Birth

The Rights of Childbearing Women

It's not uncommon to hear nasty stories from mothers who had their birthing rights violated (and often don't even know it). Whether it be a medical professional who performed an episiotomy after being expressly told by the birthing mother she did not want one, a medical professional who never informed the birthing mother of the risks and consequences of a certain procedure, or the birthing mother being restricted from food or movement during labor by a medical professional. It's clear that in some situations unless you know your rights and are determined to enforce them, your rights as a birthing mother will be violated.

Below is a list of birthing rights from The Birthing Connection website, where a PDF version is available for download.

* At this time in the United States, childbearing women are legally entitled to those rights.
** The legal system would probably uphold those rights.

  1. Every woman has the right to health care before, during and after pregnancy and childbirth.

  2. Every woman and infant has the right to receive care that is consistent with current scientific evidence about benefits and risks.* Practices that have been found to be safe and beneficial should be used when indicated. Harmful, ineffective or unnecessary practices should be avoided. Unproven interventions should be used only in the context of research to evaluate their effects.

  3. Every woman has the right to choose a midwife or a physician as her maternity care provider. Both caregivers skilled in normal childbearing and caregivers skilled in complications are needed to ensure quality care for all.

  4. Every woman has the right to choose her birth setting from the full range of safe options available in her community, on the basis of complete, objective information about benefits, risks and costs of these options.*

  5. Every woman has the right to receive all or most of her maternity care from a single caregiver or a small group of caregivers, with whom she can establish a relationship. Every woman has the right to leave her maternity caregiver and select another if she becomes dissatisfied with her care.* (Only second sentence is a legal right.)

  6. Every woman has the right to information about the professional identity and qualifications of those involved with her care, and to know when those involved are trainees.*

  7. Every woman has the right to communicate with caregivers and receive all care in privacy, which may involve excluding nonessential personnel. She also has the right to have all personal information treated according to standards of confidentiality.*

  8. Every woman has the right to receive maternity care that identifies and addresses social and behavioral factors that affect her health and that of her baby.** She should receive information to help her take the best care of herself and her baby and have access to social services and behavioral change programs that could contribute to their health.

  9. Every woman has the right to full and clear information about benefits, risks and costs of the procedures, drugs, tests and treatments offered to her, and of all other reasonable options, including no intervention.* She should receive this information about all interventions that are likely to be offered during labor and birth well before the onset of labor.

  10. Every woman has the right to accept or refuse procedures, drugs, tests and treatments, and to have her choices honored. She has the right to change her mind.* (Please note that this established legal right has been challenged in a number of recent cases.)

  11. Every woman has the right to be informed if her caregivers wish to enroll her or her infant in a research study. She should receive full information about all known and possible benefits and risks of participation; and she has the right to decide whether to participate, free from coercion and without negative consequences.*

  12. Every woman has the right to unrestricted access to all available records about her pregnancy, labor, birth, postpartum care and infant; to obtain a full copy of these records; and to receive help in understanding them, if necessary.*

  13. Every woman has the right to receive maternity care that is appropriate to her cultural and religious background, and to receive information in a language in which she can communicate.*

  14. Every woman has the right to have family members and friends of her choice present during all aspects of her maternity care.**

  15. Every woman has the right to receive continuous social, emotional and physical support during labor and birth from a caregiver who has been trained in labor support.**

  16. Every woman has the right to receive full advance information about risks and benefits of all reasonably available methods for relieving pain during labor and birth, including methods that do not require the use of drugs. She has the right to choose which methods will be used and to change her mind at any time.*

  17. Every woman has the right to freedom of movement during labor, unencumbered by tubes, wires or other apparatus. She also has the right to give birth in the position of her choice.*

  18. Every woman has the right to virtually uninterrupted contact with her newborn from the moment of birth, as long as she and her baby are healthy and do not need care that requires separation.**

  19. Every woman has the right to receive complete information about the benefits of breastfeeding well in advance of labor, to refuse supplemental bottles and other actions that interfere with breastfeeding, and to have access to skilled lactation support for as long as she chooses to breastfeed.*

  20. Every woman has the right to decide collaboratively with caregivers when she and her baby will leave the birth site for home, based on their conditions and circumstances.**

Copyright 1999, 2006 Childbirth Connection

Our Sources
The following sources, in their present or earlier editions, helped guide the development of this statement of rights:

American Hospital Association. The Patient Care Partnership: Understanding Expectations, Rights and Responsibilities, 2003.

Annas, G..J. A national bill of patients' rights. New England Journal of Medicine 1998;338(10):695-699.

Annas, G. J. The Rights of Patients: The Authoritative ACLU Guide to the Rights of Patients, third edition. Carbondale, IL: Southern Illinois University Press, 2004.

The Boston Women's Health Book Collective. Sections on "Childbearing" and "Knowledge is Power." In: Our Bodies, Ourselves: A New Edition for a New Era. New York: Simon & Schuster, 2005;417-524, 699-758.

Coalition for Improving Maternity Services (CIMS). The Mother-Friendly Childbirth Initiative, 1996.

Enkin, M., Keirse, M. J. N. C., Neilson J., Crowther, C., Duley, L., Hodnett, E. and Hofmeyr, J. A Guide to Effective Care in Pregnancy and Childbirth, third edition. New York: Oxford University Press, 2000.

International Childbirth Education Association, Inc. The Pregnant Patient's Bill of Rights. Minneapolis: ICEA, 1975.

President's Advisory Commission on Consumer Protection and Quality in the Health Care Industry. Appendix A: Consumer Bill of Rights and Responsibilities. In its Quality First: Better Health Care for All Americans.

United Nations. Universal Declaration of Human Rights, 1948.

Thank you to George Annas, professor and chair of Health Law at the Boston University School of Public Health, for clarifying the legal status of the individual rights.
Most recent page update: 11/21/2011
Related Links
Informed Consent, Informed Refusal
© 2011 Childbirth Connection. All rights reserved.

Childbirth Connection is a national not-for-profit organization founded in 1918 as Maternity Center Association. Our mission is to improve the quality of maternity care through research, education, advocacy and policy. Childbirth Connection promotes safe, effective and satisfying evidence-based maternity care and is a voice for the needs and interests of childbearing families.
Birth

Studies Confirm Homebirth Safer for Normal Births

Photograph by Sandi Heinrich
Over the recent decades many studies have confirmed the safety of home birth. However the results are strict in their findings - home birth is only recommended when accompanied by a certified midwife, or certified nurse midwife, and the risk of complication is low.

Here I present the results of large, comprehensive study comparing home births with registered midwives, versus hospital births with a physician, in British Columbia. The study group included nearly 13,000 births.

Planned home births attended by a registered midwife were associated with 45% less perinatal death compared to planned hospital birth with a physician. There were also significantly reduced rates of obstetric interventions and other adverse perinatal outcomes compared with planned hospital births attended by a physician:

Augmentation of labour = 53% less
Narcotic analgesia, intramuscular or intravenous = 88% less
Epidural analgesia = 72% less
Assisted vaginal delivery = 78% less
Cesarean delivery = 35% less
Episiotomy = 81% less
Third- or fourth-degree perineal tear = 66% less
Postpartum hemorrhage = 43% less
Infection = 74% less
Pyrexia = 77% less

Perinatal death = 45% less
Apgar score < 7 at 1 min = 26% less
Apgar score < 7 at 5 min = 1% less
Meconium aspiration = 55% less
Asphyxia at birth = 30% less
Birth trauma = 67% less
Resuscitation at birth = 44% less
Birth weight < 2500 g = 5% less
Seizures = 34% less
Oxygen therapy > 24 h = 62% less
Assisted ventilation > 24 h = 32% less
Admission to hospital after home birth or readmission if hospital birth = 39% more

What I found odd about this study was that the results were heavily adjusted to bring down the risks associated with physcian attended births, but the characteristics and confounding factors for each of the groups were identical! Here were the actual results of home births attended by midwives before they were adjusted:

Perinatal mortality = 2 fold less
Electronic fetal monitoring = 6 fold less
External tocometer = 6 fold less
Fetal scalp electrode = 5 fold less
Augmentation of labour = 2 fold less
Amniotomy = 2 fold less
Oxytocin = 3 fold less
Nitrous oxide = 8 fold less
Epidural = 4 fold less
Narcotic = 8 fold less
Spontaneous vaginal = 19% more
Assisted vaginal = 5 fold less
Cesarean = 52% less
Cesarean among nulliparous women = 67% less
Cesarean among multiparous women = 13% less

Either way, home birth with a certified midwife is shown to be as safe, if not safer than hospital birth with a physican. The added bonus is significantly less unnecessary medical intervention.

The full text study is available here:
Outcomes of planned home birth with registered midwife versus planned hospital birth with midwife or physician
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2742137/

There are also many other large studies confirming these findings:

Perinatal mortality and morbidity in a nationwide cohort of 529 688 low-risk planned home and hospital births
http://www.internationalmidwives.org/Portals/5/Home%20Birth%20-%20Netherlands%20-%202009%20BJOG.pdf
"This study shows that planning a home birth does not increase the risks of perinatal mortality and severe perinatal morbidity among low-risk women, provided the maternity care system facilitates this choice through the availability of well trained midwives and through a good transportation and referral system."

Outcomes of planned home births versus planned hospital births after regulation of midwifery in British Columbia
http://www.cmaj.ca/content/166/3/315.full
"There was no increased maternal or neonatal risk associated with planned home birth under the care of a regulated midwife. The rates of some adverse outcomes were too low for us to draw statistical comparisons, and ongoing evaluation of home birth is warranted."

Home versus hospital deliveries: follow up study of matched pairs for procedures and outcome. Zurich Study Team
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2352706/pdf/bmj00569-0045.pdf
"During delivery the home birth group needed significantly less medication and fewer interventions."
"Healthy low risk women who wish to deliver at home have no increased risk either to themselves or to their babies."

Outcome of planned home and planned hospital births in low risk pregnancies: prospective study in midwifery practices in the Netherlands
http://www.bmj.com/content/313/7068/1309.abstract
"There was no relation between the planned place of birth and perinatal outcome in primiparous women when controlling for a favourable or less favourable background. In multiparous women, perinatal outcome was significantly better for planned home births than for planned hospital births, with or without control for background variables."
"The outcome of planned home births is at least as good as that of planned hospital births in women at low risk receiving midwifery care in the Netherlands."

Home or hospital birth: A prospective study of midwifery care in the Netherlands
http://nvl002.nivel.nl/postprint/PPpp1096.pdf
"Our study has shown that for women at low risk of obstetric complications, the outcome of planned home births is at least as good as the outcome of planned hospital births for first time mothers, while for other mothers the outcome of planned home births is significantly better."
"To maintain confidence in home birth and reduce the fear of unplanned transfer to hospital, leading to an increased choice for hospital birth, it is essential that certain conditions are met. One of these is a well functioning selection system to ensure that only those women who are really at low risk are offered the opportunity and are encouraged to give birth at home."

Home versus hospital deliveries: follow up study of matched pairs for procedures and outcome
http://www.bmj.com/content/313/7068/1313.full
"Healthy low risk women who wish to deliver at home have no increased risk either to themselves or to their babies. There are no obvious disadvantages of home delivery for mother or child when the mother opts for home delivery."
"Interventions (induction, caesarean section, medication, forceps, or vacuum extraction) may be considerably less frequent in women who originally opt for home delivery:"
Hypertention = 60% less
Preterm birth = 40% less
Breech presentation = 33% less
Induction = 18%
Cesarean = 45%
Analgesics = 16%
Medication during expulsion period = 34%
Forceps or vacuum = 41%
Episiotomy with perineal lesion = 9%
Perineal lesion = 3 fold
Perineal and vaginal lesion = 25%
Intact perineum = 6 fold more
Though these results favour midwives, again these results are heavily adjusted to bring down the risks associated with hospital births with a physician. Below are the real, unadjusted results that compare specifically matched pairs of birthing mothers (if these were matching pairs why did they need adjusting?) There is a huge discrepancy, for instance a 500% increased occurrence of induction in physician led hospital births, has been brought down to just 18%. I don't see how a reduction of 482% can be justified in a group of specifically matched pairs of birthing mothers:
Induction of labour = 5 fold less
Caesarean section = 2 fold less
Analgesics = 3 fold less
Medication during expulsion period = 5 fold less
Forceps or vacuum extraction = 2 fold less
Episiotomy without perineal lesion = 3 fold less
Perineal and vaginal lesion = 4 fold less
Intact perineum = 4 fold more

Outcomes associated with planned home and planned hospital births in low-risk women attended by midwives in Ontario, Canada, 2003-2006: a retrospective cohort study
http://www.internationalmidwives.org/Portals/5/Home%20Birth%20Statsitics%20-%20Canada%20-%20BIRTH%20September%202009.pdf
"Midwives who were integrated into the health care system with good access to emergency services, consultation, and transfer of care provided care resulting in favorable outcomes for women planning both home or hospital births."
"All measures of serious maternal morbidity were lower in the planned home birth group as were rates for all interventions including cesarean section."

Outcomes of planned home births with certified professional midwives: Large prospective study in North America
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC558373/?tool=pubmed
"Planned home birth for low risk women in North America using certified professional midwives was associated with lower rates of medical intervention, but similar intrapartum and neonatal mortality to that of low risk hospital births in the United States":
Electronic Fetal Monitoring = 9 fold less
Induction = 2 fold less
Episiotomy = 16 fold less
Forceps = 2.2 fold less
Vacuum = 9 fold less
Cesarean = 5 fold less

Outcomes of 11,788 planned home births attended by certified nurse-midwives. A retrospective descriptive study
http://www.ncbi.nlm.nih.gov/pubmed/8568573
"This study supports previous research indicating that planned home birth with qualified care providers can be a safe alternative for healthy lower risk women."
"Most nurse-midwives in this study used standard risk-assessment criteria, only delivered low-risk women at home, and were prepared with emergency equipment necessary for immediate neonatal resuscitation or maternal emergencies."

It should be reiterated that the homebirths included in these studies involve certified midwives or certified nurse midwives, and the births have to meet a low-risk criteria to be deemed suitable for home birth. Below is typical of what is required.

Eligibility requirements for home birth
As referenced in the above studies:
  • Absence of significant pre-existing disease, including heart disease, hypertensive chronic renal disease or type 1 diabetes
  • Absence of significant disease arising during pregnancy, including pregnancy-induced hypertension with proteinuria (> 0.3 g/L by urine dipstick), antepartum hemorrhage after 20 weeks' gestation, gestational diabetes requiring insulin, active genital herpes, placenta previa or placental abruption
  • Singleton fetus
  • Cephalic presentation (not breech or transverse)
  • Gestational age greater than 36 and less than 41 completed weeks of pregnancy
  • Mother has had not had a cesarean section
  • Labour is spontaneous, not induced 
  • Mother has not been transferred to the delivery hospital from a referring hospital
Other important factors included:
  • Well trained midwives 
  • A good transportation and referral system
  • Midwives are prepared with emergency equipment necessary for immediate neonatal resuscitation or maternal emergencies

So what's your opinion on home birth, have you had one, would you consider having one, are you planning one? Do you agree a midwife is always needed?