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.
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.
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
- 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)
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?