Midwifery Coalition of Nova Scotia

Is Home Birth Safe?

Recommendations for the Regulation and Implementation of Midwifery in Nova Scotia, the Working Group has proposed a scope of practice for midwifery which specifies that a midwife be capable of, and willing to, provide care in all settings—in hospital, in a birth centre or at home.

Presently, in Nova Scotia, we are familiar and comfortable with babies being born in hospital. Most of us accept, without question, that the hospital is the best and safest place to give birth. We also accept, without question, that any other place of birth must be less safe.

But is this belief true? When we ask the question, "Is home birth safe," what answer do we get?

A great many studies have addressed this question, but when the way the studies have been done is examined carefully, most of the studies are flawed in some way—for example, they are too small, they consider too few variables, or the groups of women the study is comparing are not enough alike for the comparison to mean anything.

One way to get at an answer is to look at as many studies as possible, examine their methodology carefully, eliminate the studies that are so flawed that the results are misleading, and draw a conclusion based on the remaining studies. At least two researchers have done this, and have arrived at similar conclusions.

The first review was done in 1991 for the Alberta Registrar of Health Disciplines. The author did an extensive review of the literature and identified the "confounding variables and methodological problems." found in the literature. Taking all of these into account, he concluded that:

"There is no evidence that the safest place for women to give birth is a hospital."
"There is no evidence that the safest place to give birth is the home."
"There is some evidence that, with proper risk assessment, selection and care, low risk women may safely give birth at home."

The second review was published in 1997 as a chapter in the text Midwifery and Childbirth in America. This author offers a detailed compilation, discussion and analysis of all the variables that affect the validity of these studies. Based on this analysis, the author concludes:

"...the available evidence indicates that births attended by either midwives or physicians in homes and birth centres in this country can be as safe as in-hospital births provided the following conditions are in place:

The midwives must be competent, that is, have the necessary knowledge, skills and judgement...

There must be good prenatal care, with careful screening to detect and address complications and identify high-risk conditions, and the development of good communication and trust between the midwife and the pregnant woman and others who will be present during the birth.

There should be more than one knowledgeable person at the birth—either two midwives or a midwife and a trained, experienced assistant.

There should be clear, universally accepted criteria regarding referral of high-risk women for hospital birth...

There should be no disincentives to transporting women and newborns to the hospital. Transports should be viewed and accepted as an expected part of a program of out-of-hospital births. They should not be seen as a failure by the mother and her family, or the midwife.

There must be access to rapid means to transport women and newborns to hospital care. Emergency medical technicians need appropriate training to support out-of-hospital births.

There must be competent and reliable obstetric backup at a nearby hospital. This crucial component requires an effective working relationship between the out-of-hospital midwife and the doctors and nurses at the hospital. The hospital personnel must trust the judgement of the out-of-hospital birth midwife, and the out-of-hospital birth midwife must be able to rely on the hospital personnel to respond appropriately when she calls to say that she is bringing a woman or newborn into the hospital..."

The Scope of Midwifery Practice described in Recommendations for the Regulation and Implementation of Midwifery in Nova Scotia addresses many of these criteria. Others -- for example establishing referral criteria, the availability of emergency transport and the training required for emergency medical technicians—can be addressed as part of the process of integrating midwifery care into Nova Scotia's health system.

Is home birth safe?: Yes it is, when the mothers are carefully screened to determine the level of risk involved in their pregnancy and when they have good care during pregnancy and birth, provided by well-educated, competent practitioners who are a respected part of the health system. In the context of the midwifery model the Working Group is recommending and based on the available evidence, home birth will be as safe as birth in hospital.

Rooks, the author of Midwifery and Childbirth in America makes another point that is worth considering in this discussion:

"Some babies and women die for lack of immediate access to interventions that are available only in the hospital. But the opposite is also true: Some babies and women die as a result of overuse of interventions that are applied too frequently in hospitals. Currently, out-of-hospital births are an option exercised by a very small minority of women. Most of them are well informed and make this choice through a thoughtful, responsible decision-making process. If that choice exposes them to any risk greater than they would experience during a hospital birth, the difference is small. At the same time, that choice protects them and their babies from unnecessary medical interventions. The freedom to make this choice is very important to some women and their families."

The Midwifery Coalition of Nova Scotia supports the right of women and families to make this choice. We believe that the midwifery model recommended by the Interdisciplinary Working Group on Midwifery Regulation, if adopted, would ensure that the choice would be a safe one.

Prepared by Jan Catano for the Midwifery Coalition of Nova Scotia

June 1999

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Is Home Birth Safe?