The soaring epidural rates are of distress for many researchers and health practitioners, with Wagner noting 23 per cent of women who have an epidural have complications.
Homebirths result in 70-80 per cent of births being procedure free — compared to 10 per cent of hospital births.
The Cochrane Database, a database of medicine-based research, states: "There is no strong evidence to favour either Home or hospital birth. All low-risk women should be offered the possibility of considering a planned homebirth in countries where a homebirth service is backed up by a modern hospital system." In Australia, however, the government supports hospital births. Besides a small number of women in Western Australia and South Australia who have access to funded homebirth, the option puts families around $4000 out of pocket.
In the comfort of her own home
Matilda Vogner, a lawyer who now works as a researcher for an international human rights organisation in Russia, returns to her Australian home to give birth — literally. She has three children — Samina, 4, Sial, 2, and baby Suna. After hearing a lot of negativity involving other people’s encounters with obstetricians, she decided homebirths harmonised with her needs. Matilda’s only glitch was finding relevant literature on this mode of childbirth. "There’s not a lot of information about homebirth. You have to seek it out very much yourself — most of the information you do hear is about going into hospital," she says.
While her family and friends acquiesced to the idea once Matilda discussed it with them, there were still those who thought she was a little extreme. Perhaps this is because Australian women are socialised to have their babies in hospital — unless they grow up on a commune. Matilda found her birth experiences unparalleled. She developed a deep trust in her independent midwife, allowing her peace of mind that if hospital transfer became necessary during labour, obstetric staff would not simply assume control.
The independent midwife offers one-to-one care throughout the pregnancy, birth and postnatal period. Should an anomaly surface during the pregnancy, familiarity allows her to recognise it before the baby is due. If that is the case, she can recommend specialist care. Matilda’s births, however, were straightforward and she was calm knowing she would not need to birth in a labour room where unfamiliar eyes would be peering at her.
Speaking from personal experience, I mentioned I enjoyed my brief "respite" in hospital after just giving birth. Matilda says it was more important for her not to disrupt the family unit. She thought this was particularly essential with her subsequent babies, feeling it can be overwhelming for children to cope with both their mother’s absence and the arrival of a new sibling.
Perhaps we should take a leaf from the policy books of the Netherlands where the medical system sustains homebirths. Thirty-five per cent of Dutch women have their babies at home. A maternity homecare assistant provides aid during the first postnatal week, helping the mother with baby care and household tasks. The cost of these assistants is irrelevant because of the massive savings in other areas. This modality of birthing shrinks the need for specialist fees and frees up hospital beds for others. What’s more, the Netherlands has some of the best maternity outcomes in the world.
The only downfall of Matilda’s homebirth experiences was the hostile reaction she received during an early routine hospital visit with her first child, Samina. "The doctor there said it was very dangerous," she says. "I don’t think he was basing that on any actual statistics or facts — it was as if he was just having a reaction."
Matilda assessed all advice and researched the issue herself. "There are a few risks involved in a homebirth which are not involved in a hospital birth, but there are risks involved in hospital birth not involved in a homebirth," she deduced. Studies echo Matilda’s conclusion, showing the safety of homebirths for low-risk pregnancies is categorical. In fact, many researchers and health authorities question the appropriateness of a hospital environment for normal pregnancies as Australia’s childbirth intervention rates are peaking at exorbitant levels.
Little Mermaid Lucy
Rachele Meredith’s third baby, Lucy, began her swimming lessons early. She was born last year, entering the world via a kiddies’ pool filled with warm, soothing water. Rachele’s two older sons, Michael, 11, and Caleb, 7, joined husband Russell to witness the unforgettable event. Rachel asserts the finest part of the homebirth was "my husband, new baby (only a few hours old) and I sleeping soundly in bed together that first night". Had someone told her a few years back she would deliver her third child this way, she would have mocked, "That’s a bit too new age for me." She was unaware that until the 1900s, homebirth was the norm. Furthermore, when women began birthing in hospitals, maternal morbidity initially climbed due to unsanitary practices.
For her boys, Rachele chose a birth centre at the local hospital. Her reason for birthing there was that it seemed like the ideal way to avoid the sterility of the labour ward. "I chose a birth centre originally because I liked the surroundings, and not particularly for the model of care." However, she still never knew who would be caring for her during labour, calling the hospital care "fragmented". After an experience with a frazzled midwife during the labour of her second child, she began to research alternatives.
Anecdotal feedback fuelled Rachele’s thirst for an insight into homebirth. "Many of my friends were having obstetricians in private hospitals and I began to wonder why their birth stories ended dramatically — too with often with a caesarean," Rachele says. "It was in a rather mainstream pregnancy book that I noticed around one per cent of Australian women had a homebirth." Rachele, a primary school teacher, was surprised anyone did, as she had been socialised to see it as a precarious choice and only for the unconventional. Her mother, a midwife whose training replicated more of an ‘obstetrics-type nurse’, and father, a doctor, who delivered babies in his early days, were dubious about her having a baby out-of-hospital.
Rachele was determined to think tangentially and, by the time her third pregnancy was nigh, an impressive collection of articles, research papers, books and videos illustrated to her it was a pragmatic option. Lucy’s homebirth brought bliss to the Meredith family. After Lucy arrived, the whole family could function normally and enjoy their new arrival without having to arrange visits to the hospital. Rachele says Lucy’s birth in her own home and not an institution meant there would be no transition to a new environment when she was a few days old.
Rachele lists some of the unique factors of her homebirth: "No strangers prodded or poked my baby. I didn’t have to listen to conflicting information about when and how to breastfeed. Any advice or assistance I wanted was provided by ‘my’ midwife, who I knew very well. I could relax knowing that no one was going to barge in uninvited."
Rachele agrees with Matilda that a negative of homebirth is the sense of being in a minority. She recalls feeling ostracised at an early childhood centre where a group of mothers were discussing their baby’s weights on hospital discharge. As Rachele’s situation unfurled all eyes were adhered to her. Confident in her knowledge of homebirth’s safety, she still felt awkward explaining that if complications arose, the hospital operating theatre — which takes at least 20 minutes to prepare as well as the doctor needing to be called — was only two minutes away.
Rachele and Matilda’s contentment after their homebirths links with studies that show "happy" hormones have more chance of kicking in after birth at home. Jock Doubleday, an independent researcher in the US, notes his findings in his book, Spontaneous Creation: 101 Reasons Not to Have Your Baby in a Hospital. He discusses The Farm in Tennessee, where around 2000 homebirths have taken place and only 0.03 per cent of women have suffered from postnatal depression. French obstetrician Michel Odent adds to the theory, stating in his writings that by avoiding the use of drugs, so routinely administered in hospital births but not in homebirths, "We probably eliminate many abnormal hormonal fluctuations and thereby decrease the likelihood of postnatal depression."
The challenge of vaginal birth after caesarean (VBAC)
Anna Bryan had always shied away from traditional medicine, favouring natural therapies. Thus, with her first pregnancy, Anna and her partner Mark felt a normal life process did not necessitate a hospital visit. However, at around 32 weeks, baby Ella was breech, meaning a caesarean loomed. The doctor was going to attempt to manually turn the baby from the outside, but an ultrasound at 37 weeks revealed Anna’s fluid levels were formidable. This condition was enough to warrant an immediate caesarean. Anna accepted her position, just yearning for a healthy baby. She felt fortunate to be birthing at her local hospital, in the Blue Mountains in NSW. "The hospital here is a really beautiful place; we had music playing and candles burning, trying to make it as homely as possible," says Anna.
As much as Anna’s time in hospital was agreeable, when pregnant with her second child, Mali, she wanted to attempt a homebirth. She acknowledged women in her predicament (VBAC) are told by most Australian hospitals that it is a precarious choice. Chance of uterine rupture — meaning the caesarean scar opens up — is the main concern. The risk is one per cent.
Anna believes when you fall pregnant you are entering "risk zone" no matter what your situation. Research supports Anna’s circumstances. Marsden Wagner MD, MS, perinatologist, epidemiologist and former Director of Women’s and Children’s Health, World Health Organization (WHO), affirms homebirth is viable for these women. He states VBAC is perfectly safe provided emergency services are 20-30 minutes away. The elements of a homebirth, where the aim for a natural birth is prevalent, may assist a promising outcome. American childbirth writer Penny Simkin points out: "By avoiding labour inductions after previous caesareans, it’s possible that many uterine ruptures will be prevented."
Anna lives only a short trip from hospital and put her faith in her midwife’s skills and knowledge. She was rewarded with the homebirth she had hankered for, everything flowing smoothly. Two-year-old Ella was there to see her baby sister arrive and Anna says it was fantastic. "One of the really lovely things was that two or three days after the birth I thought ‘We haven’t left this room’," Anna says. "The outside world doesn’t have to be involved in this." This ambience may have assisted Anna’s natural birth. Michel Odent’s research shows "…the private and undisturbed home setting enhances the hormones and physiology of birth, making natural birth more likely".
Since Anna has had a homebirth to compare with her hospital birth, she says she feels quite despondent. "I’ve actually gone into a lot of grief around having a caesarean the first time," says Anna. She explains that feelings of disempowerment became manifest only after her sense of empowerment set in following Mali’s birth.
The problem with medicalised birth
Marsden Wagner states that Australia’s swelling childbirth intervention rates are "truly shocking". The caesarean rate is 30 per cent — 50 per cent in some private hospitals. The epidural rate is 25 per cent for public patients and 50 per cent in private hospitals.
These figures do not currently meet international best practice, as embodied in the Netherlands, Canada, the UK and New Zealand. In his article Fish Can’t See Water, Wagner discusses the risks associated with any unnatural birth procedure. He says hospital births are now routinely intervened — gratuitously. Wagner describes the "cascade effect" of intervention. In essence, the effect is: a woman is induced using drugs; the pain is more intense than normal labour pain; an epidural is requested; the epidural slows down the labour process and because it has gone on for too long; the baby needs help with more medical procedures — episiotomy, forceps, vacuum, or caesarean. All procedures come with risks to mother and baby’s wellbeing.
Of the controversial ‘C’ word, Wagner explains: "Caesareans save lives but there is no evidence that rising caesarean rates in the past two decades in many countries has improved birth outcomes." The threat of maternal mortality even for an elective (non-emergency) caesarean is almost three times higher than for vaginal birth. Further risk factors include increased respiratory problems in babies, placental problems conducive to infertility, and risk of ruptured uterus in subsequent pregnancies.
The soaring epidural rates are distressing for many researchers and health practitioners, with Wagner noting that 23 per cent of women who have an epidural have complications. An article by GP Dr Sarah Buckley, titled Epidurals: real risks for mother and baby, lists the dangers involved. The most serious is a drop in blood pressure for the mother, leading to less oxygen reaching the baby. Other hazards include prolonged back pain, urinary retention and even the slight chance of paralysis.
Comparatively, homebirths result in 70-80 per cent of births being procedure free — compared with 10 per cent of hospital births, the figure endorsed by WHO.
Wagner provided the most up-to-date research for this article. In October 2001, Dr Kenneth Johnson, an epidemiologist, and Betty-Anne Daviss, a midwife, presented to the American Public Health Association annual meeting a prospective study of planned homebirths by certified professional midwives (CPMs) in North America. The investigation of 5000 planned homebirths concluded: "Among these women, the obstetric intervention rates were far below the rates reported in low-risk hospital births, the combined intrapartum/neonatal death rate was as low or lower than rates reported for low-risk hospital births, and the maternal mortality rate was zero."
Wagner concludes that homebirths remain an enigma to mainstream culture because those in power provide the information. He says: "In order to maintain their hegemony in the medical system, doctors attack midwives — especially midwives in independent practice where they are not under the control of doctors or hospitals. The past two decades has seen a global witch-hunt of midwives so the established hospital-oriented maternity services can triumph."
A healthy baby is what is paramount to where or how you give birth, but with "choice" being a buzzword of the noughties, it appears homebirth needs to become a more accessible and acceptable option.
A passion for pregnancy
Western Australia and South Australia have the only state governments that recognise and support women’s right to choose a homebirth. The Community Midwifery Program in WA provides a model of care, allowing women the one-to-one care of a midwife and the choice to give birth where they want. However, demand outweighs supply, with many women failing to benefit from access to the program. In South Australia, the government supports the homebirths of around 70 women. @BC2:Across Australia, there is only a handful of independent midwives — working in isolation. One of these indomitable women is Jan Robinson, an independent midwife operating a busy practice in southern Sydney. Despite not being recognised by the medical system — ie no insurance company supports these autonomous midwives and they are not given Medicare provider numbers — Jan relishes her self-sufficiency, saying it enables her to form a partnership with her clients that will give them optimum care and the power to make suitable birth choices.
Jan says the women cherish lengthy antenatal visits, allowing time to discuss aspects of their pregnancies such as dietary requirements, postnatal exercises and baby care — topics usually skimmed over in the tight schedule of hospital and obstetrician appointments that last a maximum of 10 minutes.
Pleasantries aside, Jan wishes dearly for more support from health systems, as the current government policy discourages practices such as hers. "It sends out a message to women that the only right choice is that of an obstetrician," Jan says. Independent midwives can be scarce and Jan points out that in the Northern Territory it is impossible for them to practise. Some Top End women seeking a homebirth have to fly in an independent midwife from Melbourne. This is particularly disheartening for the prolific indigenous population, forced into ignoring their cultural beliefs and into hospital births. Additionally, there are those who cannot afford an independent midwife but desperately want to circumvent hospital birth. There is no record of who attends these women at birth — the Register of Births, Deaths and Marriages is notified only by the parents, with no mention of a birth attendant.
