Among the requirements for a home birth, we should first define the laws, which need to be properly regulated, as this would prevent potential further issues.

In the Netherlands, where home births have a centuries-long tradition and almost 30% of pregnant women give birth at home, the criteria are as follows:

• a pregnant woman with no risk factors in her personal, family, or obstetric history (a thorough selection of pregnant women without risk factors is done by midwives at the first check-up in early pregnancy),
• the presence of a midwife,
• access to an ambulance (no more than 15 minutes to the nearest maternity hospital) (Prelec, 2008).

After consulting a gynecologist, weighing risk factors—while also considering other criteria such as distance to the clinic, the midwife and her experience in managing high-risk pregnancies—can serve as a guide for anamnestic risks, after all important information has been recorded in the maternity record book (Lippens, 2007).

Gorjup and Drolc (2003) add that midwives should never feel it is a waste of time to take a good medical history, as further measures are decided on the basis of it.

In the next chapter, the author will present the criteria that should be met for a safe home birth. The requirements must be met by the women, the midwife who would attend such a birth, and the space where the birth would take place, along with all necessary supplies.

Criteria women must meet

Drglin (2003) writes that in Slovenia, women only exceptionally decide on a home birth. Usually, these are individuals with a very clear vision of birth who are willing to invest significant effort to meet their needs—both in preparation during pregnancy and in organizing the birth and finding birth attendants. They are often individuals active in non-governmental organizations in the field of care for pregnant women, women giving birth, and women after birth. However, only a few home-birth cases are known where women or couples decided because they were convinced that medical assistance during birth was not necessary, so the woman gave birth with only her husband’s help.

Prelec (2001) states that the requirements for a home birth in terms of pregnancy are as follows:

• a singleton pregnancy,
• a head-down (cephalic) position,
• a low-risk pregnancy (a pregnancy that progressed without any complications).

Gorenc Jazbec (2010) divides risk factors into several groups. Some cannot be influenced, while others can be avoided.

• Genetic factors, or recurring factors in families: these include various forms of hereditary diseases and other genetic mutations. We cannot influence this type of risk factor. If repeated occurrences of certain diseases or defects are noticed in the family, it is wise to consult specialists at a genetic counseling clinic before pregnancy.
• Biological factors: these include all viruses, bacteria, and protozoa. Viruses are especially dangerous in the first part of pregnancy. Among the most dangerous are cytomegalovirus, HIV, and rubella. Bacteria and protozoa can also be dangerous throughout pregnancy (salmonella, toxoplasmosis, listeriosis …). Biological factors can be avoided to some extent by being mindful of who you are in contact with, what food you eat, and the environment you live in.
• Chemical factors: chemical factors include alcohol, drugs, nicotine, caffeine, medications, pesticides, and heavy metals. This type of factor can largely, if not completely, be avoided, as most of them are habits of modern life. Great caution is also needed when taking medications, and the doctor should be informed about the pregnancy so they can assess which medicines are appropriate and which are not.
• Physical factors: physical factors mainly include various harmful forms of radiation, so it is not recommended for pregnant women to undergo X-ray imaging. Physical factors also include injuries and blows to the abdomen (traffic accidents, falls).
• Mixed factors: these include all other risk factors that cannot be classified under the categories mentioned above. These include various maternal illnesses (diabetes, phenylketonuria, epilepsy (medications—antiepileptics), high blood pressure), lack of food, poor diet, twins, triplets, and psychological stress. Stress in pregnancy is a very important risk factor, because the physiological responses the body has to stress are also experienced by the baby. This can be noticed after birth, as such a child is more irritable, cries more, and is more sensitive. It is important to know that chronic (recurrent) stress is more dangerous than one-time or acute stress.
• Certain risk factors also occur during labor itself, and special attention is needed. These include hypoxia (lack of oxygen), prematurity, where the main problem is brain hemorrhages, and breech presentation, where there is a risk of umbilical cord prolapse and thus interruption of blood and oxygen supply. This category also includes a cesarean section, as this is not the natural way a baby is meant to be born and is usually used in the case of complications.
• Of course, the postpartum period is also not risk-free. The main issues that can have consequences for the child later in life are various infections, which are quite common postpartum, lack of oxygen, jaundice, and Rh incompatibility (in a second pregnancy).

After considering all these factors, Lippens (2007) defines criteria according to which women must go to the maternity hospital:

• a due date before 37 weeks,
• more than 10 days past the due date,
• twins,
• breech and transverse presentation,
• green amniotic fluid,
• abnormal heart rate,
• hypotonia, hypertonia,
• fever,
• visible vaginal bleeding,
• umbilical cord prolapse,
• ruptured membranes for six hours without contractions,
• labor arrest for 2–4 hours.

In addition, the author notes that all the stated criteria that determine a woman’s suitability for a home birth are extensive and clearly expressed. From all this, it is clear that women who wish to give birth at home should be professionally selected based on the woman’s health before pregnancy, during pregnancy, and also the family’s health history; the condition and development of the fetus would also influence the decision, and all other criteria would need to be taken into account as well.

Criteria midwives must meet

A pregnant woman who decides on a home birth must also choose a professionally trained person to support her during birth. Birth is hard work, and the role of the midwife and nurse before, during, and after birth is responsible and professional, humane and sensitive work—providing support, standing up for, and advocating for everyone involved (Marin, 2005).

Drglin (2003) writes that most independent midwives promote normality, advocate physical and psychological support, are woman-centered and enable empowerment, and seek simple and non-invasive tools and methods before deciding to use highly advanced technology. Midwifery care is safe. Routine obstetric management brings no benefit and can increase risk. The number of interventions depends on the assumptions of those caring for women. Midwifery reduces the number of interventions, but differences between midwives can be very large. When doctors supervise midwives, the number of interventions increases; where midwives work independently, the number of interventions is lower. Midwifery care benefits both women assessed as very “high-risk” and low “risk” pregnant women. Midwifery care is cheaper. Some doctors oppose independent midwifery for political, economic, and philosophical reasons, but present their opposition as medical facts.

Marin (2005) adds that a midwife is a healthcare professional specially trained to work in maternal and child healthcare, and is therefore educated to care for women during pregnancy, during birth, and in the postpartum period. She must be able to manage a birth independently and care for the newborn, recognize danger signs that may indicate abnormalities, anticipate possible complications, and inform the doctor about them. Until the doctor arrives, she must act appropriately and provide professional assistance.

Gorjup and Drolc (2003) state that midwives who were employed in local health centers in Slovenia, in some cases, attended home births. They brought the necessary instruments and the most essential care supplies in a so-called midwife’s bag.

When a couple decides to give birth at home, the midwife who visits the pregnant woman must educate her and the family about what equipment they need to provide for the birth. It is best to have a prepared list of required items—both essential and optional (Lees et al., 2006).

Summary of activities for planning a home birth:

• The midwife and the pregnant woman determine eligibility for planning a home birth and also confirm together that all safety conditions are in place.
• The midwife provides detailed information summarizing research on the risks, benefits, and safety of planned home births.
• You should attend regular medical check-ups together with the midwife, who ensures ongoing assessment of your continued eligibility for a home birth.
• The midwife must have a plan on file, with a link to the local hospital, specifying who is responsible for receiving emergency calls, transport, and initiating emergency care. A copy of this plan is kept.
• The midwife must submit a copy of the 36-week prenatal notes to the hospital where the pregnant woman is registered.
• The midwife must ensure that a second attendant is approved for the birth, and must also inform the hospital about the course and completion of the birth (Home Birth, 2005).
• The midwife must be well prepared for possible questions from the pregnant woman and her partner. She must be able to answer any question (Wittgenstein, 2007).
• The midwife must assess which stage of labor it is, how much time is available for necessary action, and plan the order of interventions.
• In the case of advanced labor, she first prepares the instruments, positions the woman correctly, takes only the most essential information such as the duration of labor and the time the membranes ruptured, performs an obstetric examination, and only later—if there is still time—uses that time for a detailed history and the preparations described above (Kolenc, 1993).

WHO (2003) provides more detailed guidance regarding home birth:

• ensure a clean surface for the birth,
• before and after contact with the pregnant woman and the newborn, the helper washes their hands with clean water and soap,
• ensure that after birth the baby’s eyes are wiped and the baby is placed on the mother’s chest,
• cover the mother and baby,
• use instruments and a razor blade from the available medical supplies to clamp and cut the umbilical cord, and cut it when it is no longer pulsating,
• dry the baby after cutting the cord,
• wait for the placenta to be delivered spontaneously,
• start breastfeeding when the baby is ready, within one hour after birth,
• do not leave the woman alone in the first 24 hours,
• keep the mother and baby warm and dry,
• dress the baby and cover the baby’s head,
• dispose of the placenta properly—safely and in a culturally appropriate way.

Table: Supplies and items provided by the midwife

The author agrees that among the most important information are also the criteria that midwives must meet, since the midwife who will manage such a pregnant woman and later attend her home birth must prepare the woman for everything and inform her. She is responsible for the health of the woman and the baby, so she must be skilled and well prepared and ensure the greatest possible safety for both mother and child. The midwife must be well trained so that she can act correctly in the event of complications.

Criteria for preparing the space and supplies

For women who choose a home birth or a birth center, services comparable to those they would receive if they gave birth in a maternity hospital should be ensured. This should include a midwife and, if needed, medical care, education, and continuous care during pregnancy, birth, and afterwards, as well as additional social support if required (Drglin, 2003).

Bračič (2008) notes that there is usually a lot of blood during the birth of a baby and that midwives or doulas instruct parents in advance to prepare old sheets and towels. They also advise buying or renting a birth pool. Sales of these are said to have increased once or even twice in the past year. Those who have experienced the miracle of giving birth at home say that in the end, quite a lot ends up in the trash.

The midwife who will attend the pregnant woman at a home birth must check the suitability of the space and the essential supplies the pregnant woman was required to prepare, and must also confirm that the pregnant woman’s condition is appropriate for a home birth.

Burchardt (2002) adds that statistics show a high quality of births outside the maternity hospital. The following conditions are required:

• good hygiene conditions,
• good physical condition of the pregnant woman,
• a high level of knowledge about childbirth and good preparedness,
• a trusting relationship between the midwife and the parents, built already during pregnancy,
• a high level of trained midwives,
• rapid availability of a clinic based on good infrastructure,
• well-equipped midwives.

Many midwives who assist with home births work in pairs, so that one cares for the woman and the other for the baby.

Prelec (2001) agrees that the most important thing is that the conditions listed by Burchardt are met. Good hygiene conditions must include general hygiene, safe clean water, heating, and privacy. In terms of infrastructure, there must be a good connection with the hospital, access to an emergency vehicle, and fast transport.

Once the midwife checks that the conditions are met, she must also prepare the following for appropriate management:

• a sufficiently large, airy, and well-lit room,
• a birth bed that is not too low and not too soft, accessible from all sides and wide enough to position the woman crosswise on the bed,
• a sufficient amount of safe water with disinfectants (if the cleanliness of the water is questionable, the water must be boiled),
• a sufficient amount of clean linen (ironing can help achieve germ-free linen).

Items the midwife brings herself:

• necessary sterile instruments such as scissors, preferably also cord scissors, tweezers, clamps, tape or clamps for the umbilical cord, two hemostats,
• dressing materials such as sterile bandages, gauze pads, and tampons,
• other equipment such as a bedpan, thermometer, hot-water bottle for the newborn, rubber gloves, disinfectant, Credé drops.

Different authors have different suggestions regarding essential and less essential items for a home birth that the pregnant woman should prepare at the midwife’s request. Lees et al. (2006) and Jones (2009) list items and supplies in more detail, which can be divided into categories by necessity. The author defined them in a table.

Table: Birth supplies

Based on all the criteria that women and midwives must ensure, the author also defines criteria for the space and supplies. When preparing the space and supplies, the midwife informs the woman and her partner so they can ensure the minimum standard the space and supplies must meet. Any additional extras they can provide contribute to greater comfort. It is important that everything essential is truly prepared and not searched for once labor is already underway. This way, the birth can proceed calmly, with everything within reach for the woman, her partner, and the midwife.

Source: the author Sara Kac’s thesis (2012): Requirements for a home birth (women who can give birth at home), under the mentorship of Senior Lecturer Teja Škodič Zakšek, BSc Radiol. Eng., Dip. Midwife, MSc (UK)

Photo