While cost, regulation and an unsupportive healthcare system has marginalised homebirth in Australia, new hospital programs could see it become a viable option for women seeking alternatives to the traditional labour ward. By Celina Ribeiro.
Hope for homebirths
When Stephanie Mormanis told her husband she wanted to give birth to her second child at home, he was sceptical. Many people were. Or they thought it was a bit of a joke, with some friends suggesting they have a barbecue during the birth and check in on her: “How’s it goin’, Steph?”
But Mormanis was determined. In labour with her first son, now three, she arrived in hospital and it felt like Grand Central station. No one told her who they were, why they were there or what was happening, and she ended up having an emergency caesarean. She vowed never to step into a labour ward again.
The Royal Hospital for Women in Sydney this month will support its first homebirths as part of a newly established unit, but this was too late for Mormanis. When she suspected she was pregnant with her second child she contacted a recommended private practising midwife even before she took a pregnancy test. The midwife – one of reportedly fewer than 250 private midwives still attending homebirths in Australia – was already 50 per cent booked for Mormanis’s due month.
Homebirth is still rare in Australia, accounting for only about 0.2 per cent of all births. Fear and regulation have pushed it to the margins of maternity care, where private homebirth is costly and public facilities are hard to find.
By comparison, in England and Wales, National Institute for Health and Care Excellence guidelines recommend that birth at home or in a midwife-led birth centre be considered as a first option for healthy, low-risk women. There the homebirth rate is 2.1 per cent of all births. In the Netherlands it is as high as 20 per cent.
New Zealand’s homebirth rate has been about 4 per cent for a decade. While both countries are subject to the same Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) guidelines – which views homebirth as risky – New Zealand women are having their babies at home at nearly 20 times the rate of Australian women.
In New Zealand and England, the public health-care system supports and funds homebirth. With no public system support in her area at the time, Mormanis, a high school music teacher, used Facebook groups to find her private midwife.
“I was like: billions of women have given birth before me. Billions of women will give birth after me. There’s nothing wrong with me. There’s nothing wrong with women. There’s a problem with the system,” she says. “I can do this.”
When she had her first meeting with midwife Jo Hunter, her husband, an IT worker, was apprehensive. “I honestly think he thought she would walk in with some beads, waving around some thyme and beating a drum,” she says. Instead, Hunter put them at ease with her professionalism.
Mormanis gave birth to daughter Michaela naturally and without intervention in their home late last year, with two midwives and a local doula attending.
“Easily, hands down, it was the best day of my life. No question about it,” she says. “I said to my husband, ‘Sorry. It wasn’t our wedding day.’ I’ll forever apologise to my son. But by far, it was her birth. I would do it again in a second.”
But while the outcome was positive for Mormanis, it was a costly experience. She spent $5500 on her midwife and an additional $1700 on her doula. Of this, she received $900 back from Medicare.
Across the country private homebirths cost between $3500 and $6000. Regulatory changes requiring two midwives to be present at all births (as is the case in the National Health Service), frequent professional audits, and the inability to get professional indemnity insurance for labour – the current national exemption for this expires at the end of 2019 – has resulted in midwives leaving homebirth practice in droves.
For those who cannot pay, homebirth is even harder to access. In Australia, there are only 17 members of the National Publicly-funded Homebirth Consortium, which represents hospitals and birth centres offering homebirth. Some hospitals, such as the Women’s and Children’s Hospital in Adelaide, which supported 32 homebirths last year, are hugely supportive. But for most Australian women preparing to undertake one of the most significant processes of their lives, there is little choice.
Professor Caroline Homer, immediate past president of the Australian College of Midwives and director of the Centre for Midwifery, Child and Family Health at University of Technology Sydney, warns that homebirth has been pushed so far to the fringe that many midwives have come to fear it. She argues for it to be made available through all public hospitals.
“Homebirth is safe so long as the women are the right women, the midwives are the right midwives and the system supports them – whether private or public,” she says. “It’s when any of those three things aren’t working that we see problems.”
A 2014 study led by Homer, Birthplace in New South Wales, Australia, collated eight years of data from births in the state and found that women who planned to give birth at home or in a birth centre were far more likely to have a normal labour than those in labour wards, and that “there were no statistically significant differences in stillbirth and early neonatal deaths”. Another study, published in The Medical Journal of Australia in 2013, found homebirths had comparatively good rates in terms of stillbirth, vaginal delivery, haemorrhage and breastfeeding.
But the RANZCOG view, drawn from its analysis of international research on homebirth, is that while women should be supported in their birth choices: “Even in a pregnancy without complicating factors, the level of risk to mother and baby with homebirth is at a level that is unacceptable to most women.” It advocates hospitals as the safest place for labour. The Australian Medical Association is in step with the college’s position.
Michael Gannon, an obstetrician and immediate past president of the Australian Medical Association, has deep reservations about homebirth. “There is no such thing as low risk in maternity care,” he says. “Risk stratification is something which is best done after the birth. There are many, many mother and baby pairs that could have been delivered without the support of the hospital environment, but the reality is that on a daily basis we see close shaves. We see mothers or babies saved from significant morbidity or mortality by the ability to deliver care within minutes within a hospital.”
Gannon adds that the geography of Australia presents an additional challenge to safe homebirth compared with countries such as England. He says the AMA’s position reflects not only the contributions of obstetricians, but paediatricians, anaesthetists and psychiatrists, as well as midwives.
Homer says she understands the fear around it, but argues more is at play in the prevailing opposition to homebirth. She suggests the ability of midwives to look after healthy women with healthy pregnancies upsets power structures within the medical fraternity, “which is used to midwives behaving like nurses”.
And she suggests that homebirth “challenges financial arrangements”. If private health insurance rates continue to decline, and more women opt for midwife-led care, she says demand for private obstetric care may fall. “In Australia, the money gets in the way,” she argues. “Big time.”
Homer says women are angry, not scared. “We need better options for women,” she says. “It’s not okay that you just get the cattle-yard model when you’re doing something pretty important.”
And when given options, women take them. The Royal Hospital for Women in Sydney’s fledgling homebirth program is fully subscribed for next month, too.
This article was first published in the print edition of The Saturday Paper on Jul 7, 2018 as "House of birth".
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