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home birth

A Home birth is a birth that is planned to occur at home. It is often contrasted to birth that occur in a hospital or a birth centre.

Types of home births

Homebirths are divided into two types — attended and unattended births. Attended births are those at which a trained medical professional attends, usually a midwife, although sometimes a general practitioner. Unattended births, which are sometimes called freebirths may involve simply the woman herself, or a woman attended by her partner, friends, family or a birth attendant called a doula.

During a homebirth there is no access to pharmaceutical pain relief or pharmaceutical labor induction, nor equipment for emergency delivery (such as forceps, vacuum extraction, or surgery). Births necessitating these interventions would require transfer to a hospital. Depending on the midwifery practice, transfer rates can range anywhere from 5% to 40%, but most studies cite a transfer rate of about 16%.^[1]

The WHO has released a statement supporting the right of women to choose where they give birth. In the case of low-risk pregnancies, with appropriate support and contingency plans women can give birth at home. ^[2]

The Rapid Decline and Gradual Rise of Home Birth in the West

In many Western countries, home birth declined over the 20th century due to migration to urban centers, increased accessibility of hospitals and unwillingness of doctors to attend to women in their homes. As one doctor described birth in a working class home in the 1920s.

You find a bed that has been slept on by the husband, wife and one or two children; it has frequently been soaked with urine, the sheets are dirty, and the patient's garments are soiled, she has not had a bath. Instead of sterile dressings you have a few old rags or the discharges are allowed to soak into a nightdress which is not changed for days.^[3]

This experience is contrasted with a 1920s hospital birth by Adolf Weber:

The mother lies in a well-aired disinfected room, light and sunlight stream unhindered through a high window and you can make it light as day electrically too. She is well bathed and freshly clothed on linen sheets of blinding whitenes... You have a staff of assistants who respond to every signal... Only those who have to repair a perineum in a cottars's house in a cottar's bed with the poor light and help at hand can realize the joy. ^[4]

There was a revival of midwifery, the practice supporting a natural approach to birth, in the United States in the 1970s. However, although there was a steep increase in midwife-attended births between 1975 to 2002 (from less than 1.0% to 8.1%), most of these births occurred in the hospital and the US rate of out-of-hospital birth has remained steady at 1% of all births since 1989 with 27.3% of these in a free-standing birth center and 65.4% in a residence. Hence, the actual rate of home birth in the United States has remained remarkably low (0.65%) over the past twenty years. ^[5]

Home birth in the United Kingdom has also received some press over the past few years as there has been a movement, most notably in Wales, to increase home birth rates to 10% by 2007. Between 2005 to 2006, there was an increase of 16% of home birth rates in Wales, but the total home birth rate is still 3% even in Wales (double the national rate) and in some other counties of Great Britain the home birth rate is still under 1%. ^[6] In Australia, birth at home has fallen steadily over the years and is currently 0.3%, ranging from nearly 1% in the Northern Territory to 0.1% in Queensland. ^[7] The New Zealand rate for births at home is nearly three times Australia's with a rate of 2.5% and increasing. ^[8]

In the Netherlands, an opposite trend has taken place: in the 1965, two-thirds of Dutch births took place at home, but currently, that figure has dropped to less than a third – about 30%. ^[9]

Research on Safety

In 2007, after a comprehensive review of the literature, the UK’s National Institute for Health and Clinical Excellence (NICE) released the following recommendations concerning the location of birth:

With relation to women’s and babies’ outcomes for home births, there is a lack of good quality evidence. The evidence in relation to perinatal mortality is not strong enough to support past or current policies of increasing or decreasing current provision outside consultant units. Women should be offered the choice of planning birth at home, in a midwifery-led unit, or a consultant-led unit [hospital]. Before making their choice, women should be informed of the potential risks and benefits of each birth setting.

"As a minimum," the NICE report continues to state, such information should include the following:

Planning birth at home: increases the likelihood of normal vaginal birth and satisfaction in women who are committed to giving birth in this setting, compared with planning birth in a hospital
Planning birth in a consultant-led unit: increases the likelihood of pharmacological analgesia, interventions and an instrumental birth, and decreases satisfaction, compared with planning birth in other birth settings. There may be a lower risk of perinatal mortality when care is delivered in a consultant-led unit." ^[10]

Study Design

The research concerning the safety of home birth is few and far between, and much of it is of questionable methodology ^[who?]. In fact, there are no randomized controlled trials for home birth, ^[11] possibly because maternal choice is such a major aspect of home birth and thus, few mothers would be willing to be randomly assigned to either the home birth or the hospital birth. ^{[citation needed]} The studies that do exist tend to be matched cohort studies conducted either retrospectively (by selecting hospital records that match the characteristics of the home birth records),^[12] by matched pairs (by pairing study participants based on their background characteristics),^[13] ^[14] or by using multivariate analysis to control for background variables. ^[15]

However, even in cohort studies, there are many differences between women who choose to give birth at home versus in hospital. There are unquantifiable differences in home birth patients, such as maternal attitudes towards medical involvement in birth^[12], and demographically, home birth patients tend towards being more multiparous, less ethnic minorities, attend more prenatal visits, be slightly taller and lighter, of better educational background, and have fewer previous obstetric complications, including cesarean sections.^[15] Thus, none of the studies conducted were able to study a large enough group of matched births to make any definitive statements concerning perinatal mortality, and other rare complications.

The most recent research contained in the Cochrane systematic review of the literature, (published on the Cochrane database; the source from which hospital policies are usually created), states that there is not enough evidence to decide one way or another, whether home or hospital birth is safer (Olsen & Jewell: 2000 (CD000352) in Hofmeyr et al:2008:252).

Maternal safety

All medical interventions were substantially decreased in the home birth sample, including the use of any pain medication or analgesics including epidurals, forceps or vacuum extraction, episiotomy and cesarean sections. Accordingly, the likelihood of normal vaginal birth was also greatly increased in the home birth sample. The studies were able to establish that there was no difference between the home birth and the hospital birth groups in the incidence of pre-eclampsia, premature rupture of membranes, or premature birth. Except in the 1989-1992 Zurich study ^[13], the length of labor tended to be longer during home birth, which is unsurprising given the five-fold lower incidence of induction of labor in the home birth populations.

In terms of maternal outcome, no study found any statistically significant difference between the number of women that had third-degree perineal lacerations or postpartum hemorrhage. However, the 1998-1999 British Columbia study did find a three- to four-fold less likelihood of infection for both the infant and the mother,^[15] and all studies reported a substantially higher likelihood of an intact perineum in the home birth sample.

Infant Safety

Perinatal outcome is more complicated to assess due to the low incidence of mortality and the difficulty in achieving appropriate study design. No reliable evidence presently exists for differences in infant safety in low-risk women.

Legal situation in the United States

No state prosecutes mothers for giving birth outside of a hospital. However, midwives who assist at such births may be prosecuted in some areas.^{[citation needed]}

In 37 states it is legal to acquire the services of a midwife. Many midwives continue to attend mothers in states where it is illegal, while efforts are underway to change the law.

Practicing as a direct-entry midwife is still (as of May 2006) illegal under certain circumstances in Washington, D.C. and the following states: Alabama, Georgia, Hawaii, Illinois, Indiana, Iowa, Kentucky, Maryland, North Carolina, South Dakota and Wyoming.^[16] However, Certified Nurse Midwives can legally practice in these areas.

Legal situation in Australia

Although some State Governments have now introduced government funded home birth services, including the Northern Territory, Western Australia, New South Wales and South Australia, independent homebirthing in Australia may be illegal by July 2010 by default. This is due to legislation pending at that time, introducing compulsory registration of all health professionals, and requiring that all health professionals carry professional indemnity insurance. Independent midwives in most Australian States and Territories are not currently insurable, and hence by default will be unable to register as health professionals in 2010. A woman does currently have the right to hire an uninsured independent midwife to attend her homebirth. If the midwife is negligent, most have their personal assets arranged to avoid any compensation payouts. Midwives and people who wish homebirth to remain as a choice for Australian women are currently lobbying to protect the profession. In April 2007, the Western Australian Government announced that it would be expanding birth at home across the State.^[17] A review indicating a relatively higher neonatal mortality rate of babies born at term to mothers who had chosen a home birth in has led to a currently ongoing government review of home births. ^[18] Recent excess deaths at homebirths in New South Wales may also influence future political decision-making. ^[19]

Legal situation in Canada

Legality of homebirth currently is not the real issue. Coverage by Provinces public health service varies. Availability of doctors and midwives providing homebirth services also varies. Some Provinces appear to actively discourage homebirth. While other provinces are the opposite. Currently the Province of Ontario covers homebirth services as does British Columbia. ^[20] ^[21]

Famous homebirthers

Pamela Anderson ^[22]

Charlotte Church ^[23]

Cindy Crawford ^[22]

Ricki Lake ^[24]

Demi Moore ^[22]

Thandie Newton ^[25]

Kelly Preston ^[22]

Meryl Streep ^[22]

Davina McCall ^[22]

Additional reading

Spiritual Midwifery Ina May Gaskin(The Book Publishing Company) ISBN 1-57067-104-4 (1st edition 1977)
A Wise Birth. Bringing together the best of natural childbirth with modern medicine, Armstrong P & Feldman S, 1990, reissued 2007, Pinter & Martin, ISBN 978-1-905177-03-5
Having a Great Birth in Australia Ed David Vernon, Australian College of Midwives, Canberra, 2005 ISBN 0-9751674-3-X
Home Birth: A Practical Guide, Wesson, Nicky, 2006, Pinter & Martin, ISBN 978-1-905177-06-6
Lamaze Institute for Normal Birth

External links

Expert Group on Acute Maternity Services: Reference Report International Models of Maternity Care Report on maternity care released in Scotland, 2002, includes summary of how maternity care is dealt with in other countries besides the UK.
Intrapartum Care Guidelines (2007) National Center for Health and Clinical Excellence, an independent health care monitoring organization in the UK, reviewing the home birth literature.
Home Birth Reference Site, Index of Research on Home Birth
American Pregnancy Association, Home Birth, brief article outlining the pros and cons of home birth
World Health Organization, Care in Normal Birth: A practical guide, Chapter 2: General Aspects of Labor, 1997.
ACOG Statement on Home Birth, American College of Obstetricians and Gynecologists reiterates its long-standing opposition to home births (Feb 8, 2008)

References

^ Studies monitoring transfers Home birth reference site. Accessed: Aug 24, 2008
^ General aspects of Care in Labour, WHO’s Care in normal birth: a practical guide, 1997
^ A History of Women's Bodies" Edward Shorter, Basic Books, 1982, p156
^ A History of Women's Bodies" Edward Shorter, Basic Books, 1982, p157
^ Martin JA, et al. “Births: Final Data for 2005” [ http://www.cdc.gov/nchs/data/nvsr/nvsr56/nvsr56_06.pdf CDC National Vital Statistics Report] Vol 56, No 6. Dec 5, 2007.
^ http://news.netdoctor.co.uk/news_detail.php?id=17087027
^ Australian Institute of Health and Welfare (AIHW) National Perinatal Statistics Unit, 2008, Australia’s mothers and babies 2006, Perinatal statistics series no. 22, Cat. no. PER 46, Sydney, p. 20.
^ New Zealand Information Service, 2007, Report on Maternity Maternal and Newborn Information 2004, p. 64
^ Wiegers TA, et al. “Maternity Care in The Netherlands: the changing home birth rate (1998) Birth 25:190-197.
^ National Collaborating Centre for Women's and Children's Health as Commissioned by the National Institute for Health and Clinical Excellence Final Draft of Guideline on Intrapartum Care, (Royal College of Obstetricians and Gynaecologists, London, 22 March 2007)
^ Olsen O, JewellMD. Home versus hospital birth. Cochrane Database of Systematic Reviews 1998, Issue 3. Art. No.: CD000352. DOI:10.1002/14651858.CD000352.
^ ^a ^b Woodcock HC, et al. (1994) Midwifery 10:125-135.
^ ^a ^b Ackerman-Liebrich U, et al. (1996) BMJ 313:1313-1318.
^ Chamberlain G, et al. (1999) Pract Midwife 2:35. as summarized on the Home Birth Reference Site
^ ^a ^b ^c Janssen PA, et al. (2002) CMAJ 166:315-323.
^ Midwives Alliance of North America.
^ The Health Minister's controversial plan to encourage more home births.
^ [1]
^ [2]
^ [3]
^ [4]
^ ^a ^b ^c ^d ^e ^f INFORMATION: Home Birth Pregnant Women
^ Charlotte Church Gives Birth to a Baby Girl - Birth, Charlotte Church: People.com
^ Ricki Lake: Ricki Lake On The Business Of Being Born - Living on The Huffington Post
^ My Journal: Labor of Love

[1] Studies monitoring transfers Home birth reference site. Accessed: Aug 24, 2008

[WHO-2] General aspects of Care in Labour, WHO’s Care in normal birth: a practical guide, 1997

[3] A History of Women's Bodies" Edward Shorter, Basic Books, 1982, p156

[4] A History of Women's Bodies" Edward Shorter, Basic Books, 1982, p157

[5] Martin JA, et al. “Births: Final Data for 2005” [ http://www.cdc.gov/nchs/data/nvsr/nvsr56/nvsr56_06.pdf CDC National Vital Statistics Report] Vol 56, No 6. Dec 5, 2007.

[6] ttp://news.netdoctor.co.uk/news_detail.php?id=17087027

[7] Australian Institute of Health and Welfare (AIHW) National Perinatal Statistics Unit, 2008, Australia’s mothers and babies 2006, Perinatal statistics series no. 22, Cat. no. PER 46, Sydney, p. 20.

[8] New Zealand Information Service, 2007, Report on Maternity Maternal and Newborn Information 2004, p. 64

[Wigers-9] Wiegers TA, et al. “Maternity Care in The Netherlands: the changing home birth rate (1998) Birth 25:190-197.

[NICE-10] National Collaborating Centre for Women's and Children's Health as Commissioned by the National Institute for Health and Clinical Excellence Final Draft of Guideline on Intrapartum Care, (Royal College of Obstetricians and Gynaecologists, London, 22 March 2007)

[Cochrane-11] Olsen O, JewellMD. Home versus hospital birth. Cochrane Database of Systematic Reviews 1998, Issue 3. Art. No.: CD000352. DOI:10.1002/14651858.CD000352.

[Woodcock-12] Woodcock HC, et al. (1994) Midwifery 10:125-135.

[Ackerman-13] Ackerman-Liebrich U, et al. (1996) BMJ 313:1313-1318.

[Birthday-14] Chamberlain G, et al. (1999) Pract Midwife 2:35. as summarized on the Home Birth Reference Site

[Janssen-15] Janssen PA, et al. (2002) CMAJ 166:315-323.

[16] Midwives Alliance of North America.

[17] The Health Minister's controversial plan to encourage more home births.

[18] [1]

[19] [2]

[20] [3]

[21] [4]

[autogenerated1-22] ^ ^a ^b ^c ^d ^e ^f INFORMATION: Home Birth Pregnant Women

[23] Charlotte Church Gives Birth to a Baby Girl - Birth, Charlotte Church: People.com

[24] Ricki Lake: Ricki Lake On The Business Of Being Born - Living on The Huffington Post

[25] My Journal: Labor of Love

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[3]

[4]

[5]

[6]

[7]

[8]

[9]

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[11]

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[14]

[15]

[16]

[17]

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@@ Line 9: / Line 9: @@
 Homebirths are divided into two types — attended and unattended births.  Attended births are those at which a trained medical professional attends, usually a [[midwife]], although sometimes a [[general practitioner]].  Unattended births, which are sometimes called [[freebirth]]s may involve simply the woman herself, or a woman attended by her partner, friends, family or a birth attendant called a [[doula]].
-In choosing home birth, the mother generally has control over her surroundings: she can eat and drink, move freely, sleep and do anything she pleases.<ref>[[David Vernon (writer)|David Vernon]] ''Having a Great Birth in Australia'', Canberra: 2005.</ref> However, during a homebirth there is no access to pharmaceutical pain relief or pharmaceutical labor induction, nor equipment for emergency delivery (such as forceps, vacuum extraction, or surgery). Births necessitating these interventions would require transfer to a hospital. Depending on the midwifery practice, transfer rates can range anywhere from 5% to 40%, but most studies cite a transfer rate of about 16%.<ref>[http://www.homebirth.org.uk/transferstudies.htm#nbtftransfer Studies monitoring transfers] Home birth reference site. Accessed: Aug 24, 2008</ref>
+During a homebirth there is no access to pharmaceutical pain relief or pharmaceutical labor induction, nor equipment for emergency delivery (such as forceps, vacuum extraction, or surgery). Births necessitating these interventions would require transfer to a hospital. Depending on the midwifery practice, transfer rates can range anywhere from 5% to 40%, but most studies cite a transfer rate of about 16%.<ref>[http://www.homebirth.org.uk/transferstudies.htm#nbtftransfer Studies monitoring transfers] Home birth reference site. Accessed: Aug 24, 2008</ref>
 The [[WHO]] has released a statement supporting the right of women to choose where they give birth. In the case of low-risk pregnancies, with appropriate support and contingency plans women can give birth at home. <ref name=WHO> [http://www.who.int/reproductive-health/publications/MSM_96_24/MSM_96_24_Chapter2Part1.en.html General aspects of Care in Labour], WHO’s Care in normal birth: a practical guide, 1997</ref>
-==The rapid decline and gradual rise of home birth in the West==
+==The Rapid Decline and Gradual Rise of Home Birth in the West==
 In many Western countries, home birth declined over the 20th century due to migration to urban centers, increased accessibility of hospitals and unwillingness of doctors to attend to women in their homes.  As one doctor described birth in a working class home in the 1920s. <blockquote>''You find a bed that has been slept on by the husband, wife and one or two children; it has frequently been soaked with urine, the sheets are dirty, and the patient's garments are soiled, she has not had a bath.  Instead of sterile dressings you have a few old rags or the discharges are allowed to soak into a nightdress which is not changed for days.''<ref> ''A History of Women's Bodies" Edward Shorter, Basic Books, 1982, p156 </ref></blockquote>
 This experience is contrasted with a 1920s hospital birth by Adolf Weber: <blockquote>''The mother lies in a well-aired disinfected room, light and sunlight stream unhindered through a high window and you can make it light as day electrically too.  She is well bathed and freshly clothed on linen sheets of blinding whitenes... You have a staff of assistants who respond to every signal... Only those who have to repair a perineum in a cottars's house in a cottar's bed with the poor light and help at hand can realize the joy.'' <ref> ''A History of Women's Bodies" Edward Shorter, Basic Books, 1982, p157 </ref></blockquote>
+There was a revival of [[midwifery]], the practice supporting a natural approach to birth, in the United States in the 1970s. However, although there was a steep increase in midwife-attended births between 1975 to 2002 (from less than 1.0% to 8.1%), most of these births occurred in the hospital and the US rate of out-of-hospital birth has remained steady at 1% of all births since 1989 with 27.3% of these in a free-standing [[birthing center|birth center]] and 65.4% in a residence. Hence, the actual rate of home birth in the United States has remained remarkably low (0.65%) over the past twenty years. <ref> Martin JA, et al. “Births: Final Data for 2005” [ http://www.cdc.gov/nchs/data/nvsr/nvsr56/nvsr56_06.pdf CDC National Vital Statistics Report] Vol 56, No 6. Dec 5, 2007.</ref>
-When given a chance of providing care to women in hospitals or women in working class cottages, the doctors knew their preference.<ref>''Birth - A history'', Tina Cassidy, Random House, 2007</ref>
+Home birth in the United Kingdom has also received some press over the past few years as there has been a movement, most notably in Wales, to increase home birth rates to 10% by 2007. Between 2005 to 2006, there was an increase of 16% of home birth rates in Wales, but the total home birth rate is still 3% even in Wales (double the national rate) and in some other counties of Great Britain the home birth rate is still under 1%. <ref>http://news.netdoctor.co.uk/news_detail.php?id=17087027</ref>  In Australia, birth at home has fallen steadily over the years and is currently 0.3%, ranging from nearly 1% in the [[Northern Territory]] to 0.1% in [[Queensland]]. <ref>Australian Institute of Health and Welfare (AIHW) National Perinatal Statistics Unit, 2008, Australia’s mothers and babies 2006, Perinatal statistics series no. 22, Cat. no. PER 46, Sydney, p. 20.</ref>  The [[New Zealand]] rate for births at home is nearly three times Australia's with a rate of 2.5% and increasing. <ref>New Zealand Information Service, 2007, Report on Maternity Maternal and
-There was a revival of [[midwifery]], the practice supporting a natural approach to birth, in the [[United States]] in the 1970s. However, although there was a steep increase in midwife-attended births between 1975 to 2002 (from less than 1.0% to 8.1%), this did not translate into an increase in birth at home.  Most of these births occurred in the hospital and the US rate of out-of-hospital birth has remained steady at 1% of all births since 1989 with 27.3% of these in a free-standing [[birthing center|birth center]] and 65.4% in a residence. Hence, the actual rate of home birth in the United States has remained remarkably low (0.65%) over the past twenty years. <ref> Martin JA, et al. “Births: Final Data for 2005” [ http://www.cdc.gov/nchs/data/nvsr/nvsr56/nvsr56_06.pdf CDC National Vital Statistics Report] Vol 56, No 6. Dec 5, 2007.</ref>
-Home birth in the [[United Kingdom]] has also received some press over the past few years as there has been a movement, most notably in [[Wales]], to increase home birth rates to 10% by 2007. Between 2005 to 2006, there was an increase of 16% of home birth rates in Wales, but the total home birth rate is still 3% even in Wales (double the national rate) and in some other counties of Great Britain the home birth rate is still under 1%. <ref>http://news.netdoctor.co.uk/news_detail.php?id=17087027</ref>  In Australia, birth at home has fallen steadily over the years and is currently 0.3%, ranging from nearly 1% in the [[Northern Territory]] to 0.1% in [[Queensland]]. <ref>Australian Institute of Health and Welfare (AIHW) National Perinatal Statistics Unit, 2008, Australia’s mothers and babies 2006, Perinatal statistics series no. 22, Cat. no. PER 46, Sydney, p. 20.</ref>  The [[New Zealand]] rate for births at home is nearly three times Australia's with a rate of 2.5% and increasing. <ref>New Zealand Information Service, 2007, Report on Maternity Maternal and
 Newborn Information 2004, p. 64 </ref>
 In the Netherlands, an opposite trend has taken place: in the 1965, two-thirds of Dutch births took place at home, but currently, that figure has dropped to less than a third – about 30%. <ref name = "Wigers">Wiegers TA, et al. “Maternity Care in The Netherlands: the changing home birth rate (1998) Birth 25:190-197.</ref>
-== Research on safety ==
+== Research on Safety ==
-In 2009, a study of 529,688 low-risk planned home and hospital births, reported in the ''British Journal of Obstetrics and Gynaecology'', concluded: <blockquote>A home birth does not increase the risks of perinatal mortality and severe perinatal morbidity among low risk women, provided the maternity care system facilitiates this choice through the availability of well-trained midwives and through a good transportation and referral system.  <ref> de Jonge A, van der Goes B, Ravelli A, Amelink-Verberg M, Mol B, Nijhuis J, Bennebroek Gravenhorst J, Buitendijk S, ''Perinatal mortality and morbidity in a nationwide cohort of 529688 low-risk planned home and hospital births'' BJOG 2009 </ref></blockquote>
-Further, the study noted there was evidence that ''low risk women with a planned home birth are less likely to experience referral to secondary care and subsequent obstetric interventions than those with a planned hospital birth.'' <ref> de Jonge A, van der Goes B, Ravelli A, Amelink-Verberg M, Mol B, Nijhuis J, Bennebroek Gravenhorst J, Buitendijk S, ''Perinatal mortality and morbidity in a nationwide cohort of 529688 low-risk planned home and hospital births'' BJOG 2009, p9 </ref>
 In 2007, after a comprehensive review of the literature, the [[UK]]’s [[National Institute for Health and Clinical Excellence]] (NICE) released the following recommendations concerning the location of birth:
@@ Line 42: / Line 37: @@
 * Planning birth in a consultant-led unit: increases the likelihood of pharmacological analgesia, interventions and an instrumental birth, and decreases satisfaction, compared with planning birth in other birth settings. There may be a lower risk of perinatal mortality when care is delivered in a consultant-led unit." <ref name="NICE">National Collaborating Centre for Women's and Children's Health as Commissioned by the National Institute for Health and Clinical Excellence [http://www.nice.org.uk/nicemedia/pdf/IPC-cons-fullguideline.pdf Final Draft of Guideline on Intrapartum Care], (Royal College of Obstetricians and Gynaecologists, London, [[22 March]] [[2007]])</ref>
-===Study design===
+===Study Design===
 The research concerning the safety of home birth is few and far between, and much of it is of questionable methodology {{Who|date=April 2009}}. In fact, there are no randomized controlled trials for home birth, <ref name="Cochrane">Olsen O, JewellMD. Home versus hospital birth. Cochrane Database of Systematic Reviews 1998, Issue 3. Art. No.: CD000352. DOI:10.1002/14651858.CD000352.</ref> possibly because maternal choice is such a major aspect of home birth and thus, few mothers would be willing to be randomly assigned to either the home birth or the hospital birth. {{Fact|date=August 2008}} The studies that do exist tend to be [[cohort studies|matched cohort studies]] conducted either retrospectively (by selecting hospital records that match the characteristics of the home birth records),<ref name="Woodcock"> Woodcock HC, et al. (1994) ''Midwifery'' 10:125-135.</ref> by matched pairs (by pairing study participants based on their background characteristics),<ref name="Ackerman">Ackerman-Liebrich U, et al. (1996) ''BMJ'' 313:1313-1318.</ref> <ref name="Birthday">Chamberlain G, et al. (1999) ''Pract Midwife'' 2:35. as summarized on the [http://www.homebirth.org.uk/homebirth2.htm Home Birth Reference Site]</ref> or by using multivariate analysis to control for background variables. <ref name = "Janssen"> Janssen PA, et al. (2002) ''CMAJ'' 166:315-323.</ref>
-However, even in cohort studies, there are many differences between women who choose to give birth at home versus in hospital. There are unquantifiable differences in home birth patients, such as maternal attitudes towards medical involvement in birth<ref name=Woodcock />, and demographically, home birth patients tend towards being more [[Parity (medicine)|multiparous]], less ethnic minorities, attend more prenatal visits, be slightly taller and lighter, of better educational background, and have fewer previous obstetric complications, including [[cesarean sections]].<ref name = Janssen /> Thus, none of the studies conducted were able to study a large enough group of matched births to make any definitive statements concerning perinatal mortality, and other rare complications.{{Fact|date=May 2009}}
+However, even in cohort studies, there are many differences between women who choose to give birth at home versus in hospital. There are unquantifiable differences in home birth patients, such as maternal attitudes towards medical involvement in birth<ref name=Woodcock />, and demographically, home birth patients tend towards being more [[Parity (medicine)|multiparous]], less ethnic minorities, attend more prenatal visits, be slightly taller and lighter, of better educational background, and have fewer previous obstetric complications, including [[cesarean sections]].<ref name = Janssen /> Thus, none of the studies conducted were able to study a large enough group of matched births to make any definitive statements concerning perinatal mortality, and other rare complications.
 The most recent research contained in the Cochrane systematic review of the literature,  (published on the Cochrane database; the source from which hospital policies are usually created),  states that there is not enough evidence to decide one way or another, whether home or hospital birth is safer (Olsen & Jewell: 2000 (CD000352) in Hofmeyr et al:2008:252).
-However, Hofmeyr goes on to say, on behalf of the Cochrane database; "The relative benefits and risks of different settings are difficult to quantify. For a woman and her baby with no complications, the risk of an unexpected adverse event during a home birth may be smaller than risks specific to hospitalization, such as hospital-acquired infections" (Hofmeyr et al:2008). Olsen and Jewell (2000), the authors of the systematic review also state: "In countries where it is possible to establish a home birth service backed up by a modern hospital system, all low-risk women should be offered the possiblity of considering a planned home birth...." (Olsen & Jewell: 2000 (CD000352) in Buckley:2005:230).
 ===Maternal safety===
@@ Line 55: / Line 49: @@
 In terms of maternal outcome, no study found any statistically significant difference between the number of women that had third-degree [[perineal lacerations]] or [[obstetrical hemorrhage|postpartum hemorrhage]]. However, the 1998-1999 [[British Columbia]] study did find a three- to four-fold less likelihood of infection for both the infant and the mother,<ref name = Janssen /> and all studies reported a substantially higher likelihood of an intact [[perineum]] in the home birth sample.
-===Infant safety===
+===Infant Safety===
+[[Perinatal period|Perinatal]] outcome is more complicated to assess due to the low incidence of mortality and the difficulty in achieving appropriate study design. No reliable evidence presently exists for differences in infant safety in low-risk women.
-[[Perinatal period|Perinatal]] outcome is more complicated to assess due to the low incidence of mortality and the subjectivity of [[Apgar score|Apgar scoring]]. Most studies found a slight, but statistically significant, difference in Apgar score for infants at five minutes. However, the 1994 UK National Birthday Trust study found a slight advantage for home birthed infants at one minute and no difference at five minutes <ref name = Birthday />. No cohort study has conducted long-term follow up on the infants. The perinatal mortality figure still remains controversial. The Zurich study<ref name = Ackerman /> showed an equal perinatal death rate between the home birth group and the hospital birth group (2.3 / 1000), and the Birthday Trust study found a slightly higher perinatal death rate in the hospital birth group (1 / 1000 vs. 0.8/1000) <ref name = Birthday />. However, two other studies <ref name = Woodcock /> <ref name = Janssen /> did find a slightly higher perinatal mortality in the home birth group as compared to the hospital birth group. None of these results were seen to be statistically significant, since the actual mortality rate and the sample sizes were both so low, these figures have been the subject of much debate regarding the relative safety of home birth compared to hospital birth. <ref name = Janssen /><ref>Letters: The pleasures of home birth? (Response to Janssen PA, et al. 2002 ''CMAJ'' 166: 1509-1512 </ref>
 ==Legal situation in the United States==
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 No state prosecutes mothers for giving birth outside of a hospital. However, midwives who assist at such births may be prosecuted in some areas.{{Fact|date=July 2008}}
-In the early and mid 1900s, physicians pushed to have midwifery banned throughout the [[United States]]. In 37 states it is once again legal to acquire the services of a midwife. Many midwives continue to attend mothers in states where it is illegal, while efforts are underway to change the law.
+In 37 states it is legal to acquire the services of a midwife. Many midwives continue to attend mothers in states where it is illegal, while efforts are underway to change the law.
 Practicing as a direct-entry midwife is still (as of May 2006) illegal under certain circumstances in [[Washington, D.C.]] and the following states: [[Alabama]], [[Georgia (U.S. state)|Georgia]], [[Hawaii]], [[Illinois]], [[Indiana]], [[Iowa]], [[Kentucky]], [[Maryland]], [[North Carolina]], [[South Dakota]] and [[Wyoming]].<ref>[http://www.mana.org/statechart.html Midwives Alliance of North America.]</ref> However, Certified Nurse Midwives can legally practice in these areas.
 ==Legal situation in Australia==
-Although some State Governments have now introduced government funded home birth services, including the Northern Territory, Western Australia, New South Wales and South Australia, homebirthing in Australia may be illegal by July 2010 by default.
+Although some State Governments have now introduced government funded home birth services, including the Northern Territory, Western Australia, New South Wales and South Australia, independent homebirthing in Australia may be illegal by July 2010 by default.
-This is due to legislation pending at that time, introducing compulsory registration of all health professionals, and requiring that all health professionals carry professional indemnity insurance.  Midwives in most Australian States and Territories are unable to obtain professional indemnity insurance, and hence by default will be unable to register as health professionals.
+This is due to legislation pending at that time, introducing compulsory registration of all health professionals, and requiring that all health professionals carry professional indemnity insurance.  Independent midwives in most Australian States and Territories are not currently insurable, and hence by default will be unable to register as health professionals in 2010. A woman does currently have the right to hire an uninsured independent midwife to attend her homebirth. If the midwife is negligent, most have their personal assets arranged to avoid any compensation payouts.
-After the collapse of the large Australian insurer [[HIH]], the remaining Australian insurance companies ceased offering insurance to home birth midwives, as they claimed that the pool of midwives requiring insurance was too small to make it commercially viable. Without insurance, some independently practicing midwives have elected to discontinue providing independent services, even though they are qualified health professionals and are allowed to practice within hospitals.
-Midwives current inability to carry professional indemnity insurance does not currently affect a woman's right to hire an independent midwife to attend her birth.
 Midwives and people who wish homebirth to remain as a choice for Australian women are currently lobbying to protect the profession.
-In April 2007, the Western Australian Government announced that it would be expanding birth at home across the State.<ref>[http://www.abc.net.au/stateline/wa/content/2006/s1929033.htm The Health Minister's controversial plan to encourage more home births.]</ref>
+In April 2007, the Western Australian Government announced that it would be expanding birth at home across the State.<ref>[http://www.abc.net.au/stateline/wa/content/2006/s1929033.htm The Health Minister's controversial plan to encourage more home births.]</ref> A review indicating a relatively higher neonatal mortality rate of babies born at term to mothers who had chosen a home birth in has led to a currently ongoing government review of home births. <ref>[http://www.health.wa.gov.au/press/view_press.cfm?id=756]</ref>  Recent excess deaths at homebirths in New South Wales may also influence future political decision-making. <ref>[http://www.news.com.au/dailytelegraph/story/0,27574,25294178-5006009,00.html]</ref>
 ==Legal situation in Canada==
 Legality of homebirth currently is not the real issue. Coverage by Provinces public health service varies. Availability of doctors and midwives providing homebirth services also varies. Some Provinces appear to actively discourage homebirth. While other provinces are the opposite. Currently the Province of Ontario covers homebirth services as does British Columbia.
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 ==Additional reading==
 *''Spiritual Midwifery'' [[Ina May Gaskin]](The Book Publishing Company) ISBN 1-57067-104-4 (1st edition 1977)
-*''A Good Birth, A Safe Birth: Choosing and Having the Childbirth Experience You Want''. (1992), Korte, Diana, Boston, MA: USA, The Harvard Common Press.
-*''Birthing From Within: An Extra-Ordinary Guide to Childbirth Preparation''. (1998), England, Horowitz NM: USA, Partera Press.
 *''A Wise Birth. Bringing together the best of natural childbirth with modern medicine'', Armstrong P & Feldman S, 1990, reissued 2007, Pinter & Martin, ISBN 978-1-905177-03-5
 *''[[Having a Great Birth in Australia]]'' Ed [[David Vernon (writer)|David Vernon]], [[Australian College of Midwives]], Canberra, 2005 ISBN 0-9751674-3-X
-*''[[Men at Birth]]'' Ed [[David Vernon (writer)|David Vernon]], [[Australian College of Midwives]], Canberra, 2006, ISBN 0-9751674-4-8
 *''Home Birth: A Practical Guide'', Wesson, Nicky, 2006, Pinter & Martin, ISBN 978-1-905177-06-6
-*The Thinking Woman's Guide to a Better Birth, by [[Henci Goer]]
 * [http://www.normalbirth.lamaze.org Lamaze Institute for Normal Birth]
-*''The American Way of Birth'', [[Jessica Mitford]]
 ==See also==