ACM Homebirth Position Statement & Guidance: My response

The Australian College of Midwives have issued an Interim Homebirth Position Statement and Interim Guidance for Privately Practising Midwives along with a request for comments. Here is the response I have sent…

As a privately practising midwife who attends homebirths I have grave concerns regarding the above interim documents and the direction of the College in general. I am providing my comments despite having little faith that the opinions of homebirthing women and their midwives will be heard or reflected. My main concerns centre on the expectation that the midwife, rather than the woman determines risk status, and then actively blocks access to birth options based on this assessment.

Evidence-based practice?

After a review of the research literature ACM acknowledge the lack of ‘good quality’ research into homebirth yet concludes that “it seems evident from the literature that planned homebirth is a safe option for women who are at low risk of complications…”. To my knowledge there has been no research specifically examining the outcomes of homebirth for ‘high risk’ women. Therefore, we do not have adequate research about outcomes of homebirth for women who are classified as high risk. However, we do have research supporting continuity of care for all women, and often the only way in which a woman can access this care is by hiring a private midwife and having a homebirth. There is also research available regarding birth outcomes for those women you have categorised as being too high risk for homebirth. Women classified as high risk (eg. previous c-section) often choose homebirth in order to increase their chance of a successful vaginal birth after accessing this research.

It can be argued that the way in which ACM have determined ‘high risk’ (simply by the chance of an adverse event occurring) places all women in a ‘high risk’ category. A woman with a ‘scarred uterus’ has a 0.5% chance of a uterine rupture during labour. A woman with an unscarred uterus has a 1% chance of a shoulder dystocia occurring. However, ACM is not advocating that all women should birth in hospital in case they experience a shoulder dystocia.

In addition, the notion that ‘evidence-based’ means purely ‘research-based’ does not align with the vision of early advocates of evidence-based medicine from which the concept of ‘evidence-based practice’ emerged . For example, Sackett et al.’s (1996) interpretation of evidence-based medicine involves blending research evidence with the expertise/experience of the practitioner and the individual requirements and choice of the ‘patient’. This definition of evidence-based practice seems more aligned with a midwifery philosophy than one which universally applies research findings to practice. Particularly in an area in which ‘good quality’ research is difficult to come by for many reasons. Midwives should develop their own body of knowledge on which to base practice using a variety of types of evidence (experience, intuition, research, stories, etc.), rather than trying to emulate the medical profession and their narrow/technocratic definition of evidence (RCTs).

In any case the right to self determination and bodily autonomy has nothing to do with research evidence or externally defined concepts of safety.

Redefining midwifery

ACM appears to be contradicting and re-defining the role of the midwife. The International Confederation of Midwives (ICM) Philosophy of Care includes these statements:

  • Midwifery care empowers women to assume responsibility for their health and for the health of their families
  • Midwifery care takes place in partnership with women and is personalised, continuous and non-authoritarian
  • The woman is the primary decision-maker in her care and she has the right to information that enhances her decision-making abilities.
  • Midwives provide women with appropriate information and advice in a way that promotes participation and facilitates informed decision making
  • Midwifery care promotes, protects and supports women’s reproductive rights and respects ethnic and cultural diversity
The Australian Nursing and Midwifery Council state that:
  • Midwives value the woman’s legal and moral right (in all but exceptional circumstances) to self-determination during pregnancy, labour, birth and early parenting on the basis of informed decision making (Code of Ethics for Midwives)
  • Midwives focus on a woman’s health needs, her expectations and aspirations, supporting the informed decision making of each woman (Code of Conduct)
  • Explains options while recognising the woman’s right to choose (Competency Standards)
These statements suggest that the role of the midwife is to share adequate information with women and respect their right to choose ie. to determine their own risk status and place of birth. Whereas the ACM statement requires the midwife to determine the woman’s risk status and withdraw support if her choices do not align with regulations. Whilst the midwife should offer consultation and referral – to enforce it does not respect the woman’s choice (and breaches confidentiality). I also object to the use of the word ‘refuse’ and think ‘decline’ would be less judgemental in relation to women’s choice. 
According to ACM “…a midwife has the right to decline to continue to provide, or to accept, midwifery care if it is felt that this would require the midwife to practise outside of the midwife’s scope, skills and competencies.” However, the midwife’s scope is debatable because it is based on what is considered ‘normal’ (by obstetricians) and for many women and midwives VBAC, post-term, breech etc. is normal. The College should support a privately practising midwife’s right to withdraw from care if she is unable to meet the woman’s needs. For example, she does not feel adequately prepared or experienced to attend the birth and/or will bring fear to the birth room. However the midwife should also be supported if she decides not to withdraw care and instead support the woman’s decision to homebirth despite any risks involved. The alternative is to leave the woman without a care provider who can identify if the birth becomes abnormal and transfer if necessary. Whilst some women choose freebirth – this should not be a choice based on the inability to access midwifery care.
Both the ICM and the ANMC state that midwives should promote normal birth and women’s ability to birth. Assuming birth will not be normal because the woman has a uterine scar, is over 42 weeks, has twins, etc. does not reflect a trust in the birth process. Midwives should be able to identify when birth deviates from normal, and when complications arise. But to embrace the obstetric stance of ‘birth is only normal in retrospect’ does not align with midwifery philosophy.
My personal observations from within the homebirthing community

The way in which midwifery is being regulated and redefined is resulting in registered midwives being unable to reflect the philosophy of midwifery and meet the needs of homebirthing women. Women are subsequently turning to doulas and birthworkers because they are the only practitioners able to provide ‘with woman’ care at home. As a registered homebirth midwife I feel unsupported by the College and marginalised by my own profession. I don’t want to be regulated the College – I want to be supported. Perhaps an alternative homebirth statement would be: ‘Women have the right to choose where and how they wish to give birth. Midwives must provide adequate information to assist women’s decision making and support their birth choices.’

We could learn a few lessons from history re. midwifery regulation: Gloria Lemay’s podcast Licensing and regulating midwifery – at what cost?

About midwifethinking

independent midwife, lecturer and student of all things birthy
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37 Responses to ACM Homebirth Position Statement & Guidance: My response

  1. Anna says:

    Sigh. Thank you once again for a thought provoking, well-researched and relevant post Rachel. As a 2nd year BMid student, I am struggling (STRUGGLING) with the idea that I have another 18 months or so of this degree (all hospital-based), followed by years of hospital servitude before I can even think about working in the homebirth field with any sort of confidence and respect. I know we need good midwives who believe in women and birth in hospitals, I know I need to focus on THIS woman at THIS time (starfish analogy and all that). But I just don’t know how I’m going to get through the next few years as a novice without losing my faith in normal birth. How much will I be affected and changed by hospital experience (and not for the better)? And if this is the future…where our own college doesn’t even support us…Let’s just say it’s very disheartening, discouraging and disenfranchising. And I’m not even a fully qualified member of the ‘group’ yet.

  2. Rachelle says:

    Really well written Rachel. I have applied to study midwifery next year and am very concerned about the ACMs stance here. Thank you for your post- I would love to be a homebirth midwife one day that provides true woman-centred care.

  3. Lauren says:

    Rachael, another amzing post. I thrive on your well researched and well worded information. And Anna, i couldn’t agree more. I am PETRIFIED of the many years i have ahead of me working in a hospital setting on my journey to become a midwife. But i love learning, so i will see each experience as something i can learn from and hopefully in my time in these environments i can empower as many women as possible to take control, even in these settings. I am optimistic there are midwives out there, working in our hospitals that haven’t yet given up their passion and hopes for the direction in which midwifery is going. Rachael the work that you do, even just with this blog, will educate future midwives and bring about a new generation of midwifery practice.

    • comadrona says:

      Anna and Lauren and all the other Mid students who are eating their hearts out about what is ahead for them in the hospital setting. Yes, it is really difficult – I’ve been there and I’m still there but now doing a few HBs as well. Try not to work full-time if you can manage it. On your days off, try to be in touch with home birthers and their midwives. Go to meetings and support groups, offer your help as a support person at births. If you start attracting your own clients, try to form a good relationship with an experienced MW who can sit by your side at the birth – income sharing can help smooth the way there. Never give up! Every woman you meet in the hospital will benefit from your trust in birth and your respectful care. The best antidote for fear is to hang around with mothers and midwives who have none! Good luck, we all need you.

  4. Bella says:

    Well said, I can’t agree more with what you have written. I am angerd, frustrated and deeply sadend by the approach the ACM has taken on homebirth. To be honest I am lost for words. To remove women’s choice and bodily autonomy is not only unethical but also has to be illegal. This is just wrong on so many levels. Shame on you ACM.

  5. Thank you Gloria Lemay for a voice of reason and pointing us again to who we are. I have circulated a document from the Netherlands which is the road being proposed for midwives there. It needs to be read if you don.t already suspect the motives within. We are all on the thin edge of wedge.and crumpling with emotion and fear – we are being governed again by those in power who wish to crush what they do not understand or will not hear. The midwives who felt strongly about home birth were supported by John Stevenson (RIP 2011) an obstetrician who despite his safe practice was de-registered for not agreeing with his more powerful obstetric college brokers.

    Midwives who are out of their scope of practice ought to be learning from those who are willing to share the art of midwifery. This has always been the practice and those governing the practice have allowed this to occur unabated for centuries. Unfortunately there are a few midwives who need to remember that we were once in Australia practising as unregistered nurses and midwives on hospital patients low paid students, governed by hospital administrators who did not care about this unsafe and unethical policy Their delight with the below award wages and 60 hour weeks until the 1970′s when we entered University. In the 1980′s we entered the care field as qualified and more highly paid research and evidence based thinking professionals. Thanks to the Unions our wages matched our knowledge base. I truly believe that the ACM will become irrelevant if it does not change its obsequlousness. I recommend that midwives join the Union and demand once again to have equal insurance cover and legal representation for their membership. Midwives have been attracted to the ANF when threatened in recent times I believe.

  6. Birth Smart says:

    This reminds me of the recent post by Navalgazing Midwife in which she describes a clause in the California Standards of Care that seems like a reasonable way to address situations of risk. Something like this would be a nice addition to the ACM recommendations.

    California Licensed Midwives were integral in the definition of our Standards of Care, including the, arguably, most important section in them, on page eight (emphasis mine):

    “Section V, Risk Factors Identified During the Initial Interview or Arising During the Course of Care, Part B, Client’s Right to Self-Determination: In recognition of the client’s right to refuse that recommendation as well as other risk-reduction measures and medical procedures, the client may, after having been fully informed about the nature of the risk and specific risk-reduction measures available, make a written informed refusal. If the licensed midwife appropriately documents the informed refusal in the client’s medical records, the licensed midwife may continue to provide midwifery care to the client consistent with evidenced-based care as identified in this document and the scientific literature.”

    http://navelgazingmidwife.squarespace.com/navelgazing-midwife-blog/2011/8/7/why-licensing-is-a-dandy-idea.html

  7. Sheila Vaughan says:

    Thanks Rachel. You express and state the facts that I struggle to express in words. It is so refreshing to read something so profoundly TRUE, written in the same academic style, but, with TRUTH not the medical dogma which (in my personal opinion) is written by the ACM. What has happened to the professional body, the MIDWIVES professional body is astounding, puzzling and very sad in my opinion for all women of Australia.

    I say: ‘go forth, all you medical model wishing women. Those of you who wish to embrace the medical model, have your babies, your way, I give my sincere blessings. Just leave the rest of us alone to birth in the physiological model in which we trust, believe and know to be true (by research, not only my personal opinion). Kind regards- Sheila of heartfelt homebirths, Wollongong NSW.

  8. Link to Pdf file _ Moves to transform Maternity Care in the Netherlands

    http://db.tt/rxoPono

  9. Crossing says:

    The ACM is not honouring their purpose, which is to support midwifery solidarity, protect normal birth, (midwives are also duty bound to do this, I learnt as a student midwife) advocate for women’s choices, and support and uphold the profession. After working in NZ, the situation here is lamentable. The powerful medical groups are claiming power to dictate how and where women’s choices lie. Bodily autonomy is inherent in our humanity. No one bestows it upon us, and no one takes it away. There is no fight. If women and midwives acted upon this imperative, we would be declaring our human rights to choose and to work in an ethical fashion. That is what we, mothers and midwives, need to do. Rachel, I am a midwife in WA. May I please contact you privately?

  10. These words also are so well said. WE need more and we need to copy and record all of these comments. I will write to the college but I am waiting on numbers. There are comments on face book and these added together do not make a huge number. But they do make strong messages from midwives. Comments made by midwives and students are appearing to be a consensus.

    The women wanting home birth are upset but as one writer said that has been taken to the public as a very clear message/. What we need now is for midwives to put their message similar to the above more stridently. Midwives writing here and on Facebook are having their professional integrity taken away by bullies. It is the silent majority of midwives who are not voicing their distress or are they ignorant as well of the injustice and unfairness of this latest missive from the ACM or don’t they care either?

  11. Liz says:

    I too am a new BMID student and totally appalled at Australia’s position on homebirth, We call this country a developed country. UK is a leader in homebirth, NZ is well ahead in this area.
    It is violation of basic human rights when women does not have a say in how/when/and where she births. Australia is very much behind in this regard. Highest rate of cesarian section in the developed world. And this is the lucky country. Not so luckly when you get bullied into doing something which you instictively feel is WRONG!!. This is outrageous!!.
    I do not want to work in a hospital system and watch women being butchered. This is not HUMANE

  12. i live in Ontario, Canada, where being deemed high risk = get thee to a doctor. with every test administered, i worried and worried about failing and being unceremoniously kicked out of my midwife’s practice. this stuff was literally the *only* thing i worried about during my entire pregnancy. it’s funny, i get so upset when people attack my amazing experience with natural birth by saying i was “just lucky” – but i guess in a way, they’re all too correct. i *was* lucky that i managed to fit into Ontario’s oh-so-narrow definition of “normal.” sigh.

    and as usual, great post – i really hope you gals can fight this in Australia!

  13. akismet-32ffbd6711e602c958b29aa99d4ee631 says:

    This is wonderfully written. I’ve been so angry ever since I read these documents. Women’s voice has been lost in all of this and her write to choose. Your post has galvanised me into action – I have a large network of women and midwives and will be sending out posts urging everyone to respond to these documents to get them changed.

  14. Denise Hynd says:

    Sadly I will stay working in Nz rather than come home and risk deregistration supporting women!

  15. Denise it has not happened yet we need you to send your note to ACM as well.
    . I have been reassured today that a huge output from attendees In Newcastle this month will be on its way. There are small groups out there working towards condemning this outrage.

  16. Look at list on HBAC FAcebook site for address of all members of Board. I will be faxing my letters to each member as well as email and may be snail mail registered. The more we have here and on Facebook stating they will write the better.

  17. shiremum says:

    As a ‘high risk birther’ who has experienced the dangerous failings of the hospital birthing system, it saddens & scares me immensely that by this statement i could be, nay should be, ‘refused’ IM care & would be forced to freebirth my next child. It should be my right to be able to obtain professional birthing care in the place i feel safest to birth my children.

    Thankyou for putting this so eloquently for the rest of us.

  18. Lauren says:

    I agree Shiremum. Im a pregnancy yoga teacher, training to become a doula and mother to a almost 1 year old boy. I had a traumatic caesarean birth experience at a hospital and I’m not sure what I will do if homebirth is not available for my next birth. I wanted to become a doula to support women during birth so that their wishes and choices are fulfilled without so much intervention and eyes to the clock. I recently received an reply back from Nicola Roxon on the subject of Homebirths after caesareans and she pretty much wiped herself clean of the whole thing, she basically said it has nothing to do with her. And maybe it doesn’t, but wow, thanks ‘Health Minister’ for your support. Utterly disgusted. Thank you Rachael for saying it all so well.

  19. Thank you for posting this and we will share your blog with our face book fans. ACM are accountable to their members and the women & their families that we are in partnership with. I hope that everyone who reads this and our page will stand up for human rights to self determination and write a submission not only to the ACM but use whatever medium to inform the public of this outrage.
    I am a private midwife from Melbourne and I SUPPORT women who have had a previous caesarean who want the best chance to successfully birth their babies. The only way to optimise this chance is at home.
    I will definitely be returning to this blog… Cheers :-)

  20. lynda Taylor says:

    We should alway have the right to choice for ourselves what we feel is the right path for us. Lynda mother of three, pre/post yoga teacher, Doula.

  21. Response on this link by APMA to the Age Article today 13.09.2011
    My title Death to Caesar by a thousand (s) words.

    http://australianprivatemidwivesassociation.blogspot.com/

  22. Pingback: Respond to the ACM interim homebirth position statement | National Alliance for Students of Midwifery

  23. Helen Young says:

    I wholeheartedly agree. As a new-grad midwife, trained through the Post-grad program, I am saddened by the lack of support for homebirth in Australia. I had my first two babies born at home in NZ – with the same, wonderful, trusted midwife. She was competant, experienced, and used a range of skills including accupuncture and herbal remedies throughout. My first 4 hour labour resulted in a direct OP birth without problems and an intact perineum. My second baby, also OP, was born after a long labour. My further two children were born in hospital in Australia, as I felt paying for homebirths was not justified! How I would now reconsider! Though my midwives were supportive and there were ARM’s for my last two OP births, I refused further treatment, and my two babies were born healthy. These labours were much longer, I believe due to the fact that the environment was not my first choice. I had felt more comfortable at home, and free to be myself. As a registered midwife, choice for women appears non-existant. Women come to hospital and passively accept ‘doctor knows best’ philosophies. We have to stand up and support choice above all else. I agree that this is lost within the medical model as ‘risk’ takes control. Where do we as midwives fit into this picture of patriarchy? We are being lost along the way. We need to teach the medical profession about patience and positive thinking! Though we understand their ways and their choices, the medical profession seem to understand little of ours. How do we word the benefits and success of a woman feeling ‘in control’ and powerful? How does this impact the life of mother, child and family in the years that follow? I, for one, can report that there is little comparison. Homebirth for me was the right choice. Psychological well-being promotes physiological success. End of story! Come on ACM. What are we here for?

  24. The following letter is my plea to the ACM to rescind the mistaken interim guidance document currently being acted on by the APHRA Board and leading to the suspension of midwives from private practice. I believe the ACM owes an apology to its members with whom there was no consultation prior to these documents being put in to the formal process. I believe all suspended midwives should be give financial and emotional recompense for the hasty way they have been unjustly treated. The offending documents should be withdrawn forthwith. Australia is a democracy we are told. The aforementioned process reflects paternalism and autocracy if not dictatorship. Beverley Walker

    To the Australian College of Midwives ACM Board of Directors by Ordinary Mail
    PO BOX 87 Deakin ACT 2600
    ACM Board of Directors (by Email)
    DATE 19TH September 2011
    Regarding
    Response to the ACM Interim Home Birth Position Statement and Guidelines.

    It is with grave concern that I write this letter.
    My authority to comment is based on:
    1. Associate Membership of the Victorian Branch of the ACM Member No M09731
    2. Calling Card (enclosed/attached) contact details contained within .
    a. This Calling card/letter was addressed to various Politicians for lobbying purposes.
    3. My submission to the Senate regarding Bill B. 2009 (a). Appendix II contain a small portion of my Curriculum Vitae and is in Submission to National Health and Medical Research Council. (b). Appendix 1 NHMRC

    I was pleased after I read the Position Statement as I support the philosophy of midwifery which it contained. I found the anomalies in the second document extremely disturbing. The word contraindication means NO and led me to examine the words “guidelines” and “informed”. I believe that there was a contradiction in intent by the authors. The rhetoric in the position statement is contradicted by the Interim Gudiance which contraindicates the following list “There are some contraindications to a planned homebirth which women should be informed of at booking. These are: • Multiple pregnancy • Abnormal presentation (including breech presentation) • Preterm labour prior to 37 completed weeks of pregnancy • Post term pregnancy of more than 42 completed weeks • Scarred uterus”
    Guidelines = a line drawn for further writing OR defines an area in which policy is operating. I assumed that further writing will occur but it seems interim turned into a weapon to turn on home birth practitioners and used to suspend I believe 18 midwives. The word “policy” = can mean prudence, practical wisdom or expediency. Expediency is a word that brings to mind the saying “more haste less speed”. Expediency is the unseemly haste with which the ACM Board acted. Being informed means much more than giving information. I expand on that in my submission to the NHMRC , The giving of a typed information sheet does not constitute comprehensive information giving. The time given to question and give feedback and exchange ideas is limited by the busyness of the giver. Signing that you have received the piece of paper does not enable the recipient to respond in time and with opportunities to clarify and much more.

    I respectfully request that you further consider the wording and intent of the interim guidance paper with regard to:
    (1) A statement that is clear, unequivocal and which supports the legal and ethical rights of the woman to refuse or to give consent
    (2) A statement which reinforces the midwife’s obligation according to the Australian and International Codes of the Midwife, .

    The use of the word contraindication closes the door on any of those meanings.

    Therefore I strongly recommend that the second document be rewritten so that it reflects:
    (1) The midwife’s legal and ethical obligation to advise women about the types of pregnancy which require special consideration.
    a. This ought not preclude her from supporting a woman’s choice to decide where and with whom she wishes to give birth.
    b. The midwives’ role is multifaceted and not easily replicated by others it includes providing education counseling and advice about a broad range of prevention and treatment.
    c. The midwife also has responsibilities to her profession
    d. The midwife also has to consider the future health of a double entity the mother and a child which cannot argue for itself.
    (2) The woman’s obligation to consult widely and consider all the harms and benefits of
    a. Either a home or hospital birth for example twins, a global population frequency of 1: 89 or any other “contraindication” referred to in the list.
    b. The woman has responsibilities to heed advice, but not necessarily agree to consent to interventions such as termination of her pregnancy because of convenience or because of unsubstantiated risks to her baby.
    (3) The midwife/or other professional ought to be required to give a curriculum vitae and practice history including rates of chemical and instrumental inductions, caesarian or other instrumental birth, haemorrhage, episiotomy infection and epidural pain relief.
    (4) I expand on this in my submission to the NHMRC (enclosed/attached) Recommendations 4: p 8

    The use of medical terminology such as contraindication is not in my opinion, appropriate. This list of “contraindications” is what set the alarm bells ringing for me. The “list” contravenes all I believe about the conduct of birth in all settings. In particular the contraindication list has blatant disregard for those individual women who have experienced a traumatic birth in hospital. In Appendix II Section 10-15 of the 2009 Submission to the Senate Inquiry, I give some personal examples which include example of hospital condoned rape and assault.

    In conclusion, I believe I am writing to the well informed. I believe that members of the Board are there because they care about healthy strong women having healthy strong babies together with the role of the midwife in ensuring this strength is enhanced.

    I suggest that any Faculty of Midwifery which considers a higher degree for home birth has in their hands one way of ensuring the credibility and power of the midwife to negotiate birth options for their clients.

     Private Practice for midwives ought to be a concept of fair trade.
     The Home Birth Midwife with a proven commitment to excellence is the gold card/epitome of all aspects of a midwife.
     The Universities with the support of the Australian College of Midwives, in my opinion should be considering setting the standards and employing experienced proven home birth midwives in private practice as clinical educators at some level of tertiary education as I did at RMIT University for 8 years.
    I also believe that the College of Midwives should be funding a Midwives Defence Fund which gives legal assistance to midwives against unjust and unfair vexatious reporting of midwives in private practice.

    Thank you for considering my plea for a more workable approach to home birth.
    I consider this approach will achieve a better approach to non-interventionist hospital birth, which ought to be the mission of the ACM membership and Board. I also expect that there will be more work done about equitable recompense for attendance at the birth from Medicare funding.

    Yours truly,

    Beverley Walker,
    Email: bevw1@bigpond.com PO BOX 241 VENUS BAY, Victoria , 3956
    ENCLOSED/ATTACHED

    The above letter has been altered to suit my current reflections I wrote the original under unusual circumstances

    • Thanks for sharing this Beverley.
      Some great suggestions for moving forward and away from the current medicalisation of midwifery (and birth). I hope the ACM listen to the outcry they have provoked.

  25. Karen (Australian Student Midwife) says:

    “Assuming birth will not be normal because the woman has a uterine scar, is over 42 weeks, has twins, etc. does not reflect a trust in the birth process.”

    It is not assuming the birth will not be normal, it is acknowledging based on evidence that such risk factors increase the risk of an abnormal birth which can compromise the health of mother and baby – severely, if access to medical management is not prompt.

    Midwives must be advocates for women too, but women must also know the seriousness and potential outcomes of these risk factors. Most women do not have the education and training of a midwife and it is difficult to judge whether their choice is actually well informed or lead by emotion.

    Personally I agree that only low risk women – those without the risk factors mentioned – should qualify for home birth. Dealing with uterine rupture at a home birth screams maternal and fetal morbidity and mortality; etc. In any case, shoulder dystocia etc can occur in the absence of risk factors anyway, and it would be a grave mistake, even with chances so small, to risk the health or life of the mother and baby.

    • Karen the concept of risk is personal and influenced by culture and society. I am a little worried about the underlying philosophy of some of your comments:
      “it is acknowledging based on evidence that such risk factors increase the risk of an abnormal birth which can compromise the health of mother and baby”
      - a women without a previous uterine scar ie ‘normal/low risk’ is statistically more likely to encounter devastating complications such as a cord prolapse or a shoulder dystocia than a women having a vbac is likely to have a uterine rupture (<0.5% possibly less when other variables are removed such as syntocinon induction, arm etc.). We can play with stats all day but in a country where less than a third of women complete labour without induction, augmentation, instrumental birth or c-section… our stats stink and we are unable to really assess statistical risk against this backdrop of routine intervention.

      "most women do not have the education and training of a midwife and it is difficult to judge whether their choice is actually well informed or lead by emotion"
      - this is very patriarchal 'I'm the expert listen to me'. The woman has lived inside her body all her life and has grown her baby. If anybody has the best interests of the baby at heart it is the woman. All choices are influenced by emotion, culture, society… chosing to birth with a private obs is an emotional choice (certainly not as statistically rational choice) yet we accept this choice. As a midwife you are 'with woman' regardless of her choice. You provide information and support not judgement. And that includes discussions around the 'what ifs' and the limitations of the home setting for managing some rare complications. I would also question if most midwives are actually 'well informed' or just reinforcing the authoritative knowledge which according to stats is not supporting normal birth.

      "Personally I agree that only low risk women… should qualify for home birth"

      - it is not about what you agree or disagree with! What do you define as low risk? You then go onto mention shoulder dystocia as a complication that can occur in the absence of risk factors… are you therefore suggesting that all women should birth in hospital because there are no guarantees a complication will not occur.

      I am guessing you have had no experience of homebirth and are therefore commenting based on a deeply embedded 'hosptial culture' philosophy of birth as primarily dangerous and the midwife and the expert and safety technician. I would strongly suggest that you try and get some experience in this area and learn from women about why they choose homebirth.

      I am not sure where you are studying midwifery but I suggest broadening your perspective by engaging with the homebirth community and asking questions. Also check out some texts that explore evidence and midwifery philosophy and practice eg. 'Normal childbirth: evidence and debate' – Sue Downe; 'birth territory' – Fahy, Foureur and Hastie. Also this article: http://download.journals.elsevierhealth.com/pdfs/journals/1871-5192/PIIS187151921000082X.pdf

      Don't ever stop thinking critially and asking questions!

      • Karen (Australian Student Midwife) says:

        I do agree that measuring risk is very individual. Risk is hard to judge for each woman because of all her individual variables. It reminds me of contraceptive choices; I know couples who have only used ovulation tracking methods and never failed, and know many couples who prefer to double or triple up on methods just to be fail proof. Individual preferences and their own assessment and view of risk… I suppose I just fear that a woman will be so strongly influence by her own emotions that she will disregard risk and place herself in an unsafe environment. I would also like to assure you that my personal views to not influence my care as midwifery being woman centered is key.

        (Also didn’t know about the VBAC thing stats vs. non-VBAC and risky outcomes. I had a follow through who had a successful induction (post dates) with VBAC; and she really really appreciated that she could have a vaginal birth, and it was hard to find someone who would okay it, but she got there!… So I hope that is an example of me broadening my mind and seeing how going against the hospital culture was a great thing)..

        Again I stress my personal views only extend to affecting my own personal birth choices when it comes to my time. As for having women given the green light for home birth, yes it is up to them and I hope they are fully informed of any (difficult to measure yes) risks, even if my views in my personal life conflict. Professionally yes all women should have the choice. I can disregard my personal fears to trust their choices as right for them. With a harm minimisation view, it is better for a woman to have a care provider if they are at home, rather than risk free birth at home where things really could go sour.

        Sorry I hope that’s not too rambly. Sleep deprived. But thank you for your discussion and I’ll have a read of the links you posted.

        I was also thinking last night (whilst reading some textbooks!) that it’s really hard to strike a balance between the ‘hospital culture’ and the ‘homebirth culture’. I was chatting to a fellow student a few days ago about birth centre philosophies of birth environment and holistic care and pain relief and we wish all of this was presented to not just pregnant women, but to the general public. There it would strike a balance more so there are less extremes (i.e. pregnant woman wants epidural because it seems easier and safer, vs. woman with many risk factors wanting to birth far from any medical access if things become risky)..

        Also, there needs to be more studies on outcomes of home birth and ‘risk factors’ identified leading up until the birth. I acknowledge that the preferred environment will impact upon the outcome of the birth positively, and would like to see this in evidence. (Stats, your fave.)

        Just thinking out aloud. I’ll leave it there.

        • I am so pleased you are thinking and analysing the issues and your thoughts. This is the most important aspect of midwifery education and ongoing practice. Some women will disregard risk based on their strong emotions or a previous experience – this again is their choice. Women need to (and do) take responsibility for their choices and ultimately live with any consequences. I always tell the women I care for that it is my responsibility to share information with them to assist with their decision making but their decision and the outcome of their decision is their responsibility. In an emergency situation I have a responsibility to provide the best/safest care in the setting I am in with the ‘tools’ I have – that is all. As midwives we all have our own boundaries in terms of who/what we will knowingly take on and these should be made explicit to the woman.

          There has been a recent and very comprehensive study in the UK (google it) about homebirth. Based on this research midwives and obstetricians are calling for more homebirths for ‘low risk’ women. They include a clear breakdown of what they consider ‘risk’. However, I don’t give much value to quantitative studies for a number of reasons (perhaps a blog post?). Also in the UK homebirth is very medicalised ie. partograms are used which are known to increase intervention. The transfer rates are huge because of the parameters they use to define ‘normal’.
          :)

          • Karen (Australian Student Midwife) says:

            Thanks for your reply :) It’s hard when you’ve seen the extremes of what can go awfully dangerous, and the pleasures of a very low intervention labour and birth. Such a balance we need to come to in Aus, to ensure the safety of every woman and baby – whilst accommodating their preferences and keeping them as comfortable as possible with a belief in their body’s ability to labour and birth.

          • Birth can be dangerous but I urge you to always explore ‘why’. I often get the ‘if I’d had my baby at home we both would have died because xyz’ When I say ‘tell me more about your birth’… it often starts with ‘well I was induced for…’ OK so you wouldn’t have been induced at home. Most of the complications occuring during birth are a direct result of the routine interventions that are almost invisible in the system. I worked in hospitals for years so I know how we can redirect the birth journey. :)

  26. Alison Reid says:

    Thank you so much, Rachel, as always you have nailed the problem succinctly. May you be heard!

  27. Robyn says:

    Hi Rachel, thanks again for the awesome blog. Just wondering if there have been any updates. I have not been able to find any on the ACM website. And what is the situation with insurance for homebirths where you are? In the NT the home birthing service is government funded and the midwives employed in the homebirth service here are covered by the hospitals insurance. I have heard this week that our homebirth midwives will no longer be able to care for women wanting a homebirth who have previously had a Caesarian :(.
    I was also interested in your thoughts if you have the time on the national guidelines for consultation and referral. Personally I don’t see how word plays discuss, consult, refer and letter plays A,B, or C help achieve this
    ‘The aim of these Guidelines is to provide an evidence-based, structured, decision-making framework for midwives caring for women at the commencement of care, during the antenatal period; during labour and birth; and in the postnatal period.
    The Guidelines are designed to facilitate consultation, referral and integration of care between midwives, medical practitioners and other health professionals, giving confidence to providers, women and their families.’
    Whether you discuss, consult or refer is irrelevant in my opinion what is important is you act in a timely appropriate manner in collaboration with the woman when and if necessary. The knowing of who should be sent straight to hospital for immediate review and who can wait for an appointment and who the appointment should be with is not addressed.
    Also the premise that the woman is in a continuity of care model with a midwife (wishes this was an option for all women not just a minority) makes these guidelines which are already shaky at best outright irrelevant in most cases because noone is taking accountability or ownership. Sorry just a Friday night rant.

    • Hi Robyn
      The insurance issue remains the same. You need insurance for all aspects of practice with an exemption for homebirth until 2015. My guess is that in 2015 the only insurance that will become available for homebirth will require the midwife to be eligible and heavily ‘wired in’ to a hospital, and strongly regulated. It will be the end of registered non-eligible midwifery homebirth practice. This is the direction ACM appear to be supporting.

      As for the new ACM guidelines. I don’t know. I am unable to access them as they have made the decision not to share them as an ‘open access’ document. So, you either join ACM or pay for a copy. Not very woman-centred as women can no longer freely access the documents that guide their midwives practice. Bad move in my opinion.

  28. Robyn says:

    3 years on and the situation in farcical, only 2 approved prescribing courses, 1 approved peer review process, only 1 hospital approving midwives visiting rights, no insurance for homebirths and bizarre collaborative agreements. The collaborative agreements would work much better if they were recipricol with doctors and obstetricians having the same obligation to collaborate with a midwife. Better still why not just collaborate with the woman and establish a plan with her and discuss, refer, consult from there as needed if the woman consents.

    • “Better still why not just collaborate with the woman and establish a plan with her and discuss, refer, consult from there as needed if the woman consents.” Now that would be a little too sensible and woman-centred ;)

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