No place like home? Thinking twice about midwife-assisted planned home births

Over the past two decades, the number of out-of-hospital births has been on the rise in British Columbia.  This includes home births, which can be performed by registered midwives or appropriately trained physicians. 

But are home births safe?  It depends.

A recent US study investigated this question.  By analyzing the rates of neonatal mortality in births attended by certified nurse-midwives, the study found that home births had significantly higher rates of neonatal mortality, even for mothers with a low risk profile. These results are not surprising; when unexpected complications occur during labour, hospitals are much better equipped in providing immediate and life-saving intervention for both mother and fetus. 

In Canada, birth statistics suggest that hospital births are far safer than non-hospital births.  In 2018, for example, non-hospital births were 4.5 times more likely to result in fetal death compared to hospital births.  These numbers, however, do not distinguish between high-risk and low-risk pregnancies.  In fact, studies have shown that midwife-attended home births for low-risk pregnancies are as safe as hospital births, according to the Society of Obstetricians and Gynaecologists of Canada (SOGC).  As such, the current SOGC guideline supports a woman’s choice for a planned home birth, given that she is fully informed of all risks and benefits, and provided that “the birth is anticipated to be uncomplicated”.

To return to the question posed earlier, childbirth is an inherently risky process. For this reason, obstetrical procedures carry the highest rates of medical insurance premiums in Canada.  Strictly speaking, therefore, no child birth is ‘safe’ because every delivery, no matter how ‘routine’, can potentially result in catastrophic and life-altering birth injuries to the baby, including cerebral palsy and other types of brain damage.

With this in mind, any woman who is considering a planned home birth by a midwife is well advised to familiarize herself with the Standards & Policies that regulate the scope of practice of midwives in British Columbia. 

A number of important factors must be considered to ensure the safety of a planned home birth.  First, a midwife has a duty to determine if the pregnancy poses a risk to the pregnant mother and/or the fetus, and whether or not the pregnant mother is an appropriate candidate for a planned home birth. There is a long list of conditions that may preclude a midwife from attending a home birth. These conditions may be present early on in the pregnancy, or they may develop at any time throughout the pregnancy or during labour. In those cases, the midwife is required to transfer the care of the client to a physician, which would require immediate transport to hospital if the labour was underway at home. Likewise, similar criteria exist with respect to water births.  Second, a midwife has a duty to develop a written and detailed plan for a home birth. This plan should include an assessment of the home environment as a suitable birthing place.  The midwife is also required to have the necessary equipment and supplies for home birth, as well as a comprehensive transport plan to the nearest hospital in case of an emergency.  Finally, and most importantly, the midwife has a duty to obtain the client’s informed consent. In doing so, not only must the midwife discuss with the client any theoretical risks, but the midwife must also keep the client informed and updated regarding any unanticipated problems that arise at any stage of the pregnancy, including during labour.

The bottom line: 

Midwife-assisted planned home births are a relatively safe option for a certain group of low-risk pregnancies, as described by the CMBA guidelines. In obtaining the client’s informed consent for a home birth, the midwife has a duty to determine the risk profile of the pregnancy and appropriateness of the client for a home birth, to clearly communicate and discuss those risks with the client and to develop a detailed plan, including an emergency transport plan.  Most importantly, the midwife must be ready to promptly transfer the care of the patient to a physician when complications arise that exceed his or her scope of practice, or when requested by the pregnant mother.

If you have questions or concerns about your home birth experience, we are here to help.  We work in collaboration with a team of lawyers, physicians, midwives and nurses.  We will take the time to listen to your concerns, and carefully review your medical care in order to answer your questions. Please contact us for a free consultation.    

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Arash Adjudani

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