Home birth – a discussion from my soapbox

Mention home birth in social discussion and depending on the social circle you are mixing with you may get extremely polarized opinions.  In the UK, government funded and supported home birth have been part of the NHS for many years.  It is seen as a great way to reduce the burden on hospital systems and allows women to labour and birth in a place that is relaxed and comfortable.  For low risk pregnancies it is safe option because of the infrastructure and systems incorporated into the process.

In Australia, the practice seems to be strongly discouraged by both the medical systems, and the government.  This means that the services available to the midwives facilitating home birth in the UK that make it a safe system, are not offered to mothers and midwives who chose to birth at home in Australia. A woman can still choose to birth at home, however the path is not smooth or easy.  Ultimately, without access to well facilitated hospital transfers, open and accessible sharing of medical records and welcomed co-management by the medical system, choosing a home birth in Australia is certainly not the path of least resistance.

For low risk pregnancies, a home birth with good medical backup and a shared care approach is a fairly safe option.  However for those choosing to go down that pathway in either  a higher risk category, or who are not able to access things like full medical records and easy systems to transfer to hospital when things aren’t going well, a home birth put both mother and baby at risk.  When both of these factors are at play it is a scenario for disaster – one that many might say is both entirely unnecessary.  I was recently promoted to read the coroners report in this tragic case in Melbourne in 2012 – an extremely distressing and sad tale that encapsulates many of these issues.

Knowing that no mother would ever deliberately put herself or her child at risk, what prompts a family to choose a scenario where the risks are perhaps questionably high compared to the benefits?  I believe that in these cases, the answer lies in a sense of injustice, disappointment, trauma and emptiness following an upsetting hospital birth scenario.  Emergency caesarians, situations where a woman and her partner are left feeling emotionally distraught, a perceived lack of support from busy midwives on the ward,  tiredness kicking in, breastfeeding issues, a sense of not being heard regarding medical care – the list could go on.    Even the very “best” birth and post partum experiences can leave a new mum feeling lost and confused.  Throw some traumatic experiences into the mix and a woman can leave hospital feeling angry, regretful, and resentful about her hospital experience.  Its not a big leap to see then that blaming the place and the people associated with those feelings is a potentially natural next step and walking away from those systems in subsequent pregnancies is somewhat understandable.

The main problem with this scenario is that the things that lead to the unpleasant scenarios in that birthing experience, potentially mean that any subsequent labour are predisposed to slightly higher risks.  If you had a post partum haemorrhage the first time, you have about a 14% chance of it happening in a subsequent pregnancy.  So, whilst it makes sense to not  want to go back to the place where all of this unfolded in the first instance, the body of evidence, says that this is exactly there you need to be.  I feel really strongly also, that in some instances, this  information is not taken full into account by both a pregnant woman and her partner when making an informed choice – ultimately, for informed consent to be truly that, a full understanding of the risks versus benefits needs to be thoroughly explored.  This has to include a discussion of the  follow through of potential consequences for the partner and extended family – if a mother dies giving birth in a high risk home birth, do the partner and family believe that the risk benefits ratio fits with their situation – are they prepared to bring up the child or children on their own.  This decision is not just about the woman’s desires  but the whole family.

Whilst the desire to walk away from hospital and medical systems  makes some sense in these instances, I believe that the scenario could be avoided  with a relatively cheap, low risk, no side effect intervention in the weeks that follow birth- a session or two with someone from those hospital systems (preferably someone involved in the birth)  who can offer a listening ear, reassurance, education and a plan going forwards.  I believe that the missing link in many of these scenarios is just that sense of not being heard, combined with a lack of full understanding of what took place and why, and what the future consequences might be.  This is not to say that the existing systems don’t understand this, or try to implement such an approach, but recognises that resources are often limited and the capacity to offer such a service is limited.

Research tells us that not being heard is one of the primary complaints of patients utilizing  medical services.  The same series of studies also tells us that reassurance and education in itself can offer fantastic outcomes with regards to reducing distress and improving other outcomes.  We need to start seeing the time spent both listening and educating patients as a clinical entity in itself, and in doing so allowing the time and funding required to deliver it.