The status of home birth in Australia has become more contentious than ever with the introduction of legislation which requires that all services provided by registered health professionals be covered by appropriate indemnity insurance. Although never intended to prevent registered midwives from providing care in planned home births, the absence of insurance for home birth has meant that any midwife assisting in a planned home birth appeared to have to forgo midwife registration, or risk penalty.

The Maternity Services Review1 recommended that home birth not be supported, but this recommendation was based on the lack of consensus among providers of maternity care that would be required for its safe implementation. The Review remained silent on whether or not home birth should be considered as a safe model of care for the Australian maternity system.

Previously published Australian evidence shows that planned home birth in Australia is associated with a higher risk of intrapartum perinatal mortality.2-5 An article by Kennare and colleagues in this issue of the Journal reviews the outcomes of all planned home births in South Australia from 1991 to 2006, and confirms previous findings.6

Although women with recognised risk factors such as nulliparity, Indigenous status, lower occupational status and residence outside metropolitan areas were less likely to plan home birth, planned home birth was associated with a sevenfold increase in risk of intrapartum perinatal mortality compared with planned hospital birth, and a 27-fold higher risk of death due to intrapartum asphyxia.6 These differences were significant despite a sample size of only 1141 home births. Overall perinatal mortality standardised for gestation and birthweight was more than double that of planned hospital births, but because of low numbers these differences were not statistically significant.

Of course, not all severe adverse perinatal outcomes in labour can be avoided, but they are better avoided, statistically speaking, when birth is planned to take place in a hospital birth unit. Perinatal mortality is not the only relevant outcome, but it is generally accepted as a most important outcome measure.

It is also significant that the incidence of intrapartum perinatal mortality due to asphyxia had halved in South Australian hospital births during 1991–2006 compared with the outcomes recorded for 1976–1987, but hardly improved for planned home birth.2,6

Rates of interventions such as caesarean section and instrumental delivery were lower in the planned home birth group in Kennare et al’s study, but, as there was no adjustment for risk, it is unclear to what extent this is due to the model of care, and to what extent it is due to the fact that hospitals care for higher-risk pregnancies.6

There were no measurable increases in rate of postpartum haemorrhage,6 and it appears that the adoption of oxytocin into home birth practice has resulted in improvement in this outcome compared with data from previous studies in Australia.5

Notwithstanding Australian data, calls for integration of planned home birth into mainstream maternity services continue, based on international evidence of comparative safety.7-9 Advocates argue that the poorer outcomes measured in Australian studies are due to inappropriate inclusion of high-risk pregnancies that will have poorer outcomes in home birth and, if restricted to low-risk pregnancies cared for by accredited practitioners, planned home birth outcomes would be comparable or superior to hospital birth outcomes . Home birth models of care have been adopted by a small number of maternity units within the state hospital systems. The federal Minister for Health and Ageing, Nicola Roxon, has been under much pressure to move beyond the recommendations of the Maternity Services Review and provide indemnity insurance and funding for planned home birth.

The decision to exempt registered midwives from the indemnity insurance requirements but not extend further support is a political compromise. It is consistent with evidence that current planned home birth practice in Australia increases the risk of perinatal mortality, but recognises that a small minority of women will continue to choose to give birth at home and that it is safer for these women to be cared for by registered midwives, rather than give birth unassisted. As with most compromises, it angers both home birth advocates, who want indemnity and funding provided, and opponents, who argue that a different professional standard is being applied for the benefit of a noisy minority.

The decision essentially maintains the status quo. Uninsured midwives can continue to provide care for women planning to give birth at home without risk of professional sanction (as they have since 2002). But, given the accumulated evidence from Australia spanning 30 years, facilitating and funding home birth in an autonomous setting would be contrary to the principles of evidence-based health administration.

The outcome is that midwives can continue to provide care for women who have planned home births, but are required to provide full disclosure to their clients that they are not indemnified, and in return must provide data and participate in a safety and quality framework that will be overseen by the Victorian Department of Health. This should ensure a gradual accumulation of data (including statistics on outcomes such as maternal and perinatal morbidity) that can inform future policy direction, and also encourage adherence to proper clinical risk assessment and management to minimise preventable mortality and morbidity. Those who argue that planned home birth in Australia can be safe will have to show this on the basis of accumulated evidence before any further changes can be considered.

With time, the gulf between the politics and science of home birth in Australia should narrow, allowing health policymakers to focus on evidence-based decisions, rather than political ones.