We’re midway through a series on birth and this week I’m addressing the topic of homebirth. As someone who was lucky enough to birth two children at home, this is the information – or at least a small portion of it – that I wish I’d had access to before embarking on my homebirth journey.
You may remember Noni Hazelhurst’s 2016 Logies hall of fame induction speech where she mentioned that the greatest joys of her life to date were the homebirths of her two sons. I watched that speech having had my first taste of homebirth only a few months prior and was happy to see a moment of public recognition for such a misunderstood and sadly, taboo topic.
Due to our cultural bias towards medicalised birth in this country, the decision to birth at home with a private midwife was not one I could take lightly at the outset. Approximately 0.3% of births take place this way in Australia and only 0.1% in New South Wales. Whilst the rates are climbing steadily in this country (we saw a rise of 54% in 2010, for example), these are still low figures compared with other parts of the world – our closest neighbour New Zealand has over ten times this rate (3.4%) and in some of the Scandinavian countries it’s over a hundred times higher.
So, to arrive at a place of genuine comfort with the idea of homebirth, I had to embark on a long, intensive period of research that thankfully led me to the firm conclusion that homebirth was not only a safe choice, but one that could offer an exhaustive list of benefits I hadn’t considered previously.
One thing that quickly became apparent in my research was that positive birth experiences tend to flourish wherever a woman feels safest. For many women this will indeed be in a hospital setting – for others like myself, and especially those who have had a traumatic hospital experience previously, it may be at home.
This piece is by no means a critique of the former, it’s simply an attempt to give some airtime to the relatively unknown benefits of the latter – a brief distillation of my understanding, for anyone considering this option.
What is homebirth
Homebirth is a planned event where a woman chooses to give birth at home, with care provided by a qualified midwife or midwives. In Australia, there are essentially two options of achieving this: through a hospital homebirth program linked to a public hospital or engaging a privately practising midwife.
Unfortunately, for the majority of women, there are significant hurdles to accessing either of these options: homebirth programs often have a long list of eligibility requirements that exclude many otherwise low-risk women and the cost of engaging a midwife in private practice will set you back around six thousand dollars.
Thankfully, most midwives offer reasonable payment plans and according to surveys undertaken in large homebirth forums and social media groups, it’s nearly impossible to find anyone who regrets investing the money – even though many have indeed struggled to do so.
Why do women choose homebirth?
There are countless reasons to birth at home. Too many for one article in fact, so I’ll be expanding on this area – including some of the more obscure benefits I wish I’d known about – in next week’s column.
However, to have an informed discussion around safety, we need to understand the primary advantages offered by homebirth. They include:
• Automatic access to the ‘continuity of care’ model
• Lower rates of medical intervention and associated complications
• Much higher rates of normal, physiological birth
What is continuity of care?
The continuity of care model refers to the process of receiving support from the same midwife or midwives throughout pregnancy and labour and in the weeks following birth. This model is not unique to homebirth, as some hospitals and birthing centres offer programs in this vein, however homebirth offers this model by default.
According to the literature, continuity of care is the ‘gold standard’ for birthing women and the fact that the large majority of women in Australia are unable to access this model (regardless of where they choose to birth) is a travesty.
This is the central issue addressed so eloquently in the recently released, multi-award-winning Australian film, ‘Birth Time’ – a must-watch for anyone interested in the topic of birth.
It is well established in the literature that women who receive continuity of care are more likely to have a normal physiological birth, a more positive birth experience with far greater satisfaction rates and are more likely to successfully breastfeed. Babies born to mothers receiving this type of care are more likely to be born at term and healthy. (To put it a little more bluntly, less babies die, in this model of care.)
Instead of short sessions with different care providers, women in this model receive longer, in-depth visits of up to an hour, over the course of their pregnancy. The relationship that builds between woman and midwife over this period allows a much quicker and more accurate recognition of when things deviate from normal – not only during labour, but also in the postpartum period, when mental health becomes a concern.
This brings us to the issue of safety and wellbeing.
Is homebirth safe?
The most common objection to homebirth from those who are unfamiliar with the literature (and unfortunately this includes many GP’s who are often the first port of call for parents in early pregnancy), are concerns relating to the safety of women and their babies.
There is now ample evidence, including large population-based studies, systematic reviews and metanalyses, which consistently show that homebirth is a safe option for low-risk women.
Few people are aware of the fact that for low-risk women in developed nations, homebirth is statistically as safe as birthing in a hospital. In fact, if we look beyond the archaic paradigm that considers perinatal deaths to be the only measure of a safe, successful birth (regardless of whether the mother is permanently injured or severely traumatised), it could even be argued that homebirth is safer!
Homebirth under these circumstances is not associated with increased rates of perinatal death but does result in lower rates of obstetric interventions and maternal morbidity, including severe perineal trauma, postpartum haemorrhage, birth trauma and postpartum depression.
Why are homebirth complications so rare?
Due to the lack of interventions and other factors that we’ll elaborate upon next week, homebirth complications are extremely rare. Unlike in a hospital setting, midwives are a constant presence in the room, calmly observing the labouring woman with undivided attention. They are therefore better equipped to accurately decide when management or intervention might be warranted and will generally suggest a hospital transfer long before any niggling issue becomes an urgent situation.
That said, midwives are trained and fully capable of taking care of the majority of complications that can arise and bring a range of equipment to enable suturing, resuscitation, management of bleeding and IV delivery – just as they would have access to in a hospital.
It’s not necessarily an either / or situation
The beauty of homebirth is that the option to transfer to hospital is always available. Hospital transfers usually take place for pain relief, fatigue or slow or stalled labour.
The average transfer rate is 37% for first-time mothers and 7% for subsequent births. Whilst there’s a significant difference in these transfer rates, there’s no difference in the rates of adverse outcomes.
Urgent transfers are rarer than one might think – only 4% of planned homebirths according to one review and studies have shown that there is no higher risk for mother or baby upon being transferred.
Stay tuned for the second part of this article where we’ll expand on some of the remarkable and unique benefits of homebirth, such as the surprising discovery I made throughout this process: that birth can be one of the most profoundly pleasurable experiences of a woman’s life!