A coroner is urging changes to laws on homebirths after investigating the deaths of three newborns in South Australia.
Deputy Coroner Anthony Schapel held an inquest into the deaths of three babies during or soon after separate homebirths involving the same midwife, Lisa Barrett.
The inquest heard she had been deregistered as a midwife but kept working as a birthing advocate before the birth of the third child involved.
The coroner was told Ms Barrett had also been involved in the delivery of another baby which died in similar circumstances in Western Australia.
The inquest started into the death of one baby, Tate Spencer-Koch, who died in 2007.
The court first had to determine whether the baby was live at birth and therefore a person by law, allowing an inquest.
The proceedings were delayed for nearly a year as midwife Lisa Barrett took her fight to the Supreme Court, then the High Court.
She appealed against a Coroners Court ruling that an inquest could be held into the baby's death because pulseless electrical activity detected in the baby after her birth was considered a sign of life, which made her a person by law.
Ms Barrett was unsuccessful in both higher jurisdictions.
The inquest then encompassed the death of a second baby, Jahli Hobbs, who died in April 2009.
While the inquest was in progress, a twin died during a homebirth attended by Ms Barrett in October 2011.
The death of that baby, Tully Kavanagh, was then included in the inquest.
It also received evidence that had been gathered on the death of another infant in Western Australia, where Ms Barrett had also been present at the delivery.
Mr Schapel concluded all three infant deaths were preventable.
"All three infants died after complications that were experienced in the course of their deliveries. These were complications of a kind that from time to time occur in deliveries of the types involved in these cases and were therefore not entirely unpredictable," he found.
"It has been established in each instance that their deaths arose from complications that were well understood in advance as being risk factors in respect of the types of deliveries that would need to be performed."
The coroner also commented on Ms Barrett's involvement.
"In 2005 she commenced a homebirthing practice as a privately-practising midwife. In early 2011, Ms Barrett relinquished her registration as a midwife and commenced practice as a birth advocate, working privately within the homebirth industry. She continued to provide services at homebirths in that stated capacity and charged for her services," he said.
Mr Schapel voiced doubt about Ms Barrett's evidence on her involvement in the two births in 2011 of Tully Kavanagh and a baby in Western Australia, which he said led him to believe she was acting as more than a birth advocate.
"To my mind, Ms Barrett's evidence that she was a mere birth advocate, not performing the duties and responsibilities of a midwife, has to be rejected," he concluded.
Mr Schapel said each death might have been avoided had there been deliveries by elective caesarean section in a hospital.
"I find that if Tate's labour and delivery had occurred in a hospital, there would have been a greater level of assistance to properly manage the complication of shoulder dystocia and that on a balance of probabilities the delay in Tate's delivery caused by the resulting obstruction would have been minimised," he said.
"Her death may therefore have been prevented.
"I find that as a matter of certainty that if due to the perceived risk of obstructed delivery [the baby's mother] Ms Spencer had undergone an elective caesarean section, Tate would have been born in a healthy state."
On Jahli Hobbs' death, he found:
"Jahli was immediately prior to her labour and delivery a healthy unborn infant. It was known in advance of Jahli's delivery, and in particular by the midwife Ms Lisa Barrett, that Jahli was in a breech position within the uterus.
"If Jahli's mother, Ms Naomi Hughes, had undergone a natural childbirth in hospital it is likely that she would have been the subject of continuous monitoring and that foetal distress may well have been detected at an earlier point in time, thereby hastening Jahli's delivery.
"I find as a matter of certainty that, if Ms Hughes had undergone a caesarean section, Jahli would have been born in a healthy state."
The Deputy Coroner also highlighted the risks in the case where one of two twins died.
"There are clearly-identified risks associated with the delivery of twins and in particular to the second-born of twins," Mr Schapel said.
"Tully was the second-born of twins. Tully was born en route to the Women's and Children's Hospital from the home of his parents. The first twin, Ruby, had been born at that home. There was a delay in excess of one hour between the delivery of Ruby and the delivery of Tully.
"I find that this delay was a substantial contributing factor in Tully's death. During that period a placental separation occurred, thereby giving rise to the fatal hypoxic event. The death of Tully Kavanagh would probably have been prevented if the labour and delivery had occurred in a hospital.
"It can be said with certainty that if Tully had been born by way of elective caesarean section, Tully would have survived."
He recommended better education for people considering homebirths, as well as legislative changes to make it an offence for people to operate as unregistered midwives.
Mr Schapel also wants practitioners to be required to notify health authorities of patients intending to have homebirths.
The Australian Medical Association says it supports many of the recommendations made by the Deputy Coroner.
Dr Peter Sharley said setting up alternative birthing centres was an interesting suggestion.
"There's already in existence birthing units in the major obstetric hospitals and perhaps we need to boost that up such that is doesn't look like a hospital, doesn't smell like a hospital and quite clearly is led by midwives with the back-up of doctors," he said.
SA Health Minister John Hill said the inquest findings were a landmark and would lead to much more debate about homebirths.
- Additional reporting by Candice Marcus