Beyond the Battle over Birth - Article in the Australian today by Christine Jackman
"LIKE most babies, the arrival of Mia Davies was eagerly anticipated by her parents. So, too, was the arrival of Joseph Thurgood-Gates, due several months later.
But beyond the joy almost every birth in modern-day Australia generates, there really shouldn't have been much more to link the two infants. Mia was born in Brisbane, Joseph in Melbourne and they were among 297,900 Australians born in 2010.
Tragically, however, Mia and Joseph would be linked permanently as members of a wretched subset of those national birth statistics -- neonatal deaths (842 of which occurred in Australia in 2010) -- and by the fact that the confused events preceding their respective deaths ensured both would be the subject of inquests.
Victorian coroner Kim Parkinson's inquiry into baby Joseph's death was widely reported around Australia before it was adjourned last month, amid revelations a video of his mother's labour had been located.
Before then, the court had heard Kate Thurgood chose to have her baby at home, after her three previous children were delivered in hospital by caesarean section. At 41 years old, and with this history of caesareans, Thurgood would have been considered a high-risk prospect, according to obstetric convention.
But things became more complicated. Her pregnancy continued two weeks beyond the due date, and when she presented at Monash Medical Centre with bleeding, but not in labour, doctors advised the baby was in a breech (or "feet-first") position and recommended an immediate caesarean.
Thurgood declined. The next afternoon, she began labouring at home, with a private midwife arriving at 6pm and another shortly before 9pm. Soon afterwards, they determined that Joseph's heart rate had dropped dangerously low, and convinced Thurgood to return to the hospital.
But it was too late. Joseph was born at 10.16pm "pale, floppy and showing no signs of life," according to one doctor, who also told the inquest he had been "obstructed" from carrying out his duties by one of the midwives who had accompanied Thurgood, as well as the mother herself. Despite resuscitation attempts, Joseph died five days later, after his life support was switched off.
Like several other home births and "free births" (births outside hospital where the mother even eschews attendance by a trained midwife) that have gone wrong, media reports prompted angry comments from talkback callers and online posters, decrying women who opt out of the hospital system as indulgently placing their babies at risk.
Meanwhile, another inquest was proceeding in Brisbane. Like Joseph Thurgood-Gates, Mia Davies was not breathing by the time she entered the world. And she, too, would die soon after her birth, her parents having to face the horrible task of turning off her life support.
But that is where the similarity ends. Because baby Mia was born in one of Australia's largest hospitals -- the Royal Brisbane and Women's Hospital -- where her mother Gayle received attention from at least three specialist consultant doctors after her labour was induced. The little girl had been diagnosed in utero with congenital defects, including holes in her heart, but these were not considered life-threatening.
"There was no worry, no tension in the room," Gayle Davies told the inquest, recalling the early stages of her labour. "It all seemed hunky-dory."
However, at some point, Mia's heart rate began to falter, to a point later identified as "overtly abnormal" by Rebecca Kimble, the hospital's clinical director of obstetric services. But doctors and nurses attending the birth did not react to the unfolding emergency.
Staff continued to attempt to deliver the distressed infant naturally. "Why on this occasion did people behave so bizarrely?" Kimble, who was not involved in the delivery, would later testify. "That's one of the things that has baffled the department."
The inquest continues.
In contrast to the Thurgood-Gates inquest, there has only been one major newspaper report of the inquest (in this newspaper) and no community outrage. Similarly, last month, there was limited reporting or reaction to two more inquest findings -- one in South Australia and the other in the Northern Territory -- following neonatal deaths in hospitals, despite both hearing admissions of communications failures in the delivery suite and staff ignoring health guidelines.
Australian College of Midwives spokesperson Hannah Dahlen says this double standard, in which the mainstream community castigates women as self-indulgent or cavalier when they spurn the safety of hospital delivery suites, only to turn a blind eye when that safety is revealed to be less than guaranteed, is nothing new.
"Six to seven babies die in Australia every single day, and the vast majority do so in hospital," says Dahlen, who is also an associate professor in midwifery at the University of Western Sydney. "Most of them you'll never hear about. But not a single baby dies in a home birth without it becoming a media story often reported in hysterical, soap opera-like terms.
"If we put the details of those six or seven babies dying in hospital every day into the newspaper, we would all be terrified of hospitals. But we know that's erroneous. The thing is, it's just as erroneous to be terrified of home birth."
Dahlen, who has been called as an expert witness in some inquests, is far from a no-holds-barred advocate of home birth -- "our [college] position is that home birth is a safe option for low-risk women only, when attended by a competent midwife" -- and makes it clear the college would never endorse free birth, where a mother gives birth without any trained caregiver present.
But she says Australian mothers are being forced into making more radical choices, by a system that refuses to acknowledge or support women's preferences.
"What we have in this country, unfortunately, is a determination to prove home birth unsafe, and that's being achieved by not fixing the health system as a whole to make it safe," Dahlen says. "I've never had a woman turn to me and say 'I don't want to go to hospital' (when complications arise in a home birth) and I've always engaged with the hospital system as a midwife.
"But in some areas there's this attitude that if we make it as difficult as possible to engage with hospitals, hopefully home birth will go away And that's when you create this religious cause, where you send women underground and where they start making dangerous choices like free-birthing."
Professor Caroline Homer, director of the UTS Centre for Midwifery, Child and Family Health, agrees. "Free-birthing is a phenomenon that's really concerning. But women are choosing these things because they want to have continuity of care with a midwife, they want to give birth in water, they want to try to have a vaginal delivery after a caesarean, but the system won't support that. Even if they don't actually want a home birth, they are forced to go out of the system if they want those [other] things."
She notes inquests into home birth tragedies seldom explore why the mothers have been so reluctant to give birth in hospital. "Situations like [the Thurgood-Gates case] ring warning bells for me but nobody seems to have asked: what happened in those three previous caesareans that made her so frightened to go back? Because surely there was a lot of grief and trauma before. And why was there no clinician who was prepared to support her in a controlled environment, who could acknowledge those fears, address them and help her give birth in a supported way? As carers, we must not have looked after her very well."
That said, there is hardly a groundswell of resentment against conventional obstetrics or hospitals; in Australia, fewer than 900 babies are born at home every year, or about 0.3 per cent of all planned deliveries.
Rupert Sherwood, president of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG), points out it would be dangerous to base strong arguments -- either for or against the place of birth -- on such a tiny data set, adding that the "place of birth" debate is one where statistics can be misleading.
"You can find data to support whichever stance you want," Sherwood says, "but it's never been put forward [by RANZCOG] that having your baby in one particular place is a guarantee of safety.
"There is no 'best' model, apart from one that suits a woman and her partner, with informed consent and recognition that there is usually one or more healthcare professionals involved, potentially in a team outing."
Still, home birth numbers are steadily climbing again across the Western world, accompanied by impassioned public debate; so much so that last year, RANZCOG devoted an entire issue of its O&G magazine to the topic.
In one article pointedly titled "Jumped or Pushed?", obstetrician Michael Nicholl -- hardly a radical, given his status as Royal North Shore Hospital's clinical director of Women's, Children's and Family Health -- acknowledged hospitals were contributing to the phenomenon.
"In metropolitan areas, rather than an active decision to birth at home, the reasons for home birth were often an active decision not to give birth in hospital," Nicholl wrote. "It wasn't that home birth was the only option, but rather that hospital birth wasn't an option. Maternity care does not sit well with a hospital's primary focus on acute adult medicine and surgery."
Should birth be considered a process demanding acute medical care? Sherwood warns when things go wrong, they go wrong quickly. But how often do they go wrong -- and does hospital care insure against that happening, or actually contribute to the problem? The international, peer-reviewed research is not as unequivocal as the occasionally hysterical reaction to home birth might suggest.
A 2009 Cochrane Review of all relevant "home birth versus hospital birth" studies concluded giving birth at home was at least as safe for low-risk women as hospital birth, particularly in cases where the mothers had delivered their first babies in hospital.
"The change to planned hospital birth for low-risk pregnant women in many countries during this century was not supported by good evidence," the review concluded. "Planned hospital birth may even increase unnecessary interventions and complications without any benefit for low-risk women."
Indeed, it is this increase in medical intervention in birth, with limited evidence to support the long-term safety of such procedures, that particularly worries Caroline Homer.
"In a country where caesareans in private hospitals are reaching 60 per cent, what we're witnessing is a great, unnatural experiment," Homer argues. "I'm not doctor-bashing. I don't think it's medicine's fault. Society as a whole now encourages this expectation that there must be a magic pill or a magic operation to fix everything.
"So women are demanding (intervention in birth) out of fear but there is an onus on us as health professionals to provide it only where it is backed by strong evidence."
She points to a growing body of evidence that suggests children delivered by caesarean section are at greater risk of diabetes, asthma and other illnesses.
"Labour is an important part of physiology, so we have to ask what this means for the future. Meanwhile, we're in the bizarre situation where we have to do research to prove that the normal is OK. We're told we need to do research to show that standing up to deliver your baby is OK, or not having a monitor on all the time is OK."
Still, one thing is clear when interviewing health professionals who have attended births that have been complicated. Their opinions do not reflect the vitriol that can be found in blogs devoted to the topic.
"It would be really inappropriate to ever use a case to say 'we told you so' and we try really hard not to do that," says Rupert Sherwood.
Adds Homer: "I think what we learn from these cases is that we need to fix the whole system, not demonise one particular part of it. I'd make a plea for people to come together, and not let women be put in the middle of a battlefield."