Home birthing: the fiscal nips and tucks to our health system

All politics is local, and more often than not personal. Just a fraction of Australians birth at home but their fervour is at times evangelical. In Canberra’s grey rain this week, 2,000 devoted mums and midwives won a two-year reprieve from being deregistered and fined if they attend a home birth.

But there were few cheers for Minister Roxon’s back flip. Landmark reform stemming from the recent National Maternity Services Review proposes autonomy for midwives around prescribing certain drugs and ordering tests as well as long awaited access to Medicare and indemnity cover. But for home birthing midwives, there will neither be Medicare support nor any form of indemnity protection.

When it comes to the safety of low-risk mums birthing at home, the world’s foremost medical evidence authority is the Cochrane Collaboration. With appropriate hospital support says Cochrane, home birth and hospital mortality for low-risk bubs is comparable. Cochrane believes women have a right to choose between the two options.

A final fillip for home births is that Cochrane acknowledges that outcomes for mums may actually be worse in hospitals. The largest of all studies was a nationwide cohort of 529,688 low-risk planned home and hospital births by de Jonge in the Netherlands. It found "that planning a homebirth does not increase the risks of perinatal mortality and severe perinatal morbidity among low-risk women, provided the maternity care system facilitates this choice through the availability of well-trained midwives and through a good transportation and referral system".

For many mums, the traumatic hospital experience is the centrifugal force pulling hundreds out of our maternity wards to deliver at home. Midwives have followed, disenchanted by the “clock-in clock-out” hospital work and the constant turnover of care. They see hospitals as fragmented, overly medicalised and homebirth as a relationship-based approach rather than a technical exercise in baby delivery. The cascade of hospital interference includes needles and gas, probes and clips through to forceps, extractors and ultimately caesarean section.

For most of us gadgets and tools are part of the safe baby syndrome, the community expectation that every baby arrives in perfect health. Home birthers are rankled by any suggestion that they would ever subject their babies to any undue risks by delivering at home and believe massive nation-wide cohort studies back their claims.

Less acknowledged is that home births exert a counter-pressure upon our hospital system. Birth plans, continuity of care, the demand for fewer interventions and the reemphasis upon emotional attachment to mums are all hospital trends originating from the home birthing movement.

Few realise that the emerging threats to home birthing have more to do with the global financial crisis than any bigotry, intolerance or obstetricians. Late last year, flawed Treasury modelling prescribed a ridiculously large stimulus which threw Australia into debt faster than any other country. Like all resource exporters, our economy barely stumbled, but it’s too late to recover the cash. Now it’s up to Treasury to claw back the balance sheet. From alcopops and cataracts to IVF and pathology, our health system is paying the price for the ill disciplined spending elsewhere.

Until now the fiscal nips and tucks to our health system have been politically painless. Taxing alcohol drew public health support, pathologists are mostly corporate and cataract surgeons far too wealthy to arouse public sympathy in any case. Conception however is the most incendiary moral issue in medicine and our elected officials are about to learn birthing isn’t far behind. Australians rarely march in the streets; certainly not for blood tests or eye operations. But mums choosing home births do so in the context of historical resistance to their choices.

The Health Minister understands that extending indemnity cover to include community midwifery will come at a cost. It may only be 0.5 per cent of women who deliver at home, but actuarial analysis is complicated by the infrequency of intranatal misadventure and the potential for multi-million dollar payouts. Those calculations deserve to be performed, and insurers allowed to work with the sector to agree on how insurance can be made available.

The Health Minister’s two-year moratorium is a brief reprieve before home birthing again becomes illegal. Bad policy in two years is still bad policy. Its one thing to decimate home birthing by setting up an exclusive “registration” club for midwives which excommunicates those attending home births. It is an even greater affront to fine them. Such an approach will draw quality mainstream midwives out of home birthing and imperil safety.

The Minister would be far better advised to draw midwifery together under a single maternity care system of registration, indemnity and support. Home birthing will never disappear; we owe our mums and their babies a comprehensive system which recognises, insures and drives high quality maternity in hospital and at home. In this regard, Australia need only look to New Zealand for a two-decade track record of integrated community midwifery.