Insights gained from a homebirth review conducted in Western Australia show that the decision to have a homebirth is more complex than is often assumed.

The traditional reason given as to why women seek homebirth is that, in the eyes of the woman, home provides the ideal environment in which to welcome your newest member of the family; a familiar environment with your own bed, access to your own bathroom, and care from people you trust. Medical orthodoxy taught me and my colleagues that this was irresponsible as it did not take into account the inherent risks associated with all births.

In 2008, along with Prof Caroline Homer, I was asked by the Western Australian (WA) Department of Health to review homebirths in WA.¹ The insights gained from that review suggest a rather different story. Reflecting on those insights since 2008, together with examination of my own personal dealings with ‘failed homebirths’ at the hospitals where I have worked over the last 25 years, indicates that the truth, at least in part, probably lays elsewhere. In metropolitan areas rather than an active decision to birth at home, the reasons for homebirth were often an active decision not to give birth in hospital. It wasn’t that homebirth was the only option, but rather that hospital birth wasn’t an option. The stories from women
and their partners are ones of ‘being backed into a corner’ with ‘nowhere else to go’ or a perception of being ‘pushed’ away from hospital care rather than ‘jumping’ for homebirth. Which begs the question: are the systems of care we have set up in hospitals contributing to the demand for birth at home?

The WA review was not directed to question the future of homebirth in WA, but was to make recommendations to optimise the safety of mothers and babies who choose homebirths. The review uncovered issues that could be divided into the three broad categories: structure, process and outcome. It subsequently made 24 recommendations directed at various levels within the maternity care system. Many of these recommendations were aimed at the issues that were driving the demand for homebirth.

There were four main themes that emerged from our interviews during the review:

• midwifery continuity of care;
• access to water immersion for labour and birth;
• vaginal birth after caesarean; and
• access to ‘birth centre’ environments.

Other themes related to the management of breech presentation, management of multiple pregnancy and autonomy in decision-making around screening, testing and monitoring. The issues raised were often against the background of a personal previous poor hospital experience, both public and private, or the poor experience of a relative or close friend.

Continuity of care

Midwifery continuity of care was a dominant theme. Women and their partners wanted care that began early in the pregnancy and continued through to labour and birth and, ultimately, to the end of the postnatal period. They wanted this care to be given by a single clinician or by a small group of clinicians they could get to know during the course of the pregnancy. Many had been disappointed by a previous experience of fragmented public hospital care or incomplete private care.

Water immersion

Water immersion for labour and birth was perhaps the most emotive issue. The restrictive physical environments and the lack of non-pharmacological methods of pain relief in many hospitals were deterrents to hospital birth. The desire for access to water immersion in labour and birth was strong. Where the physical infrastructure was available in hospitals, often the restrictions on their use meant they were effectively not able to be used by these women. There was often strong medical opposition to the use of water immersion based on folklore rather than the evidence or lack thereof.

Vaginal birth after caesarean

Vaginal birth after caesarean appeared to be a particular sticking point. Many women were unhappy with the circumstances surrounding their previous caesarean section birth or births. Many felt that while they had signed consent for the procedure(s) that they felt pressured into making the decision. Many felt that the counselling for the caesarean section did not include all the options available to them at the time or that the information provided was not balanced. Thus women wanted more involvement in decision-making for their next birth and wanted to avoid fighting for their choice of mode of birth. This is particularly borne out in women I have come across over the years who have had two previous caesarean sections who subsequently elect to labour at home. They have often attempted to engage with public or private hospital providers but the issue of a vaginal birth in these circumstances is ‘not negotiable’, hence the women go elsewhere for care. Rather than managing the 1.6 per cent risk of uterine rupture² in an environment with ready access to recognition and rescue of an emergency situation, the lack of ‘negotiation’ results in an attempted birth in an environment with rudimentary safety systems.

Birthing environment

Access to ‘birth centre’ environments remains a desire for many women and their families. The inability of many hospitals to provide a comfortable, private, labour-enhancing environment is a strong disincentive for hospital birth for some women. Many hospital environments are not seen as family friendly nor are they seen as capable of providing ‘individualised’ rather than ‘standard’ care.

Clinical risk management

This concept of ‘individualised’ rather than ‘standard’ care came up in the other themes as well, particularly regarding obstetric issues such as breech and multiple pregnancy and the decision-making to do with screening, testing and monitoring. The inability of care providers to ‘negotiate’ some issues, particularly in cases where there is inconsistent evidence, contributes to some women opting out of hospital-based care. The inflexibility of hospital systems may give clinicians certainty in their practice, but it gives some women the feeling of a need to seek alternatives. Individualised clinical risk management rather than risk avoidance, with its subsequent risk transference, is surely more preferable from a health system perspective.

Lessons learnt

The themes identified in the review are echoed in the published literature on the choice of birth settings. So, what are the lessons learnt from my perspective? Firstly, it has strengthened my belief that maternity care does not sit well with a hospital’s primary focus on acute adult medicine and surgery. Maternity care begins and ends in the community and only briefly intersects with the acute setting. While the birth event is clearly important from a safety and quality perspective, the way we organise care needs to focus more on the other issues raised in the review and elsewhere. While some of these issues are addressed in the National Maternity Services Plan³ under the work streams of access, service delivery, workforce and infrastructure others require particular work. These include:

• truly woman-centred care;
• the availability of continuity of care(r) models in the public sector;
• access to midwifery care in the private sector, including groups of obstetricians and midwives working collaboratively;
• more innovative birth unit design;
• individualised clinical risk management rather than individuals and/or hospitals practising pure risk avoidance; and
• improved communication between care providers and women.

It seems apparent that existing maternity care systems are for some women too medicalised and restrictive, and do not meet their needs. Developing a maternity care system with a diversity of options that are both safe and satisfying for women and their families is essential.