California College of Midwives Standards & Guidelines
~ Section Four ~ October 2004
A Clarifying & Statistically-relevant Definition of a Midwife-attended “Planned Home Birth” for practical, political, policy purposes
A professionally-attended and planned home birth with a licensed midwife is intentional –– that is, a thoughtful and informed decision mutually made by the parents and the midwife after onset of active labor, with conservation of wellbeing of both mother and baby being the foremost criteria for decision-making.
A. PHB conforms to the standard criteria for community-based midwifery: an essentially healthy mother, at term with a normal pregnancy, displaying an active progressive labor that can reasonable be expected to lead to a normal vaginal birth under physiological management (i.e., not requiring any artificial, forcible or mechanical means to advance labor or bring about delivery).
B. The PHB decision manifests itself by the parents as purposefully choosing to remain in a domiciliary setting (client home or independent birth center) after onset of progressive labor. The PHB decision manifests itself for the licensed midwife by continuing to provide intrapartum care in a domiciliary setting after onset of progressive labor until one of the two following events occurs:
1. The baby is born normally or
2. A social, psychological or medical circumstance requires the family or the midwife to arrange for immediate or emergent transport.
C. Transports that occur after the intrapartum decision to remain at home is made (the declaration of PHB in a healthy mother with normal pregnancy as recorded in the client’s chart), those occurring during or immediately after delivery or within 6 hours of the birth, whether relating to mother or baby, are properly categorized as a PHB requiring medical evaluation, medical care or emergency services.
When a medical complication requires a childbearing woman who had been receiving midwifery care to transfer to obstetrical services during prenatal care or during labor, she often finds herself referred to by medical personnel as a ‘failed home birth’ (FHB). The term “failed home birth” is often factually wrong or represents a misunderstanding of community-based midwifery care and planned home birth. For example, the most common reason for this mislabeling is that in fact no “attempt” to deliver the baby at home ever occurred, usually because the mother was never in active labor at home. The important point is that an appropriately timed hospital transfer of a laboring woman is a successful management strategy, and not a failure on the part of either mother or midwife.
Appropriately Timed Transfer or Transport vs. “Failed Home Birth” Status
Transports that occur after the intrapartum decision to remain at home is made (the declaration of PHB in a healthy mother with normal pregnancy as recorded in the client’s chart), those occurring during or immediately after delivery or within 6 hours of the birth, whether relating to mother or baby, are properly categorized as a PHB requiring medical or emergency services.
However, it should be noted that the accurate statistical definition of a planned home birth (PHB) must take into account several situations surrounding community-based midwifery care that are not appropriate precursors to a PHB and for which it is not appropriate to categorize these situations as ‘failed home births’.
The operative principle to be examined is the intention (or lack of) to remain in a domiciliary setting for the intrapartum events and the opportunity (or lack of) to assumption responsibility for midwifery management by the midwife. When a medical complication or other situation has eliminated the client’s opportunity to safely labor or give birth at home before the midwife has assumed the responsibility for domiciliary management of active labor, the resulting outcome statistics cannot properly be ascribed to a “planned home birth” in vital statistic collection and when conducting scientific studies.
The following situations do not meet the criteria for PHB and therefore cannot accurately be considered to be a ‘failed home birth’, nor can morbidity or mortality be directly ascribed to the domiciliary location of the birth or the quality of care provided by the licensed midwife.
1. Prenatal transfer to medical care, including the elective pre-labor transfer of client to an obstetrical provider for hospital induction of labor
2. Precipitous birth at home of premature baby (less than 37 completed weeks of gestation), with or w/o midwife being present, or other high risk precipitous birth occurring before arrival of midwife or immediately upon her arrival, before emergency transport could be accomplished
3. Immediate transfer or transport of client due to phone triage or initial exam by midwife at the client’s home that reveals a condition requiring immediate medical evaluation or emergent medical attention
4. Desultory prodromal or latent phase of labor that does not progress to active labor after appropriate midwifery support or the elective transfer of care during the early (non-progressive) phase of labor in which the parents elect to drive themselves to a medical facility for obstetrical services
5. Maternal or neonatal complications arising more than 6 hours after the birth (the customary time that families are discharged from independent birth centers or provided with “early discharge” from hospitals)