There are some changes happening to private midwifery practice and insurance in Australia which may have some important ramifications to women wishing to give birth outside of the hospital system.
Why women are choosing homebirth
In our practice, we sadly have many clients who have suffered physical or psychological injuries (or both) when giving birth. These injuries can have profound effects on every aspect of their lives.
In 2023, there was a NSW Legislative Council Inquiry which examined the experience and prevalence of birth trauma before, during and after birth. The findings of that inquiry echoed the stories of the women we have acted for and highlighted the experience of a lack of autonomy during pregnancy and birth, including that:
- Decisions about the birth, and most particularly during labour, were made for them rather than with them or by them;
- There was inadequate information and explanations provided about the risks of interventions and possible alternatives in labour, and feeling pressured to make decisions;
- The overall labour and birth experience was dehumanising, with the decisions of others affecting women and their babies without any control or input by them.
Is homebirth safe?
Generally speaking, yes, homebirth can be safe, but not necessarily for everyone.
A review of 20 studies dated between 2000 and 2016 examining the outcomes of planned homebirth in ‘low risk’ pregnancies was undertaken and published by Safer Care Victoria in 2021.
In summary of the findings:
- There was no statistically significant difference in the rates of stillbirth or neonatal death;
- Homebirth was associated with a higher rate of ‘normal’ vaginal birth and a lower rate of caesarean birth or the use of instruments such as forceps and vacuum to assist;
- There was no difference in the rates of severe perineal trauma (vaginal tearing);
- Homebirth was associated with lower rates of manual removal of the placenta and post-partum haemorrhage.
Importantly though, this data only relates to pregnancies that are categorised as low risk, meaning that there is a single baby in a head-first position (with chin tucked to chest) being born at 37 to 42 weeks gestation, and that there is no history of a previous caesarean section or any conditions which may increase the risk of adverse outcomes during pregnancy and birth. In our experience, the number of women choosing to have children and who would meet these criteria are very small, with most showing at least one risk factor.
The assessment of risk
Adequate monitoring during a woman’s pregnancy and an accurate assessment of the pregnancy’s risk status is critical in minimising complications, which can be life-threatening to both mum and baby, occurring in a homebirth setting. The recent findings of a Victorian Coroner in the Inquest into the Death of Baby R serve is an important illustration of this.
Baby R tragically died six days after birth due to a lack of blood-flow to his brain during his birth, causing a brain injury. Baby R’s mother had given birth to her previous child by way of an emergency caesarean section due to an obstructed labour. She then suffered a post-partum haemorrhage.
The experience had been very traumatising for her, and she wished to avoid a further birth in the hospital setting. She consulted with a private midwife who considered Baby R’s mother’s pregnancy to be ‘low-risk’, despite her previous caesarean section and post-partum haemorrhage, and therefore offered to provide her services in the home setting.
Coroner Dubrow found that this assessment was not consistent with national best practice guidelines and that the midwife had failed to adequately advise Baby R’s mother as to the specific risks to her and her child during homebirth and failed to appropriately refer her for a consultation with an obstetrician.
Transfer to hospital
A further finding by the Coroner in the case of Baby R was that the midwifery assessments and monitoring provided during the labour at home were deficient. It was found that under the relevant midwifery guidelines, there should have been earlier consultation with the hospital when signs of fetal distress were present, leading to earlier transfer to hospital and the likely avoidance of Baby R’s death.
In a similar case involving neonatal death, NSW Police have taken the extraordinary step of bringing charges against two midwives attending a homebirth in Newcastle, after allegedly failing to respond appropriately to complications during labour and the mother’s subsequent requests to attend hospital over a two-day period.
Insurance – what is changing?
Ordinarily, private health practitioners in Australia are required to hold professional indemnity insurance against claims made against them, including claims of medical negligence. However, until recently, there has been no such insurance product offered by any private insurer for privately practicing midwives providing intrapartum care during a homebirth (as opposed to pre and post-natal care only). Privately practising midwives were therefore granted an exemption from the insurance requirement, with the federal government underwriting insurance costs.
This insurance exemption will end as of 31 December 2026, when all privately practicing midwives will require private insurance coverage if they are providing intrapartum care. Under the federal government’s Midwife Professional Indemnity (Commonwealth Contribution) Scheme, the Commonwealth will contribute to the insurer 100% of the cost of indemnified claims arising out-of-hospital intrapartum services provided by endorsed midwives.
It may seem as though this is a positive change providing additional protection to women choosing private homebirth and to privately practising midwives. However, a review of the Policy and Product Disclosure Statement of the sole insurance product currently available shows that there is an important exclusion in the coverage provided, including claims where the midwife has failed to take ‘all reasonable steps’ to comply with the relevant national midwifery guidelines with respect to consultation and referral and quality and safety in place at the time.
Considering this exclusion in light of the case examples discussed above where it is clear the relevant guidelines were not followed, it would appear that the midwives involved would arguably not be indemnified for any claim of medical negligence brought against them by the parents in the event of psychological injury as a result of their birth experience and the loss of their child. This could severely limit any compensation that may be available.
In fact, it could be argued that for most (if not all) medical negligence claims against privately practising midwives to be successful, it would be necessary to demonstrate that there had been a significant departure from the relevant best practice guidelines leading to maternal or fetal injury, and that subsequently the insurer’s indemnity for the claim may be denied.
It is unclear at this stage how this exclusion will be applied in practice, however, this should certainly be an important consideration for women when choosing to give birth outside of the hospital system under the care of a privately practising midwife.