Friday, April 20, 2012

Home birth regulations around the world

Midwives across the United States face arrest or imprisonment if they practice in a state that does not recognize their certification, such as this Indiana CPM Ireena Keeslar who was arrested and released on $10,000 bail. Keeslar serves a large Amish population in her county and, ironically, can practice legally just over the border in Michigan.

In Ontario, Canada, midwives and consumers have been calling for birth centers; currently the province's midwives can only attend home or hospitals births. The neighboring province of Quebec has a long, successful history of birth centers with 11 currently in operation. But since Ontario began regulating midwifery in 1994, it has only offered women the choice of home or hospital birth. Just a few weeks ago, Premier Dalton McGuinty announced a $6 million pilot program of 2 birth centers in Ontario. The locations are yet to be determined; one will likely be in Toronto.

If you thought having a home birth was difficult in Canada (where in some provinces you have to book a midwife the minute you take a pregnancy test) or in the US (where midwives practice "under the table" in several states), Israel is taking home birth regulations to a new level. Last December, the Israel health ministry drafted new rules regulating home birth. Some of the proposed restrictions include:
  • The mother must obtain a "letter from her family doctor testifying that she is both physically and mentally sound"
  • The home can be no more than 30 minutes from the hospital
  • The room where the birth will take place must be at least 10 square meters (108 sq ft)
  • Birth attendants must recertify in neonatal resuscitation every year, rather than every 2 years
  • Maternal temperature cannot go above 37.8 degrees Celsius
  • Active labor must begin within 6 hours of the water breaking
  • The placenta must be born within an hour
  • The attendant must return to reexamine with woman 24 hours after the birth
The proposed regulations are a round-about way of further restricting, if not stopping, home birth. A few of these (more frequent NNR certification, 24-hour postpartum visit) may be reasonable, but most place onerous burdens upon woman seeking home births. After public criticism of these guidelines, the Israel health ministry delayed their implementation and organized meetings with stakeholder groups, including home birth midwives.

In the UK, the BBC series Call the Midwife, about midwifery in 1950s London, has sparked renewed interest in caseload community midwifery. Annie Francis, programme director of Neighborhood Midwives, describes what caseload midwifery looks like:
Once they've booked with us, we'll guarantee that they'll be seen by a midwife they know, whether it's in their home or in a clinic, every single time they need to see a professional during their pregnancy, birth and afterwards. If their needs change and they need to see an obstetrician, we'll go with them. If they end up needing a caesarean section, we'll still be there by their side.

We're expecting that between 80 and 90% of our clients will give birth at home – and that's compared with a national home birth rate of around 2% [in England], although studies show that many more women would like home births than are currently given the chance to have one.

In the Czech Republic, the Prague Municipal Court ruled that hospitals must provide home birth services to women who desire them. "[R]eferring to a recent ruling of the European Court of Human Rights in a similar case in Hungary, the judge said women indeed have the right to choose the place where they give birth to their children. The court also said that the woman was entitled to all necessary assistance from the hospital because the state had so far denied the registration of private midwives who would otherwise do the job." More articles on the topic here and here and here.

In Australia, Professor Euan Wallace, director of obstetrics at Southern Health, has called for more publicly funded home birth programs.

A South Asian study found that using delivery kits and associated clean delivery practices improved infant survival for babies born at home in "rural areas with limited access to healthcare." The kits include soap, a sterilized blade for cutting the cord, clean string for tying the cord, and a plastic sheet.

Finally, in Liberia, President Ellen Johnson Sirleaf "has given a strict mandate that no woman should give birth at home, as has traditionally been the case." Health officers commented that in order to make the mandate effective, the country must build more maternity centers, especially in remote areas.


  1. There were actually 2 Indiana midwives arrested. The other was Jeannie Stanley. Apparently, they are really being targeted! I live in Indiana and am planning a homebirth with a CNM in a few weeks. My midwife and her partner are the only 2 I know of in this area of northern Indiana that can legally attend homebirths. There is no way they can take on all the cliental left behind if more CPM's have to stop practicing! I know there are more CPM's still attending Amish births in the area. Hopefully, they are spared and the law is changed! They are really needed, especially for the Amish.

    1. I live right in the middle of this firestorm. There are lots of midwives here for the Amish, Jeannie chose not to be legal. She was not allowed to even do births at the New Eden Birthing Center, not just home births. Yes, we have a birthing center for the ladies who do not want to go to the local hospital. That is where most of the Amish go. I haul Amish for a living and have transported MANY of them to New Eden, and know hundreds of them personally.

  2. As to the Czechoslovakia news, since 1993 there are actually two different countries - Czech Republic, where these news come from and Slovakia, where homebirth is legally very problematic.

    (I've lived in US for the past 6 years, birthed my second child at home in New Jersey and moved to Slovakia 2 weeks ago. I'm not looking forward to navigating the local system if we decide to have another baby here.)

  3. Do you know the story of hungarian midwife Agnes Gereb?
    Very interesting, not fair, discriminating women and the choices they make.

  4. CPMs do not actually practice legally in Michigan, although evidently some of them think they do.

    Folks including Friends of Michigan Midwives are working on licensure now.

    1. CPMs do not practice legally in any state unless that state has passed a law that specifically provides for licensure (25 states) or legal status without licensure (Maine and Missouri). Michigan is one of 15 states that is actively pushing for licensed legal status for CPMs, along with Alabama, Illinois, Indiana, Iowa, Maryland, Massachusetts, Mississippi, Missouri, Nebraska, North Carolina, Ohio, Pennsylvania, Rhode Island, South Dakota, as well as Puerto Rico. Plans for licensing laws are underway in several other states, including Connecticut, DC, Georgia, and Kentucky.
      If you live in any of these states, find your local Friends of Midwives or birth activist organization and come help us push for licensure laws. Until CPMs are licensed in every state, women will not have assured access to CPMs, who are specialists in out-of-hospital birth.
      Check out the map at the Push for Midwives website:

    2. CPM's can practice in Michigan legally by default. They are not recognized, but not illegal.

    3. There is no such thing as "legally by default".

      Unless they are explicitly licensed, they can be charged with practicing medicine or nursing without a license. MANA's chart is out of date and should not be continuing to perpetuate this myth.

  5. Where does all the anti-homebirth sentiment come from? Do they really believe they aren't safe? Yes there are a some instances that baby/mother has had complications and the worst has happened, but the same thing happens at hospitals. Does that make hospitals unsafe?

    Not sure if you watch Bones, but there was an episode that Bones (brilliant anthropologist)refuses to have a hospital birth and wants a homebirth. The father took her to the hospital for the tour and she brought her light that make bodily fluids glow and stated all the possible germs the hospitals harbor. It was too funny - especially since her opinion was right!

  6. I love that I live in Ontario Canada. I have received excellent midwifery care and wish everyone was given such autonomy.

  7. I just recently read an amazing book Unassisted Childbirth by Laura Kaplan Shanley and have to say that this is an option I would go for. What are they going to do... arrest women who choose this option? Should government have this much say in a woman's life? Absurd!

  8. I wanted to make a note about Liberia and conditions in developing countries in general. In rural communities around the world, trained birth attendants and access to emergency services might be hours or even days away. Where I lived in Paraguay, there was not a single motorized vehicle in the village. Getting to a medical center where a c-section could be performed meant a six-hour journey in an ox cart. At the same time, women in many poor countries are more prone to obstructed labor because of poor nutrition during childhood and early marriage and pregnancy AND to severe postpartum hemorrhage because of underlying anemia, due both to poor nutrition and intestinal parasites. Many men - who control decision making and family money - are indifferent to the potential dangers of childbirth and do not want to spend money on an attendant for the birth. In many parts of the world, a woman cannot be transported without her husband's permission. If he is working in another part of the country, the woman with an obstructed labor will simply labor and labor and labor - for days - until she dies. Liberia has one of the highest maternal mortality rates in the world. It is not comparable to home birth in the United States or Europe. For the president of the country to say she has a goal of ending home birth is for her to say that women's lives actually matter. Can we hope for a future in which Liberian women can have the option of giving birth safely at home or safely in clinic or hospital? Of course. But that is not the world as it is right now.

    1. chingona--totally agree with you. I almost put some disclaimer in my post about home birth in developing nations not being at all the same thing as home birth in industrialized nations with easy access to obstetrical services. But I figured it was pretty self-evident so I left it out :)

      I like the approach that some South American countries have taken better than the Liberian approach: instead of outlawing home birth, they are enticing women to birth in clinics by offering things that women want, like upright/vertical birth.

    2. I didn't get the impression from the article you linked that Liberia outlawed home birth. It never actually defines what the "mandate" means, but it seems more likely that it's a mandate to the health system to get women into clinics. I took it be similar to a mandate that, for example, every family have access to clean drinking water. That doesn't mean it would be illegal to drink contaminated water. (Bad analogy, I know.)

      I do agree that clinics should offer things that women want and just generally respect women. In Paraguay, I heard over and over again from women that they didn't want to go to the clinics because "they cut you there." But the doctors and nurses really believed routine episiotomy was a positive intervention. It was frustrating. It seems, from the article, that the problem in Liberia is mostly that they just don't have the health infrastructure.

  9. Here in Australia there is still a big push to make homebirth harder. Just this week a paper was submitted by one state which, if adopted, would make it impossible for a woman to have a homebirth after c-section, or for twins. Unfortunately there are a couple of very outspoken anti-homebirth OB's, and the mainstream media love to publish opinion pieces labelling homebirthers as incense-burning hippies who don't love their babies enough.

    1. Hey, the Fremantle Herald is pretty mainstream media—although independent—and its coverage doesn't label homebirthers like that at all. Check out their coverage of the issue at Go to the issue of 21-4-2012 (top left-hand corner has editions listed in a scroll-down bar) to check out the front-page story. There's also a fantastic opinion piece by "rebel" obstetrician Dr Ralph Hickling on page 5 of the current issue (28-4-2012) where he says doctors should get out of the way and let midwives do their thing.




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