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Anti-Homebirth GP Rhetoric

Here is a telling article from Ausdoc. Pretty obvious on the disgusting attitude of medics to womens choice to birth at home, Some of the comments at the bottom sound like they are from a comedy. It’s hard to believe that Doctors get away with this crap. Luckly the Lovely Kylie Booth hails from South Australia.

general practitionerI am finding more and more that GP’s do not want to even help women with routine bloods for group and hb. This is immoral and I’m sure First do no harm has no meaning anymore. One GP recently said to me, “my insurance won’t allow it unless she sees an Obstetrician”. When I asked “surely insurance shouldn’t dictate good and safe practice”, she replied “It’s the way of the world”. How is it possible for the AMA to take this position and get away with it? When are we going to tell them to get stuffed because it’s just not good enough.

ETHICS: The evidence regarding homebirth for low-risk women can be contradictory, putting GPs in a difficult situation when patients ask for advice.

By John Kron

Adelaide GP Dr Kylie Booth offers the choice of homebirth to pregnant patients at low risk of labour complications. She sees it as her professional and clinical duty to do so.

“My concern is that women who want a homebirth are being discouraged by most doctors, causing many of them to opt out of the medical system and, as a result, miss out on receiving adequate antenatal care,” Dr Booth says. “As a GP who is open to homebirth, I can help these women stay within the system and have the best of both worlds, as natural a birth as possible but with a clinical safety net.”

Dr Booth, a mother of two young children, didn’t always think this way. “Five years ago I was like the average doctor who is taught that homebirths are dangerous and believed that only uninformed hippies do them,” she says.

“But after my own labour experience with my first child, who was a caesarean section, I investigated the evidence and found that what I had been taught was incorrect,” she says.

“My current understanding of the evidence is that midwife-led care and homebirth for low-risk pregnant women are associated with a lower risk of intervention during labour and better outcomes for the baby compared [with] hospital care.”

Dr Booth’s position is supported by a 2006 Cochrane review titled Home Versus Hospital Birth, which concluded in its “implications for practice” section that “there is no strong evidence to favour either home or hospital birth for selected, low-risk pregnant women”.

“In countries and areas where it is possible to establish a homebirth service backed up by a modern hospital system, all low-risk pregnant women should be offered the possibility of considering a planned homebirth and they should be informed about the quality of the available evidence to guide their choice,” the review said.

However, this is in contrast to the Royal Australian and New Zealand College of Obstetricians and Gynaecologists, which adopts a harm-minimisation approach to homebirth.

Dr Jeff Taylor, chairman of the college’s GP obstetrics advisory committee, says calling labour a natural thing is misleading. “Let’s not forget that 100 years ago natural used to mean a 10% death rate for mothers and babies,” he says.

This comment is simply not true Dr Taylor is lying to us… Maternal Health. At the beginning of the twentieth century, for every one thousand live births, six to nine women died of pregnancy-related complications. Sepsis was the leading cause of maternal death, with half of the cases following delivery (often performed without following the principles of asepsis), and half associated with illegally induced abortion. Hemorrhage and preeclampsia (convulsions) were other leading causes of mortality. In response to the high maternal and infant mortality rates, and to women’s suffrage, Congress passed the Maternity and Infancy Act.

“My reading of the available evidence is that there is a doubling of the perinatal death rate in the homebirth group.

“This is reinforced by my clinical experience,” says Dr Taylor, who is a GP obstetrician in Naracoorte in rural SA.

So How many babies has Dr Taylor in his experience seen tranfer into his hospital and die?

“Many times I have been present during labour where everything seems fine, but suddenly a complication occurs — like pronounced fetal distress — requiring immediate instrumental or operative delivery. It is too difficult to predict these complications … it is safer to be in a hospital where care can be provided quickly.”

However, in its 2008 position statement, the college recognised that a small number of women will choose a domiciliary environment in which to give birth.

“Women seeking homebirth should be … informed regarding the increased risks of homebirth in comparison to hospital birth for women and their babies, as demonstrated by available evidence … counselled regarding the significance of these risks as applied to their own obstetric condition [and] urged to consider giving birth in a suitable hospital environment such as a birthing centre,” the statement says.

So what should GPs do when there appears to be conflicting evidence and advice?

Dr Charles Douglas, senior lecturer in clinical ethics and health law at the University of Newcastle, says doctors should present the evidence to patients and allow it to speak for itself, while acknowledging that there is controversy over the issue.

“It depends on how much detail the patient wants to hear, but I would explain the standout opinions such as the [college’s] position statement and Cochrane review,” he says.

“It is also important to explain the risks in relation to the woman’s specific clinical situation. For example, if she is high risk, it is incumbent on the GP to discourage homebirth and to encourage a hospital birth because it is in the best interest of the woman and baby,” Dr Douglas says.

“If she is low risk, the next question involves looking at the available services for homebirth. For example, if the woman is in a rural area with only one midwife with below-average skills, the doctor should explain the risks of harm and discourage homebirth. Alternatively, if the woman is in an urban area near a hospital, it is more likely to be encouraged.”

Dr Taylor says doctors should be respectful of the woman’s right to make an informed choice, but with an important proviso.

He says doctors who disagree with homebirths should avoid being so negative that women are scared off any medical intervention. “But at the same time we shouldn’t be actively helping women to find a midwife to have a homebirth,” he says.

Dr Douglas agrees that respecting a patient’s autonomy is not limitless and doctors shouldn’t excessively compromise their clinical opinion.

“For example, a cancer patient might be refusing traditional effective treatment and seeking alternative therapies that have no proven efficacy. You are not under an obligation to find an alternative therapist for that patient,” he says.

“Similarly, where homebirth is manifestly dangerous, I don’t think doctors should feel that they must facilitate such a birth. On the other hand, in a low-risk situation it seems reasonable to help the patient find the service she wants. And in every case it is important to maintain a relationship with the patient and remain prepared to provide the degree of medical intervention that she might need and is willing to accept.”

Professor Wendy Rogers, professor of clinical ethics at Sydney’s Macquarie University and a former GP, says by not helping the patient to find a suitable midwife, the doctor is doing the patient a disservice.

“It is much better if there is a team providing care to the woman including a doctor to provide backup and a plan for going to hospital in an emergency,” Professor Rogers says.

“If the safety of the woman and baby is the doctor’s highest concern, then it is better to support the woman’s decision, which she is most likely going to end up doing anyway, rather than discouraging her. For doctors who can’t do that, they should refer the woman to a midwife and doctor who can, as soon as possible.”

One of the arguments against pregnant women choosing a homebirth is that they should do more to consider the rights of the unborn child to avoid harm.

Dr Taylor says women have rights, but they also have responsibilities. “At the end of the day, they have a responsibility to weigh up their birth experience versus an increased risk to [their] baby.

“Of course I understand that every woman will have a different perception of the risks. For example, there are women who regard vaginal delivery as too risky and choose a caesarean section. On the other hand, a woman may decide that the risks of homebirth are small and go ahead with it,” he says. “We don’t have a right to argue against the decision that a woman makes, and we certainly can’t stop women from doing what they want to do. It is the same as smoking cigarettes during pregnancy. Ultimately, the patient has the final right to decide.”

GP Dr Booth says the UN statement on the basic human rights of women states that women have the right to have control over, and decide freely and responsibly, on all matters related to their sexual and reproductive health.

“Some people believe that the child’s rights override the mother’s. However no woman would ever put her baby’s life at risk. A mother’s instinct is always to protect, and birthing at home is often the best start you can give your baby,” she says.

PRACTICAL RECOMMENDATIONS

WHILE the Royal Australian and New Zealand College of Obstetricians and Gynaecologists’ 2008 position statement strongly states that the college does not endorse homebirth, it provides practical recommendations including:

Women choosing homebirth should be cared for by both an experienced medical practitioner and a registered midwife, each of whom has agreed to participate.

It is recommended that women considering homebirth should seek information from their homebirth provider about the provider’s experience in homebirth, and their contingency plan in the event of an emergency including options for hospital transfer. Details of medical indemnity cover should also be ascertained.

All women booked for homebirth should be recorded by the relevant health authority. The health authority and care provider must ensure adequate and compulsory documentation so that meaningful data can be obtained for quality assurance.

Health professionals caring for women having homebirth have an obligation to ensure a system for immediate transfer to an obstetric hospital in the event of an emergency.

GOVT PROMISES TO RECONSIDER INDEMNITY

THE Federal Government has promised it will reconsider proposals regarding indemnity cover for midwives who offer homebirths.

The government initially said homebirths would not be covered by its indemnity scheme for independent midwives, due to come into effect next July. Midwives and supporters of homebirths have warned that the proposed laws will mean women cannot access registered midwives for home births.

The issue was brought to a head by debate on draft laws related to the National Registration Scheme planned for next year, which means health professionals will not be registered unless they are insured. The government plans provide indemnity cover for independent midwives working in hospitals. The cost of indemnifying each independent midwife has been estimated at $60,000-$100,000, but this does not include the cost of insurance for offering homebirths.

Homebirth Australia says the draft laws effectively stop registered midwives legally attending homebirths.

The Australian College of Midwives says the prohibitive indemnity costs faced by midwives offering homebirths mean that without government support they would have to give up, effectively driving the practice underground.

The government is examining ways of allowing homebirths to continue without imposing prohibitive costs on midwives, Health Minister Nicola Roxon said in a statement.

“I recognise a very small proportion of women would like to have homebirths and am … investigating if there is some way we can provide this as an option without making the proposed midwife indemnity insurance unaffordable,” she said.
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* “I recognise a very small proportion of women would like to have homebirths and am … investigating if there is some way we can provide this as an option without making the proposed midwife indemnity insurance unaffordable,” said Ms Roxon.

After the NSW case Simpson v Diamond in which $9 million was awarded in damages, there is no way that I can see midwives’ indemnity being of reasonable cost.

Why? Because risks in home birth that are readily dealt with in hospital are magnified when there is a lone midwife trying to cope with an unexpected complication. Transport and help are urgenly needed but asphyxia and hypoxic brain damage appears within minutes.

Only massive subsidies from the taxpayer will allow a small number of women the indulgence of indemnity for a home birth.

Further, as plaintif lawyers enjoin whoever they can in a suit, state-run entities are likely to be sued as well (ambulance if “late”, staff doctors at receiving obstetric unit etc).

Expect hardheads in state treasuries to knock all this madness on the head.

Posted by Jim Wilkinson 15/09/2009 2:16:09 PM

* We’ ll always have a dilemma until the common law can deliver a single attitude to people whose actions have harmed a fetus.

Doctors and midives can be sued for negligence, even towards a fetus, whereas a mother judged mentally competent can do whatever she likes (short of criminal acts) eg giving birth at home despite risk to her fetus, or refusing a Caesarean Section.

Mothers cannot be sued by their offspring even if eg the mother has knowingly used excess alcohol or taken addictive drugs in pregnancy, whereas the hapless doctor can be sued for all sorts of things (eg fail to diagnose rubella, giving drugs that turn out to be teratogenic, damage during labour).

Untill the law decides that mothers cannot willingly expose their fetus to risk, a few women will continue to take chances with home birth.

Posted by Jim Wilkinson 14/09/2009 8:30:18 AM

* As a provider of home births, I wonder whether Dr Booth will get the same government support for indemnity that the private midwives will get…

Posted by TracyS 11/09/2009 5:02:10 PM

* The midwive’s lobby argues for government funding of their professional indemnity on the basis that obstetricians have partial government funding for this purpose – but that funding applies to their non-paying public hospital patients (since the indemnity crisis of a few years ago, till which time they had to privately insure to cover all patients they treated). Since the midwives are in this to promote private practices in home-birthing, they should have to cop the premium for the risk incurred – just like the rest of us.

Posted by Ronald Watts 10/09/2009 3:38:04 PM

* Given that insurers are great at calculating risks and costs, if home birth is so low risk, why aren’t home birthing midwife insurance premiums lower? Some GP’s choose not to do proceedures such as obstetrics , including in rural areas where obstetrician access is lacking because the premiums are too high. Does the Government step in to provide them with free insurance? If not, why should the midwives get it?

Posted by Wondering 10/09/2009 3:38:19 AM

6 responses to “Anti-Homebirth GP Rhetoric”

  1. ries

    while there are many things to comment on here, I am getting sick and tired of the adage that my choice for home birth is based on my need for a "birthing experience" over safety of my baby… maybe just maybe, I read the cochrane data base, and have concluded that a home birth IS the safest option for my baby and myself. No forced episiotomy without asking me, no bath plug pulled coz the midwife is scared or inexperienced, no forced fetal monitoring that make me go insane and take painkillers I did not want, that cross the placenta and drug out my baby. no being forced to lie on a bed so the dr has a better view… no time clocks for my labour….etc etc..all experienced in hospital to make someone else feel safer or in control. These things affect my experience yes, but more importantly, the health of my baby. fetal distress? is there a link with maternal stress, and or adrenaline surges when a labouring woman feels threatened? will labour slow down..? duh! stop equating my choice to home birth with selfishness, when the health of my baby IS the most paramount thing I have researched several times over for 9 months at a time… Many of these commenting Dr's clearly think WOMEN are selfish or uniformed…when clearly they are only concerned with their cost of insurance, malpractice threats and providing only uninformed opinion, not evidence and support to thinking women (and their partners)!!!

  2. Amy HBACer

    "The government plans provide indemnity cover for independent midwives working in hospitals. "

    Maybe the definition of "independent" has changed recently? Coz I didn't think it included working for a hospital, and if they aren't working *for* the hospital but just *in* the hospital, how does that then cover homebirths… it doesn't!!!

  3. jessandgarry

    To ries… you don't have to have drugs in hospital, you don't have to lie on your back… and you don't even have to have a doctor! You can make it as natural as you want it to be.

    You ARE creating an increased risk to your baby by having it at home … and the evidence shows it. If everything goes to plan yeah it's great… BUT, if something goes wrong your life and your INNOCENT baby's life is at risk!

    Three of my close friends have chosen home birth… and ONE of the births turned out fine.

    Another of my friends DID need help while delivering her baby at home and didn't have it. As a result her baby was starved of oxygen and now has cerebral palsy. What a gift to give your child through what I believe is an AIRY FAIRY notion of being natural.

    The saddest case of all resulted in death. The baby must have been in fetal distress and it went undetected because the baby was not monitored… he was kicking during the labour process… and was born dead. RIP Harley James.

    We have the facilities to ASSIST mothers-to-be and REDUCE the risks associated with the birthing process. In my opinion you are definitely a selfish mother if you do not use them.

    To anyone who risks their child with home birth, I hope it all turns out for the best. I would hate to see another baby suffer because of their mother's choices.

  4. Lisa Barrett

    Unfortunately Jessica you are wrong, all the research shows that homebirth is safe. Check out Alexander Maclennons research, well documented and famous literature showing CP as an antenatal event and not a birth trauma. He is a well respected Obstetrician and not pro homebirth in anyway.

    The saddest of all cases at home AND HOSPITAL result in death. You have no idea if the baby must have been in distress. Check out how many babies totally monitored at the hospital die at birth.

    Maybe do a little more research and then comment again.

  5. jessandgarry

    Unfortunately Lisa it is only your OPINION that I'm wrong. It is VERY WRONG to state that ALL the research says homebirth is safe… this article is in fact a response to doctors who BELIEVE hospital is a SAFER option, hence the title "anti home birth GP rhetoric". There is research to support both viewpoints – that is why it's such a heated topic.

    After home birth being such a topic in my friend circle I did do a lot of research before having my children.

    It was an Ob who told Kelly that her baby must have been in fetal distress – I wouldn't make such a presumption. And as for the CP, I am repeating information passed on to the mum by her doctor also.

    After studying at uni for 6 years, being thrown a person's name to support an argument doesn't hold much weight. There is an ocean of research out there and thus it's not hard to find something to support your opinion whether it's correct or not. However, I am very interested to read what he has to say.

    Each one of my friends who have experienced home birth (none in SA, I must add) said next time they would choose to have their baby in hospital… I think that speaks volumes.

    The crux of it is (and I know this point will be highly contested… but it's my belief and I have a right to it) there is a good reason that the large majority of mums have their babies in hospital – and I don't think it comes down to funding… I think it's where they feel most comfortable. Sure there are a handful who want a home birth, but they are the minority.

  6. Lisa Barrett

    It isn't just my opinion, it is the view of the WHO, maybe read the joint statement of the Royal College of Obs and Gynae and the Royal College of midwives in the UK. Unless you have a large amount of homebirth friends one or two dont speak volumes as there are thousands of traumatised hospital birth women with a different view. You didn't even bother to throw in anyones name or any research to back up your argument so I must wonder where you are coming from. It wouldn't matter if you studied in uni for 50 years the facts are the same.
    I am sorry that you feel so angry about this.
    I'd love to see the research you did when you made your decision.