Home birth or hospital delivery? Choice and safety should come first

Finding out you are pregnant is a source of joy for most people.  

But it’s also a time for big decisions – including around how and where you want to give birth.   

Kai Hodgkin remembers discussing the topic when she was in her first year of studying midwifery.  

“I remember very clearly having conversations with other students about home birth and saying ‘I think choice is really important, but gosh I would never have a homebirth. That seems like a risky thing to do’,” she says. 

But by the time she became pregnant herself, she had changed her tune.  

“I had become increasingly challenged by what birth in hospitals looked like,” Hodgkin, a midwife herself, says. “I knew I couldn’t have my baby in a hospital, not unless I really needed to.”  

As a PhD scholar at The Australian National University (ANU), Hodgkin is investigating midwifery care outside of hospital in low-income settings.  

She says the evidence is clear that homebirths in high income countries are safe for women with ‘low risk’ pregnancies, provided they have a qualified birth attendant with them and can access a hospital if needed. But in Australia, fewer than one per every hundred births occur at home due to limited homebirth programs. 

Hodgkin was among this small number of women who gave birth at home. A publicly funded program wasn’t readily available at the time, so she called on her midwife friends to assist. 

Everything went smoothy for Hodgkin and her baby, but she says this doesn’t mean it’s right delivery method for everyone. 

 “I am an advocate for choice,” she says.  

Hodgkin wants women to be more empowered in their birth choices, and to have information readily available that supports them in their decision-making process.  

It’s a fine balance between under and over-intervention in the childbirth space. While under-intervention can lead to poor child and maternal outcomes, over-intervention can lead to unnecessary caesarean sections or induction of labour. 

“Across all models of care in Australia approximately two-in-five women have caesarean sections, and there is just no physiological way this many women can’t give birth vaginally,” says Hodgkin.  

“I meet a lot of women who choose a private obstetrician. They think because they have to pay for it, it must be the best. But one-in-two women will have a caesarean under private care in the ACT, regardless of if they are high-risk or not.”  

“Research shows that most women don’t want a caesarean unless necessary. So this tells us caesarean rates are mostly driven by care providers, not by women.” 

There are differences in the roles obstetricians and midwives play during pregnancy and birth. Obstetricians are the experts in physical medical care and have the skills to manage complex and high-risk situations. They perform life-saving interventions such as caesarean sections and forceps births.  

Hodgkin says midwives take a less clinical approach.  

“Midwives take a holistic view of childbirth care, supporting emotional, social, cultural wellbeing in addition to physical safety,” she says. “But we are constantly assessing for any complexities that develop and will work with obstetricians when needed.”  

When Hodgkin fell pregnant with her second child, she was living in Indonesia.   

“I got a scholarship to go and do my Honours year there,” she recalls. “And it turned out I got pregnant.” 

She decided to give birth at home again. While homebirths in Indonesia are not the norm, Hodgkin found it much easier to navigate the health system to find a midwife and obstetrician to support her than in Australia. 

Inspired by her experience, she embarked on a PhD to compare births in different settings in Indonesia.  

“Choice is a human right. I have a problem with anything that eliminates somebody’s choice.”

Her findings? Midwife-led clinics were associated with the lowest infant mortality at birth and did not over- or under-intervene.  

Homebirths, on the other hand, were associated with under-intervention even for low-risk women who had a health professional present.  

Women embarking on homebirths often faced barriers to accessing additional care, and didn’t have the autonomy to make health related decisions. These factors contributed to homebirths having the highest infant mortality rate. 

“I would encourage women at low risk in Indonesia to consider having their babies at a midwifery led clinic – they’re all over Indonesia and are affordable. The village midwives seem to decrease rates of intervention while promoting safety,” says Hodgkin.  

There are only a handful of stand-alone midwifery clinics in Australia, and Hodgkin sees this as a missed opportunity.  

She says the research is clear: stand-alone midwife clinics offer a safe middle ground for women who want to deliver in a non-clinical environment, but are not comfortable with a home birth.  But ultimately, Hodgkin says women should be able to choose where they give birth.  

In Australia, birthing with either a midwife or obstetrician are safe, and so an individual’s personal views, medical needs and values should determine their lead carer.  

“Choice is a human right. I have a problem with anything that eliminates somebody’s choice,” Hodgkin says.