Home birth under fire – again.

Caroline LovellHome birth has been in the headlines again following the release of the damning coroner’s report of the tragic death of Melbourne woman, Caroline Lovell who died as a result of massive postpartum haemorrhage in 2012 shortly after giving birth to her second child in her Watsonia home.

Let me just state from the outset that I believe this was an utterly preventable tragedy. Caroline Lovell’s midwife, Gaye Demanuele and her less experienced assistant midwife, Melody Bourne acted recklessly and with a complete disregard for safe home birth guidelines. My heart goes out to Caroline’s husband and their two children, who will grow up without their mother. Ms Demanuele should be prosecuted and never allowed to practice midwifery again. Ms Bourne, who had never practiced hospital-based midwifery has left the profession altogether.

But do I believe home birth is dangerous? No. Not if correct guidelines are observed, the mother is supported by a skilled and experienced midwife and a transfer plan is in place.

Do I believe that home birth should be outlawed? Absolutely not.

It upsets me that the media has taken hold of a tragic story like this and twisted it in order to create sensationalism.

A recent article in The Age reported that “renegade midwives and unqualified birth assistants who pose a risk to women and their babies can expect jail terms for repeat offences under new laws being introduced by the Victorian Government.

This includes midwives who have forfeited their midwifery registration and continue to offer services to pregnant women, such as assistance during home births. It also includes people who call themselves doulas or birth assistants that could put women and their babies at risk because of inadequate training and anti-medical views”.

Lumping midwives and doulas (or birth attendants) together is ridiculous. Doulas are trained to provide emotional and physical support for a labouring woman. The doula’s role does not extend to providing medical advice of any kind, nor should she have any direct involvement with a woman’s professional care providers. Doulas are not medically trained and the term “birth assistant” is misleading. They do not assist at births. They attend births. There is a huge difference and a doula who takes it upon herself to go beyond those boundaries should not be allowed to practice as a doula. However, due to a lack of any national guidelines or standards of practice, this is harder to enforce as there is no national registration of doulas – and therefore no way to be “deregistered” as one.

Perth-based journalist Karalee Katsambanis wrote in a recent article that “West Australians to sit up and take note to prevent any further deaths from a stupid and extremely dangerous practice”.

She goes on to say, “home birth always has been and always will be a game of Russian roulette, because, when things go wrong everyone wants answers and blames everyone except themselves.

Most of us have known women who seem to think they are the only ones ever to be going through a pregnancy, that they know best and that the rest of us who have had children know nothing.

These women ignore medical advice, because they want to believe that if they go into hospital like most normal people, they will be robbed of some kind of mythical birthing experience. Twaddle.”

I think it is fair to say that Ms Katsambanis is not a fan of home birth. She thinks that women who choose this option are reckless, selfish and in it for some kind of “experience” – all at the expense of their baby’s life.

Not only are her observations inaccurate, they are downright insulting to every woman who has ever made the informed choice to give birth at home.

In 2014, the National Institute for Health and Care Excellence (NICE) released new guidelines regarding the safety of home birth. NICE compared the outcomes for “low-risk” women giving birth in four different settings: the standard hospital maternity (obstetric) unit, alongside midwifery units (AMU – separate midwife-led units alongside an obstetric unit), a freestanding midwifery unit (FMU) and birth at home.

When looking at rates per 1,000 women, they found that most outcomes were generally similar or slightly better in the home, compared to the hospital setting. Results included the following:

  • Rates of spontaneous (not induced) vaginal birth were broadly the same in all settings, though slightly higher at home and in freestanding units.
  • Use of epidural or spinal anaesthesia for pain relief was lower at home compared to other settings.
  • Instrumental delivery rates (i.e. use of forceps or ventouse): for multiparous mothers (women having their second or subsequent baby), 9 per 1,000 at home, compared with 12 in FMU, 23 in AMU and 38 in hospital. For first-time mothers, 126 at home, 118 FMU, 159 AMU and 191 at hospital.
  • Rates of caesarean: for multiparous mothers, 7 per 1000 with planned home birth, 8 for FMU, 10 for AMU and 35 for planned hospital births. For first-time mothers, 80 for planned home birth, 69 at FMU, 76 at AMU and 121 for planned hospital births.
  • When looking at outcomes for the baby, there was no difference in rates of complications between birth settings for babies born to multiparous women.

Home birth has been around since, well, time began! It is an accepted and valid option in many countries around the world including The Netherlands, the United Kingdom and New Zealand. All these countries also have a long-standing tradition of midwifery-led care.

Australian midwives attending home births are required to be eligible midwives – that is, highly qualified midwives with a minimum of three years of hospital-based experience.

According to The Australian College of Midwives position statement on home birth services;

  • Birth for women and their families is a major life event and a rite of passage that should be respected and facilitated. Women have a right to decide where they wish to give birth to their baby. It is important that all childbearing women have access to evidence based, unbiased information that includes the potential advantages and disadvantages of birth at home.
  • Care from a midwife with consultation, referral and transfer mechanisms is key to safety.
  • Midwives have a responsibility to ensure that their decisions, recommendations and options of care are focused on the needs and safety of the woman and her baby.

According to the Coroner’s report, Caroline Lovell should never have been a candidate for home birth. She had an obstetric history of postpartum haemorrhage and Gaye Demanuele failed to adequately review her medical history – instead relying on Caroline’s own version because apparently she thought Caroline was a good “historian”. And most damning of all, when Caroline knew herself that something was terribly, terribly wrong – in her words, “I’m dying” – her midwife dismissed her, assumed she was having a panic attack and gave her Arnica and the homeopathic Bach flower remedy, Rescue Remedy.

In her antenatal appointments with Gaye Demanuele, a transfer plan was never discussed and when Emergency Services were finally called, they were given misleading information regarding Caroline’s situation, and the paramedics began treating her for suspected cardiac arrest. A postpartum haemorrhage was not on their radar. Had it been, they very likely would have transferred her to hospital much quicker instead of focusing purely on CPR. We will never know if this could have changed the tragic outcome.

The death of any mother or baby in childbirth is utterly heartbreaking, especially one that is preventable. But home birth should not be on trial here. Gaye Demanuele is.

Tanya Strusberg is a Lamaze Certified Childbirth Educator (LCCE) and founder of birthwell birthright, an independent childbirth education practice based in Melbourne. In 2015, Tanya was inducted as an FACCE (Fellow of the Academy of Certified Childbirth Educators) in recognition of her significant contribution to childbirth education. Through her internationally-accredited Lamaze Educator Training program, she is very excited to be training a new generation of Australian Lamaze educators.

Last, but absolutely not least, she is also the mum of two beautiful children, her son Liev and daughter Amalia.