Birth on the Fringe: high-risk homebirth and contentious decisions in maternity care

Homebirth is a minority choice in Australia (less than 0.4% in 2020). It is available through publicly funded homebirth programs as well as independent midwives, but it is becoming progressively more difficult to access. Despite being a minority option, homebirth is an emotive and polarising issue. Women who choose homebirth when they are assessed as "high-risk" are making an even more contentious choice. High-risk homebirth raises a number of legal and bioethical issues around choice, autonomy and risk. My argument is that it is overly simplistic to frame high-risk homebirth from a position of conflict between women's autonomy and the interests of the fetus. Women and the fetus should not be seen as being in conflict. Rather, there should be a recognition that they are in a relationship. The clinical evidence around risk is contested and I discuss some of the conflicting studies. In any event, women balance and prioritise different kinds of risk. They may choose to accept the increased risk of homebirth in order to obtain a different benefit, such as being able to birth in a familiar environment with a lower risk of obstetric intervention. Strong, trusting relationships between women and their care providers will ensure that risk is discussed appropriately. I also argue in favour of a relational conception of autonomy, where strong relationships with care providers can also increase women’s autonomy. This approach places pregnant women in the best position to make informed, authentic decisions on behalf of the fetus as well as themselves. Rather than focusing on whether women are “right” when they choose high-risk homebirth, I propose that a pragmatic and compassionate approach is to try and accommodate contentious birth choices rather than abandoning these women on the fringe of maternity care. Women can choose to accept the consequences of their choices, even if this means failing to comply with medical advice