Volume 192 - Issue 12
Planned home and hospital births in South Australia, 1991–2006: differences in outcomes
Authors: Marc J N C Keirse, Robyn M Kennare, Graeme R Tucker and Annabelle C Chan
Med J Aust 2010; 192 (12): 726-727. || doi: 10.5694/j.1326-5377.2010.tb03723.x
Published online: 21 June 2010
Published online: 21 June 2010
In reply: Dahlen and colleagues overlooked that we excluded births without professional antenatal care (n = 1217), ensuring that all 1141 planned home births in our study were cared for by registered midwives.1 Nonetheless, we appreciate their acknowledgement that our article contains useful recommendations. Yet, they failed to endorse these recommendations in their letter and in the earlier critique to which they refer. They instead draw attention to a lack of difference in total mortality, but dismiss large differences in intrapartum and asphyxia-attributed mortality through their misinterpretation of confidence intervals. Rare outcomes, such as these, inevitably have wide confidence intervals. However, it is wrong and misleading to use the lack of precision in how much more frequent they are as an argument to dismiss their significantly much higher frequency.
We tend to agree with the above correspondents, though, that proper integration of home birth care in maternity services might prevent some avoidable deaths that are a recurrent feature in Australian home birth studies.1-3 Indeed, we postulated this too.1 However, it is fallacious to assume that differences in outcome between Australia and other countries, to which the correspondents refer, are merely an issue of funding and access to hospital privileges for autonomous practitioners. The Netherlands,4 for example, has more than 40 000 home births a year, but only three midwifery academies, with a 4-year curriculum. Australia has less than 1000 home births a year, fewer than it has midwifery students, most of whom learn both nursing and midwifery within 4 years. Midwives in the Netherlands are medical professionals and carefully select only low-risk pregnancies for home birth.4 In Australia, on the contrary, many independent midwives accept home birth for pregnancies that are not low risk.1,2 Adherence to approved policies for planned home birth5 and collaboration with hospital services must be a prerequisite to their integration into maternity services. Unless leaders and teachers of the midwifery profession in Australia unequivocally condemn home birth for women with substantial risks, such as twin pregnancy or previous caesarean section, babies will continue to die needlessly, irrespective of any funding models.
References
- Kennare RM, Keirse MJNC, Tucker GR, Chan AC. Planned home and hospital births in South Australia, 1991–2006: differences in outcomes. Med J Aust 2010; 192: 76-80. <eMJA full text>
- Bastian H, Keirse MJNC, Lancaster PAL. Perinatal death associated with planned home birth in Australia: population based study. BMJ 1998; 317: 384-388. 0_CACJJECC
- Crotty M, Ramsay AT, Smart R, Chan A. Planned homebirths in South Australia 1976-1987. Med J Aust 1990; 153: 664-671. 0_pgfId-2045614
- de Jonge A, van der Goes BY, Ravelli ACJ, et al. Perinatal mortality and morbidity in a nationwide cohort of 529 688 low-risk planned home and hospital births. BJOG 2009; 116: 1177-1184. 0_CACBAJIA
- Department of Health, South Australia. Policy for planned birth at home in South Australia. Adelaide: Government of South Australia, 2007. http://www.health.sa.gov.au/PPG/Default.aspx?tabid=189 (accessed May 2010).