Home birth and the National Australian Maternity Services Review: too hot to handle?

Background

In February 2009 the Improving Maternity Services in Australia – The Report of the Maternity Services Review (MSR) was released, with the personal stories of women making up 407 of the more than 900 submissions received. A significant proportion (53%) of the women were said to have had personal experience with homebirth. Little information is provided on what was said about homebirth in these submissions and the decision by the MSR not to include homebirth in the funding and insurance reforms being proposed is at odds with the apparent demand for this option of care.

Method

Data for this study comprised 832 submissions to the MSR that are publicly available on the Commonwealth of Australia Department of Health and Aging website. All 832 submissions were downloaded, coded and then entered into NVivo. Content analysis was used to analyse the data that related to homebirth.

Findings

450 of the submissions were from consumers of maternity services (54%). Four hundred and seventy (60%) of the submissions mentioned homebirth. Overall there were 715 references to home birth in the submissions. The submissions mentioning homebirth most commonly discussed the ‘Benefits’ and ‘Barriers’ in accessing this option of care. Benefits to the baby, mother and family were described, along with the benefits obtained from having a midwife at the birth, receiving continuity of care and having a good birth experience. Barriers were described as not having access to a midwife, no funding, no insurance and lack of clinical privileging for midwives.

Conclusion

Many positive recommendations have come from the MSR, however the decision to exclude homebirth from these reforms is perplexing considering the large number of submissions describing the benefits of and barriers to homebirth in Australia. A concerning number of submissions discuss having had or having considered an unattended birth at home due to these barriers. Overall there is the belief that not enabling access to funded, insured homebirth in Australia is a violation of human rights. It appears that homebirth was considered by the MSR as ‘too hot to handle’ and by dismissing it as a minority issue the government sought to avoided dealing with homebirth as a ‘sensitive and controversial issue.’     

Birth centres and the national maternity services review: response to consumer demand or compromise?

Background

In February 2009 the Improving Maternity Services in Australia – The Report of the Maternity Services Review (MSR) was released and recommended improving women's access to and availability of birth centres. It was unclear if this was in response to an overwhelming request for birth centres in the submissions received by the commonwealth or a compromise for excluding homebirth from the maternity service reforms.

Aim

The aim of this paper was to examine what was said in the submissions to the MSR about birth centres.

Methods

Data for this study comprised 832 submissions to the MSR that are publicly available on the Commonwealth of Australia Department of Health and Ageing website. All 832 submissions were downloaded, and read for any mention of the words ‘birth centre’, ‘birth center’. Content analysis was used to categorise and report the data.

Results

Of the 832 submissions to the MSR 197 (24%) mentioned birth centres while 470 (60%) of the submissions mentioned homebirth. Only 31 (4%) of the submissions to the Maternity Review mentioned birth centres without mentioning home birth also. Most of the submissions emphasised that ‘everything should be on the menu’ when it came to place of birth and care provider. Reasons for choosing a birth centre were identified as: ‘the best compromise available, ‘the right and natural way’ and ‘the birth centre as safe’. Women had certain requirements of a birth centre that included: ‘continuity of carer’, ‘midwife led’, ‘a sanctum from medicalised care’, ‘resources to cope with demand’, ‘close to home’, and ‘flexible guidelines and admission criteria’. Women weighed up a series of requirements when deciding whether to give birth in a birth centre.

Discussion

The recommendation by the MSR to expand birth centres and ignore home birth is at odds with the strong view expressed that ‘everything should be on the menu’. The requirements women described of birth centre care are also at odds with current trends.

Conclusion

If there is to be an expansion of birth centres, service providers need to make sure that women's views are central to the design. Women will not cease having homebirths due to expanded birth centre options.     

Multiparous women's confidence to have a publicly-funded homebirth: a qualitative study

Background

Hospital birth is commonly thought to be a safer option than homebirth, despite many studies showing similar rates of safety for low risk mothers and babies when cared for by qualified midwives with systems of back-up in place. Recently in Australia, demand has led to the introduction of a small number of publicly-funded homebirth programs. Women's confidence in having a homebirth through a publicly-funded homebirth program in Australia has not yet been explored.

Aim

The aim of the study was to explore the reasons why multiparous women feel confident to have a homebirth within a publicly-funded model of care in Australia.

Methods

Ten multiparous English-speaking women who chose to have a homebirth with the St George Hospital Homebirth Program were interviewed in the postnatal period using semi-structured, open-ended questions. Interviews were transcribed, then a thematic analysis was undertaken.

Results

Women, having already experienced a normal birth, demonstrated a strong confidence in their ability to give birth at home and described a confidence in their bodies, their midwives, and the health system. Women weighed up the risks of homebirth through information they gathered and integration with their previous experience of birth, their family support and self-confidence.

Discussion

Women choosing publicly-funded homebirth display strong confidence in both themselves to give birth at home, and their belief in the health system's ability to cope with any complications that may arise.

Implications for practice

Many women may benefit from access to publicly-funded homebirth models of care. This should be further investigated.     

Not addressing the root cause: An analysis of submissions made to the South Australian Government on a Proposal to Protect Midwifery Practice

BackgroundReports of unregulated birth workers attending birth at home, with no registered midwife in attendance (freebirth), have become more frequent in Australia in recent years. A Coronial Inquiry (2012) into the deaths of three babies born at home in South Australia resulted in a call for legislation to restrict the practice of midwifery to registered midwives. A Proposal to Protect Midwifery Practice in South Australia was issued as a consultation paper in January 2013.AimTo report the views of those making a submission to the Proposal to Protect Midwifery Practice in South Australia.MethodsThirty submissions to the South Australian Government were downloaded, read and thematically analysed.FindingsTwenty-five (81%) submissions supported the legislation, 5 (16%) opposed it and 2 (6%) were neither for nor against. Support for the proposed legislation was strong, however the underlying root causes that have led to the rise of UBWs attending homebirth in Australia were not addressed. Recommendations called for all stakeholders to work with women to develop a better framework of care that respected and met their needs and choices whilst safeguarding maternal and neonatal health.ConclusionsThe Proposal to Protect Midwifery Practice may promote greater protection of midwifery practice however, Private Indemnity Insurance (PII), collaborative agreements and power struggles associated with the medical domination of childbirth continue to marginalise homebirth and prevent women from accessing the care they want and need. These unresolved issues represent the root causes for UBWs attending homebirth; hence the proposal is only a partial solution.     

Developing a Core Competency Model and Educational Framework for Primary Maternity Services: a national consensus approach

BackgroundAn appropriately educated and competent workforce is crucial to an effective health care system. The National Health Workforce Taskforce (now Health Workforce Australia) and the Maternity Services Inter-Jurisdictional Committee funded a project to develop Core Competencies and Educational Framework for Primary Maternity Services in Australia. These competencies recognise the interdisciplinary nature of maternity care in Australia where care is provided by general practitioners, obstetricians and midwives as well as other professionals.ParticipantsKey stakeholders from professional organisations and providers of services related to maternity care and consumers of services.MethodsA national consensus approach was undertaken using consultation processes with a Steering Committee, a wider Reference Group and public consultation.FindingsA national Core Competencies and Educational Framework for Primary Maternity Services in Australia was developed through an iterative process with a range of key stakeholders. There are a number of strategies that may assist in the integration of these into primary maternity service provider professional groups’ education and practice.ConclusionsThe Core Competencies and Educational Framework are based on an interprofessional approach to learning and primary maternity service practice. They have sought to value professional expertise and stimulate awareness and respect for the roles of all primary maternity service providers. The competencies and framework described in this paper are now a critical component of Australian maternity services as they are included in actions in the newly released National Maternity Services Plan and thus have relevance for all providers of Australian maternity services.     

Traditional birth attendants’ roles and homebirth choices in Ethiopia: A qualitative study

BackgroundIn Ethiopia, it is encouraged that labour and delivery care are performed under the observation of skilled/trained midwifery or medical professionals. However, 70% of all births occur outside the healthcare system under the care of unskilled birth attendants, family members, or without any assistance at all.ObjectiveThis study aimed to assess the reasons for choosing homebirth and the role of traditional birth attendants in Arba Minch Health and Demographic Surveillance Site.MethodA qualitative, exploratory study was carried out between May and June 2017. Twenty-nine semi-structured interviews were conducted with various respondent groups such as traditional birth attendants, pregnant women, skilled birth attendants, and health extension workers. Data were transcribed and for analysis, structured as per the participants’ responses, sorted and categorized as per the topic guide, and presented in narrative form.FindingsThe study revealed that traditional birth attendants are actively engaged in assisting homebirths in the selected area. It was also found that many women still prefer traditional birth attendants for childbirth assistance. Reasons for choosing homebirth included lack of transport to health care facilities, distance to health care facilities, lack of respectful care at health care facilities, and the friendliness of traditional birth attendants. Lack of formal partnerships between traditional birth attendants and the health system was also observed.ConclusionsThere is a need to incorporate traditional birth attendants as a link between healthcare facilities and pregnant women; thereby, improving respectful care at the healthcare facilities.     

Regulation of unregistered birth workers in Australia: Homebirth and public safety

Background

Australian midwives are regulated under the National Registration and Accreditation Scheme. Unregistered birth workers may provide midwifery services at homebirths without any regulatory oversight. To address this issue, several states have passed legislation enabling prohibition orders to be made (negative licensing) against unregistered health practitioners who fail to comply with a statutory code of conduct developed for those not covered by the National Scheme.

Inclusion and exclusion criteria for publicly-funded homebirth in Australia: A scoping review

BackgroundThere are fifteen publicly-funded homebirth programs currently operating in Australia. Suitability for these programs is determined by a series of inclusion and exclusion criteria.AimThe aim of this scoping review is to identify common inclusion and exclusion criteria for publicly-funded homebirth programs and other related factors that affect access to these programs.MethodsA Google search was conducted for publicly-funded homebirth programs listed on the National Publicly-funded Homebirth Consortium website. Public websites, documents, and policies were analysed to identify inclusion and exclusion criteria for these programs.FindingsEleven of the 15 publicly-funded homebirth programs mention the availability of homebirth on their health service website, with varying levels of information about the inclusion and exclusion criteria available. Two of the programs with no information on their health service website are covered by a state-wide guideline. Additional details were sought directly from programs and obtaining further information from some individual homebirth programs was challenging. Variation in inclusion and exclusion criteria exists between programs. Common areas of variation include restrictions relating to Body Mass Index, parity, age, English language ability, tests required during pregnancy, and gestation at booking to the homebirth program.ConclusionThe inclusion and exclusion criteria for a publicly-funded homebirth program determines women’s access to the program. Limited publicly available information regarding inclusion and exclusion criteria for many publicly-funded homebirth programs is likely to limit women’s awareness of and access to these programs.     

Where do low risk women live relative to maternity services across Victoria? Expanding access to public homebirth models across Victoria

ProblemCurrently <1% of Australian women give birth at home.BackgroundIn Australia there are very few options for women to access public funded homebirth.AimWe aimed to use geo-mapping to identify the number of women eligible for homebirth in Victoria, based on the criteria of uncomplicated pregnancies and residing within 15–25 kms of suitable maternity services, to plan future maternity care options.MethodsRetrospective study of births between 2015 and 2017 in Victoria, Australia. All women who were identified as having a low risk pregnancy at the beginning of pregnancy were included. The number of women within 15 and 25 km of a suitable Victorian public maternity hospital and catchment boundaries around each hospital were determined.FindingsBetween 2015 and 2017, 126,830 low risk women gave birth in Victoria, of whom half live within 25 km of seven Victorian hospitals. Currently, 2% of suitable women who live close to the current public homebirth models accessed them.DiscussionWe present a method to inform the expansion of maternity service options using Victoria as an example. On the basis of the maximum number of low risk women living close by, we have also identified the Victorian maternity services that would be most suitable for creation of public homebirth or low risk continuity of midwifery models.ConclusionThis approach could can be used to plan other maternity care services.     

Maternal Health Care Seeking Behavior in a Post-Conflict HIPC: The Case of Rwanda

Rwanda is one of nine post-conflict heavily indebted poor countries (HIPC) of the world. There was a worsening of health indicators since the early nineties on account of conflict. In light of this, we examine factors affecting maternal health care seeking behavior in Rwanda using three rounds of Rwanda Demographic and Health Survey (RDHS) data (1992, 2000, and 2005). We find that progress towards increasing the share of assisted deliveries has been slow. There has been no significant increase in the proportion of women seeking antenatal care. This could partially explain why a large proportion of women continue to deliver at home without professional assistance. Further, women who gave birth in the 5 years preceding the 2000 RDHS are less likely to deliver in a health facility than those who gave birth in the 5 years preceding the 1992 RDHS. We do not find such a result for the year 2005. We also find that women are more likely to deliver at home with professional assistance in 2000 and 2005 compared to 1992.     

Response to Ermisch, Martin, and Wu

Our recent paper in Demography (Gray, Stockard, and Stone 2006) has attracted the close scrutiny of several prominent academics. Three sets of formal comments, authored independently by Ermisch, Martin, and Wu (EMW), appear in this issue of Demography. In this response we argue that the analysis and evidence of our 2006 paper have withstood the scrutiny of EMW. In particular, we find that a substantial part of the rising share of nonmarital births since 1970 is due to a selection effect associated with marriage. This same selection effect also explains how birth rates could rise in both groups, even though their combined birth rate did not. In sum, though we appreciate the opportunity to expand on several key aspects of our 2006 article, we see no reason to substantially revise any of our major conclusions based on the EMW comments.     

An ethnographic study of the interaction between philosophy of childbirth and place of birth

BackgroundOrganisational culture and place of birth have an impact on the variation in birth outcomes seen in different settings.AimTo explore how childbirth is constructed and influenced by context in three birth settings in Australia.MethodThis ethnographic study included observations of 25 healthy women giving birth in three settings: home (9), two birth centres (10), two obstetric units (9). Individual interviews were undertaken with these women at 6–8 weeks after birth and focus groups were conducted with 37 midwives working in the three settings: homebirth (11), birth centres (10) and obstetric units (16).ResultsAll home birth participants adopted a forward leaning position for birth and no vaginal examinations occurred. In contrast, all women in the obstetric unit gave birth on a bed with at least one vaginal examination. One summary concept emerged, Philosophy of childbirth and place of birth as synergistic mechanisms of effect. This was enacted in practice through ‘running the gauntlet’, based on the following synthesis: For women and midwives, depending on their childbirth philosophy, place of birth is a stimulus for, or a protection from, running the gauntlet of the technocratic approach to birth. The birth centres provided an intermediate space where the complex interplay of factors influencing acceptance of, or resistance to the gauntlet were most evident.ConclusionsA complex interaction exists between prevailing childbirth philosophies of women and midwives and the birth environment. Behaviours that optimise physiological birth were associated with increasing philosophical, and physical, distance from technocratic childbirth norms.     

Paperbark and pinard: A historical account of maternity care in one remote Australian Aboriginal town

Background and aimMaternity care in remote areas of the Australian Northern Territory is restricted to antenatal and postnatal care only, with women routinely evacuated to give birth in hospital. Using one remote Aboriginal community as a case study, our aim with this research was to document and explore the major changes to the provision of remote maternity care over the period spanning pre-European colonisation to 1996.MethodsOur research methods included historical ethnographic fieldwork (2007–2013); interviews with Aboriginal women, Aboriginal health workers, religious and non-religious non-Aboriginal health workers and past residents; and archival review of historical documents.FindingsWe identified four distinct eras of maternity care. Maternity care staffed by nuns who were trained in nursing and midwifery serviced childbirth in the local community. Support for community childbirth was incrementally withdrawn over a period, until the government eventually assumed responsibility for all health care.ConclusionsThe introduction of Western maternity care colonised Aboriginal birth practices and midwifery practice. Historical population statistics suggest that access to local Western maternity care may have contributed to a significant population increase. Despite population growth and higher demand for maternity services, local maternity services declined significantly. The rationale for removing childbirth services from the community was never explicitly addressed in any known written policy directive. Declining maternity services led to the de-skilling of many Aboriginal health workers and the significant community loss of future career pathways for Aboriginal midwives. This has contributed to the current status quo, with very few female Aboriginal health workers actively providing remote maternity care.