Homebirth and collaborative care agreements: an assessment of risk management for obstetricians.

Homebirth remains a contentious topic in Australia. At issue is the concern about the safety of giving birth at home. Opponents of homebirth point to the fact that any labour can develop sudden and unpredictable complications, leading to adverse outcomes for mother and/or baby. Those supporting homebirth state that with appropriate selection of low-risk pregnancies, and with care provided by accredited and competent health professionals, the incidence of problems is low, and safe outcomes can be achieved.

Published articles support either argument, but attempts to produce irrefutable evidence, in the form of adequate randomised controlled trials have failed.¹

Differences of opinion exist between RANZCOG and the Royal College of Obstetricians and Gynaecologists (RCOG):

• RANZCOG does not endorse homebirth and cannot support the practice of homebirth due to its inherent risks and the ready availability of safer birthing practices.²
• ‘RCOG and the Royal College of Midwives support homebirths for women with uncomplicated pregnancies.’³

Both Colleges provide references in support of their positions. RANZCOG emphasises that homebirth in Australia is associated with poorer outcomes for mother and baby, as compared to hospital birth. RANZCOG, however, supports the principle of personal autonomy in decision-making, but advises that if a woman is planning a home birth, she should be fully informed of all the potential adverse maternal and perinatal outcomes, as well as considering all the possible benefits. RCOG supports homebirth for low-risk pregnancies on the ground that it is safe, plus the fact that a successful birth gives an increased sense of empowerment, control and self esteem to the woman. RCOG however acknowledges ‘there are no known risk assessment tools which have an effective risk predictive value concerning outcomes in the antenatal period or in labour.’³

Both Colleges agree that women choosing homebirth should be cared for by experienced health professionals. RANZCOG states that both a doctor and midwife should be involved. Both Colleges agree that arrangements must be in place to facilitate rapid transfer to hospital if necessary.

The exact incidence of homebirth in Australia is not known. RANZCOG estimates that around 0.2 per cent of births in Australia occur at home. In 2009 this would have equated to around 590 births.

Philosophically, it is apparent that the obstetrician can adopt a position for or against collaborating in a homebirth, depending on which College statement he or she prefers.

For the obstetrician who chooses not to support homebirth and not enter into a collaborative care arrangement, there still remains the possibility of being asked to attend in an emergency situation when a complication of a planned homebirth has occurred. It is generally accepted that medical practitioners have an ethical responsibility to provide medical assistance to a person in need of urgent or emergency care, even where there is no pre-existing doctor-patient relationship.

In some circumstances, a medical practitioner (in addition to this ethical obligation) also has a legal duty to provide medical care in an emergency. Factors governing whether a legal duty exists include:⁴

• whether the request to attend is made of the medical practitioner in his/her professional capacity;
• the degree of physical proximity between the patient and practitioner;
• the practitioner’s competence to respond to the emergency, such as being appropriately qualified, having the necessary equipment and being available (in other words, not currently providing urgent treatment); and
• the condition of the person in need being made known to the practitioner.

What should the obstetrician who wishes to collaborate with a homebirth practitioner do? The most important action would be to meet with the homebirth practitioner (HBP) to establish agreed principles and practices, and to formalise these in writing. Several issues need to be discussed.

1. Is the HBP compatible with you and your style and standards of practice?
   Continuing and mutually supportive communication between the parties (including the patient) is essential to provide high quality care. All parties should be comfortable in discussing issues of management in a pregnancy.
2. Is the HBP accredited, competent and confining pregnancies in your geographical area?
   If the HBP is not known to you it is essential to request and check references. Geographical proximity to the hospital
   is necessary to enable rapid transport in the event of a complication occurring in labour.
3. How much care should the obstetrician provide?
   The Birth Centre model recommends the obstetrician see the patient at or around booking, at 36 weeks’ gestation, and at any other time if a problem develops. This arrangement should also apply to homebirth collaborative care.
4. What are the exclusion criteria for homebirths?
   The obstetrician and HBP must agree on what criteria indicate that a homebirth is no longer appropriate. There are many lists from many institutions of criteria which indicate a pregnancy is no longer low risk. All are very similar. Strict adherence to these criteria is essential for a safe homebirth, and only low risk pregnancies should continue with a planned homebirth.
5. Who takes charge when a patient is transferred to hospital? This must be agreed from the commencement of the collaboration. There have been many instances of resistance to medical obstetric management in hospital from homebirth patients and at times HBPs, when transfer to hospital occurs. There should be an agreement that once the patient is in hospital the obstetrician will make decisions and discuss these with the patient. The HBP should be supportive of these decisions.

Having reached a situation of mutual agreement and compatibility, a formal contract including the list of exclusion criteria should be drawn up and signed by both parties.

Probably the greatest concern for many obstetricians contemplating a collaborative care arrangement is the uncertainty about who is liable in the event of an adverse outcome caused by the negligence of the obstetrician, HBP or both. The uncertainty is increased when the HBP does not have indemnity insurance, as the only avenue for likely financial compensation is then with the obstetrician and his or her indemnity insurance provider. Generally speaking in the absence of an employment arrangement, or an arrangement where the obstetrician has agreed to supervise or direct the HBP in the performance of the HBP’s professional duties, at law⁵ each practitioner will be responsible for their own provision of health services to the patient.

Currently, midwives cannot obtain insurance cover for planned homebirths. They have a two-year exemption from 1 July 2010 until 30 June 2012 during which their registration does not require they hold professional indemnity insurance for planned homebirths.⁶ When assisting in relation to a planned homebirth, if the obstetrician and the midwife were both found to have been negligent in providing treatment and the midwife has no insurance cover or assets, then the obstetrician may be liable for 100 per cent of any compensation amount awarded to the patient.⁷

Should an obstetrician collaborate? The choice is up to the individual. There is agreement among many obstetricians, including the immediate Past President of RANZCOG, that collaborative maternity care in any pregnancy is likely to produce the best outcome for the patient. Both doctors and midwives want to have a healthy mother and baby at the end of a confinement. With cooperative collaborative care it is anticipated that, in addition to achieving the desired safe outcome, there is a greater likelihood that all parties will experience a high level of satisfaction about the birth.