral system.'

International trends regarding home birth
In many developed countries, home birth declined rapidly over the 20th century. In the United States home birth declined from 50% in 1938 to fewer than 1% in 1955; in the United Kingdom a similar but slower trend happened with approximately 80% of births occurring at home in the 1920s and only 1% in 1991. In Japan the change in birth location happened much later, but much faster: home birth was at 95% in 1950, but only 1.2% in 1975.[11]
Midwifery, the practice supporting a natural approach to birth, showed a revival in the United States during the 1970s. However, although there was a steep increase in midwife-attended births between 1975 to 2002 (from less than 1.0% to 8.1%), most of these births occurred in the hospital and the United States rate of out-of-hospital birth has remained steady at 1% of all births since 1989 with 27.3% of these in a free-standing birth centre and 65.4% in a residence. Hence, the actual rate of home birth in the United States has remained remarkably low (0.65%) over the past twenty years.[13]
Home birth in the United Kingdom has also received some media attention over the past few years as there has been a movement, notably in Wales, to increase home birth rates to 10% by 2007. Between 2005 to 2006, there was an increase of 16% of home birth rates in Wales, but the total home Welsh birth rate is still 3% (double the national rate) and in some other counties of Great Britain the home birth rate under 1%.
In the Netherlands, in 1965, two-thirds of Dutch births took place at home, but currently that figure has dropped to less than a third, about 30%
In Australia, birth at home has fallen steadily over the years and is currently 0.3%, ranging from nearly 1% in the Northern Territory to 0.1% in Queensland. The New Zealand rate for births at home is nearly three times Australia's with a rate of 2.5% and increasing.

The legal and funding situation in Australia
The 2009 Federal Budget provided additional funds to Medicare to allow more midwives to work as private practitioners, allow midwives to prescribe medication under the Medicare Benefits Schedule, and assist them with medical indemnity insurance. However, this plan only covers hospital births. There are no current plans to extend Medicare and PBS funding to home birth services in Australia.
As of July 2010, all health professionals must show proof of liability insurance. Midwives who attend home births will be excluded from the indemnity requirement for two years while the government seeks to make affordable insurance available.

Internet information
Homebirth Australia is an advocacy group promoting the right of Australian women to be able to access home birth.
The group's internet site can be found at http://www.homebirthaustralia.org/who-homebirth-australia

In 1996 the British Medical Journal (BMJ) published a study of the outcomes of planned home and planned hospital births in low risk pregnancies using midwives in The Netherlands. The study concluded the outcome of planned home births is at least as good as that of planned hospital births in women at low risk receiving midwifery care in the Netherlands.
An abstract of this study and these findings can be found at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2352715/
The study can be read in full as a pdf at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2352715/pdf/bmj00569-0041.pdf
(Please note, you will need to scroll down about half way through the opening page to find the relevant study.)

In 2005 The British Medical Journal (BMJ) published the findings of a study by Kenneth C Johnson and Betty-Anne Daviss titled 'Outcomes of planned home births with certified midwives: large prospective study in North America'
The study concluded 'Planned home birth for low risk women in North America using certified professional midwives was associated with lower rates of medical intervention but similar ... neonatal mortality to that of low risk hospital births in the United States.'
The full text of the article outlining this study can be found at http://www.commonwealthmidwives.org/pdfs/bmj%20study.pdf

On July 4, 2007, the South Australian Health Department released its 'Policy for
Planned Birth at Home in South Australia'. The full text of this document can be found at http://www.nmh.uts.edu.au/cmcfh/research/policy.pdf

On January 17, 2010, the Australian Medical Association (AMA) published a report drawing the public's attention to a recent statistical study pointing the risks associated with home birth. The AMA does not support the practice.
The full text of the report can be found at http://ama.com.au/node/5275

On July 9, 2010, The Herald Sun published an opinion piece by Susie O'Brien commenting on the risks associated with home birth and focusing on the experiences of Australian entertainer Dannii Minogue whose attempted home birth had recently had to be completed in a hospital setting.
The full text of this report can be found at http://www.heraldsun.com.au/opinion/home-birth-not-worth-risk-dannii/story-e6frfhqf-1225889562865

On July 9, 2010, The Border Mail published a report by John Conroy in which the claim is made that the successful birth of Dannii Minogue's son shows the safety of home birth as when something unexpected occurs the delivery can be concluded at a hospital.
The full text of this article can be found at http://www.bordermail.com.au/story/52032/dannii-showed-home-birth-safe/

On July 31, 2010, the British medical journal, The Lancet, published an editorial warning against the dangers of home birth following its publication of a study indicating the risks associated with home birthing.
The full text of the editorial can be found at http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2810%2961165-8/fulltext

In 2011 Australian College of Midwives published a Homebirth Literature Review. The review looks at the safety findings of a wide range of studies conducted between 1995 and 2011. The review concludes 'It seems evident from the literature that planned home birth is a safe option for women who are at low risk of complications and who receive care from qualified attendants with adequate access to support, advice, referral and transfer mechanisms.'
The full text of this review can be found at http://www.midwives.org.au/lib/pdf/documents/Homebirth_Literature.pdf

On March 29, 2011, the online academic opinion site, The Conversation, published a point of view by Maralyn Foureur, Professor of Midwifery at University of Technology, Sydney. Professor Foureur argues that hospitals need to supply flexible, well-equipped birthing centres to help meet the needs of women who want a less clinical option.
The full text of this comment can be found at http://theconversation.edu.au/hospital-birth-units-make-stress-heads-out-of-mums-460

On November 11, 2011, the online media commentary site Crikey published a comment by Dr Andrew Pesce, a Sydney obstetrician and gynaecologist and former president of the Australian Medical Association, defending a review of planned home births in South Australia between 1991 and 2006 which indicated a statistically significant increase in the numbers of babies dying following a planned home birth.
The full text of Dr Pesce's comment can be found at http://blogs.crikey.com.au/croakey/2011/11/11/concerns-continue-about-unsafe-home-birth-practices-dr-andrew-pesce/

On November 14, 2011, the online media commentary site Crikey published a comment by Hannah Dahlen, Associate Professor of Midwifery, University of Western Sydney, and national media spokesperson for the Australian College of Midwives. Dahlen takes issue with Dr Andrew Pesce, a Sydney obstetrician and gynaecologist and former president of the Australian Medical Association in his opposition to home birthing and suggests the need for a more wide-ranging debate whose ultimate goal should be making all births - whether they take place at home or in hospitals - as safe as possible.
The full text of this comment can be found at http://blogs.crikey.com.au/croakey/2011/11/14/home-births-its-time-to-broaden-the-focus-of-the-debate/

On January 31, 2012, The Punch published an opinion piece by Tory Shepherd titled 'Home births are prone to many complications'. Shepherd argues that pregnant women need to be able to make an informed choice about the type of birth that is best for them and their children; however, she is concerned about the misinformation minimising the risks associated with home birth.
The full text of this opinion can be found at http://www.thepunch.com.au/articles/home-births-are-prone-to-many-complications/

On January 31, 2012, Herald Sun commentator Susie O'Brien posted a blog comment titled 'Homebirthing is just too risky'. The post attracted 189 comments.
O'Brien's opinion and the posted responses can be accessed at http://blogs.news.com.au/heraldsun/seewhatsusiesays/index.php/heraldsun/comments/homebirthing_is_just_too_risky/

On March 15, 2012, The Atlantic published a comment by Adam Wolfberg, an obstetrician specializing in high-risk pregnancies at Tufts Medical Center in Boston and an assistant professor of obstetrics and gynaecology at Tufts University School of Medicine. Professor Wolfberg argues that all births should take place in a hospital. The full text of this article can be found at http://www.theatlantic.com/health/archive/2012/03/the-case-for-hospital-births/254304/

On May 29, 2012, the online academic opinion site, The Conversation, published a point of view by Hannah Dahlen, Associate Professor of Midwifery at University of Western Sydney. The comment is titled 'Pushing home birth underground raises safety concerns'. Dahlen argues that making supported home birth more difficult will simply encourage those who wish to give birth at home to do so at greater risk.
The full text of this opinion piece can be found at http://theconversation.edu.au/pushing-home-birth-underground-raises-safety-concerns-6825

On June 25, 2012, the online academic opinion site, The Conversation, published a point of view by Meredith McIntyre, Senior Lecturer in Midwifery at Monash University. The comment concludes, 'There's now sufficient international evidence to support the conclusion that there's no difference in the safety of healthy mothers who give birth in hospital or at home when they are in the care of qualified midwives working within rigorous guidelines.'
The full text can be found at http://theconversation.edu.au/home-birth-is-a-viable-and-safe-option-for-most-women-6885

On June 28, 2012, a New South Wales coroner found that found a Sydney home birth contributed "unnecessarily" to the death of a baby girl and stated that expectant parents need to be aware of the dangers of bringing a child into the world without medical help. The birth occurred without the aid of a midwife.
A report on the coroner's findings was published in The Telegraph and can be accessed at http://www.dailytelegraph.com.au/business/breaking-news/baby-died-after-cord-entanglement-coroner/story-e6freuz0-1226410986230

Arguments in favour of home birth
1. There is little difference in the mortality or morbidity (disease) rate between home births and those that take place in a clinical setting
Data regarding the relative safety of home births compared to those which take place in a clinical setting is difficult to interpret in part because at least in Australia the number of mothers availing themselves of the home birth option is so small (approximately .3 per cent).
However, a recent study conducted in Canada suggests that home births need be no more hazardous than those which occur in a hospital or birthing centre. The study was released out of Ontario and published in the September 2009 issue of Birth journal. It examined the outcomes associated with planned home-birth compared to planned hospital birth, facilitated by midwives, in Ontario over a three-year period (from 2003-2006). The authors found that there is no difference between planned home and hospital birth when comparing peri natal and neonatal mortality rates (or maternal mortality rates, either).
For the baby, the rate of peri natal (relating to the period immediately before and after birth) and neonatal mortality was very low (one in a thousand) for both groups, and no difference was shown between groups in peri natal and neonatal mortality or serious morbidity (disease). No maternal deaths were reported in either setting. All measures of serious maternal morbidity were lower in the planned home birth group as were rates for all interventions including caesarean section.
A longitudinal study conducted in Great Britain which compared the results for home births and those which took place in clinical settings in 1958 and 1970 came to similar conclusions, except it suggests that outcomes were better.
The study concluded, 'Analyses of the published results of national surveys and specific studies, as well as of the official stillbirth statistics, consistently point to the conclusion that peri natal mortality is significantly higher in consultant obstetric hospitals than in general practitioner maternity units or at home, even after allowance has been made for the greater proportion of births in hospital at high pre-delivery risk.'

2. Home birth has been shown to be an advantageous experience in some countries
It has been argued that the home birth experience has many advantages over that of giving birth in a clinical setting and that, in countries where it is an accepted option, the outcomes for mother and child can be better than for those where birth occurs in a clinical setting.
Among the advantages claimed for home birth is that it reduces the rate of what many regard as unnecessary medical interventions. Primary among these interventions is caesarean section, the incidence of which, critics argue, is actually increased by medical management of labour which can disrupt the natural birthing process, thus making a surgical procedure necessary.
Sarah Buckley (MD) claimed in her 2009 publication 'Gentle Birth, Gentle Mothering: A Doctor's Guide to Natural Childbirth and Gentle Early Parenting Choices' that 'Some of the techniques used [in a clinical setting] are painful or uncomfortable, most involve some transgression of bodily or social boundaries, and almost all techniques are performed by people who are essentially strangers to the woman herself. All of these factors are as disruptive to pregnant and birthing women as they would be to any other labouring mammal - with which we share the majority of our hormonal orchestration in labour and birth.'
A 2008 survey of 2,792 mothers conducted through the Fairfax Essential Baby website highlighted the traumatic and unsatisfactory experiences of many Australian women giving birth in an overstretched clinical system. A particularly alienating feature of this system was described as its "one-size-fits-all" service, which dismisses the special needs of individual women. Such experiences fuel women's desire for home birthing.
In the Netherlands there is widespread acceptance of home birthing and approximately one in three births occur at home under the care of a midwife. A 1996 study of the outcomes of 1836 home births compared to those in a clinical setting over the same period found that for women not giving birth for the first time, peri natal outcomes were significantly better for those who gave birth at home than for those who did so in a clinical setting. For first time mothers, managed for risk factors, the outcome was no different to that for women who had selected a clinical setting.
A landmark study by Johnson and Daviss in 2005 examined over 5,000 United States and Canadian women intending to deliver at home under midwife. They found equivalent peri natal mortality to hospital birth, but with rates of intervention that were up to ten times lower, compared with low-risk women birthing in a hospital. The rates of induction, IV drip, episiotomy, and forceps were each less than 10% at home, and only 3.7% of women required a caesarean.
The study concluded, 'Planned home birth for low risk women in North America using certified professional midwives was associated with lower rates of medical intervention but similar intrapartum and neonatal mortality to that of low risk hospital births in the United States.'


3. It should be up to the mother to determine where the birth of her child occurs
Under Australian law, women have the right to determine what, if any, medical treatments they will be subject to. This includes a right to determine the conditions under which they will give birth.
The South Australian government policy on giving birth at home declares 'The woman's wishes for childbirth should be respected within the framework of safety and clinical guidelines. The autonomy of pregnant women is protected in both law and jurisprudence, and it is the duty of health professionals to accommodate that autonomy in as safe a manner as possible for both woman and baby.'
The United Nations has stated that the human rights of women include their right to have control over, and to decide freely and responsibly on, all matters related to their sexual and reproductive health.
Despite declining rates of infant and maternal death, there has been a long-term trend toward increased maternal dissatisfaction with giving birth in a clinical setting. An Australian survey conducted in 2004 found that the main sources of dissatisfaction with birth were the mothers' perceptions of a lack of involvement in decision-making, having 'obstetric interventions' and 'unhelpful caregivers'.
With one in four children being born by caesarean section, many women, their families, midwives and some doctors are seeking a more 'natural' environment for uncomplicated births. Increasingly, emphasis has been placed on the quality of a woman's birth experience. In this climate, supporters of home birth argue that the home birthing option should be more readily available to Australian mothers.

4. Home birth planning should be undertaken and only women with problematic pregnancies should be discouraged from home birthing
There are known circumstances that indicate that a home birth represents an unacceptable risk. Supporters of home birth argue that rather than discouraging all pregnant women from contemplating home birth, each state should have guidelines which clearly stipulate which pregnancies are likely to be safely delivered at home and how this can be achieved.
Australian data have shown unacceptably high risks for the baby from planned home birth for twin pregnancies, pregnancies outside term (37 to 41 weeks) and breech presentations all of which contraindicate home birth. Planned home births, when
meconium is present, also have a higher rate of meconium aspiration than do health unit births.
South Australia has guidelines which state a planned birth at home should be attended by two qualified practitioners, one of whom should be a registered midwife experienced in home births. Appropriate experience with home births should include having participated in at least five home births under supervision.
The qualified practitioner will conduct a careful screening to ensure that the woman's condition is suitable for giving birth at home, that she has no foetal or maternal contraindications, and that she has the capacity to make informed consent.
The guidelines also indicate which domestic circumstances should preclude home birth. These are more than 30 minutes travelling time from a support health unit or hospital; lack of easy access (in case transfer during labour is warranted); lack of clean running water and/or electricity; lack of cleanliness and hygiene; domestic violence; recreational drug use.
It is also recommended that women planning to have a home birth be advised to have the minimum range of tests recommended as part of antenatal care for all pregnant women. The qualified practitioner must have direct access to the results of the tests. Other tests may need to be done depending on the woman's clinical circumstances.
The woman must be provided with an SA Pregnancy Record that must be completed at each and all visits to a health professional.
All women must be offered appropriate counselling on and screening for foetal anomalies. The woman should be advised to have a general medical examination from a general practitioner of her choice before deciding on a home birth to eliminate previously undiagnosed disorders; this assessment should occur early in pregnancy.
It is advisable that a woman intending to have a home birth is booked with a health unit in early pregnancy. In the event of complications during pregnancy, labour, birth or the postnatal period, transfer to a health unit may be necessary.

5. Restricting midwives' access to home births makes it more difficult for women to exercise a free choice
It has been claimed that the fact that there is no Medicare rebate for home birth and virtually no private health insurance rebates are significant impediments to women choosing home birth.
Australia has a national midwifery register. Midwives must be insured to join the register - but private insurers no longer provide cover for births at home and the Federal Government has refused to subsidise professional indemnity for home birth claims. This is not an issue for hospital-run home birthing programs (where midwives are employees of the hospital); however, it is significant for independent midwives and has contributed to a large decline in the last two years of the number of independent midwives who are willing to attend home births. Another obstacle is that mothers cannot claim on Medicare for midwifery expenses where a birth occurs at home. Women and their partners pay around $3,000 to $6,000 for a midwife's care.
Justine Caines, the secretary of Homebirth Australia, has claimed these laws effectively stop registered midwives legally attending home births. Caines has criticised the federal government's position in a submission she made to a Senate inquiry into the new legislation governing midwives and their Medicare coverage.
Ms Caines states, 'The national registration requirement is absolutely appropriate. What is not appropriate has been the [federal government's] response [via its health minister] to say "I will enable the funding of one-to-one midwifery care through Medicare for midwives who care for women birthing in the hospital system, but I won't do it for home birth."'
Given that most international studies demonstrating the safety of home births have been conducted in a context in which qualified midwives were in attendance, supporters of home births maintain that not funding midwives, through Medicare, to attend home births places at risk those mothers who choose home births. It has also been argued that denying Medicare funding in this way reduces the freedom of choice of those mothers not prepared to proceed with a home birth without a midwife present.

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.'

Further implications
The debate over the relative safety of home births is unlikely to be readily resolved. There are disputes about terminology, sample size and other considerations which potentially cloud the interpretation of data making it very difficult for the relatively uninformed to judge the safety of home births.
However, home births would definitely be less dangerous if strict guidelines were followed, discouraging problematic candidates from taking this option.
Excluding pregnant women likely to have difficult births from home birthing requires better education rather than legislation. All Australian states have variations of the Victorian Medical Treatment Act which require the informed consent of the patient before a medical procedure can be administered. Therefore, seeking to mandate that certain types of pregnancy require a hospital delivery would be extremely difficult.
It would be better if, as part of all women's antenatal care, they were made aware of what pregnancies might be safely delivered at home and which would be better delivered in a clinical setting. Information delivered clearly and without prejudice is the best way to ensure that a woman considering a home birth knows whether this is a good option for her and her child.
Another area of concern is access to a midwife. All international and Australian studies indicate that having a qualified midwife at a home birth dramatically improves the likelihood of a positive outcome for mother and child. Australia has introduced a national registration procedure for all practicing midwives. This appears a sensible measure, designed to guarantee the quality of help supplied by midwives. However, to be registered midwives have to be insured and most insurance companies will not ensure midwives practising outside a hospital setting. The federal government has similarly refused to indemnify midwives delivering babies in their mothers' homes. The federal government has also decided that mothers cannot claim a Medicare rebate for the services of a midwife at a home birth.
This means that mothers who wish to deliver at home are now more likely to do so without a midwife. This greatly increases the risk to both them and their unborn children.
The Government may actually be attempting to discourage women from taking up the home birth option because of safety concerns; however, in making it very difficult for home birthing parents to secure the services of a midwife the unintended consequence will be that those who do go ahead with a home birth will be at a greater risk than they were formerly.

Newspaper items used in the compilation of this issue outline
AUST, November 16, 2011, page 9, news item by Sue Dunlevy, `Higher risk of babies dying in home births'.
http://www.theaustralian.com.au/news/health-science/higher-risk-of-babies-dying-in-home-births/story-e6frg8y6-1226196164708

AGE, December 15, 2011, page 5, news item by A Lowe, `Earlier intervention in delivery could have saved baby, says coroner'.
http://www.theage.com.au/victoria/earlier-intervention-in-pregnancy-could-have-saved-baby-says-coroner-20111214-1ouyw.html

AGE, December 21, 2011, page 5, news item by A Lowe, `Coroner to probe home birth death'.
http://www.theage.com.au/victoria/coroner-to-probe-home-birth-death-20111220-1p3zx.html

H/SUN, February 2, 2012, page 14, comment by Miranda Devine, `Home births a risk'.
http://www.heraldsun.com.au/opinion/home-births-are-still-risky/story-e6frfhqf-1226260028122

H/SUN, January 31, 2012, page 1, news item by Lucie van den Berg, `Home birth tragedy'.
http://www.news.com.au/national/mum-dies-in-home-birth-tragedy/story-e6frfkvr-1226257823611

AGE, January 28, 2012, page 14, news item, `Home births gaining popularity in the US'.
http://www.theage.com.au/world/home-births-gaining-popularity-in-the-us-20120127-1qlom.html

AGE, February 11, 29012, page 6, news item by Kate Hagan, `Coroner warns of home-birth risks'.
http://www.theage.com.au/victoria/warning-over-home-births-20120210-1smf9.html

AGE, March 3, 2012, page 7, news item (photo) by Julia Medew, `Home birth risks draw call for hospital backup funding'.
http://www.theage.com.au/victoria/home-birth-risks-draw-call-for-hospital-backup-funding-20120302-1u8ft.html

AUST, June 7, 2012, page 12, news item by Rebecca Puddy, `Newborn deaths all needless: coroner' (ref to home births inquest).
http://www.theaustralian.com.au/national-affairs/state-politics/newborn-deaths-all-needless-coroner/story-e6frgczx-1226386772065

AUST, June 8, 2012, page 3, news item by Rebecca Puddy, `Midwives loophole to be shut'.
http://www.theaustralian.com.au/national-affairs/health/midwives-loophole-to-be-shut/story-fn59nokw-1226388127471