Giving birth

Nova Scotia has cancelled all home births—could it happen in other provinces?

The choice to have a home birth in Canada has been thrown into question this week, after the Nova Scotia government suspended midwifery-led home births without consultation of midwives.

Paris Semansky was on the fence about having a home birth up until days before her second daughter’s birth a little over a week ago. Her midwife was the chief of midwifery at Michael Garron Hospital in Toronto, and had been updating her regularly about hospital changes due to the escalating COVID-19 pandemic.

“We had already been self-isolating for a week and a half, and it was an ongoing conversation about the option of having a home birth,” she says. Then, she learned the hospital’s separate entrance to the labour and delivery ward was closed down. “I would have had to go through the front door, to the same lineup with everybody getting triaged to even get into the hospital,” she says. “That was our tipping point.”

Semansky had a low-risk pregnancy, and didn’t want to take the chance of exposing herself and her husband to coronavirus. Her previous birth was in hospital with midwives, and she felt confident that she could deliver at home this time. Her daughter Mira was born on her bed, without complications, after a five-hour labour.

But the choice to have a home birth in Canada has been thrown into question this week, after the Nova Scotia government on March 30 suspended midwifery-led home care, including births, without consultation of midwives.

“We appreciate how significant and special giving birth is for all women and their families and therefore we understand that changes to pregnancy and birth plans will be most unsettling,” said a press release issued by the Nova Scotia Health Authority and the IWK Health Centre paediatric hospital in Halifax. “The interruption of home birth services supports provincial efforts to minimize the spread of COVID-19 and keep Nova Scotians safe. The decision also protects small teams, like the midwives and birth attendants, so they can continue to provide midwifery services.”

Quebec, too, recently took similar measures to halt home births, but the option was subsequently reinstated after the implementation of additional measures related to COVID-19, including asking midwives to cap birthing partners to only one asymptomatic companion, and ensuring the family voluntarily self-isolated for 14 days prior to the birth.

Will home birth be cancelled in other provinces?

Following Nova Scotia’s decision, the Canadian Association of Midwives (CAM) said that their midwives are actively engaged in discussions with government and public health agencies in other provinces.

“National midwifery leaders are currently working in their provinces and jurisdictions to ensure that midwives are at the table when discussions around place of birth are happening, to ensure that the best options are available to families across Canada,” CAM president Nathalie Pambrun told Today’s Parent. “Midwives, as autonomous primary care providers, must be consulted regarding criteria around home births or births in any location.”

The presidents of the Ontario and British Columbia midwives’ associations, the two largest groups in the country, expressed disappointment about the Nova Scotia suspension of home births but said they don’t believe they will be affected. Nova Scotia has only 13 midwives while Ontario and BC have around 1,000 and 400 respectively, which helps to give them a greater voice in healthcare decisions.

Midwives are demanding support and access to to protective gear

Midwives, like all primary care providers, are working to adapt to the new reality of the COVID-19 pandemic. They’re taking extra precautions, such as wearing personal protective equipment (just like other healthcare providers) and substituting virtual and phone visits when possible with clients.

Throughout the pandemic, midwives have been providing uninterrupted care for their patients—whether in a home, hospital or birth centre setting—as they closely monitor the COVID-19 outbreak, and have been seeing higher demand for home birth, as many clients want to stay as far from hospitals as possible. They also help to alleviate stretched hospital resources.

But one of the biggest challenges midwives are facing is getting increased access to testing and personal protective equipment, says Pambrun. Her organization is also urging health regions to consider “temporary birth centres” with sites and staff that are clear of COVID-19-infected people receiving acute care.

SOGC says feeling toward home births “evolving”

Following the Nova Scotia decision, the president of the Society of Obstetricians and Gynaecologists of Canada (SOGC) told Today’s Parent that thoughts around home births in the setting of COVID-19 are evolving, but that the SOGC has not taken a stand against them for asymptomatic pregnant women. “It is still their choice to have a home birth, provided they can receive care from two experienced midwives who are willing to provide that,” says B. Anthony Armson.

He adds that the SOGC has not made a statement and does not have a position that home births are “contraindicated” in women who are otherwise healthy and are not known to have COVID-19. The SOGC’s updated COVID-19 guidelines say that pregnant women who are COVID-19-positive or symptomatic should deliver in hospital where they would have ready access to an interdisciplinary team including infectious diseases and seizure assessment.

Armson, who is based in Halifax, says he believes Nova Scotia’s decision came down to a lack of protective equipment for midwives, as well as increasing uncertainty over the availability of ambulances should a labouring woman need to be transported to hospital from her home. In the UK for example, some midwifery clinics have had to suspend home births because they could not rely on ambulance services for backup.

“Transportation may be a problem because ambulances are busy looking after other patients and the whole process of cleaning between one transport to another, so there could be delays in the event of a complication, more so now than previously,” he says. “I think those factors are influencing the appeal of home birth during this pandemic.”

The Ontario and BC midwives say they have not heard of any ambulance delays in their communities, but would expect that their paramedic colleagues would reach out to them if that was the case. In Ontario for example, about 30 to 40 percent of home births for first babies are transferred to hospital, but only about five percent are emergency transfers requiring an ambulance.

Jon Barrett, chief of maternal-fetal medicine at Sunnybrook Hospital in Toronto, agrees that one of the biggest issues is the lack of protective gear for all healthcare workers, including midwives. “Midwives will tell you they don’t have enough masks, so they are using the hospital’s supply, which is fine, it’s nobody’s supply…it just illustrates that there’s not one group that is unscathed here, there is no group that has a better answer, we’re all trying to work together to do the same thing.”

Home births as a form of physical distancing

For many midwives and pregnant women, home births may be the best possible form of physical distancing. “As hospitals see a surge in COVID-19 in the coming weeks and months,” says Pambrun, “it’s important to consider the important role that midwives can play in reducing the number of patients entering and overburdening these facilities, which may further spread of the virus.”

Obstetrician members of the SOGC, including Armson, have stated that there are still advantages to home births in low-risk pregnancies, but that cases must be assessed on an individual basis.

Meanwhile, Canadian midwives continue to offer choices. “Choice of birthplace, especially in the context of the pandemic, must be decided by midwives and childbearing families following best available evidence,” Pambrun says, adding that there is no evidence to support that home birth is unsafe for the midwives or the client when they are using personal protective equipment. “People will continue to have home births regardless of suspension of services. It is the duty and scope of midwives to ensure access to care for people who want to birth at home.”