An increasing number of women from regional and remote towns are opting for home birth, in a likely attempt to access continuity of care.

“Women want continuity of care, so they can build a relationship of trust with the person who will be attending them at their birth, and to explore all the options for care and tests in detail,” says Griffith University Midwifery Lecturer and PhD Candidate, Carolyn Hastie.

“They also want this care to be available near or in their homes. 

“For regional women, they have limited options for where they can birth and if they are in a small town they are likely to need to travel a significant distance to birth. There are fewer birth services in Australia now than there were 20 years ago.

“They also are not likely to have access to continuity of care at their local hospital and there are few private midwives in practice in regional areas, thereby limiting their options further.”

A midwife working in caseload practice, either privately or publicly funded, provides holistic antenatal, intrapartum and postnatal care up to 6-8 weeks for home birthing women, and their partner.

“Her role at birth is to attend to the woman, to offer guidance if the woman seeks it, or if the midwife sees a reason to offer it, and to assist her transfer to hospital if that is what the woman asks for,” says Ms Hastie.

“To give birth in the familiarity of one's home, surrounded by loved ones with a trusted midwife, after months of meticulous preparation and research is a deeply transformative and empowering experience for not only the woman and her baby, but for everyone who witnesses it.

“For the woman, most of the midwifery care she receives is not during the birth itself, it is in the months of lead up, where with the midwife's help, she prepares everything that may be needed for an efficient and safe birth, including an emergency escalation plan to hospital. 

“The care in her own home for the weeks afterwards is also an invaluable reassurance and comfort at a crucial time of bonding and recovery.”

According to Ms Hastie, the midwifery experience is significantly different when assisting with a home birth, when compared with a hospital birth.

“The hospital is ‘our territory’ and so we are familiar and ‘in charge’ even when we consciously share power with the woman and her family. 

“In the woman’s home, both the woman and her partner/family are in charge.

“That change in power structure affects everything, from accessing food, bringing in equipment, discussing what the woman wants to do; what happens to the baby after birth.

“As homebirth midwives, we have to set up a trusting partnership – there is no other way to do it.

“Whilst caseload midwives always seek to ensure power is shared and women have agency; it is much easier to unconsciously override that when a woman gives birth in a hospital. 

“Working with birthing women at home is much more relaxed, calmer and satisfying for everyone, including the midwife.”

But while assisting with a home birth is an appealing option for many midwives, there are several factors they need to be aware of before doing so.

“Medicare regulations require privately practicing midwives to have a ‘collaborative arrangement’ with a GP or obstetrician for the woman to access Medicare Payments,” says Ms Hastie.

“Sadly, many GP’s and obstetricians are resistant to that idea and decline to form such an agreement, limiting midwifery practice. 

“An MBS review is underway, and it is hoped that the requirement for collaborative practice agreements will be scrapped.”

There is also an AHPRA requirement that two midwives are present for the birth.

“This requirement is difficult to fulfil in regional areas of Australia and as a result, there are a number of privately practising midwives have ceased practice as they are unable to guarantee two midwives at births.”

Another potential challenge for privately practising midwives, says Ms Hastie,  is that even when birth goes well, if it is considered to be ‘outside’ hospital guidelines for the woman to have been supported to birth at home, the midwife may find herself reported to the Australian Health Practitioner Regulation Agency.

“Whilst these notifications are usually dismissed, it can be a time of great distress for the midwife concerned.”

For a midwife to assist with a home birth,  they must be endorsed with AHPRA.  To provide antenatal and postnatal care, a midwife must be insured and endorsed to do so. There is currently no insurance for care during labour and birth at home.

Any midwife can be second midwife for a home birth, however, that midwife, unless they are endorsed and insured, must not provide antenatal or postnatal care. 

While home births are increasing in some areas, misunderstandings about birth generally, mean birthing at home is still relatively rare, says Ms Hastie.

“Few people understand the WHO's findings that over 80% of women can birth normally and that the best outcomes come with continuity of care, near or in women's homes delivered in the wellness paradigm. 

“The physiology of birth and how to optimise the release of birth hormones for efficient birthing is also not widely understood, even by many maternity carers and designers of birth rooms.

“The hierarchical model of obstetrics over midwifery in this country also has the impact of people thinking they have the best care when they have an obstetrician and that 'just having a midwife' is somehow a lesser option in terms of safety and professionalism, when this couldn't be further from the truth.”