Home birth and the National Australian Maternity Services Review: Too hot to handle?

Article Outline

• Summary
• Introduction
• Method
• Findings
• Benefits of homebirth
  • Benefits to the mother, baby and family
  • Benefits of midwifery care
  • Benefits of continuity of carer
  • The positive experience of homebirth
• Barriers to homebirth in Australia
  • Access to a midwife
  • Funding
  • Insurance
  • Clinical privileging for midwives
• Free birth/unattended birth at home
• Freedom of choice in birth is a human rights issue
• Discussion
• Conclusion
• Acknowledgement
• References
• Copyright

Summary 

Background

In February 2009 the Improving Maternity Services in Australia – The Report of the Maternity Services Review (MSR) was released, with the personal stories of women making up 407 of the more than 900 submissions received. A significant proportion (53%) of the women were said to have had personal experience with homebirth. Little information is provided on what was said about homebirth in these submissions and the decision by the MSR not to include homebirth in the funding and insurance reforms being proposed is at odds with the apparent demand for this option of care.

Method

Data for this study comprised 832 submissions to the MSR that are publicly available on the Commonwealth of Australia Department of Health and Aging website. All 832 submissions were downloaded, coded and then entered into NVivo. Content analysis was used to analyse the data that related to homebirth.

Findings

450 of the submissions were from consumers of maternity services (54%). Four hundred and seventy (60%) of the submissions mentioned homebirth. Overall there were 715 references to home birth in the submissions. The submissions mentioning homebirth most commonly discussed the ‘Benefits’ and ‘Barriers’ in accessing this option of care. Benefits to the baby, mother and family were described, along with the benefits obtained from having a midwife at the birth, receiving continuity of care and having a good birth experience. Barriers were described as not having access to a midwife, no funding, no insurance and lack of clinical privileging for midwives.

Conclusion

Many positive recommendations have come from the MSR, however the decision to exclude homebirth from these reforms is perplexing considering the large number of submissions describing the benefits of and barriers to homebirth in Australia. A concerning number of submissions discuss having had or having considered an unattended birth at home due to these barriers. Overall there is the belief that not enabling access to funded, insured homebirth in Australia is a violation of human rights. It appears that homebirth was considered by the MSR as ‘too hot to handle’ and by dismissing it as a minority issue the government sought to avoided dealing with homebirth as a ‘sensitive and controversial issue.’

Keywords: Maternity Services Review, Midwives, Home birth, Medicare, Insurance, Funding, Continuity of care

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Introduction 

‘Imagine a woman being forced to birth at home when what she craves and needs is the support of a hospital. Imagine a woman being forced to birth in hospital when what she craves and needs is the support of her familiar home environment. The miracle of producing new life, and bringing that life into the world should never be overshadowed by a lack of birth options- certainly not in today's society’ (submission, Maternity Services Review)

The Australian Commonwealth Department of Health and Ageing set up a Maternity Services Review (MSR) in September 2008 and called for public submissions from interested stakeholders in response to a discussion paper aimed at improving maternity services and expanding the range of birthing options available. Over 900 submissions were received by the Department of Health and Ageing (DOHA) and the majority (54%) were from consumers. DOHA also conducted a series of ‘invitation only’ roundtable forums with a range of organisations and individuals on a series of topics. The results of these public submissions and roundtable forums formed the basis for the MSR, which was released in February 2009. On the 21st February 2009, Improving Maternity Services in Australia – The Report of the Maternity Services Review,¹ was released by the Federal government.

There are some very positive recommendations for women and midwives that have come from the MSR. Key amongst these was the commitment to close the gap on disadvantage for Aboriginal and Torres Strait Islander mothers and babies in partnership with Indigenous people themselves. Another important recommendation relates to improving the access of rural women to safe, collaborative maternity care as close as possible to where they live. Likewise the proposed extension of the Medicare Benefits Schedule and the Pharmaceutical Benefits Schedule to eligible midwives is essential to support the full contribution that midwives can make to maternity care in urban, rural and remote areas. The market failure in providing insurance for privately practising midwives is also addressed in the Report.¹ Whilst the recommendations are positive, excluding homebirth from the reforms and not addressing funding and insurance for homebirth services is its major weakness.

The MSR reported that the personal stories of individual women made up 407 of the more than 900 submissions received and many of these women (53%) had personal experience with homebirth.¹ Although the MSR does not report what was said about homebirth in the submissions, 823 of the submissions are publicly available on the Department of Health and Ageing website. It is important to note that the submissions from women to the review are unlikely to be representative of women's views generally in Australia as there is a proportionally high number of submissions mentioning homebirth compared to the rate in Australia. Despite this it is difficult to reconcile how one of the key themes in the submission, the call for better support around homebirth as a mainstream option, is one area the MSR Report does not attempt to address.

Homebirth is mentioned 31 times in the MSR report, mostly in the context of justifying reasons for not including homebirth in the reforms. The reasons cited were: to not risk polarising the professions further; that some States had already made this option available to women through public funded models of care; the fact that insurance was unlikely to be successful for homebirth and that homebirths comprised a tiny number of the births and were declining.¹ It is clear that the voice of the medical profession dominated in these statements.

Homebirth is an option for only a few women in Australia through publicly funded models of care and for women who choose to hire a privately practicing midwife. The private models of homebirth remain unfunded and uninsured. This is out of step with maternity service reforms in comparable countries such as New Zealand, the United Kingdom and Canada where home birth is supported as a mainstream option with public funding and affordable insurance available. These factors contribute to the fact that a small number of women (886 or 0.3%) choose to have a planned homebirth in Australia. We also know that 2053 (0.5%) women gave birth in places other than planned hospital or home. This group includes birth before arrival and free birth.²

The aim of this study is to examine what was said about homebirth in the 832 submissions publicly available on the DOHA website.

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Method 

This is a qualitative descriptive study that examined the 832 submissions made to the MSR that are publicly available on the DOHA website. The submissions were downloaded from the DOHA website and content analysis was used.

After multiple readings of transcripts for mentions of homebirth, content analysis was carried out involving the initial identification and coding of key ideas and beliefs around homebirth in the textual data. Five hundred and forty eight of the 832 submissions were loaded into NVivo for analysis and the remaining 284 submissions were hand coded. These submissions had to be hand coded as some of the documents on the DOHA website comprised hard copy submissions that were scanned or handwritten and so could not be loaded into the NVivo software. NVivo is a software package that helps researchers organise and analyse qualitative data. The codes identified were used to organise data in NVivo.³ As there were concerns that not all mentions of homebirth in the submissions was being identified using NVivo all the submissions were searched by hand again for any mention of homebirth using the word ‘home’ as search term and then reading the sentence to determine if it was a reference to homebirth. This resulted in identifying another 130 mentions of homebirth. Data were analysed according to what was said in the submissions about homebirth, as well as how often this was mentioned and by whom. The process of analysis involved research team members analysing transcripts independently, then comparing the identified codes for similarities and differences, before grouping or categorizing the data into two broad categories related to the benefits of and barriers to homebirth. Extracts/quotes from the submissions are included below, however names are not used and if a hospital or individual is referred to this has been removed. If the quote came from a consumer, or professional, etc. this noted at the end of the quote.

Ethics approval was sought but not deemed necessary, as these are now publicly accessible documents.

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Findings 

Of the 832 submissions that are available on the Department of Health and Ageing website 450 (54% of submissions) were from consumers, 123 (15%) from individual midwives, 75 (9%) from professional groups or organisations, 88 (11%) from community groups, 49 (6%) from individual professionals (doctors, psychologists, etc.) other than midwives, 36 (4%) from academics (mostly midwives and obstetricians) and 11 (1%) from doulas (Table 1).

Table 1. Submissions received by the Maternity Services Review by author group.

Homebirth was discussed in 470 (60%) of the submissions and was mentioned 715 times in the 832 submissions received. The majority of submissions mentioning homebirth were from consumers (n=327). Free birth (also known as unattended birth, ‘unassisted birth’, ‘unhindered birth’ and ‘pure birth’) was discussed in 26 (3%) of the submissions and mentioned 47 times. A free-birth is a planned homebirth that the parents arrange to be intentionally unattended by any midwife or obstetrically trained professional, even if professional care is sought during pregnancy. In this respect, free-birth goes far beyond traditional planned homebirth, which is intentionally attended and unplanned homebirth which is unintentionally unattended

Most of the submissions focused on two main areas: the benefits of homebirth and the barriers to accessing homebirth in Australia.

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Benefits of homebirth 

The benefits of home birth were clearly articulated in the vast majority of the submissions to the MSR (475 references). These benefits were often described in terms of benefits to the mother, baby and family. The benefits of midwifery care and the value of continuity of carer was a strong theme (Table 2). Overwhelmingly the submissions to the MSR reported a highly positive experience of home birth. The only submissions critical of homebirth were from the medical profession.

Table 2. Benefits of homebirth described in submissions to the Maternity Services Review.

Benefits to the mother, baby and family 

The benefits of homebirth to the mother, baby and family were described (113 times) as helping mothers to feel safe and secure in the belief that this contributed to the birth being straightforward. The ability for children and other family members to be involved was seen as very important:

It [homebirth] also provides an environment that is family centred, where the partner is more likely to be actively involved because they are familiar with the environment and caregiver. Siblings can also be involved in the birth more freely at home. This then facilitates bonding between the parents and siblings with the new baby (Individual professional).

Several of the submissions pointed to the clear benefits of homebirth to the baby and the importance of giving their baby an optimal start in life in a gentle and supported environment:

We are still living with the consequences of this with our firstborn's emotional and cognitive damage caused by interventions used in her birth eleven years ago [in hospital]. I can contrast this with my home birthed daughter's gentle and peaceful birth. She has a confidence and joy about her, which is well beyond the expected abilities of a three year old (Consumer).

Benefits of midwifery care 

The benefit of midwifery care was presented as a unique element of the homebirth experience and was the most frequently cited of the benefits (140 times). It was evident that midwives provided important support and contributed to women feeling empowered during their births. The relationship formed over the months of pregnancy appears key to the trust and respect that is generated:

In this way the relationship between the woman and midwife is one based on mutual respect and trust built up over time. It is the quality of such a relationship that leads to women experiencing an empowering birth and leads to a good starting point as a new mother (Professional Group).

Women also described midwives as having and taking time to be with women, listening, talking and providing information. This was described as lacking in the resource stretched, fragmented and time poor mainstream maternity care system. The contrast between midwifery care and obstetric care was also notable:

However, my homebirth experience was a totally different experience [from my hospital experience]. The many hours that were spent chatting to my midwife provided me with a whole new confidence. I think I had over 11 appointments, lasting several hours each during my antenatal care. Support I would never have received through the hospital system or a private obstetrician (Consumer).

The promotion and protection of normal birth was mentioned several times in the submissions as being important to women and an important part of the homebirth experience and the role of the midwife:

Midwives who attend homebirths, for example, have a strong desire to facilitate normal birth and are very skilled in their practice of keeping birth normal. As a result we see positive outcomes for both mother and baby (Consumer).

The ability to discuss anxieties and fears with the midwife was reported as being important in enabling birth to proceed smoothly and safely:

The personal relationship I had with my midwife enabled me to discuss many anxieties and fears I had around this second birth (because of my previous experience) and I felt fully supported at all times. I had a wonderful, straightforward homebirth and I don’t believe the birth would have gone so well in any other setting (Consumer).

Benefits of continuity of carer 

The benefits of continuity of care were frequently cited (110 times) in the submissions received by the MSR. Consumers of homebirth care argued that continuity of carer was experienced best under this model of care:

By having one midwife who remained with me through the entirety of the pregnancy and birth, my needs were directly met by someone who had increased knowledge of me, my body and my baby over time. This is by far superior to the current model of Australia's maternity care (Consumer).

There were powerful descriptions in the submissions of the physical and emotional effect continuity of care had on women and their families:

To have continuous support of a carer we all knew well, to get to know our back up carer, to have our midwife know our history and accommodate our preferences, present us with information and allow us to make informed decisions was bliss!! (Consumer).

The positive experience of homebirth 

Homebirth as a positive, fulfilling experience was a dominant theme in the submissions (112 references). Women described home birth as transforming them and impacting on their lives in a positive way beyond the birth:

My son was born at home in the dark stillness of a warm summer night. My husband played a vital role in the whole birth and we both had skin on skin contact immediately after the birth. Unbelievable joy, pride end elation were very present in our home that night and for the following days. I stood up after the birth showered and dressed myself I felt triumphant and calm and funny enough breastfeeding was effortless and lovely (Consumer).

The experience of homebirth was also described as helping to heal past trauma:

Having made the choice and being fortunate enough to find a midwife has given me an opportunity to heal some to the scars of my hospital experiences (Consumer).

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Barriers to homebirth in Australia 

The barriers to homebirth were another common theme in the submissions (456 references) and were mentioned almost as often as the benefits. Problems with accessing a midwife obtaining funding, insurance and clinical privileging for midwives were the most commonly mentioned barriers (Table 3).

Table 3. Barriers to homebirth described in the Maternity Services Review.

Access to a midwife 

The problems women encountered trying to access a midwife were frequently mentioned in the submissions (104 times). It was common for other countries’ (such as the Netherlands) improved maternity systems to be contrasted with Australia's. The ease of access to homebirth in these countries was contrasted strongly with women's experiences in Australia:

We wished to carry on the Dutch family tradition of giving birth at home and found it surprisingly challenging to engage the services of an independent midwife [name of city] (Consumer).

The scarcity of midwives able to or willing to offer homebirth services was mentioned in the submissions as well as how overworked the few remaining ones were and the impact this had on women:

My midwife became the only [name of city] based midwife, and she became saturated with client's, many of whom she had to decline due to workload. Ordinarily my midwife would only take 2 expected mothers due in the same month; she ended up with 4 other women due to give birth two weeks around my due date…I had an incredible amount of stress and anxiety about how my second birth would be. I did not see this was in anyway the fault of the midwife; there was simply no way for reassuring me how things would unfold (Consumer).

Funding 

Of all the issues discussed in submissions to the MSR, lack of funding was mentioned most (207 references). The financial difficulties women and their families experienced trying to access a homebirth were evident:

I am now pregnant with my third baby and again I am choosing to have a homebirth and to employ the services of the same independent midwife – once again paying her full fee out of our family's (limited) income. Thankfully, the midwife is willing to take payment in instalments, which makes it possible for our family (Consumer).

I am lucky enough to have wonderfully supportive parents who recognized my desires to birth my baby at home and lent me the money for a homebirth (Consumer).

It was also apparent in the submissions that consumers were fully aware that their choice of a homebirth was actually saving the government and taxpayer a significant amount of money and they were perplexed as to why the government would not fund this cost effective form of care:

Why homebirth is not supported by Medicare is beyond me. Of course our private cover was useless. Our homebirth would have cost far less than our last effort through ‘the system’ (Consumer).

The prohibitive cost of homebirth meant some women felt forced to make birth choices they would not have, had homebirth been more available and funded:

As home birth was too expensive for us I elected to birth in the birth centre at [name of birth centre], 50 minutes from my home where I felt at least I could be relatively well supported during my birth in a woman friendly environment. Even though the birth environment was more home like I met multiple midwives during my care, was not cared for by a known midwife at my birth and was discharged 4 hours later (my choice) with one post natal home visit by a stranger (Consumer).

It was clear that lack of funding was viewed as limiting choice in the maternity system:

So I put to the review both that to truly offer a choice to birthing women and to achieve the best outcomes for both mother and baby homebirth must be properly and equitably funded by the government and midwives insured. Anything less is a travesty (Consumer).

The few women in Australia able to access publicly funded homebirth pointed to this as being a wonderful option for them and one that should be expanded:

I was very fortunate for the second homebirth to have a free homebirth with [name of homebirth program]. For women such as myself, low risk, confident and comfortable to birth in my home, this is an amazing service I feel should be available to more women (Consumer).

Insurance 

The lack of insurance for midwives to provide homebirth services was identified (100 times) as a major barrier to accessing a homebirth in the submissions and there were frequent requests for this to be remedied:

Due to the lack of medical indemnity insurance for midwives, it is not possible to arrange a home birth with an independent midwife in [name of city] (Community Group).

The considerable risk to the midwife and families receiving midwifery care where there is no insurance was recognised as being unacceptable:

Unfortunately midwives who choose to provide a homebirth service in their community are doing so without indemnity insurance. This poses a risk to the financial security of the midwife and her family. The woman in the midwives’ care is also left financially disadvantaged in the unlikely event of an adverse outcome. The government needs to assist midwives to obtain appropriate and affordable professional indemnity insurance. Insurance companies are under the false impression that homebirths are unsafe (Consumer).

Clinical privileging for midwives 

Access to clinical privileging for midwives were also requested in the submissions (45 times) and acknowledged to be essential in order for seamless transfer to happen if required during a homebirth:

Allow Independent midwives admission rights to public hospitals (Individual professional).

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Free birth/unattended birth at home 

Of particular concern is the fact that free birth or unattended birth at home was mentioned in 26 (3%) of the submissions to the review with a total of 45 references. It was discussed as a direct consequence to lack of access to a midwife and the financial burden associated with homebirth in Australia. While there are some women who will make this choice regardless of availability to midwifery care, it was clear in the submissions received the decisions made were due to lack of access to a midwife or prohibitive cost:

I recently had my fourth baby at home without a midwife. I really wanted a waterbirth and there is nothing in [name of geographic area] that supports this. Although I did have access to an independent midwife, the $3500 plus extra money for her fuel costs was just too much for us to spend on a birth. If midwives had Medicare numbers I could have had a midwife present and not have to resort to a free birth (Consumer).

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Freedom of choice in birth is a human rights issue 

It was clear that underlying all these discussions about the benefits and barriers to homebirth that it was considered a human rights issue about the freedom of choice. Removing the choice of place of birth and caregiver from women and their families was at the heart of this outrage:

Reproductive rights are human rights and without freedom of choice, and the World Health Organisation's preferred model of care, one-to-one midwifery care, women's reproductive rights, and thereby our human rights are currently being denied. Please don’t limit our choices and don’t allow such human rights denial to continue (Consumer).

The only negative comments made regarding the choice of homebirth came from submissions from the medical professional groups and individuals and these provided an obvious barrier when it came to the MSR making recommendations:

Homebirth is NOT supported as it is associated with an unacceptably high rate of adverse outcomes (Medical group).

The government should not introduce any publicly funded arrangement which is based on independent midwife care for mothers and babies in Australia (Medical group).

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Discussion 

In Australia homebirth remains unfunded at a Commonwealth level and midwives have been uninsured since 2002. The publicly funded homebirth services in New South Wales, South Australia, Northern Territory, Western Australia and Victoria are small (range 10–120 women per year), with strict risk criteria and limited to certain geographical areas. The remaining States and Territory have no publicly funded homebirth services (Queensland, Tasmania and the Australian Capital Territory). Privately practicing midwives in contrast are less restricted by geographic limitations, with some even crossing State and Territory borders. This is in direct contrast to other countries such as New Zealand, the United Kingdom, Canada and the Netherlands where homebirth is available as part of the public health service and it is either partially or totally funded and midwives are insured to provide this service.

This study reports the breadth and depth of women's interest in homebirth articulated in the submissions to the MSR (715 references). The benefits were often described in terms of benefits to the mother, baby and family. The benefits of midwifery care and the value of continuity of carer was a strong theme. Overwhelmingly the submissions to the MSR reported a highly positive experience of home birth. In contrast, mainstream maternity services in Australia are delivered within a highly medicalised and fragmented system that does not facilitate the development of relationships between women and midwives and has resulted in some of the highest intervention rates during pregnancy and birth in the world. While Australia is one of the safest countries in the world to give birth for non-Indigenous women it is not meeting the needs of all. Maternal and perinatal outcomes for Indigenous women remain much worse than the rest of the population.⁴

Most women in Australia give birth in conventional labour ward settings (97.3%), with few women able to access birth centres (2.0%), and even fewer able to access home birth (0.3%).² Around 130 maternity units have shut in the past ten years across Australia, resulting in women travelling greater distances from home to give birth. The rate of caesarean section has climbed in both private hospitals (22% in 1991 to 41% in 2006) and public hospitals in Australia (16% in 1991 to 28% in 2006).¹ This is much higher than in countries such as the Netherlands (14%), Sweden and Finland (16–20%). Australia's caesarean section rate is now 25% higher than the average rate of all OECD countries and ranks as fourth highest. Other interventions in birth, such as induction of labour, epidural anaesthesia and use of pharmacological analgesia, have also risen in the past ten years. It appears, however, that the majority of women seek to have a normal labour and birth and feel more satisfied when this is achieved with minimal intervention.⁶

It was clear in this study that access to continuity of carer was a major factor for women choosing to have a homebirth (mentioned 110 times). It was clear that the physical and emotional benefits of continuity of midwifery care were evident to consumers. A Cochrane Systematic Review of midwifery continuity of carer compared to other models showed an increase in women's satisfaction with their maternity care as well as being clinically effective and safe.⁷

One argument against the practice of giving birth at home is the lack of scientific evidence. While home birth advocates cite research, which is supportive of the safety of homebirth, and homebirth critics cite papers that show a lack of safety, the studies examining the safety of home birth have consistently found comparable perinatal mortality among low risk women giving birth at home with a midwife, and low risk women giving birth in hospital, but lower intervention rates and maternal morbidity.⁸, ⁹, ¹⁰, ¹¹, ¹², ¹³, ¹⁴ Likewise, studies have shown that when women with high risk pregnancies give birth at home the perinatal mortality is increased.¹⁵, ¹⁶, ¹⁷ There is good evidence to support low-risk homebirth with a qualified midwife as a safe, reasonable and cost effective birth option that results in less medical intervention and government spending on maternity care. It is clear that the voice of the medical profession while small in comparison to large numbers of submissions dominated loudly when it came to the MSR making its recommendations.

The more complex but equally relevant argument about how women understand safety is less debated and considered less valid by some. Cultural, emotional and spiritual safety rarely appear in the mainstream debates about the safety of homebirth yet qualitative research would indicate this dominates in women's decision making regarding choice of place of birth.¹⁸, ¹⁹ These ‘other’ considerations of safety are seen articulated in the submissions to the MSR.

The fact that there were 26 submissions referring to women's intention to freebirth or previous experience of freebirth due to lack of affordable accessible homebirth services is concerning. While there has been little research into freebirth in Australia there is some evidence this is increasing.²⁰ Where homebirth is not offered as a valid choice (funded and accessible) to women there also appears to be a corresponding increase in freebirth.²¹

The MSR stated that, ‘we must ensure first, that practice is based on evidence and second, that we are not allowing our safety and quality concerns to prevent us acting on evidence that supports changes to practice’.^1(piii) It also stated, ‘it is important that safety and quality do not become the catch cry to limit consideration of innovation and reform to care approaches. It is vital that approaches to change are evidence based and take full account of consumer preferences’.^1(p1) The MSR claims are perplexing if we consider the number of submissions made to the MSR asking for greater access to funded and insured homebirth that are obviously ignored in the final report. Support for homebirth is both innovative and evidence based. It is apparent from our study that the only way the government could dismiss what was clearly an overwhelming issue in the submissions it received (the need for funded, insured and accessible homebirth) was to conclude, “that, while homebirth is the preferred choice for some women, they represent a very small proportion of the total” (p. 20). However, it is rare for people to ask for access to services that are widely available so the strong focus on accessible homebirth should be seen as an area of unmet need in a country out of step with the rest of the world, rather than dismissed as the protestations of a minority. The response from the MSR, despite the large number of submissions requesting funding and insurance for homebirth makes one question a tokenistic purpose behind the entire process. Most concerning is the possibility that the authors of the MSR were more concerned with ‘political safety’ than meeting the expressed choices of women and responding to the evidence. This is alluded to in the following quote:

“In recognising that, at the current time in Australia, homebirthing is a sensitive and controversial issue, the Review Team has formed the view that the relationship between maternity health care professionals is not such as to support homebirth as a mainstream Commonwealth-funded option (at least in the short term). The Review also considers that moving prematurely to a mainstream private model of care incorporating homebirthing risks polarising the professions rather than allowing the expansion of collaborative approaches to improving choice and services for Australian women and their babies.^1(p21)

There are several limitations associated with this study. The submissions from women to the review are unlikely to be representative of women's views generally in Australia as there is a proportionally high number of submissions mentioning homebirth compared to the rate in Australia. Many of these women were clearly motivated by consumer group advocacy to be active in regards to an issue that is considered important. We were also not able to view several submissions to the MSR as they were confidential and not open to public scrutiny, so we are unaware what was said in these.

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Conclusion 

Despite the keen interest from Australians regarding the choice of homebirth in Australia, current maternity service reforms have largely ignored requests for homebirth to be supported by the Australian maternity care system. Despite the review team claiming their aim to be to expand birthing choices to women and prioritise safe evidence based care,¹ homebirth as an option for women and privately practicing midwives in Australia was not recognised or supported by the MSR. Most concerning is the possibility that the authors of the MSR were more concerned with ‘political safety’ than meeting the expressed choices of women and responding to the evidence. There is a concerning number of submissions that discuss having had or having considered an unattended birth at home due to these barriers. Overall there is the belief that not enabling access to funded, insured homebirth in Australia is a violation of human rights. It appears that homebirth was considered by the MSR as politically ‘too hot to handle’ and by dismissing it as a minority issue the government sought to avoid dealing with homebirth as a ‘sensitive and controversial issue’.¹ We would argue given the numbers of submissions in support of such a discreet area of health care the government has completely underestimated the community outrage over this decision and that homebirth itself has become an issue that is now too hot not to handle.

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Acknowledgement 

To the University of Western Sydney for providing funding for the study through the Internal Research Grant Scheme 2009.

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