In Australia, as in many high-income countries, women can choose to give birth at home, in a birth centre or in a birth unit. In New South Wales (NSW), the most populous state in Australia, there are over 97,000 births a year [1]. Annual figures from the most recent data (2016) show that in this state, 96.6% of women gave birth in a hospital labour ward, 2.2% gave birth in a birth centre and 0.2% gave birth at home [1].
There is now strong evidence that for women with a healthy pregnancy, especially those having their second or subsequent baby, giving birth at home or in a BC is a safe option [2,3,4,5,6,7,8,9,10,11,12]. The small proportion of women who have used BCs in NSW in 2016 (2.2%) or who have chosen to give birth at home (0.2%) reflects either the lack of availability or desirability of such services, notwithstanding the demand for greater choice of birth setting by women and health practitioners [13,14,15].
The Australian National Review of Maternity Services released in 2009 sought perspectives from a range of stakeholders regarding maternity services in Australia in order to inform priorities for the development of the National Maternity Services Plan (The Plan) which was released in 2011 [16]. As a result, The Plan outlined priorities including increasing access to local maternity care by expanding the range of models of care with an associated increase in birth setting options [16]. The Plan was a result of submissions from women who indicated they want options regarding their pregnancy care and choice of place of birth. During the Maternity Services Review, over 900 submissions were received, the vast majority (n = 832) were made by women and maternity care providers [17]. Consistent themes emerged such as wanting increased access to a midwife-led and continuity of care and more options for place of birth, including homebirth and birth centres [13, 14].
According to the 2016 NSW Mothers and Babies Report [1] there are 62 maternity hospitals with birth rates over 200 per year. This number comprises 47 public hospitals and 15 private hospitals. There are three possible settings in which to choose to give birth – in hospital, in a birth centre or at home in NSW, however these settings are not necessarily available across the state. A hospital labour ward (HLW) is within a hospital (public and private) and is staffed by midwives and doctors. There are five birth centres (BC) co-located within hospital grounds or adjacent to hospital labour wards, they are staffed by midwives (although obstetricians and registrars are available in some settings if interventions are required) and are designed to provide a home-like environment. There are also five free-standing midwifery led birth centres in NSW which are located within a hospital campus, albeit some distance from obstetric and neonatal specialties. Women who require transfer to higher level care at these birth centres are transported by car or ambulance to the closest maternity hospital.
Birth trajectories
While women usually choose where they would like to give birth at the beginning of pregnancy, the process is dynamic due to complications or risk factors that may develop, making the pathway or trajectory for women who plan to give birth at home or in a birth centre difficult to predict at a service level. A woman intending a homebirth, for example, may commence her pregnancy with no significant history of illness or pathology only to find her plans changed as the pregnancy continues and a complication arises. This may result in a change of birth setting, either during the pregnancy or in labour; the latter made sometimes more difficult due to a lack of integration between the providers of homebirth and hospital services [18]. In countries where homebirth and freestanding birth centres are well integrated into maternity services (UK, Netherlands), transfers between places of birth are facilitated by local policies and protocols which support the need to change location, including during labour, to the preferred or more appropriate birth setting [19]. By contrast, a maternity system lacking in integration between providers and places of birth, as is common across Australia, creates barriers for a smooth transition from home to hospital where indicated [18].
Transfer rates from planned homebirth to hospital vary by country as well as by parity, with predictably lower rates in multiparous women. The rates of intrapartum transfer from home to hospital in studies over the past 10 years from a number of high-income countries varied from 8.8 to 21.0% overall [4, 9, 20,21,22]. When stratified by parity, the rates were 24 to 39.1% for nulliparous women and 4.8 to 12.3% for multiparous women. Transfer from a midwifery unit (either alongside or freestanding) to hospital were 12.4 to 33.9% overall [4, 9, 10, 22,23,24,25] and by parity, 25.4 to 37.8% for nulliparous women and 5.3 to 14.0% for multiparous women. Reasons for intrapartum transfer range from request for analgesia and slow progress in labour (non-urgent) to fetal distress and haemorrhage (urgent) the latter being less common [21, 24, 26, 27].
While transfer rates in NSW have been reported overall, little is known about what happens to women who commence labour in their planned place of birth, and their babies during and after transfer. Anecdotally, support for the expansion of homebirth and birth centre services has been hampered by a belief that this intrapartum change of venue adds a layer of unnecessary risk to women and their babies [28, 29]. This study explores these events during labour, which include planned place of birth, transfer from home or a birth centre to hospital, actual place of birth, mode of birth and neonatal admission to special care nursery/neonatal intensive care unit (SCN/NICU), described as birth trajectories, for a low-risk cohort of women from NSW from 2000 to 2012. This information will aid in our understanding of the intrapartum transfer rate and subsequent interventions and assist with maternity service development and expansion of options for women interested in birth at home or in a birth centre. It will also inform understanding of the costs in different settings, because the costs of birth at home or in a birth centre should include the cost associated with transfer where applicable.
The aim therefore was to investigate the birth trajectories of women at low risk of complications who at the end of pregnancy plan to give birth at home, in a birth centre or a hospital labour ward. The development of this decision tree framework was also undertaken to inform a future costing of these birth settings.