Today, pregnant women in Slovenia are expected to give birth in a maternity hospital. In some countries, this is not so self-evident; dual processes are taking place in which demands for home births and demands for hospital births are being asserted simultaneously. The very idea that all births should take place in maternity hospitals has not been part of the official system everywhere, and in some places parallel systems of hospital birth and home birth have developed. For home births, a professional obstetric first aid service and rapid transport to the nearest maternity hospital must be organized (Drglin, 2003).

In some countries, matters regarding home births are legally regulated. In Slovenia, these matters are unfortunately not legally regulated, which can lead to problems that have arisen in neighboring Hungary, where laws are also not regulated (Ternovszky v. Hungary, 2010).

Premru Sršen (2007) says that pregnant women today have many opportunities to learn about everything related to childbirth, namely from their personal gynecologist, from books, magazines, internet forums, and in parenting classes. The modern pregnant woman is generally well informed about what happens before and during childbirth. With greater awareness among pregnant women, their demands and wishes for participation and co-decision-making in the process during childbirth are increasing. Healthcare staff must give every pregnant woman the opportunity to actively participate in decisions. The opportunity to co-decide gives them a sense of trust and security.

Drglin (2003) adds that in Slovenia, those who strive for out-of-hospital birth usually encounter a host of problems—ranging from prejudice and ridicule to technical and professional obstacles. It is not officially possible to hire a midwife or doctor who would lead a home birth. Those rare few who decide to give birth at home are faced with a major challenge, as they must arrange for a birth attendant themselves and, in an emergency, ensure the fastest possible transport to a maternity hospital.

Ogden (1998) adds to all this that women, despite wanting to have control, do not want the feeling of responsibility if something goes wrong. Therefore, the choice of whether to give birth at home is a complex process that involves weighing the arguments for and against this decision.

The biggest problem, however, is the fact that hospital birth is so self-evident that it is not officially possible to hire a professional to assist at home. There are also no official channels through which one could arrange first aid and transport to a maternity hospital in advance in case of complications. Thus, the decision for a possible next home birth would be difficult despite a positive experience. Also, due to the self-evidence of hospital birth, problems arose with registering the child as a citizen because the child was not born in an institution and was therefore without a certificate of arrival into the world (Drglin, 2003).

Despite the fact that some obstetricians have linked women’s wishes to give birth at home with female selfishness or, at best, with ignorance—claiming they want a beautiful birth experience at the child’s expense—pregnancy and birth are events that occur in and through the mother’s body. A woman’s ability to give birth, combined with a strong desire to raise a healthy child, are powerful advantages (Bailes and Jackson, 2000).

Hungary

Hungary has a similar tradition regarding childbirth as Slovenia. Just as the desire for home births is emerging in Slovenia, it is also emerging in Hungary, where they also do not have safe home birth enabled. This does not, of course, mean that it is prohibited. Home birth has been legalized, but midwives do not have the competence to independently lead home births and therefore may not offer “services” outside the maternity hospital.

Home birth in Hungary was highlighted primarily through the Hungarian midwife Agnes Gereb, who worked as an independent midwife and assisted in 3,500 home births. After a complication during a birth outside a maternity hospital in October 2010, she was sentenced to 2 years in prison and a 10-year ban on practicing (Mamazofa.org, 2010).

In the case of Ternovszky v. Hungary dated December 14, 12. 2010, the government took the position that under Hungarian law, any healthcare worker who assists in a home birth risks conviction. In the plaintiff’s view, this effectively prevents healthcare workers from assisting in home births as long as there is no comprehensive legislation on home births in Hungary. The complaint of the plaintiff, born in 1979 in Budapest, resonated widely in the public. At the time of this lawsuit, the plaintiff was pregnant and wanted to give birth at home in her own home.

The government opposed the woman’s complaint about the choice of home birth and the alleged violation of rights guaranteed by Articles 8 and 14 of the ECHR. The European Court of Human Rights found that in the stated case, the right under Article 8 of the Convention, which guarantees everyone the right to respect for their private life, was violated.

The Court took the position that healthcare workers should assist in home births. The legal prohibition of home assistance, due to which the plaintiff could not give birth at home but had to give birth in a hospital, therefore constituted an inadmissible interference with the provision of Article 8 of the ECHR. The plaintiff was awarded compensation (Ternovszky v. Hungary, 2010).

All these events point to gaps in the laws that appear in Hungary, the Czech Republic, Poland, and also in our country. And until the laws are properly regulated, such problems will unfortunately continue to occur.

The Netherlands

Ternovszky v. Hungary (2010) states that the Netherlands is a highly developed country with official home births. This occurrence of home births varies by region and also among large cities.

The maternity care system in the Netherlands is based on risk-based selection. For healthy pregnant women (the so-called primary level), midwives or general practitioners provide care throughout pregnancy, childbirth, and the postpartum period. Women and their partners decide whether to give birth at home or in a maternity hospital. For women at high risk during pregnancy and childbirth, an obstetrician-gynecologist (secondary level) provides care, and after birth they decide who will take over care, a midwife or gynecologist. In cases where consultations with an obstetrician are needed due to increased risk during pregnancy and childbirth, they decide on a case-by-case basis who provides the best care. In collaboration among midwives, general practitioners, and obstetricians, they have developed a system for identifying risks during pregnancy and childbirth, based on the Kloosterman list (Drglin, 2003).

Toet (2007) writes that according to Dutch guidelines, pregnancy is not a disease, so health insurance companies do not cover full hospital costs except in cases of high-risk pregnancy. This means that the Dutch Ministry of Health supports home birth, as do midwives.

Midwives and general practitioners can obtain a license to manage normal, healthy pregnancies and pregnancies with minor risk factors, as well as normal births. A midwife should lead an average of 120 births per year. They are organized into the Koninklijke Nederlandse Organisatie Verloskundigen (“Royal Midwifery Organization”), which has a long tradition. The work of an independent midwife includes care during pregnancy (10–12 examinations), leading the birth, 5–7 postpartum examinations, and a postpartum examination at six weeks. Midwives have a completely autonomous position, protected by law (Drglin, 2003).

Pajntar (2004) adds that they have precisely developed criteria for traditional home births; they know exactly which pregnant woman can stay at home and which must go to the maternity hospital.

Drglin (2003) says that according to data for the year 2000, 205,000 children were born in a country with 16 million inhabitants. 83% of care for pregnant women took place initially at the primary level. Half of the births took place at the primary level, of which general practitioners led 8% of births. A good third of women gave birth at home, and to briefly summarize various studies on midwifery or obstetric care—midwifery care can differ from obstetric care in “philosophy,” style, and practices. As can be discerned from the accounts of many women, well-being in a maternity hospital is associated with the presence of a supportive midwife. Judging by data on the work of midwives in the Netherlands (and elsewhere), properly trained midwives are capable of selecting high-risk pregnancies. As verified research data shows (on the importance of birth attendants, which is often also associated with the place of birth), midwives have at least as good results in leading births as maternity hospitals.

A study cited in Ternovszky v. Hungary (2010) was conducted in the province of Gelderland and compares obstetric outcomes between home births and hospital births. The result shows that birth for first-time mothers with low-risk pregnancies who gave birth at home was as safe as if they had given birth in a hospital. For low-risk multiparous women, the outcome of home birth was considerably better than for births in a hospital.

Table: Number of births in the Netherlands by location 1995–2002 (%)

(Batec, 2004)

Batec (2004) says of these tables that they are surprising and unsurprising at the same time, and that they are not surprised that they teach that the success rate of home births and midwifery participation in birth is much higher than in hospitals. However, many are surprised that the proportion of home births in the Netherlands has fallen dramatically in the last four decades and that compared to countries where Scandinavian midwives attend almost all births, Dutch midwives have an extremely low rate, attending less than half of births.

Read also: A Slovenian Woman’s Experience with Pregnancy and Childbirth in the Netherlands

New Zealand

In New Zealand, before 1990, there were some encouraging measures to provide midwifery services for home births. Midwives were entitled to some funding for leading home births, but incomes were significantly lower than those received by midwives employed in hospitals (Hendry, 2009). Midwives in New Zealand gained autonomous professional status that year. The Nurses Amendment Act was renewed the same year with the difference that midwifery is separated from nursing based in New Zealand professionally and legally, and they are treated as separate and distinct professions (New Zealand College of Midwives). Hendry (2009) adds that the number of midwives available to women for home birth has increased over time, while physician supervision has decreased. Within two years, the branch of this organization expanded throughout the country, and the first national conference was held regarding the home birth association. In the early 1980s, this organization began to form close contacts with other women’s groups and became an important factor in the establishment of the New Zealand College of Midwives.

Home Birth Aotearoa (2002) is a national organization representing many local associations throughout Aotearoa, New Zealand. Home Birth Aotearoa supports and celebrates home births and provides women giving birth with information about the option of home birth.

The Home Birth Aotearoa association (2002) says that historically, the rate of home births varies greatly from region to region. Data received from the New Zealand College of Midwives shows that the rate of home births is increasing and that their percentage has risen to approximately 7%. It is evident that in some areas where there is good local support from home birth associations and midwives, the rate is much higher (for example, a 10% share found on the West Coast of the South Island).

Wagner (2008) says that in New Zealand, women can choose whether to give birth at home, in a birthing center, or in a maternity hospital, with the help of a midwife or doctor—and thus have complete control. Kirkham (2003) argues that for LMC midwives who are grounded in the normal birth mindset, the ideal place for a woman to give birth is at home. He also agrees that they are certainly most advanced in this regard in New Zealand, where they encourage home birth by having the state pay for midwives’ services, but if a woman specifically wants to give birth in a hospital, she must pay for it herself. The exception is, of course, when there are medical problems requiring hospital care. In short, doctors act, as a rule as surgeons, only in high-risk cases.

The standards set out by the New Zealand College of Midwives that must be met are as follows:

STANDARD ONE: The midwife works in partnership with the woman.

STANDARD TWO: The midwife supports every woman’s right to freely choose and consent to her birth experience.

STANDARD THREE: The midwife collects and comprehensively documents assessments of the woman’s and child’s health and well-being.

STANDARD FOUR: The midwife maintains and regularly updates records, and provides the woman and other relevant persons with access to them.

STANDARD FIVE: Midwifery care is planned together with the woman.

STANDARD SIX: Midwifery activities are prioritized and must be carried out appropriately; the midwife must not endanger the woman’s life.

STANDARD SEVEN: The midwife is responsible for taking timely action herself and calling for necessary help.

STANDARD EIGHT: The midwife fully evaluates her practice.

STANDARD NINE: The midwife concludes midwifery care together with the woman.

STANDARD TEN: The midwife develops and shares her knowledge with others in the profession, initiates and encourages research (New Zealand College of Midwives, 1986).

Australia

The chapter begins with a description of the care models that participated in the development, then describes the system and culture of the urban Australian maternity service that prevailed before changes were introduced, so that the context in which the models of traditional hierarchical and medical structure were developed can be seen (Brodie and Caroline, 2009).

The STOMP Model

Brodie and Caroline (2009) mention STOMP (St. George Outreach Maternity Project), which is the first model they established with others, with the stated goal of changing the culture of maternal and child care.

There are two STOMP teams located in each of two separate areas in the southern suburbs of metropolitan Sydney: Hurstville and Rockdale. Each team consists of seven full-time midwives working together, namely six midwives per team. An additional midwife is needed to cover annual leave.

The Rockdale team was established in early 1997. The Hurstville team followed approximately six months later. Both are still successful and well supported now, a decade later, and both have excellent results.

The goal of each STOMP team is to provide the full spectrum of care for 30 births per month or approximately 360 women per year. From experience, they say that this population of women, 30 births per month, is handled by a team of seven midwives working in this model—a midwifery team. This means that one midwife, who is on average on annual leave for a very long time, has five births. Regardless of risk factors, all women can give birth with STOMP, as there is good collaboration with obstetricians in each team. One of the midwives from each STOMP team is always on call for women who have any questions. They are available 24 hours every day. In the Australian system, most women receive hospital-based care. Women usually choose the STOMP model because it is convenient for them to participate and to be involved in community-based clinics before birth. In the early days of this program, women were assigned to STOMP team care, where a controlled study was developed and the beginning of a culture change strategy. Now most women living in areas near community centers routinely take the initiative of the offered STOMP model. Women who do not live in these areas and are served by community centers have hospital care available, although they can still request the STOMP model.

A randomized controlled trial of the established STOMP model showed very significant benefits for women.

After birth, women are transferred to the postpartum ward. Some choose to stay in the hospital for postpartum care, while others complete early with the community-based STOMP model.

Ternovszky v. Hungary (2010) states that in Australia, data were collected explaining that the selection of non-risk and low-risk pregnancies is partially successful. In planned home births, the number of transports to the hospital and the rate of obstetric interventions were low. Maternal and child deaths were also low. Unfortunately, data on preventive factors were not provided.

In 1999, the hospital supported birthing centers and recommended to the government that such centers be reviewed and determined where women could have natural birth and experienced midwifery care. At that time, primary healthcare from midwives in Australia was not common, and birthing centers were seen as a place where such care could be provided. Birthing centers were against the status of the hospital system, so they were strongly opposed by certain obstetricians working in the hospital at the beginning of this decade.

The birthing center consists of two rooms and two prenatal spaces. The rooms are more home-like than standard hospital rooms. For example, each has a double bed, not birthing beds.

About ten years later, the birthing center—the model at St. George Hospital—had a small number of midwives who entered work programs to work in eight-hour shifts. This system meant that women could not be guaranteed to have a consistent midwife. Also, at that time, the birthing center did not submit any postpartum care plan. In 2001, they therefore decided to redesign the way the birthing center operates with a different, new model where women get to know the midwife well, as she guides them through the continuum of pregnancy, birth, and the early postpartum period. Thus, the TANGO model was born (Brodie and Caroline, 2009).

Canada

A Canadian study published in 2006 in the British Medical Journal showed that in general, women who gave birth at home had fewer medical interventions, including epidurals, episiotomies, and vacuum extractions, than women who gave birth in hospitals. Data from more than 5,000 women in Canada and the USA who gave birth at home with certified midwives were compared with data from more than three million low-risk women who gave birth in hospitals. Overall, the study showed that when it comes to low risk, safety for home birth and hospital birth is the same. In Canada, there are around 330,000 births each year, with less than 10% participation of midwives among those who choose to give birth at home. Nevertheless, home birth data remains controversial, particularly advocated by physicians who see very high-risk pregnancies and births (Anne Daviss and Johnson, 2005).

It is normal for women in Canada to give birth in a hospital. In most provinces, home birth is possible, depending on location, and in independent birthing centers. Leading a home birth requires a conversation with a family doctor or obstetrician. Pain relief, including epidural anesthesia, is available in departments across Canada. Hospitals traditionally have separate spaces for the prenatal period, birth, and postpartum recovery (Pregnancy, 2008).

The Canadian Institute for Health Information (2004) adds that doulas are also valued in Canada, and there are increasingly more births where they are present. Doulas provide non-medical emotional support to mothers and their families during birth and the postpartum period, but do not perform clinical tasks. Two types of doulas are available, providing support primarily during labor and birth, and postpartum. Also prominent in Canada are rural births, where many different healthcare workers provide care for women and children before, during, and after birth, but they note a decline in the overall birth rate, while at the same time an increase in the rate of births requiring more specialized care and having the potential to affect maternal care providers. In rural areas, there are hospitals that have these services provided, but more and more mothers are demanding that they have various care options available. In some hospitals, family doctors or general surgeons also perform cesarean sections.

In Ontario, Canada, 22 midwives collected data on planned home births for the years 1983 to 1985. 90.6% of births occurred at home, 9.4% required transport to a maternity hospital, 4% were cesarean sections, no perinatal deaths, and one fetal death (Drglin, 2003).

The Birth of the Future

The World Health Organization states in its recommendations that the most appropriate environment for most women in labor is home. Women and their birth attendants who choose this option must be provided with appropriate diagnostic, consultative, and other services they need. The development of birthing centers rooted in local communities should be encouraged, where midwives would offer services to women seeking alternatives to home birth. According to WHO recommendations, birth must be recognized as a healthy life event, from which it follows that home is the most appropriate birth environment (Drglin, 2003).

Wagner (2008) argues that by increasing the autonomy of midwives and simultaneously increasing the autonomy of women, which can be achieved by combining the forces of enlightened midwives, women, progressive doctors, public health professionals, and with the support of politicians and journalists, truly humane obstetric care can be achieved. Thus, in Slovenia too, responsibility for what happens during childbirth will gradually return to women expecting a child and to their families. For, as Drglin (2003) says, for an individual pregnant woman, the decision of where to give birth to her child is one of the most important. If she plans a home birth, she will give birth fairly freely and without major restrictions. If she chooses a maternity hospital, it is advisable to choose one whose practices, policies, and approach are “mother-friendly.”

Source: thesis by author Sara Kac (2012): Conditions for Home Birth (women who can give birth at home), under the mentorship of senior lecturer Teja Škodič Zakšek, dipl. ing. rad., dipl. midwife, MSc (UK)

Read also:

• Midwifery in Northern Norway – experience from an independent midwifery unit
• 3rd Student Midwifery Forum more than successful
• Routines – Why do we do what we do?
• Water Birth – study published in early 2016

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