What are the forces that are exerted within our communities, pulling women, and midwives, toward professionally acceptable standards and actions?
How does a midwife make a clear and timely call, telling the woman who has employed her to provide homebirth services, that homebirth is no longer recommended?
Where is the cut-off, between low- and high-risk?
The ACM National Midwifery Guidelines for Consultation and Referral (ACM Guidelines 2008 - which are available to download free as a .pdf) set out situations in which a midwife is expected to consult with, and refer a woman to, an appropriate medical/obstetric service provider. Conditions listed under category C, requiring referral, include chronic hypertension, pre-eclampsia, multiple pregnancy, breech presentation at Term, coagulation disorders, diabetes requiring Insulin treatment, and many other medical and obstetric conditions and complications that may co-exist with the pregnancy, or arise during pregnancy, birth, or the postnatal period. A woman experiencing these complications requires coordinated maternity care from a team of medical, midwifery, and possibly other disciplines.
Another all-too-common-today situation is a woman who has had caesarean surgery for one or more previous births. According to the ACM Guidelines (2008), previous caesarean is category B, meaning that the midwife is required to facilitate consultation with a medical or other health care provider. The ACM Guidelines do not attempt to differentiate between those for whom homebirth is not recommended.
The South Australian Report of the Maternal, Perinatal and Infant Mortality Committee on maternal, perinatal and post-neonatal deaths in 2009 recommendations state clearly that "A previous caesarean section and breech presentation are contraindications for home birth."
As noted at the APMA blog, obstetrician Andrew Pesce has given advice on a way forward for those who want to bring homebirth into mainstream maternity care, with:
"Until those individuals and groups which advocate for publicly funded home birth unambiguously and publicly state home birth is unsuitable for high risk pregnancies, their advocacy will remain at the fringes of the maternity system."
- What do you want to do?
- Why do you want to do that?
- What is likely to happen if I say "no"?
"I find the 'trust birth' claim far too naive ... but I think a lot of women in their bubble want to believe it. Perhaps all our easy access to IT - internet/emailgroups/facebook etc has something to do with which women choose homebirth now and why and who and how cult followings get supported, possibly blindly."
I wonder today if some women are misusing maternity care, and abusing the trust of their midwives, in a cult-like way that over-rides partnership, and puts the woman's experience first and foremost.