Inclusion and exclusion criteria for publicly-funded homebirth in Australia: A scoping review

The financial impact of offering publicly funded homebirths: A population-based microsimulation in Queensland, Australia

BACKGROUND

Despite strong evidence of benefits and increasing consumer demand for homebirth, Australia has failed to effectively upscale it. To promote the adoption and expansion of homebirth in the public health care system, policymakers require quantifiable results to evaluate its economic value. To date, there has been limited evaluation of the financial impact of birth settings for women at low risk of pregnancy complications.

OBJECTIVE

This study aimed to examine the difference in inpatient costs around birth between offering homebirth in the public maternity system versus not offering public homebirth to selected women who meet low-risk pregnancy criteria.

METHODS

We used a whole-of-population linked administrative dataset containing all women who gave birth in Queensland (one Australian State) between 01/07/2012 and 30/06/2018 where publicly funded homebirth is not currently offered. We created a static microsimulation model to compare the inpatient cost difference for mother and baby around birth based on the women who gave birth between 01/07/2017 and 30/06/2018 (n = 36,314). The model comprised of a base model - representing standard public hospital care, and a counterfactual model - representing a hypothetical scenario where 5 % of women who gave birth in public hospitals planned to give birth at home prior to the onset of labour (n = 1816). Costs were reported in 2021/22 AUD.

RESULTS

In our hypothetical scenario, after considering the effect of assumptive place and mode of birth for these planned homebirths, the estimated State-level inpatient cost saving around birth (summed for mother and babies) per pregnancy were: AU$303.13 (to Queensland public hospitals) and AU$186.94 (to Queensland public hospital funders). This calculates to a total cost saving per annum of AU$11 million (to Queensland public hospitals) and AU$6.8 million (to Queensland public hospital funders).

CONCLUSION

A considerable amount of inpatient health care costs around birth could be saved if 5 % of women booked at their local public hospitals, planned to give birth at home through a public-funded homebirth program. This finding supports the establishment and expansion of the homebirth option in the public health care system.

Skills and knowledge of midwives at free-standing birth centres and home birth: A meta-ethnography

PROBLEM

When midwives offer birth assistance at home birth and free-standing birth centres, they must adapt their skill set. Currently, there are no comprehensive insights on the skills and knowledge that midwives need to work in those settings.

BACKGROUND

Midwifery care at home birth and in free-standing birth centres requires context specific skills, including the ability to offer low-intervention care for women who choose physiological birth in these settings.

AIM

To synthesise existing qualitative research that describes the skills and knowledge of certified midwives at home births and free-standing birth centres.

STUDY DESIGN

We conducted a systematic review that included searches on 5 databases, author runs, citation tracking, journal searches, and reference checking. Meta-ethnographic techniques of reciprocal translation were used to interpret the data set, and a line of argument synthesis was developed.

RESULTS

The search identified 13 papers, twelve papers from seven countries, and one paper that included five Nordic countries. Three overarching themes and seven sub-themes were developed: 'Building trustworthy connections,' 'Midwife as instrument,' and 'Creating an environment conducive to birth.'

CONCLUSION

The findings highlight that midwives integrated their sensorial experiences with their clinical knowledge of anatomy and physiology to care for women at home birth and in free-standing birth centres. The interactive relationship between midwives and women is at the core of creating an environment that supports physiological birth while integrating the lived experience of labouring women. Further research is needed to elicit how midwives develop these proficiencies.

Relationships are the key to a successful publicly funded homebirth program, a qualitative study

BACKGROUND

In Australia, publicly-funded homebirth is a relatively new option for women and their families. Two years after the inception of two publicly funded homebirth services in Victoria in 2009, a study found that midwives' experiences were more positive than doctors. There is no recent evidence on the perspectives of midwives and doctors of publicly-funded homebirth programs.

AIM

To explore the experiences of midwives and doctors participating in or supporting one publicly-funded homebirth program in Australia.

METHODS

An interpretive descriptive approach was used following individual in-depth interviews via 'Zoom'. Participants included midwives and doctors who provide or support the homebirth service at a large metropolitan health service in Melbourne's western suburbs. Data were thematically analysed.

FINDINGS

Interviews were conducted with 16 homebirth midwives, six hospital-based midwives, and nine doctors. One central theme and three sub-themes demonstrate that effective relationships are critical to a successful publicly-funded homebirth program. Collaboration, teamwork, and mutual respect across professions were reported to be integral to success. The midwife-woman relationship was highly valued and especially important to provide continuity during transfers to the hospital where this occurred.

DISCUSSION

Effective relationships underpin collaborative practice and are critical for safe healthcare. Shared common learning opportunities such as simulation training sessions and multi-professional forums to discuss cases were perceived to assist the development of these relationships.

CONCLUSION

Effective relationships within and between midwives and doctors are key to collaborative practice, which underpins a successful publicly-funded homebirth service. Health services can support this by maintaining a respectful and supportive culture amongst staff.

Ten years of a publicly funded homebirth service in Victoria: Maternal and neonatal outcomes

BACKGROUND

Rates of homebirth in Australia remain low, at less than 0.3% of all births.

AIMS

To report maternal and neonatal outcomes of ten years of a publicly funded homebirth service, 2009-2019.

METHOD

Retrospective analysis of clinical outcome data including neonatal outcomes of women who requested a homebirth at a large metropolitan health service in Victoria, Australia. The primary outcomes included: maternal outcomes (mortality, transfer to hospital, place and mode of birth, perineal status, type of third stage of labour, postpartum haemorrhage), and neonatal outcomes (mortality, Apgar score at five minutes, birthweight, breastfeeding initiation, significant morbidity, transfer to hospital).

RESULTS

Referrals for 827 women were reviewed; 633 remained eligible at 36 weeks gestation, and 473 (57%) birthed at home. Compared to women who did not, women who had a homebirth were significantly more likely to be multiparous, have a normal vaginal birth and an intact perineum, less likely to require suturing and less likely to have blood loss of more than 500 mL. Compared to infants not born at home, infants born at home were significantly less likely to require resuscitation, more likely to be of normal birthweight and exclusively receive breastmilk on discharge. There were no maternal deaths and one neonatal death of a baby born at home before the arrival of a midwife.

CONCLUSIONS

The outcomes for women accepted into the publicly funded homebirth program suggest appropriate triaging and case selection. A publicly funded homebirth program, with appropriate governance and clinical guidelines, appears to be a safe option for women experiencing low-risk pregnancies.