Canada gets it right following the good example of Wales: out of hospital birth is accepted as a reasonable choice.
February 12, 2019
In the February issue of the Journal of Obstetrics and Gynaecology Canada (JOGC), Canadian obstetricians released an updated statement on home birth – No. 372 Statement on Planned Home Birth. This statement, written jointly with midwives, is a refreshing response to the evidence on place of birth in a setting where there are appropriately trained midwives and an integrated health care system. In many ways, unlike its neighbour to the south, Canada is able to provide this kind of favourable setting. Registered midwives are offered privileges that permit them to follow their clients to the hospital for continuity of care and collaboration with obstetricians when a transfer is needed. These midwives are well integrated into the health care system and importantly, “no punitive or financial disincentives exist for those transfers”.
In its statement, the Society of Gynaecologists and Obstetricians (SOGC) refers to the safety of home birth, quoting metanalyses of research studies. It is now accepted that women who birth at home have increased spontaneous vaginal births; a reduction in interventions; lower maternal morbidity; less use of intrapartum pain medications; fewer obstetric anal sphincter injuries, operative vaginal deliveries, episiotomies, caesareans, infections, and fewer postpartum haemorrhages. At the same time no difference in neonatal death, new born APGAR scores, NICU admissions, severe adverse neonatal outcomes or intrapartum stillbirth is found between midwives attending births in the hospital and midwives attending births at home.
SOGC concludes that for low-risk populations “data indicate that individuals at low risk for poor perinatal outcomes who plan homebirth with a regulated provider in an integrated health care system may have improved obstetric outcomes without increased neonatal morbidity or mortality.” A cautious and well evidenced conclusion which might be the first time a national professional group of obstetricians has acknowledged that for fit and healthy women with no medical problems the mantra that it's best to give birth in or next to an obstetric unit just in case 'something goes wrong' is in fact not true.
Women benefit from collaborative and respectful behaviour toward themselves and their families, but also between midwives and doctors who cooperate keeping the common goal of good outcomes in mind. Where this doesn’t exist it is hard for home birth to flourish. Following the research published in The Place of Birth in 2011, the Welsh Government issued guidance to local health boards that facilities should be made available so that 45% of women should be able to access out of hospital births. It had also previously set a target of 10% of birth to be at home. Although neither of these targets has so far been met, the guidance and target setting help to establish a positive culture and 'normalise' birth away from obstetric settings more appropriate for women with additional needs . Canada and Wales share the reality of a large and powerful neighbour to whom in this respect they are showing the way.
Association of Ontario Midwives. Choice of Birthplace: Guideline for Discussing Choice of Birthplace With Clients: Methodology and Review of Evidence. Toronto: Association of Ontario Midwives; 2017.
Campbell, K., Carson, G., Azzam, H., & Hutton, E. (2019). SOGC CLINICAL PRACTICE GUIDELINE: No. 372-Statement on Planned Homebirth. Journal of Obstetrics and Gynaecology Canada, 41, 223–227. https://doi.org/10.1016/j.jogc.2018.08.008
Planned home birth. Committee Opinion No. 697. American College of Obstetricians and Gynecologists. Obstet Gynecol 2017;129:e117–22.