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Ready to implement a publicly funded homebirth program? Consider this

Practice Translation

Homebirth in Australia

The safety of homebirth in high-income countries is largely uncontested – at least in the research literature. When women who are ‘low risk’ at onset of labour plan to give birth at home, they have similar or better outcomes, compared to similar women who plan hospital birth.1,2 Women desire homebirth because they want to avoid unnecessary intervention, feel comfortable and free to make choices, and have midwifery continuity of carer.3 Additionally, planned homebirth for selected women at low-risk of complications offers health services cost-savings.4,5 There are an increasing number of Australian programs that provide free access to homebirth provided by hospital-employed midwives.6 These are referred to as publicly funded homebirth programs.

A case study

A case study was recently published to assist in the scale-up of Australian publicly funded homebirth programs.7 The case study details the process of setting it up, including governance structures and processes, clinical standards, and equipment requirements.7 In addition, the article reports on clinical outcomes collected over the first 9-years, as part of quality assurance for the project.7 The case study provides an opportunity to translate what works to assist implementation of other publicly funded homebirth programs.

Recommendations

  1. Establish a homebirth steering committee and working groups The steering committee included executive management, consumers, doctors (obstetricians, paediatricians, and anaesthetists), midwives, a quality co-ordinator, a project officer, representatives from professional midwifery bodies, and local paramedical staff.7 Smaller working groups developed specific policies and procedures in response to mapping the woman’s journey and planning care at key points.7
  2. Develop a clinical guideline that meets the needs of the local area A multi-disciplinary working group developed the clinical guideline for approval by the steering committee and ultimately health service executive.7 The guideline was informed by international evidence about homebirth programs and outcomes.7
  3. Determine mandatory education and credentialling requirements Mandatory education requirements for midwives to provide homebirth included adult and neonatal resuscitation, intravenous cannulation, perineal repair, waterbirth, maternity emergency, and fetal surveillance.7 The credentialling process included that midwives with no homebirth experience initially received supervision from an experience homebirth midwife. In the case study, all midwives and paramedical staff participated in biennial simulation of maternity emergencies in a home setting.8
  4. Consider needs for additional equipment For example, the service may decide to purchase neonatal resuscitation equipment of the same standard as hospital equipment, specifically so it can deliver designated pressures for continuous and intermittent ventilation.7 Midwives also need laptops with remote access to complete documentation and birth outcome data.
  5. Develop administrative processes for homebirth admission and discharge In the case study, they developed a virtual ward.7 This meant that when the midwife attends to the woman at home in labour, she notifies the hospital to admit the woman. Again, when the baby is born, the baby is admitted to a virtual cot. This system enabled the service to access funding for an uncomplicated vaginal birth including consumables.
  6. Embed the program in a low-risk midwifery group practice In this widely available model, known midwives provide continuity of carer across pregnancy, birth and postpartum. In the case study, women planning homebirth had labour and birth care provided by known midwives either at home or in the hospital (in the event of a transfer).7
  7. Implement a collaborative process for risk assessment In the case study, the woman, the midwife, and the consultant obstetrician discussed birth planning together, with reference to the inclusion, exclusion, and transfer criteria.7 Assessment for homebirth suitability was ongoing during pregnancy (e.g., booking, 36-weeks). Risk assessment continued during labour, birth and immediate postpartum to ensure timely and seamless transfer if needed.7
  8. Review all outcomes for first 12-months In this case study, all outcomes were reviewed by the practice improvement committee; any adverse outcomes were reviewed through usual processes.7

Conclusion

Less than 0.5% of Australian women access homebirth,9 despite strong evidence of safety, quality, and cost-savings. “Ultimately, the goal should be to ensure that all women who are suitable and would like a homebirth can access safe evidence-based care”.6 Well-designed publicly funded homebirth programs are central to achieving this goal.

Highlighted article

White, C., Tarrant, M., Hodges, R., Wallace, E. M., & Kumar, A. (2020). A pathway to establish a publicly funded home birth program in Australia. Women and Birth, 33(5), e420–e428. https://doi.org/10.1016/j.wombi.2019.09.007

Blog written by

Dr Jyai Allen

References

  1. Hutton, E.K., Reitsma, A., Simioni, J., Brunton, G., & Kaufman, K. (2019). Perinatal or neonatal mortality among women who intend at the onset of labour to give birth at home compared to women of low obstetrical risk who intend to give birth in hospital: a systematic review and meta-analyses. E Clinical Medicine, 14, 59-70.
  2. Scarf, V.L., Rossiter, C., Vedam, S., Dahlen, H.G., Ellwood, D., Forster, D., Foureur, M.J., McLachlan, H., Oats, J., Sibbritt, D., & Thornton, C. (2018). Maternal and perinatal outcomes by planned place of birth among women with low-risk pregnancies in high-income countries: a systematic review and meta-analysis. Midwifery, 62, 240-255.
  3. Hauck, Y., Nathan, E., Ball, C., Hutchinson, M., Somerville, S., Hornbuckle, J., & Doherty, D. (2020). Women’s reasons and perceptions around planning a homebirth with a registered midwife in Western Australia. Women and Birth,33(1), e39–e47. https://doi.org/10.1016/j.wombi.2018.11.017
  4. Callander, E. J., Bull, C., McInnes, R., & Toohill, J. (2021). The opportunity costs of birth in Australia: Hospital resource savings for a post-COVID-19 era. Birth,48(2), 274–282. https://doi.org/10.1111/birt.12538
  5. Scarf, V. L., Yu, S., Viney, R., Cheah, S. L., Dahlen, H., Sibbritt, D., Thornton, C., Tracy, S., & Homer, C. (2021). Modelling the cost of place of birth: a pathway analysis. BMC Health Services Research, 21(1), 816. https://doi.org/10.1186/s12913-021-06810-9
  6. Tuck, M., White, C. & Homer, C. (2021). Homebirth in Australia: from shadows to mainstream. O&G Magazine. Retrieved from https://www.ogmagazine.org.au/22/3-22/homebirth-in-australia/
  7. White, C., Tarrant, M., Hodges, R., Wallace, E. M., & Kumar, A. (2020). A pathway to establish a publicly funded home birth program in Australia. Women and Birth, 33(5), e420–e428. https://doi.org/10.1016/j.wombi.2019.09.007
  8. Kumar, A., Wallace, E. M., Smith, C., & Nestel, D. (2019). Effect of an in-situ simulation workshop on home birth practice in Australia. Women and Birth, 32(4), 346–355. https://doi.org/10.1016/j.wombi.2018.08.172
  9. (2020). Australia’s mothers and babies 2018—in brief. Australian Institute for Health and Welfare. Retrieved from: www.aihw.gov.au/reports/mothers-babies/australias-mothers-and-babies-2018-in-brief/contents/table-of-contents.