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The AMA says we are “shooting the messenger” re homebirth critique

Further to the posts below on the homebirth study, the AMA has sought right of reply.

Dr Andrew Pesce, for those who haven’t been following the story thus far, is the president of the AMA (which opposes homebirth), an obestetrician and gynaecologist, one of the reviewers of the new study, and also the author of the MJA editorial on the study.

He writes:

“Home birthing is a controversial issue in Australia and this week’s debate around the South Australian study is proof of this.

As would be expected, both sides of the debate put their cases strongly and passionately.  Unfortunately the passion sometimes gets in the way of the facts and the evidence.  Melissa Sweet’s critique of my editorial in the Medical Journal of Australia is a case in point.

My editorial was primarily about the politics of home birth.  Most neutral commentators have commended me on the balance of the editorial.

As AMA President, I transparently declared a potential conflict of interest based on the policy of the AMA.  I presume the College of Midwives, which strongly advocates for home birth and the role of private midwives, has similarly declared its potential conflict of interest in their complaint to Media Watch.

But let’s look at the study itself.  All the results mentioned are accurately reported, relevant and statistically significant.

The seven-fold increased risk is a statistical prediction of the most likely risk according to the data.  It is arrived at after exclusion of babies dying from congenital abnormalities and other conditions before the onset of labour.  The fact that it is statistically significant – despite relatively low numbers of planned home birth – is of more concern, not less.

The overall rate of perinatal deaths was not different, but only if you ignore the fact that a larger number of women planning to give birth in hospital have risk factors and complicated pregnancies.

When adjusted for prematurity and low birth weight, the overall perinatal mortality rate for all pregnancies planning a home birth was double that of planned hospital birth.  This difference did not reach statistical significance, but it is here that the relatively low numbers make the study’s findings unable to detect a statistically significant difference at this level of risk.

The study identified the same contributing factors that were found in a previous larger Australian review (Bastian H, Keirse MJNC, Lancaster PAL. Perinatal death associated with planned home birth in Australia: population based study. BMJ 1998; 317: 384-388).

The Bastian study found poor adherence to risk assessment, lack of monitoring of foetal wellbeing and delayed response to emerging complications in home births.

Incidentally, that study was actually designed under the auspices of, and funded by, Homebirth Australia, but the results are now repudiated by that organisation.

If a justification is needed for the AMA highlighting the concerning results of this study, it is that home birth advocates continue to deny the higher risks of current home birth practice, and the need for adequate risk assessment and management.

And, to be fair, my editorial did mention the lower intervention rates, the similar rate of post partum haemorrhage and other favourable outcomes of home births found in the study.

My point that the decisions regarding government policy regarding home birth should be based on evidence (light) rather than political pressure (heat) paraphrases the view apparently endorsed by Ms Sweet at the conclusion of her piece.

But what is the evidence for Ms Sweet’s claim that the MJA’s inclusion of an editorial by the AMA President has slanted media coverage?  There was not one mainstream media organisation that did not give coverage to criticism of the study (and the AMA) by home birth advocates.  Rather than slanting the story, my editorial provided an opportunity for home birth advocates to put their case.

As for the AMA media release, it does what any media release is meant to do: it emphasised the key messages around the AMA’s position on home birth.  By the same token, the media releases from midwives and home birth advocates state their position.

The AMA media release says clearly that the AMA supports women having choice about where they have their babies.  The AMA media release stresses the need for evidence and safety.  There is balance – far more balance than the commentary on this important issue that is found on home birth websites.”

• Dr Andrew Pesce is President of the AMA and a practising obstetrician and gynaecologist at Westmead Hospital in Sydney

Meanwhile, Croakey has just caught up with the 22 Jan issue of Australian Doctor, which has a page one story on related issues, including details of a study of the first 100 births through the St George Hospital Homebirth Program in NSW, published in the Australian and New Zealand Journal of Obstetrics.

The story says the study has reported “reassuring outcomes” and that “a growing number of obstetricians are calling for more support for safe homebirth models despite the AMA’s resolute opposition to the practice”.

Professor Michael Chapman, who has been involved in the St George program, is quoted saying that homebirths involving experienced midwives following strict hospital transfer protocols were appropriate for a small group of low-risk women who preferred to give birth at home.

He said: “Homebirth conducted in a random disorganised manner with independent midwives and patients who are pushing the boundaries of safety have given it a bad name. But in a controlled environment, I do believe the risks are minimal.”

Update: The AMA has been in touch to advise that Dr Pesce was a reviewer on this paper as well.

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  • 1
    Midwife
    Posted January 21, 2010 at 3:56 pm | Permalink

    Poor Dr Pesce is feeling attacked and now Prof Chapman speaks out? How do they think homebirth midwives feel???
    Homebirth with a private midwife is NOT “conducted in a random disorganised manner”. I live and work in Melbourne as a private midwife and I can tell you that our midwives are far more experienced and professional than many I have seen working in the “controlled environment” of our hospitals. We are members of our professional organisations, are peer reviewed, have codes of practice and regularly participate in ongoing professional education. We arrange for hospital back-up bookings (where the hospitals or doctors will allow it – most don’t!), carry emergency equipment and have guidelines for consultation, referral & transfer.
    What doctors and hospitals seem forget is that women still have the right to choose how, where & with whom they give birth. Provided they are given all the information, they actually do have the right to make their own decisions. You or I may not agree with them, however my job is to support the women, not coerce or bully them. That is what women experience in “controlled environments”!
    Maybe take a look at yourselves before you condemn homebirthing families and the midwives who support them.

  • 2
    AJ
    Posted January 21, 2010 at 5:13 pm | Permalink

    Surely for Dr Pesce to be reviewing this journal article constitutes a major conflict of interest. For starters he is the President of the AMA and the AMA owns and publishes the Medical Journal of Australia. The AMA, with Dr Pesce as its key advocate, is knee-deep in a political campaign against homebirth. So in order to avoid any perception of bias the Journal should be going to a different expert to review this article (given that according to their website they have a panel of 3000 experts to review articles and Dr Pesce cannot be the only one who specialises in obstetrics). I am not saying that Dr Pesce is biased but an appearance of bias is as good as the real thing and generally to be avoided at all costs.

    The Journal’s website links to the World Association of Medical Editors Position Statement on “Conflict of Interest in Peer-Reviewed Medical Journals”:
    http://www.wame.org/conflict-of-interest-in-peer-reviewed-medical-journals

    Here are some sections of it that I found pertinent:

    “However, it constitutes a problem when competing interests could unduly influence (or be reasonably seen to do so) one’s responsibilities in the publication process. If [conflict of interest] COI is not managed effectively, it can cause authors, reviewers, and editors to make decisions that, consciously or unconsciously, tend to serve their competing interests at the expense of their responsibilities in the publication process, thereby distorting the scientific enterprise. This consequence of COI is especially dangerous when it is not immediately apparent to others. In addition, the appearance of COI, even where none actually exists, can also erode trust in a journal by damaging its reputation and credibility. ”

    “A COI exists when a participant in the publication process is directly affiliated with an institution that on the face of it may have a position or an interest in a publication. …Professional or civic organizations may also have competing interests because of their special interests or advocacy positions.”

    “Reviewers should be asked if they have a COI with the content or authors of a manuscript. If they do, they should be removed from the review process. “

  • 3
    midwife
    Posted January 21, 2010 at 5:30 pm | Permalink

    It seems the messenger needs shooting in the foot? Andrew’s statement …”Incidentally, that study was actually designed under the auspices of, and funded by, Homebirth Australia, but the results are now repudiated by that organisation…further inflames the current situation and is questionable.
    Let me remind you the Bastian study was not done with the knowledge or consent of Australian Private Midwives (Homebirth) at the time. Private midwives were never informed, they did not give consent for their stats to be used and were not aware that the Bastian, Keirse study was being undertaken or funded by HBA.
    Our birth summary sheets, packed in boxes were taken from the HBA Office at the time and used without our consent. I speak of mine in particular. At no time was I informed by the authors or did I give my consent for Bastian or Keirse to use my stats for research presentation or publication. I spoke directly to Bastian. The consequences remain a stigma, there is a total lack of trust and that research remains controversial today. Interesting to say the least, by the responses and statistical critiques, the MJA article by Keirse et al, is also questionable today!
    Andrew, it is clear that you have a self interest and a clear AMA Union vendetta to remove the option of homebirth from Australian women and private midwives. It will not work, not in your lifetime or mine. Birthing at home is internationally acceptable. It is not about medical rebuff or politics it is about women’s decisions. Homebirth has never been extinguished and never will be while women continue to make informed decisions about their bodies, their babies and their birth. You would be best guided by the AMA, your Union, to use your time and skills more proficiently, rather than waste our time in dealing with you while you persistently try to eradicate the only sector of the midwifery profession, that genuinely provides women with safe, continuous maternity services. Professional, private midwifery services provided by the same midwife from early pregnancy right through to the sixth postnatal week, in the home, and is re contracted for future services, some for six and more babies. Would it be fair to say, why don’t you just get on with obstetrics and stop interfering in Midwifery and in particular privately contracted homebirth?

  • 4
    midwife
    Posted January 21, 2010 at 5:54 pm | Permalink

    Funny Professor Chapman, you to make an inflammatory statement and once again we respond. Privately contracted homebirth has been around forever and has only become an issue for the medical profession since their income has been threatened with the Labour Government’s, Maternity Services Review. Homebirth over a quarter of a century in my private midwifery practice and that of many of my colleagues has never been “conducted in a random disorganised manner”. Where did you get this information? Can you provide the evidence to support your statement? Have you ever worked with private midwives in their homebirth practice? Better still how many homebirths have you been to? Australian Privately Practising Midwives are not ‘pushing’ boundaries. On the contrary, women are. Responsible, self employed professional midwives respond to these women and provide the services they seek. Hospitals have only recently become part of the tax payers’ homebirth services and that is commendable. It is a real pleasure to know that homebirth is to be accessible for more women with access to midwives (not necessarily the same midwife) employed by the system. All we have to do now is to establish birthing on country so that the discrimination surrounding homebirth is completely reversed and all women will have the option to birth wherever they want, with the skills of primary services of midwives.

  • 5
    shell
    Posted January 21, 2010 at 7:18 pm | Permalink

    Dr Pesce is clearly on a personal and professional vendetta against home birth and private midwives. His ‘evidence’ that homebirth is risky or unsafe is 2 babies who died at a home birth in 16 years??? What about the 2447 babies who died in SA hospital births in the same period?

    When we look at the real evidence and see the truth about birth statistics from the perinatal data reported across the country at the Australian Institute of Health and Welfare what we find about homebirth is in 2006, there were 708 planned homebirths, representing 0.2% of all women who gave birth, that were reported nationally. There were 2091 fetal deaths in Australian hospitals in 2006. NO BABIES DIED AT HOME DURING PLANNED HOME BIRTHS IN 2006. This does not sound like the frightening 27 times more chance of a baby dying of asphyxiation or 7 times more deadly that this study and the headlines claim.

    AMA and RANZCOG must stop their scare mongering for political and financial gain and look at how to improve the safety of mothers and babies during birth in ALL settings. Women will continue to home birth as they have done for centuries and the medical establishment must provide willingly the support and backup for those women and their chosen care providers, their private midwives.

    It is unacceptable that the President of the AMA, himself an obstetrician has chosen to take this study and use it for his own political gain.

  • 6
    Croakey
    Posted January 22, 2010 at 6:30 am | Permalink

    Just a reminder to those posting comments: I will edit out aggressively personal attacks and any that are potentially defamatory. Some of the comments on this post have been edited.

  • 7
    Gary Caganoff
    Posted January 22, 2010 at 11:57 am | Permalink

    Gee, I didn’t feel like we did a ‘random and disorganised’ birth at home. I felt it was rather free and intimate and well supported. But then, I’m just a radical homebirthing father ‘pushing the boundaries of safety’ with my wife and midwife.

    Seriously, I actually think these guys have no connection to their feelings. Their own UNSAFENESS stems from there lack of connection to their feelings, which clouds there own intuitive trust that women’s bodies know how to birth and nor having dealt with their own fears of safety. You might think this sounds strange, but think, these guys have probably NEVER attended a NATURAL birth. They have only been trained in INTERVENTION. Which is OK when things DO go a bit wrong (and I’m not against a hospital back up). So MEN, LEAVE THE WOMEN ALONE AND LET them come to you for support if they need it. And then give it 100%, free of YOUR OWN fears.

  • 8
    presidentranzcog
    Posted January 22, 2010 at 2:41 pm | Permalink

    The Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) has been following the latest media furore about home birth and its safety, this one occasioned by publication of an article by Kennare and Keirse et al in the most recent edition of the Medical Journal of Australia (MJA), on a retrospective review of homebirth outcomes in South Australia. RANZCOG’s position on homebirth is outlined in a College Statement, with the link http://www.ranzcog.edu.au/publications/statements/C-obs2.pdf . The response has been predictable, with some passionate condemnation of the study by home birth supporters, and more measured responses from professional groups, including RANZCOG, who do not support home birth, and the Australian College of Midwives (ACM), who do. The statistics and their analysis have been examined exhaustively by the authors, Dr Pesce, in his accompanying editorial in the MJA, and on this blog spot by Sweet, and latterly by Dahlen and Homer for ACM.

    Retrospective studies have their own problems but do represent ‘what happened’, and the fact remains that certain outcomes in the study, such as the risk of perinatal death in home birth, were statistically significant. It is all very well for Ms Sweet to consider confidence intervals in disparaging the results, but she conveniently forgets to mention that the outcomes of the study may not be at the lower end of the confidence intervals, as she implies, but could be at the high end, making home birth much more risky than it already appears to be. Be that as it may, the study does add to our knowledge of home birth in an Australian setting, and the results should be interpreted in that context, and should be used as part of counselling for women considering birth outside hospital.

    The polarisation of the home birth debate between devotees of it, and those who have doubts, based on such evidence as we have about its safety, has reached an impasse. In RANZCOG’s opinion, Dr Pesce’s editorial in the most recent MJA was a reasonable interpretation of the study, and the current politics surrounding home birth. It is important that evidence about safe practice in maternity is reported, and incorporated into clinical practice, to better refine and improve systems of care, and clearly, results of current studies have to be used in counselling, to allow women to make as informed a choice as possible about their maternity care. To deny reported evidence, or to try to ‘dumb’ it down, when statistically significant findings have been reported, is mischievous, unhelpful ,and is the antithesis of evidence based medicine.

    Rather than ‘shoot the messenger’, as seems to have happened to Dr Pesce, it might be helpful in resolving the impasse and progressing the debate for a few things to happen. These could include

    1. An acknowledgement by home birth advocates that best available Australian data would support the view that home birth is more risky for mothers and babies than hospital births

    2. Attempts being made by professional groups involved in maternity care to build a safe framework around attempted home birth, as outlined in the RANZCOG statement, acknowledging that it will remain a choice for a small number of women

    3. Acceptance of the fact that some women do have added risk in pregnancy, and that they should not attempt home birth, and should be dissuaded, as far as possible, from making that choice

    4. Critical appraisal of hospital birth practices that disenfranchise women’s choice during childbirth, and instituting changes in those practices

    5. Mandatory data collection, and multi-disciplinary audit of outcomes for homebirth

    RANZCOG remains hopeful that the ongoing work that is happening as a result of the Maternity Services Review will result in positive changes to the way maternity care is delivered in Australia, and it is important that the different groups involved in provision of that care work collaboratively and with good will to effect those changes.

    Ted Weaver
    RANZCOG President

  • 9
    public homebirth
    Posted January 22, 2010 at 3:49 pm | Permalink

    “There is balance – far more balance than the commentary on this important issue that is found on home birth websites.”

    I am a homebirther who is passionate about homebirth but I agree with this statement & believe that at lot of home birth advocates need to take a deep breath & calm down. Yes it is scary for them to imagine homebirth may be outlawed but getting carried away is not helping our case.

    I believe in the right of women to make an informed choice about where they give birth. I think we need independent midwives in order to prevent the further rise of freebirthing as well.

    However Pesce makes a valid point that government policy should be encouraging safe practice.

    This is why we need more homebirth programs like the one run out of St George Hospital.

    I started a facebook group to advocate for this http://www.facebook.com/group.php?gid=131067042972&ref=mf & when I have more time hope to do more. This has made me unpopular in homebirth circles, as homebirth advocates are more concerned to protect the right of high risk women to homebirth (which i agree needs to be protected) than extend the right to the thousands of low risk women who cannot afford a private midwife, or who would prefer to birth in a system where they can make the choice at the last minute, or who simply don’t know much about homebirth but would benefit from the option ENORMOUSLY.

    Giving birth at home through the St George hospital program was the best thing that has ever happened to me. I would never had experienced homebirth if it hadn’t been for this public program. I would like to see greater cooperation between obstetricians & midwives to make this possible for greater numbers of women.

  • 10
    john2066
    Posted January 22, 2010 at 5:35 pm | Permalink

    Recent statistics show many obstetricians making over 2 million bucks a year out of medicare alone. Out of Medicare alone. Virtually all of the so called ‘safety net’ funding just went straight into multi millionaire obstetricians pockets.

    The doctors will simply pull out any stops to keep their lucrative multi million dollar incomes. Of course, what they WILL stop are any moves to have more surgeons; or any treatments that they can’t profit from, only they will determine how many new members will be admitted.

    Its quite simply time for a taxpayer/consumer revolt against the multi millionaire medical specialists.

  • 11
    Croakey
    Posted January 27, 2010 at 9:47 am | Permalink

    It seems that Dr Weaver may have missed some of my Crikey piece, which stated:

    “The home-birth babies were more likely to die during labour and delivery (intrapartum death) but the numbers were so small, there is a wide range of uncertainty surrounding the estimates of how their risk compared with the hospital group’s. (And remember that the overall perinatal death rate for the two groups was the same).

    Where the media generally reported home-birth babies being seven times more likely to die during delivery, the estimate ranges from them being anywhere between 1.5 and 36 times more likely to have this happen. Such a wide-ranging estimate means, as the authors themselves state, “small numbers with large confidence intervals limit interpretation of these data”.

    To go back to the actual numbers, over the period of the study, there were 247 intrapartum deaths among the planned hospital births and two among the planned home births (one of which occurred in a baby who ended up being born in hospital).

    A similar caution surrounds the widely reported finding that home-birth babies were 27 times more likely to die from lack of oxygen during delivery. Again, this finding had wide confidence intervals, with the estimate ranging from eight to 89 times greater — clearly, another one to take with caution.”

    I don’t believe this is “disparaging” the results; it is simply repeating what was reported by the researchers.

    Both the AMA and RANZCOG commentary infer that I am a homebirth advocate. Just for the record, I am neither an advocate for or against homebirth. I am, however, an advocate for informed public debate about health issues and I don’t believe the AMA/MJA press release or the subsequent commentary by the AMA and RANZCOG contributed to an informed debate.

    I am also an advocate of the need to reorient health services around the needs of patients and the broader community – rather than the interests of the professions, bureaucrats and politicians. Maternity services is an area ripe for such reform, as has been reinforced by the much of the recent debate.

  • 12
    mjnc
    Posted January 27, 2010 at 2:19 pm | Permalink

    A very warm Australia Day seems to be a good opportunity to blow some cold air onto the home birth debate that has produced so much hot air in recent days. It is also a good opportunity to emphasize that home birth in Australia is not necessarily comparable to home birth anywhere else. People, who have not read the original article on the outcomes of home birth in South Australia (Medical Journal of Australia, January 18, 2010), can easily succumb to the heat that it has created. This may well apply to the majority of people who visit this website. So, let’s be clear about it from the start.
    As conflicts of interest and protecting one’s turf, seem to be what the heat is all about, let’s be explicit about this too. I am an obstetrician, but I derive no income from any births, whether at home or in hospital. Having opted to pursue academic objectives, I have never had the desire nor the time to engage in private practice. I am the corresponding author of the article in the Medical Journal of Australia (MJA) and responsible for anything that is bad in it. (My co-authors may take responsibility for the rest.) I am also responsible for drafting the ‘Policy for Planned Home Birth in South Australia’ and for anything that is bad in this too. Everyone, who can access this Crikey website, should also be able to access that policy on the website of the South Australian Government and judge for themselves whether I am biased against or in favour of home birth. The web address for the policy is: http://www.health.sa.gov.au/PPG/Default.aspx?tabid=189.
    So, what about the study in the MJA? Did it show that home birth is unsafe? No, it did not! What it did show is that too many women in this country embark on a home birth in circumstances that are detrimental to the wellbeing of their baby. Contrary to what Professors Homer and Dahlen seem to suggest, in the third dot point of their commentary, many of these women are aided and abetted (at no small cost to themselves) by registered midwives who should know when and for whom home birth is safe and when it is not. Yet, not all of these midwives seem to know or seem to be willing to put that knowledge into practice. Is it surprising that no insurance agencies will provide indemnity cover for a practice that has shown a deplorable lack of self-regulation and quality assurance? It is easy to blame this on doctors, the Australian Medical Association (AMA), governments, or anyone else. The reality is that insurance companies have risk managers, who would be out of a job, if they did not know how to assess risks. I would argue that there are a number of independent midwives, who can learn a few things from them. This is not to say that there are no others and that there are no midwives who actually provide a superb service.
    From the contributions on this website, it is easy to gain the impression that Dr Andrew Pesce should be vilified for writing an editorial on the subject, because he happens to be the President of the AMA, which is opposed to home birth as it is practiced in Australia. Even the editor of the MJA, Dr Martin Van Der Weyden, seems to deserve criticism for publishing the editorial (and perhaps also the study), because the MJA is owned by the AMA. These two individuals, of course, are merely doctors and therefore alleged to be defending their turf.
    No such assumptions seem to apply to professors of midwifery, even if they seem to represent the College of Midwives on this issue. Whether Professors Homer and Dahlen actually presented the view of the College of Midwives or their own view is for them to judge and not for me or anyone else. Appearances can be misleading, but the messages in their comment are barely disguised and clear for everyone to read. There are mainly three that deserve attention from people, who may not have the time or energy to read the original article in the MJA, but who are intelligent enough to distinguish innuendo from fact. The first is that the data presented in the article are low level evidence. The second is that many of the deaths can be explained away. The third is that whatever bad outcomes are left may have nothing to do with registered midwives. Let’s deal with each of these in turn.

    I. The study presents low level evidence
    Professors Homer and Dahlen refer to a hierarchy among research data that has become commonly known as ‘levels of evidence’. Not everyone understands this, but at the top are systematic reviews of randomised controlled trials and at the bottom are expert opinions. On that scale, the home birth study in the MJA is, indeed, low level evidence. In fact, all home birth studies, conducted anywhere in the World, are low level evidence, on that scale. In our article, which really should be read instead of relying on biased extracts, we reported that there have been two attempts to obtain high level evidence. One was initiated about 15 years ago in England and another was attempted recently in The Netherlands. Both, predictably, collapsed nearly as soon as they had started. There are just too few women who like to leave an important decision, such as whether to give birth at home or in hospital, to the toss of a coin. We also pointed out that it is unlikely that high level evidence will ever become available and certainly not in Australia. Presumably, Professors Homer and Dahlen know this too, but labelling a study as ‘low level evidence’ has some attractions.
    For people, who are not familiar with the hierarchy among these so-named ‘levels of evidence’, it may be worth pointing out that many decisions in life are based on ‘low level evidence’. This includes, for example, whether one should take the stairs or jump through the window when leaving the top floor of a building. There is no high level evidence to say which is safest, nor which is quickest. Yet, most people will know the answer.
    So, there is basically nothing wrong with Professors Homer and Dahlen considering that this study is low level evidence, except for the overtone that is implied. It would have been nice, if they had been able to mention that the evidence, presented in the MJA article, still rates substantially higher on the evidence scale than academic or professional opinion. In fact, such opinion (including that of Professors Homer and Dahlen or anyone else) is recognised to be at the very bottom of the conventional levels of evidence.

    II. How many deaths can be attributed to home birth?
    There is not much wrong either with the second approach of Professors Homer and Dahlen in explaining deaths away. As we pointed out in the article, there were very few deaths and only three home birth deaths for which we thought that they might have been prevented. There are two issues here, however. First, for an individual mother, even one baby who dies is one too many. Second, Professor Homer and Dahlen’s approach of excluding deaths, for one reason or another, resembles arguing that our road toll is not as bad as it seems, because may people do not die on the spot, but in the ambulance or in hospital thereafter. Few people would be convinced, though, that the accident has nothing to do with their deaths.
    Further on in their comment, the professors continue the argument by stating that ‘transferring to hospital if or when risk factors develop during pregnancy is appropriate practice’. This is certainly true, but our study showed that this ‘appropriate practice’ is not practised appropriately enough, early enough, and frequently enough for hospitals to be able to address the issue. If it was, there would not be such a large difference in the frequency of preventable death between planned home and planned hospital births.
    Professors Dahlen and Homer are certainly correct that many of the deaths occurred in home births that were not low risk. Where is the evidence, however, that registered midwives in this country confine their home birth practice to women who are low risk? Where is the evidence that they actively dissuade women, who are not low risk, or decline taking on a job that is too big to handle? Moreover, where is the evidence, even in the contribution of Professors Dahlen and Homer, that leaders of the profession, whether it be its academics or its College, consider this issue crucial enough to reinforce it, let alone enforce it?

    III. Were the planned home births under the care of a registered midwife?
    At first glance, there is nothing wrong with the third comment either. Having reviewed all deaths in great detail, we know whether these women and babies were cared for by registered midwives. That information is not in the publication. We deliberately withheld it to respect the privacy of the individuals involved. Professors Homer and Dahlen might not know, but the College of Midwives, if it were to take its mission seriously, might know that all potentially preventable deaths had been under the care of registered midwives.
    Although it is not explicitly stated, the comment seems to imply that the safety of home birth results from having a registered midwife present. It does not. It depends on registered midwives, mostly independent midwives in private practice, knowing what is and what is not too risky and applying this to their practice. The frequency with which private midwives accept home birth for women, who have a twin pregnancy or who had a previous caesarean section, is a case in point. The risk of something serious happening during labour after a previous caesarean section is small, only about 1 in 200. However, when it does occur, the lives of both mother and baby are in the balance and there is nothing that can be done about it at home.
    Regrettably, Professors Homer and Dahlen missed an excellent opportunity to emphasize this to their colleagues and everyone else. I certainly hope that their comments were meant for general consumption and do not reflect the teaching that midwifery students receive. If not, hot Summer days may be the least of what we have to worry about in this country in years to come.

    On Australia day, it is sad to realise that Australia still has a deplorable track record on safe home births. Professor Michael Chapman is quoted on this website as attributing this is to the way it is conducted “in a random disorganised manner with independent midwives and patients who are pushing the boundaries of safety”. The statement may be a bit too general, but I basically agree with it. I also agree with Dr Andrew Pesce, whether he is president of the AMA or not, that this act needs to be cleaned up before we can progress any further. If those, who are so vociferous to defend or promote home birth, were equally vociferous in insisting on, complying with, and teaching adequate safety standards, we may still have hot Australia days, but there would be very little hot air left in the home birth debate. Moreover, mothers and babies would benefit greatly.

    Marc J. N. C. Keirse
    January 26, 2010

  • 13
    shell
    Posted January 29, 2010 at 2:00 pm | Permalink

    Dear Marc Keirse

    In your own words in your comments above you say about the study you authored “Did it show that home birth is unsafe? No, it did not!”

    Why then does the AMA send out press releases claiming the study proves homebirth has “higher safety risks” and “higher death rates” when in fact the study says the planned hospital births group has a fetal death rate of 8.2 per 1,000 which is 328% higher than the 2.5 per 1,000 fetal death rates for women who birthed at home.

    We live in a world where we go to war to make peace and this study and it’s use by the AMA is just another example of that.

    Your study and the AMA press release led the Australian public to be reading headlines about homebirth being ‘deadly’ ‘risky’ and ‘unsafe’ right before a Senate vote on the maternity legislation and yet Dr Pesce claims he wants more evidence based decisions and less politically motivated decisions (as per his editorial in the MJA).

    And you wonder why homebirth advocates feel upset?

    The AMA should focus on how hospitals can provide a better birth experience for women and babies who choose to birth there.

    In the recent Age survey of maternity services 63% of 1855 mothers who gave birth in the past five years agreed that public maternity units resembled ”herding yards” when asked if it was an appropriate description.” No wonder women choose to stay home!

    Leave women in peace to have our babies how we choose to, instead of attacking women who homebirth and the highly skilled private midwives who support us.

    Michelle Meares

4 Trackbacks

  1. ...] This post was mentioned on Twitter by Melissa Sweet, sandra blok. sandra blok said: The AMA says we are “shooting the messenger” re homebirth critique: Further to the posts below on the homebirth st… http://bit.ly/7U85qq [...

  2. ...] Link [...

  3. By give birth - StartTags.com on January 28, 2010 at 12:28 am

    ...] headed from Chicago to Boise, with a stop in Salt Lake City. There were 123 people were on board,The AMA says we are shooting the messenger re homebirth …The overall rate of perinatal deaths was not different, but only if you ignore the fact that a [...

  4. ...] release and an accompanying editorial by the AMA president, Dr Andrew Pesce (see here, here and here, for example of the previous Croakey [...

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