There’s been a lot of conversation lately about all the extra choices being offered to pregnant and birthing women. Such as publicly funded homebirth programs and birth centres. In terms of the maternity care revolution, my question is: just what, if anything, are these additional options adding to the landscape? How are they improving and increasing choice, autonomy and respect for birthing women and midwives alike. There’s a huge range of opinion on this ranging from: “they are offering women nothing” to “they are fantastic programmes that are offering women greater choice”. Sure they ARE additional options, but are they adding to the illusion of choice or are they adding REAL choice?
Birth centres and publicly funded homebirth programs certainly have the potential to add choice to the landscape. While they are obstetrically managed, by the hospital, they are also a way of “normalising” homebirth and midwifery care. Because the hospital wouldn’t “allow” something that was risky, right? So if they are allowing homebirth it MUST be safe. If you manage to tick all the boxes necessary it can be a great way to convince unsupportive family and friends that you are NOT doing something reckless and that homebirth is a safe option.
Anna from Qld has chosen a publicly funded homebirth program for her 5th birth due to the fact that her husband is not comfortable with an independent midwife.
A midwife attending a woman at home. Image courtesy of Wikimedia commons
Amy from NSW also chose publicly funded homebirth as a compromise with her partner. “He was sold on the lack of cost and the association with the government and hospital. I just wanted to birth at home”.
We also have some huge issues in Australia in regards to access to independent midwives. We are finding that there are fewer and fewer independent midwives as many of them either become medicare eligible (requiring them to follow hospital based protocols with regards to which women they are able to support at home) or leaving the profession due to issues surrounding insurance and vexatious reporting.
Chrissy from NSW chose a publicly funded homebirth program for her 2nd birth due to being unable to access an independent midwife in her area.
And if you do have independent midwives practicing in your area they need to be available for your estimated birthing time. And then you need to be able to pay for them. Costs vary widely but you can generally expect to pay between $2000 - $5000 dollars – even if you are able to secure a payment plan this is a lot of money for most families and you still have the risk that you will end up birthing in hospital anyway if complications arise.
Heidi from NSW has used both IMs and public homebirth and found herself quite stressed at one point during her pregnancy with an IM that she would end up birthing in hospital anyway, as the only reason she chose to hire an IM was due to wanting another homebirth. The IM fee was a significant cost for her family. She did not have this concern during her publicly funded homebirth because at that point she did not realise how much better birthing at home was!
But birth centres and public homebirth programs are very strictly managed. They are only available to women who are deemed to be low risk and are generally only available in metropolitan areas. And they are only able to take limited numbers of women each month. Given the exclusion criteria I am generally more surprised when I hear of a woman actually giving birth at home or in the birth centre than I am to hear they have been transferred out. Women can be “risked out” of the program at ANY point and left to find alternative care or simply referred to the general hospital birth suite.
Image courtesy of Wikimedia Commons
Tenielle from Victoria was excluded from the family birth centre on the basis of previously having had a stillbirth. While she felt that the midwives, who would have been the ones attending her birth, were supportive, the decision was made by the director. The decision was not based on her current health or circumstances and the fact that personal one-to-one care would have been extremely beneficial for her was completely overlooked. Tenielle was forced to choose a hospital to birth in and was treated very poorly – promises were broken and she was left deeply traumatised by her experience. She found this particularly hard to take after being treated well and having a positive birth experience for the stillbirth of her son. “If the birth centre had accepted me, I wouldn’t have ended up with a livebirth that was more traumatising than my stillbirth”.
Many women find themselves risked out of the program halfway through their pregnancy with few options left available to them.
Anna from Qld birthed her third baby in a birth centre and her experience was so positive she signed up straight away to birth number 4 there as well. However after a borderline result from the GCT at 26weeks her care was transferred to general birth suite. She was forced to see whoever was on duty and as such was given “5 different stories on how my labour and after birth care was going to happen…I ended up such a mess about it that my husband and I decided to switch to a private OB at 32 weeks”. Anna has signed up for a publicly funded homebirth program for her next birth but is second guessing her decision due to the strong emotional stress and worry of being abandoned again during her pregnancy.
Kerrin from SA was dropped from a homebirth program at 6 months pregnant due to her BMI being outside their policy guidelines. The OB “refused to budge. So I sacked them, hired an Independent Midwife and had a beautiful, easy, powerful, wonderful homebirth”.
Women can also find themselves risked out of the program during labour due to extremely narrow obstetric parameters. While most women would agree that if there were actual health issues then a transfer would be a sensible option, women are upset with the prospect of being transferred, with no consultation, simply due to “policy”.
CTG machine. Image courtesy of Wikimedia Commons
Belinda from Qld had planned to birth her first baby through the birth centre but “I was labelled too high risk for birth centre care during labour at 42 1 due to my gestation. I was asked to come up to birth suite for a ctg and then denied the chance to return back to the birth centre. But I was threatened with it from 40 11”. Belinda’s baby was born by caesarean. She did not feel compelled to “fight the system” for her second birth and simply chose an independent midwife to attend her at home. That experience was so positive for her and her family that she made the same choice for her third birth.
For me the idea of bodily autonomy is that WOMEN are the ones who decide how, where and with whom they will birth their babies. These programs DO NOT increase this. The decision as to whether a woman is “allowed” to birth outside of the hospital is made by the hospital. It is based on hospital policy rather than the evidence for protocol, or even the actual current health of the birthing woman. In many cases it is based on things which happened during a previous pregnancy and women have no say in how their risk status will be assessed. And whether or not a hospital employed midwife is able to attend a woman outside of the hospital is also dictated by these policies. A midwife acting outside of her employer’s policies will likely lose her job.
Caroline from Vic advised that her midwife was “fabulous and adaptable” and that “interestingly she has gone independent now, partly, I believe, because of the more restrictive guidelines that seem to have crept in over the past few years”.
Women are also not being respected enough to be given ALL the information needed in order to make an informed decision. Many women access these programs without being aware of what the exclusion criteria are and without being informed of what will happen if they fail to “tick all the boxes” throughout pregnancy and labour.
Anonymous from Qld accessed a birth centre for her pregnancy and birth. She was not told upon applying that if she failed the glucose tolerance test that she would no longer be eligible to birth in the birth centre.
The fact that women are being denied their right to decline these, and other, tests is also disturbing. Essentially women are being told they may only remain within the program if they give up their legal right to make an informed decision in regards to certain tests and procedures. Women are not generally being advised of the benefits, risks and alternatives of procedures or asked to make an informed decision in any way.
As with ANY birth it appears that whether or not a woman has a positive experience is dictated largely by whether her primary care giver is a good match for her. It’s really important to ensure that your primary care provider matches your birthing philosophy and supports your goals.
Danielle from NSW has had mixed experiences but says that the reason she has gone back to the same service is because her midwife is “amazing…She is woman-focused, empowering and not at all afraid to buck the system when required”.
Frances from Vic described her midwife as “wonderful”.
Publicly funded homebirth and birth centres can provide women with amazing and beautiful birth experiences.
Louise from NSW describes her publicly funded homebirth as a “wonderful experience. My midwives were amazing support people and I had excellent follow up care.”
Sarah from NSW had such a great experience that she “recommends the service to anyone and everyone!”
Heidi from NSW has used both publicly funded homebirth and independent midwifery care and found her publicly funded homebirth to be a far more positive experience.
Public homebirth and birth centre programs result in many beautiful, positive birth. Image courtesy of Wikimedia Commons
In terms of the maternity care revolution what are these programs contributing? They are adding a choice for women, but probably their biggest contribution is in normalising out of hospital birth and midwifery care. They are also an attractive option for low risk women who do not have the funds to hire an independent midwife. But it is really important to realise where the power lies within these programs: With the obstetric patriarchy. These are still a hospital based option requiring birthing women and midwives to “follow the rules”. They are also only available to a very small percentage of birthing women – there is still a desperate need for a birthing revolution for high risk women and women from rural Australia.
The government really needs to look harder at sorting out the insurance issues for independent midwives and also funding truly independent midwifery led birth centres thereby allowing women a true choice for non-hospital based care. It is extremely important that the decision making power be taken back by birthing women. It is the right of every Australian woman to decide how, where and with whom she births her baby – regardless of whether someone else deems her to be “high risk” and regardless of whether she lives in a metropolitan area. EVERY woman deserves REAL choice, REAL autonomy and REAL respect.
For further information about the maternity care revolution we need in Australia: