Natural birth represents a set of physiological phenomena through which the live fetus and the placenta are expulsed from the uterus through the birth canal. However, specialized health care authorities recommend medical supervision of this process in hospitalized conditions. Some women opt to deliver in their own home, claiming advantages like a more familiar environment and the absence of feeling restricted by the medical staff(1,2). Despite this comfort and freedom, these patients endanger themselves and the newborn, the risks being maximum when they choose home birth without the supervision of the specialized medical staff. Some studies stress the higher risk of complications at birth and the higher rate of neonatal resuscitation in case of home birth(3,4).
At present, in Romania there is no specific legislation associated with home birth. The purpose of this paper is to emphasize the potential implications of home birth from medical and legal point of views.
Materials and method
The paper presents a retrospective study conducted in the clinical departments of obstetrics and gynecology of the “Pius Brînzeu” Clinical County Hospital of Timişoara. The study included the women who delivered at home and were admitted into the hospital in the immediate postpartum period. The study was conducted in the 2017-2018 period. Out of the total of 5264 births recorded in both departments in the studied period, in 11 cases the birth took place at home (0.21%).
The number of cases with home birth increased by 2.7 times in 2018 compared to 2017. This aspect determined us to study the phenomenon of home birth. In all cases, the patients delivered at home, claiming no specialized medical supervision at the time of the delivery. All pregnancies were with a single fetus. After delivery, all patients along with the newborn were transported (by a requested ambulance of the patient) to the hospital for medical examination and admission. Eight patients were brought by the ambulance in the third stage of labour and three patients entered in the emergency room in the fourth stage of labor. Two women developed postpartum hemorrhagic shock, and three patients presented lacerations of the perineum that needed immediate surgical care. The rest of the cases did not present significant complications at the moment of admission. With the exception of one patient who gave birth in breech presentation, all the other patients delivered in cephalic presentation.
Seven patients were unemployed, and the rest of them had a job. Regarding the residence environment, only three patients lived in rural settings. The average of newborn’s birth weight was 2770 g (varying from 950 g to 3410 g).
The average time from the moment of delivery to the moment of admission to hospital was 14 minutes in case of the patients who delivered in Timişoara. The fastest transfer took 10 minutes, and the longest took 19 minutes.
The average of admission days was 6. Usually, a patient who delivered in hospitalized settings is discharged after three days.
Home delivery generally implies, aside the mother’s wish, an adequate legislation, and appropriate equipment and conditions that allow the medical staff to assist the patient in her home. Also, an emergency service, prepared to react in prompt time, in order to avoid maternal and neonatal complications, should be present.
The legal context in Romania
We can analyze the legal context from two perspectives: the medical personnel duties and the patient’s rights.
Home birth with specialized medical supervision is not permitted by the Romanian health system regulations.
According to law, home care means any medical care provided by specialized staff at the patient’s home, which contributes to improving the wellbeing of the patient physically and mentally. Home care provided by medical staff is a regulated process. The Ministry of Health issued a list of the approved home care procedures to be performed by authorized medical staff and institutions. Home birth is not included in this list(5). Therefore, there is no available procedure or legal background for authorizing a health care provider to assist or supervise home birth.
In conclusion, physicians and midwives are not allowed to assist home births. The existence of a duty of care(6) does not mean that the medical act has to be performed according exclusively to the patients’ special requests, but in accordance with the applicable laws and medical guidelines.
People tend to assume that they have an absolute right to control what is done with their bodies. Article 8 of the European Convention on Human Rights gives anyone, very broadly, a right to live his or her life as they please(7). This might include the pregnant woman right to decide about the place and the procedure of the delivery. But what happens if the newborn health status deteriorates as a result of home birth without medical supervision? Or in the case of accidentally killing the newborn?
Should these be regarded as criminal acts? Should the prosecutors initiate criminal proceedings against the mother?
The Romanian criminal law contains two applicable sets of norms: in relation with the pregnancy and in relation with the labor/delivery.
The pregnancy status allows the women to decide regarding her body during pregnancy, regardless the consequences for the fetus (personal injury or death). According to the Romanian criminal law, the interruption of pregnancy or injury to the fetus during pregnancy by pregnant woman is not punished(8).
But the legislator regards differently the injury of the fetus during birth. By the Romanian criminal law, an injury to the fetus during birth, which prevented the installation of extrauterine life, is punishable by imprisonment from three to seven years. An injury to the fetus during childbirth, which subsequently caused the child a personal injury, is punished by imprisonment from one to five years, and if it resulted in the death of the child, the sentence would be two to seven years in prison. The punishment limits will be reduced by half if the injury of the fetus is committed during the birth by the mother in a state of psychological disorder(9).
The injury or death of the newborn can occur also after delivery, due to improper conditions or negligence. The unintentional injury or killing of a person is also punished by imprisonment(10). The mother knew or had to know that home birth without medical supervision poses a threat to the newborn life. However, she decided to deliver the baby at home, against medical recommendations. According to the medical law, she has the right to refuse the medical treatment. The law also states that the medical personnel’s legal liability ends when the patient does not follow the doctor’s recommendations. Therefore, the mother is very likely to take the whole responsibility for her and her newborn’s child health status.
According to law, the medical personnel has the mandatory duty to inform the patient about all the risks involved in home birth and to recommend only the authorized medical procedures and locations for delivery(11). In case of breaking this legal requirement, the patient could argue that she was not informed about the risks involved and the consequences of home birth without authorized medical, and the medical personnel should be liable for the injury or death of the newborn both civilly (paying compensations) and criminally.
The situation of home birth in other countries
Different colleges endorse different ideas regarding home birth. While the midwives of The Royal College of Obstetrics and Gynecology and of the American College consider that home birth can take place in case of uncomplicated pregnancies after an informed consent, the American Congress of Obstetrics and Gynecologists and the American Academy of Pediatrics advise against this practice despite the absence of the obstetrical risk(12,13).
Specialized literature reveals contradictory results. While some studies report a higher rate of complications such as low Apgar scores, neonatal seizures and neurologic dysfunction, however, other studies conclude that if the birth is attended by a registered nurse in a planned home setting, the chance of adverse neonatal effects will not differ from a delivery in a hospital(14,15).
Nevertheless, despite the same perinatal mortality rate, the overall neonatal death rate is higher in the group that was attended at home (1.26 per 1,000 versus 0.32 per 1,000 in a hospitalized setting)(15).
The incidence of planned home birth varies, The Netherlands having the highest rates of home birth (20%)(16). The most frequent reasons for choosing a planned home birth are the sense of autonomy and the familiar setting. When compared the women who tried to give birth at home, but ended up delivering in the hospital due to complications, with women who were first-hand attended in a hospital, the first group had a lower rate of obstetrical (epidural anesthesia, labor augmentation or episiotomy)(17,18) and medical interventions (blood transfusions)(14). Also, the rate of delivery through caesarean section was lower (5.2% versus 8.1%)(14). Women with a planned home birth had less complications regarding breastfeeding. In order to have a safe home birth, infrastructure and staff criteria should be taken into consideration, such as: the presence of an experienced certified midwife, enough equipment for home birth delivery and fast communication system with integrated maternity, as well as professional timely organized intrapartum transfer in case of complications(19).
A systematic review that evaluated the rate of transfer to a hospital in case of planed home birth reported a rate which varied from 9.9% to 31.9%(20).
Home birth still remains a public health and a social security issue. The patients must be informed about the risks that they expose themselves to when they decide to give birth at home unattended by a medical specialist. Medical professionals, if requested to assist the birth at home, must consider all aspects described and to advocate for the observance of the patient’s rights, but within legal limits, without endangering the life of the mother or the newborn.
Conflict of interests: The authors declare no conflict of interests.