The homebirth controversy: Informed consent and a child’s right

According to Homebirth Australia, the latest Australian data shows homebirth rates have increased by 56% in one year; there were 863 homebirths in 2009 and 1345 in 2010. Following this, there have been inquests around the country looking at homebirth deaths in recent years. We had the opportunity to hear from Ann Catchlove* on informed consent, a child’s right and the rate of deaths and injuries as a result of homebirth prior to her presentation at the upcoming Obstetric Malpractice Conference in June.

What are the major changes that you’ve observed during your time working in the homebirth area?
Ann: I have been involved as a consumer representative in maternity services since 2009. The big change that has taken place in that period in relation to homebirth has been the introduction of the National Registration and Accreditation Scheme with its requirements for registered health professionals to hold professional indemnity insurance. Privately practicing midwives attending homebirths have been granted an exemption from this requirement as there is no product available for them to purchase. The future of the exemption is uncertain. It was due to expire in June 2015 but there is word that it may now be extended until the end of 2015.

It does seem that governments are unwilling to let the current situation continue indefinitely. This is understandable – it is not fair that mothers or children who are injured as a result of the negligent conduct of homebirth midwives have no effective recourse. At the same time I do think there are risks to ending the exemption if it means that there are no legal avenues for women to choose homebirth. It is not in the interests of safety for homebirth to become an essentially unregulated practice of questionable legality.

Another change is that some midwives are choosing to no longer be registered but continue to provide the same homebirth services under the title of “birth worker” or similar. An example is the case of formerly registered midwife Lisa Barrett who went on to be the care-provider in 3 further homebirth deaths as a “birth advocate” after handing in her registration. At present in most states (except South Australia) it is legal to practice midwifery without being registered as long as the title “midwife” is not used.

“The internet and the rise of online communities (particularly Facebook and discussion forums) have changed the way in which women get information about their birth options and the risks involved in them.”

Some online communities that are focused on homebirth can stifle robust discussion and prevent negative stories about homebirth being shared within them. Particular online communities have also allowed certain midwives to develop a following that is unrelated to their skill or competence. These midwives are lauded as experts when their outcomes do not reflect this.

Is consent always informed, e.g. emergency caesarean or breech birth?
Ann: No. As a consumer representative I have had many women tell me that they did not feel as though they received adequate information on which to base the decisions they made during pregnancy and labour. Women often feel that they haven’t been informed of alternative options (for example the possibility of vaginal birth after caesarean or vaginal breech birth) and that they have been pushed to make a choice they were not entirely happy with. Women also often report that they were not made aware of the risks of a particular course of action – a common one is the impact of a caesarean on future pregnancies.

Similarly many women that plan homebirth do not give fully informed consent. Their midwives do not give impartial and accurate risk information and sometimes also strongly push for a particular choice.

“It is very difficult for women to make informed decisions about homebirth as there is a lack of comprehensive safety information available.”

There is a body of research that points to homebirth being a comparatively safe choice for women with uncomplicated obstetric histories and low risk pregnancies. The limited applicability of this evidence is not often acknowledged. The Birthplace in England study, for example, showed that there were no statistically significant differences in outcomes between home and hospital birth for the babies of women who were low risk and had already had an uncomplicated pregnancy. Low risk meant that the women included had no significant medical conditions (such as high blood pressure, diabetes or infections), were not obese, were giving birthing after 37 weeks, had not had a prior caesarean and were not expecting twins or having a baby in a breech presentation. For low risk women having their first baby there was an increased risk for the baby in giving birth at home. Additionally the study only included women giving birth with midwives who were employed through the National Health Service.

The study showed that homebirth can be comparatively safe when certain conditions are met. We know however that many women choosing homebirth in Australia do not fit the profile of the women included in this study. It is a woman’s right to choose homebirth if she wishes but midwives need to explicit about the limits of the evidence so that women are making informed decisions.

There is very limited research on comparative outcomes for women who are not low risk. One Australian study that did include women with risk factors was the Bastian study. It is now over 15 years old but it found that for low risk women there was no significant difference in outcomes between home and hospital births. It did find that the home birth mortality rate was 1 in 14 for breech presentation and 1 in 7 for twins.

“Woman have the right to make their own choices and to decline recommended care but their care-providers must provide accurate, credible information on which women can base those decisions.”

From the child’s point of view, is it fair for high-risk mothers to be birthing at home?
Ann: This question assumes a conflict between the mother and child’s point of view that I don’t think actually exists in most cases. Most high-risk mothers who choose homebirth do so genuinely believing that they are making the best choice for their child. They are not prioritising their own comfort, they are choosing what they believe will give their child the best start in life. Unfortunately, in many instances women are making these decisions based on incomplete or incorrect information.

A number of the cases that we have seen in recent years demonstrate the enormous trust that women place in their midwives and the responsibility that midwives have to give accurate information and advice. The inquest into the death of Joseph Thurgood-Gates showed this very clearly. A mother with multiple risk factors chose homebirth with the full support of her midwife who failed to clearly convey the risks of the decision in the antenatal discussions and to identify and communicate with the mother regarding complications that arose during the birth. The Coroner found that the failure of the midwife to provide clear risk advice to his mother indirectly contributed to Joseph’s death and that the failure to transfer when problems first arose was a contributing factor in his death.

There is also a reluctance among homebirth and midwifery advocates to be upfront about risks. Much is made of the evidence that points to homebirth being a safe choice for women at low risk of complications but the flip side is not clearly articulated.

“Homebirth has never been established as a safe choice for women with risk factors. We need to be clear about this.”

Women do not hear this information from midwifery advocates and quite often not from their midwives either.

The assumption that high risk women are unconcerned with the safety of their babies and hold intractable views is made by both sides of the debate and it does women a great disservice. In assuming that a woman cannot be reasoned with hospital staff lose the opportunity to understand and address women’s motivations in choosing homebirth. In attributing bad outcomes to women who are determined to homebirth irrespective of risk midwives lose the opportunity to learn from bad outcomes and identify ways to improve their communication and their practice.

In your opinion, are there too many deaths or injuries as a result of homebirth?
Ann: Sadly yes. However the data that is available makes it difficult for women to access information about this. Homebirth statistics take up just one page in the latest Australian Mothers and Babies report (released in December 2014 and covering births in 2012). The information contained in the report doesn’t give us all the information we need to truly understand how many babies died during or shortly after a homebirth. The report only gives us the number of homebirth fetal deaths (stillbirths). Out of 1177 babies born at home, there were 6 fetal deaths or 5.1 per 1000 births (another way of looking at it is that 1 in 200 homebirths resulted in a fetal death). A fetal death is one in which the baby dies before it is fully separate from its mother. So the rate does not include babies that were born alive and died in the hours or days after birth which is not uncommon (these are classified neonatal deaths). All of the homebirth deaths that have gone to inquest are neonatal deaths – none of these get counted in the fetal death statistics.

Looking just at fetal deaths the rate for homebirth (5.1 per 1000) seems to compare favourably with the overall fetal death rate of 7 per 1000 births. However the general stillbirth rate includes babies born from 20 weeks or weighing 400 grams or more. The vast majority (82.2%) of all stillbirths occur before 37 weeks. Very few homebirths are pre-term (only 1.3% of homebirths in 2012 were). When we look at all births in Australia from 37 weeks onwards the fetal death rate was only 1.37 per 1000. The homebirth fetal death rate is over 3 times higher.

We need the homebirth data to be reported on more thoroughly so that women can make informed decisions. A really useful statistic to have would be the intrapartum death rates. This would allow us to see the impact of place of birth during labour.

*Ann Catchlove is a lawyer with extensive experience as a consumer representative in maternity services. She has sat on numerous committees including the Expert Advisory Committee on National Evidence-based Antenatal Care Guidelines. She currently sits on the Consultative Council on Obstetric and Pediatric Mortality and Morbidity and is undertaking a Master of Laws specialising in health and medical law. Ann will elaborate on the legal issues concerning homebirth at the upcoming Obstetric Malpractice Conference on the 22-23 June.