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.