making birth safer

... for the mother and her baby.

All maternity professionals are expected to act in a way that protects the wellbeing and safety of mother and baby. That's a reasonable expectation of any society. Midwives have guidelines and codes of practice and decision-making frameworks that are all structured around principles of safety and quality. 

The tragic death of a woman, Caroline Lovell, after giving birth at home in a Melbourne suburb, has thrust homebirth midwifery into the media spotlight. I have written about the breaking news at the MIPP blog. One comment summed up the situation,

"A tragic event is made sadder by the tendency of traditional media to suggest a causal link between the setting for this birth and the poor mother's passing before the facts have come to light."

I do not have information about the facts of this case, and I therefore cannot form an opinion.  I have heard the TV reports, read the newspaper reports and online commentators, and had conversations with other midwives and members of the community who have heard rumors.  A TV reporter who spoke to me before recording an interview told me that a leading legal person in Victoria had commented that she considered homebirth midwives to be "cultish".  I reject this notion.   There is nothing at all cultish in professional midwifery as described in international and Australian definitions and standards: the standards against which all midwives are judged. 


I am hoping that whatever tests are done, the autopsy, coroner's inquiry and report, and the investigations by the Nursing and Midwifery Board of Australia will satisfy my need, as a member of this community, to be confident that in this case, there was no professional negligence or unprofessional conduct.  I would have this expectation regardless of where the death occurred.

Many women have contacted their midwives with messages of love and support.  Women have also told their midwives that they are being questioned by concerned family members about their plan for homebirth.

The decision to give birth at home is made by the mother, with professional advice from her midwife.  If the labour is not progressing well, it's crucial that decisions about transferring care to hospital are made in a timely fashion.  This is the midwife's responsibility - not the woman's choice.  A labouring woman cannot be expected to monitor her own progress.  A mother and baby have limited reserves.  When the demands of the birthing process become more than the mother or baby can be reasonably expected to cope with under natural situations, the best option is to transfer care to a hospital which provides emergency obstetric care.  There can be no guarantees of particular outcomes. 

Dear reader, I have only touched on these deep and potentially unsettling issues.  The intense media interest in this case passed quickly.  However, midwives who are ready to learn from each situation will not forget.

The reports by Coroners are placed on the public record.  For example, a baby death in hospital from perinatal asphyxia. 

Thankyou for your comments

Transfer from home to hospital

A transfer from planned home birth, to hospital, can bring challenges to both the mother and the midwife, testing the partnership and trust between them.

From time to time, and at times unexpectedly, I need to arrange transfer to hospital. Being able to transfer care, without anxiety, from midwife-led primary care in the woman's home, to medically supervised specialist care in hospital is one of the most basic 'acts' that a midwife must be able to carry out in protecting the wellbeing of mother and baby.

Midwives working in hospital-based homebirth programs, and even birth centres, have a strict set of rules to follow. Any clinical finding that could be interpreted as an unacceptable 'risk' (such as previous caesarean surgery) or an escalation in 'risk' for mother or baby (such as meconium stained liquor) means that the midwife has no choice other than to follow the risk management process set down by the hospital.

Midwives working independently, in a private employment relationship with each woman, are able to consider the situation more broadly. This does not mean that midwives practising privately are unconcerned about risk. But it can allow a more holistic (whole-person) assessment of the situation, often meaning that the woman who is considered unacceptable for 'low risk' hospital-managed models (homebirth or birth centre) is able to proceed without any complication to giving birth to a healthy baby in her home, in the care of a midwife.

A publication that has guided and informed my practice in a significant way since the mid-1990s is the World Health Organisation (WHO)'s Care in Normal Birth: A Practical Guide (1996).

This paper does not primarily deal with the issue of 'home birth' or 'hospital birth': it focuses on 'normal birth'. That's a really important point. If birth is normal, the place of birth is of little consequence as long as the mother's and baby's needs are met. The midwife is fully able to attend such a birth, providing appropriate care.

The WHO (1996) paper provides a clear discussion of the 'Risk approach in Maternity Care' (p3), stating that

"An assessment of need and of what might be called "birthing potential" is the foundation for good decision making for birth, the beginning of good care. What is known as the "risk approach" has dominated decisions about birth, its place, its type and the caregiver for decades now (Enkin 1994). The problem with many such systems is that they have resulted in a disproportionately high number of women being categorised as "at risk", with a concominant risk of having a high level of intervention in the birth. A further problem is that, despite scrupulous categorisation, the risk approach fails signally to identify many of the women who will in fact need care for complications in childbirth. By the same token, many women identified as "high risk" go on to have perfectly normal, uneventful births."

The picture of the process of ongoing decision making in the birth process is described in some detail, including this series of highlighted paragraphs:

"Risk assessment is not a once-only measure, but a procedure continuing throughout pregnancy and labour. At any moment early complications may become apparent and may induce the decision to refer a woman to a higher level of care." (p3)

"We define normal birth as: spontaneous in onset, low risk at the start of labour and remaining so throughout labour and delivery. The infant born spontaneously in the vertex position between 37 and 42 completed weeks of pregnancy. After birth mother and infant are in good condition.
However, as the labour and delivery of many high-risk pregnant women have a norml course, a number of recommendations in this papeer also apply ot the care of these women." (p4)

"In normal birth there should be a valid reason to interfere with the natural process." (p4)

In recent years I have perceived a strong movement by the birthing consumer movement in this country, whereby a woman's 'choice' has become the guiding principle in calls for better maternity care. Choice that is not balanced by the critical judgment of a skilled midwife or other professional can be more dangerous than Russian roulette. A midwife cannot provide optimal maternity care if the woman's choice is more important than any other factor.

A woman giving birth has only one real choice: to either do it herself, or to submit to the medical care available. If there is a valid reason to interfere in the natural process, the midwife is bound to advise that intervention, even when it clearly goes against the woman's 'choice' or wishes.

This is often the situation when a midwife recommends transfer from home to hospital.

One of the key principles articulated by midwives in practising privately for planned home birth addresses the time of transfer:

"We support seamless and reliable processes by which midwives are able to make hospital bookings for women planning homebirth, and arrange transfer to the hospital in a timely way when needed."

[APMA Position Statement on Planned Home Births with a Midwife]

Thankyou for your comments