Planned homebirth in Australia

Debates about homebirth have a long tradition of producing more heat than light.1 This is not because people on opposite sides of the fence have a lack of reasonable arguments. Those opposing homebirth rightly argue that, irrespective of how well selection processes work, unexpected complications can and do arise and that several of these cannot be remedied within the home environment. Proponents, on the other hand, argue that complications are rare and that the home environment protects against undue interference in what is basically a natural process. They assert that hospital births lead to interventions that are not risk-free and are disproportionately frequent compared with the benefit that can be derived from them. Undeniably, there is truth to both sides of the debate. Both arguments boil down to an issue of numerators and denominators. As risk is everywhere, the issues are what and how much risk is acceptable and how much action is warranted to avoid that risk. Having both mother and baby to consider does not simplify matters. Essentially, this is what fuels the debate and produces the heat, because there is little light that can be shed on any of these questions.

The article by Catling-Paull and colleagues2 in this issue of the Journal is a commendable attempt to throw some light on the subject in the same way that recent studies in Canada,3 England4 and the Netherlands5 have done. Although widely different in size, they have two unifying features. The first is that they provide some useful numerators on what the major risks to the baby might be. The second is that their denominators relate to homebirths attended by qualified professionals within well regulated systems of governance. Interpreting the findings outside that realm is clearly unjustified, as previous Australian studies have shown.6,7 Assuming that similar findings might apply outside the governance of the public health care system is certainly a few leaps too far.

When drawing conclusions, it is good to realise that there is some debate on what is or is not a planned homebirth.1 Everyone agrees that a woman giving birth at home accidentally or unintentionally is not having a planned homebirth — but that is where consensus ends. Australian perinatal data collections exemplify this. In the Northern Territory, South Australia, Tasmania and Victoria, “planned” refers to the intended place of birth at the time of booking during pregnancy. In the Australian Capital Territory, New South Wales, Queensland and Western Australia, it refers to the intended place of birth at the onset of labour.8 Studies limited to what was planned at the onset of labour tend to overlook that labour constitutes at best only 0.5 per cent of the duration of a pregnancy. It is reasonable to consider only the end of pregnancy if one wishes to examine the effect of the birth locality and what is available within it. It is also fair to acknowledge that women may change their mind during pregnancy about where to give birth. It is not fair, though, to assume that the choice of birth locality is independent of other choices made throughout pregnancy. The high waterbirth and breastfeeding rates in the current study actually testify to that effect.2 When virtually no woman waits for the onset of labour to choose her preferred birthing place, why should we consider outcomes only from that point onwards? Perhaps it may embellish intervention and transfer rates, but there is nothing wrong with timely referral from home to hospital when the need arises either in pregnancy or in labour. If anything, it may add strength to the vast difference between properly governed homebirth programs and the homebirths that create newspaper headlines from time to time.

The low intervention rates reported in the study2 are commendable and commensurate with data elsewhere.3,4 What is less commendable is the low rate of oxytocic prophylaxis to prevent postpartum haemorrhage.2 Admittedly, and despite this, there was a low frequency of postpartum haemorrhage;2 however, its frequency is usually underestimated. It is a major cause of the most devastating pregnancy outcome, maternal death,9 and little can be done about it at home. Oxytocic prophylaxis is a very small price to pay for increased safety.10

In the final analysis, many may wonder why there should be publicly funded homebirth programs when data suggest that only 0.5 per cent of pregnant women in Australia opt for a homebirth.8 It is everyone’s prerogative to have an opinion on homebirth. However, it is a woman’s prerogative and her fundamental human right to determine her reproductive behaviour, and this includes how and where to give birth. The issue is how to accommodate the autonomy of pregnant women in as safe a manner as possible for both mother and baby. The study by Catling-Paull et al2 is a worthwhile contribution to that question.