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.
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.