This is the first of several blog posts I want to write reflecting on the inquest into the case of a woman who died in hospital after giving birth at home in Victoria, Australia.
In part 1 I discuss the context in which homebirth and homebirth midwives are regarded in Australia and allude to some of the challenges faced by them in carrying out their work including attitudes toward homebirth, concepts of risk and communicating with mainstream services.
I have worked as a midwife in Australia for the last 20 years and I was interested to know more about a recent case where a woman had died in hospital after giving birth at home. I attended one day of the initial coroner’s enquiry and then another day of the inquest.
I admit that I really wanted to know whether this would be a case of putting homebirth on trial and/or independent midwifery. Does that sound cynical? Let me explain the context.
Fewer than 2% of births in Australia are planned homebirths. Other countries are more accepting of the model – it is the default model of care for women with normal pregnancies in The Netherlands. In the UK there is official acknowledgement that homebirth is a safe and reasonable option for many women and that it also serves to (pragmatically) relieve some burden on an already overcrowded hospital system. Both of these countries have an enduring culture of midwifery care for pregnancy and childbirth. This is not a coincidence.
But if you think that homebirth in Australia is only a marginal dreadlocks- tie-dye- hippyfest please note that there are a dozen or so publicly funded homebirth programs currently operating in Australia, many connected with maternity hospitals.
Despite this, generally speaking, the mainstream maternity care system has little respect for alternatives.
A friend of mine, planning a homebirth, presented at a large tertiary maternity teaching hospital with some elevated blood pressure late in her pregnancy – as suggested by her independent midwife. The doctor who she saw in the emergency department asked her first up why she was trying to have a home birth – didn’t she care about the health of her baby?
So that’s just one lousy case, but it’s what I have found to be a pretty standard (and disappointing) reflection of the general attitude to homebirth amongst medical (and many midwifery) staff in the hospital system.
I say disappointing because the choice a woman makes about her care in pregnancy and birth should surely be respected.
Where there is no respect for this choice, women who have planned to birth at home and then unexpectedly need hospital care may indeed face a hostile audience (see above).
We live in a world arranged around risk management – in life as in maternity care. In this coroner’s case there was considerable discussion of the risk status of the woman in question.
In Australia some women are considered to be of sufficiently low risk to “qualify” for a homebirth in the public system or with an independent midwife. Others don’t make the cut and are assigned to more medicalised care. Pre-existing medical issues or a chequered obstetric history place them at “high” or “higher” risk.
The social science discussion around our modern obsession with risk acknowledges the rationalist and neoliberal influence on our thinking – where things are quantifiable they are containable and manageable.
Right…?
I pity the person who claims to be able to contain and manage that behemoth we know as childbirth. Still, we try.
In an ideal world, independent midwives look after low risk women as per professional guidelines.
Independent midwives, however, are often sought as carers by women who have been traumatised by the mainstream maternity care system or healthcare system in general (or even other institutions). These women quite understandably seek the woman-centred, continuity of caregiver, non-interventionist philosophy that defines homebirth midwifery – regardless, or indeed perhaps because of, their “risk status”. Independent midwives may face the very difficult decision of whether to continue to care for a woman beyond her scope of care or risk the woman deciding to birth on her own without care.
Paradoxically, women who have the most challenges in their pregnancies or birth – which may or may not translate as their “risk level” are also known to benefit from a relational model of care involving continuity of caregiver… just as their low-risk peers do.
Which is just the kind of model that an independent midwife offers. And yet we know that independent midwives may have difficulty communicating and collaborating with more mainstream maternity services because of attitudinal barriers related to homebirth.
Independent midwives who care for those women least likely to engage with mainstream maternity models need to be valued by that system and offered every chance available to provide the care that this woman and her family need. This would involve mainstream services being open to supporting rather than condemning women and midwives working in this model of care.
Every pregnant and birthing woman needs care not only in relation to her risk status but her individual needs.
jenhock 
Thanks Jen, words of reason, and of utmost importance compassion and understanding….you’ve said all I’ve been wanting to say and feeling these last few weeks. So thank you for saying what I’m sure I couldn’t have said quite as well as you….I think you should send this article to the Age btw…xx
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Kind words Sue – thanks.
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As a mother who experienced a traumatic birth & then worked incredibly hard to breastfeed my baby until 20 months I am confused. I’m confused because I notice that the same group of professionals so concerned for a woman’s emotional welling being during her birthing experience that they are taking on ‘high risk’ mothers to birth at home are the same group so insistent that mothers exclusively breast feed. It appears that the desparate concern for a woman’s wellbeing is suddenly over once her baby arrives & she is required to produce breastmilk. I recall being thoroughly traumatised, exhausted & broken following my pregnancy & birth. I was spending 14+ hrs a day either feeding or expressing. I was socially isolated, exhausted & desperate to be doing the right thing. The advice I got from the professionals who had previously been so concerned about my emotional experience? Express MORE. Feed MORE. And I did- with little effect, other than to wear me down to an emotional place it took me two years to get back from. Where had the all the concern for my emotional experience gone? Where was the woman centred care spoken so much about by midwives now that my baby had arrived? As the years have passed & I worked through my trauma, I have come to wonder if the push for ‘natural’ birth & exclusive breastfeeding is not about actual women & actual babies- but more about creating an environment where childbirth & breastfeeding remain the domaine of midwives.
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Thanks for your response Linda. I’m sorry that your experience of birth and breastfeeding were traumatic. Normal birth and breastfeeding may seem to some like ideology-laden pursuits, but then I guess everything is an ideological stance if you think about it. Midwives support normal birth primarily because they believe in the awesome-ness of women’s bodies to birth. Ditto breastfeeding.
I’m not sure where you live with regard to the maternity care you received, but it sounds like you were in a very difficult “place” to cope with the demands of mothering a newborn and recovering from a traumatic birth. In fact your experience of birth is what midwives want women to be able to avoid. Do you think your breastfeeding experience was connected to this birth experience? If you think so, let me ask you – what could have happened to improve your experience of both birth and breastfeeding?
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My breastfeeding was related to my birth experience in that I had a large blood loss (from placental abruption) & a premature baby who I was separated from overnight for the 6 wks she was hospitalised. My experience was of midwives, lactation consultants & MCHNs adamantly insisting that my milk supply would be solved by increasing demand. It wasn’t until months spent doing nothing but feeding & expressing & dealing with a constantly hungry baby that a private lactation consultant pointed out that my large blood loss & baby’s prematurity would be effecting my supply. A small amount of formula was introduce & things quickly turned around. In fact I believe the increased rest helped inprove my supply & the formula was then no longer required. I went on to breadfeed until 20 months. What would have helped is a more individualised approach from the professionals I dealt with, rather than the absolute non waivering insistence about supply & demand.
With regards to my birth experience, it was traumatic & yet thanks to the people looking after me it was a triumph, as it resulted in a live baby.
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Linda it sounds like you had an incredibly challenging time with all this. I am delighted that an LC was able to help you put the pieces back together – how much better would it have been to have this support right from the start! My research – as you probably know – is about LC’s. I am interested in looking at how they support women because I think excellent breastfeeding support is crucial and anyone in contact with new mums and babies has to know this stuff! Your story is further evidence of this. Things need to change in order for women to get the help they need when they need it.
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I will begin by saying I am a midwife who now works in a MGP within a hospital that does not offer home birth. And that I support women who want home births. On occasion I have heard of women looking at home birth as they believe their choices would not be supported ie VBA3C and supported them in our MGP.
This is comment on things that I believe are not discussed. Although discussed is not the right word.
Home birth can different depending on what country it is practiced in. These are my observations only. In Australia it is often the “traumatized woman” that seeks home birth. As a result the midwife is often caring for “high risk” women. In the UK because it is more accepted home birth is an acceptable option. However women who choose home birth have access to nitrous oxide and narcotics and post partum oxytocin. This I learned from a UK midwife many years ago. In home birth in the USA the practice is again different. An example – A home birth midwife told me that if one of their babies is born through meconium liquor the midwife will stay 24 hours to ensure the baby has adequate observation. I understood from what was said this was common practice.
As you rightly said in Australia a large number of women seek home birth because they are traumatized by their birthing experience. Or because they are not supported in their choices by care providers. I believe if women are supported to have a vaginal birth with their first pregnancy and a VBAC if they wish with subsequent pregnancy there would be less women seeking home births because of trauma and need for support for their choices. And as a result Australian midwives would be less likely to be asked to support “high risk” women.
There is a them and us mentality with home birth and hospital midwives. We are all midwives who care to the best of our ability the women who choose that option. This is from personal experience. A couple of years ago I attended a home birth conference. During a session we were asked to divide into small groups to discuss different topics. We were commenting about Antenatal class content. I mentioned that I practiced in a hospital. One of the ladies verbally attacked me to the point I was in tears. My reply was “You do not know me. You do not know how I practice. You have no right to comment unless you know these things.” I mention this not for sympathy but to illustrate the them and us mentality of some who support home birth and if we are honest some who don’t support it also.
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Thanks Robyn for sharing your experiences. My work has been with home birth as a hospital midwife looking after women transferred in labour … Such a privilege. We all play a part. I agree that dogmatism of any variety is unhelpful.
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https://pioneerboerwoman.wordpress.com/2016/03/01/my-natural-home-water-birth/
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