Monday, April 20, 2009

making sense of risk management and safety in maternity

In the past couple of months the Australian homebirth and independent midwifery world has been experiencing a new level of challenges and threats to our very existence. The precipitating event was the release of the report of the Maternity Services Review. I have attempted to keep a running record of the published articles and other media, at the MiPP blog.

The safety of homebirth is the key issue in the minds of those who support, and those who are seeking to outlaw homebirth. How can 'safety' be so contentious? Is one party so biased that they can't see what is clear to the other? Are these professional people, on both sides of the fence, not intelligent, well educated, and supposedly ethical people? And what about the parents - consumers who choose homebirth, even though they have to pay for the privilege of not using the hospital? Are these people blinkered, uninformed, even careless about the safety of women and their unborn children?

I know most of our regular blog watchers are aware of these and other related questions, but for those who are still unsure, here are a few recent links:

Largest study in the world confirms homebirth is safe

SMH reporter Miranda Devine, in A home birth is not a safe birth ...

Dr Pesce's comment [ABC Unleashed] on 6 baby deaths in WA in 4 years, which he considered to be proof of the danger of homebirth. "The WA health department said:
"... that it is likely that the setting of the birth did not affect the outcome in at least five of the six deaths."

Another statement in the same article reported "a three-fold increased risk of a full term, otherwise healthy baby dying during a planned home birth ..." The paper from which this information was sourced has come under strong criticism for its methodology. Internationally respected epidemiologist Marsden Wagner, in reviewing the paper, noted that conclusions drawn about unacceptable death rates from unreliable sources are not valid.

There are many more references - both in favour of, and against, homebirth. The use of numerical data (quantitative) in understanding evidence must also be balanced with the qualitative research that seeks to report on 'why', and 'how' a particular decision is made or outcome is reached, rather than just 'how many'.

Complicating the whole picture is the rise in the number of unattended home births. There are anecdotes of the tragic death of babies born at home, and 'near miss' experiences, in recent months. Within the stories I have heard about births that have gone wrong, I have been shocked at assumptions that people have made, in justifying choices and decisions.

For example:
A mother planning unattended birth was told to send her husband or a friend to a St John Ambulance resuscitation course, to learn how to resuscitate a baby that is born not breathing.
Another mother took that plan a step further by employing a midwife to be present at her birth, but did not allow that midwife to auscultate the baby's heart sounds prior to the birth.
A mother giving birth unattended experienced delay from the birth of the baby's head to the birth of the rest of the baby. It took many minutes - too long - and the baby did not survive. A midwife would have been expected to intervene in an attempt to protect the life of the child.

I feel that I'm stating the obvious, but it needs to be said. Resuscitation does not work if a baby is already dead.

Much of the risk management in maternity care - both midwifery and obstetric - is to identify babies or mothers 'at risk' of poor outcomes in birth, and to take steps to prevent damage or death. None of us have a crystal ball: it's all about drawing a line. Homebirth is safe because there are important features of homebirth that minimise risk: for example, the mother's own environment; the absence of dangerous drugs and uterine stimulants; the one-to-one focused attention of the midwife. The Dutch maternity system, in which about a third of all births are at home, and for which safety has been clearly demonstrated, requires the midwives to screen women for risk. Women are expected to be referred to specialist (hospital) care if they develop complications, or if they are not progressing well, or ...

I cannot make generalisations about the practices of independent midwives and homebirth in Australia. It is likely that some have their heads in the sand (or in the clouds?), and are ignoring risk. What about homebirth for babies in breech presentations, twins, failure to progress? VBAC? Post maturity? Grand multiparity?

These are not yes-no answers. As some of my clients know, I will attend homebirths for women who would not be acceptable under most risk management selection criteria that I am aware of. That's one of the benefits of being 'independent'. Each woman can be addressed as an individual; each decision can be made individually; the care is woman centred in a way that may not be carried through in service guidelines. My commitment is to be 'with woman' - not to homebirth. If the woman is well and progressing well in spontaneous labour, she is free to decide where is the best place for her to give birth.

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