A 1986 World Health Organisation report concluded that "home is the most appropriate birth setting for most childbearing women. Women (and their attendants) choosing this option must be provided with necessary diagnostic, consultative, emergency and other services as required, regardless of place of birth."(1)

In the Netherlands, where the perinatal mortality rate is one of the lowest in the world, approximately 35% of all births take place at home. An integrated system of home birth services includes well-trained midwives who carry emergency equipment, and a well-established system for emergency transport and the reception of home birth transfers in hospital.(2)

The College of Midwives of British Columbia (CMBC) endeavours to unite practitioners (midwives, physicians, nurses, hospital staff and ambulance personnel) with the common goal: that home birth be made as safe as possible for mothers and babies in B.C.

Informed choice
Midwifery promotes decision-making as a shared responsibility between the woman, her family (as defined by the woman) and her caregivers. Midwives recognise women as primary decision makers.

The CMBC supports a woman's right to choose to give birth in her own home with her family. The World Health Organisation describes health as multi-dimensional.(3) Decisions about health are based on many factors including physical, emotional, social, spiritual and cultural considerations. Women must be free to make decisions regarding birth based on all of these factors. Birth is more than a physical or medical event.

In 1993, the American College of Obstetricians and Gynaecologists issued the following statement:

Informed consent is an expression of respect for the patient as a person; it particularly respects a patient's right to bodily integrity, to self-determination, and supports the patient's freedom within caring relationships. It also makes possible the active involvement of the patient in planning and care through a process that includes ongoing shared information and developing choices. This freedom is maximised in relationships marked by mutuality and equality.(4)

The International Confederation of Midwives' Code of Ethics states that: "Midwives respect a woman's informed right of choice and promote the woman's acceptance of responsibility for the outcomes of her choices. Midwives work with women, supporting their right to participate actively in decisions about their care, and empowering women to speak for themselves on issues affecting the health of women and their families in their culture/society.(5)

Thoughout pregnancy and childbirth, midwives have the duty to fully inform the women in their care about the safety, efficacy, risks and benefits of care options and to support women in making decisions about their care, including their choice of birth place.

Safety
For parents and care providers concerned with childbirth, the issue of safety is central. In supporting normal birth at home, the CMBC is not advocating that all births take place at home. There are mothers and babies who will be safer in hospital and many mothers will choose hospital birth.

Available evidence confirms that for low-risk women, a planned home birth with trained attendants is a safe and viable option.(6, 7, 8, 9, 10, 11, 12, 13) In Alberta, a review of the literature on the safety of home birth was undertaken for the government and conlcuded that "with proper risk assessment, selection and care, low risk women may safely give birth at home."(14) A ten-year retrospective evaluation of 49,371 births (10,998 out of hospital) in Washington state found no significant difference in neonatal mortality between licensed midwives, physicians and nurse-midwives, regardless of place of birth.(15)

The literature has demonstrated that when home births are planned with a well-screened population of women, and attended by professionally trained midwives carrying emergency equipment, optimum safety conditions are met and the best outcomes are achieved.(16, 17, 18, 19, 20) The CMBC has developed a list of Indications for Discussion, Consultation and Transfer of Care(21), as well as Indications for Planned Place of Birth(22) to guide midwives in risk assessment.

It is often assumed that a hospital, by virtue of immediate access to technological support, provides maximum safety. In fact the available literature does not provide conclusive evidence that hospital birth is safer for properly screened clients. Many hospitals in rural and northern communities do not provide on-site operative delivery, and have emergency equipment comparable to the equipment a midwife carries to a home birth. With careful antenatal screening, these hospitals have been able to deliver safe and effective care to women and their babies.(23, 24, 25)

Even where home birth numbers are small, it has been observed that it is at home that birth is most likely to remain normal.(26, 27) Home birth provides midwives with an opportunity to observe normal birth without intervention, which can in turn lead to a reduction in interventions in hospital. Providing home birth services offers the opportunity to examine and promote normal birth, as well as to support one of midwifery's fundamental principles - choice.(28)

Internationally, maternity care is moving toward clinical practice that is evidence or research-based(29) and current research does not support the routine use of many obstetrical procedures.(30, 31) In several countries, including the U.K.,(32) Australia(33) and the U.S.,(34) initiatives are underway to encourage health care professionals to offer home birth as a safe and viable option for low-risk women. The CMBC encourages further research to determine the minimum conditions which support safe home birth in British Columbia and supports full participation in the Ministry of Health's Home Birth Demonstration Project.(35)