In Vitré, in Ille-et-Vilaine, child protection services temporarily removed two children from their families, including a baby who had just been born at home. If the authorities deny any link between this home birth and the placement, the case has caused a great stir and has given rise to various rumors about the legal framework for home birth in France. What about?
Nothing prohibits home birth
In France, no law prohibits home birth (AAD). “They can occur unexpectedly as well as be desired and organized by the future mother”, explains the General Directorate for the Provision of Care (DGOS) of the Ministry of Health, contacted by e-mail. A woman can give birth at home by « accident », but also by choice, by being accompanied by a midwife (“assisted home birth”) or not (“unassisted birth”).
However, almost all births have taken place in hospitals since the 1950s, due to medical progress and public perinatal policies aimed at reducing infant mortality.
According to historical data from INSEE, between 1980 and 2016, so-called “extra-hospital” births represent between 0.5% and 1.9% of the total (738,000 births per year in 2021), with a very large majority “assisted” births.
The Professional Association for Accompanied Home Birth, which brings together some 70 liberal midwives accompanying women from pregnancy to birth, carries out its own count in its activity reports. In 2018, it identified 1,347 women who chose AAD, 133 of whom had to be transferred to maternity. In 2019, 1,298 women were monitored: 1,081 started labor at home and 910 actually gave birth at home without the need for a transfer (before or after birth). In 2020, a year marked by the health crisis, 1,503 women undertook an AAD process, 223 were referred to maternity during pregnancy, 150 started working from home but had to be transferred before the birth of the child. ‘child.
AAD is not encouraged by the authorities
The DGOS, guarantor of the supply of care according to public health guidelines, summarizes the French political framework as follows: if home births are possible, “we consider that they do not allow, in optimal conditions, to meet the needs of safety and quality of care that must surround birth, a situation that is never free of risks, neither for the mother nor for the child”.
The Ministry of Health promotes the development of a middle way between the medical environment and the home, with birth centres, “structures with very little medical care and located outside the walls of the hospital”. After years of procrastination, a law allowed their creation on an experimental basis in 2013, still attached to hospitals. There are eight of them to date, in which women with so-called “low risk” pregnancies can be treated exclusively by midwives.
The notions of safety and risks incurred are central in the production of medical standards. And home birth is considered to be more “at risk”. Even if the scientific discussion on this subject is complex and nuanced. “In France, birth is considered “at risk” a priori. It is postulated that the medical risk is always present, that a pathology can arise in the mother as well as the child until after birth. The medical profession is implementing protocols and monitoring technologies to measure and possibly counter it. These measures apply to all women, including those who are classified as being at low risk., analyzes Béatrice Jacques, sociologist specializing in health, author of a thesis on childbirth. Other countries, such as the Netherlands, have the opposite assumption. “We are not ignoring the risks, but we will intervene when they arise, she reports. Birth is less medicalized because the medical profession prefers to let physiology do its thing and intervene only when necessary. »
Other European countries have also opened up to assisted AAL. In England, the colleges of obstetrics support it, under very specific conditions (“low-risk” pregnancy, planned and organized home birth, simple and rapid transfer to a maternity hospital, etc.). But it remains a minority: 2.7% of English women gave birth at home in 2017, according to the National Health Institute.
The medical community remains reluctant
In France, AAD is a subject of debate within the medical community, between obstetrician-gynecologists and midwives, particularly those who practice in a liberal environment. State graduates and approved by social security, they are the only ones within the medical profession to be able to practice it.
There are many obstacles: resistance from their profession and the National Council of the College of Midwives; difficulty or even impossibility of obtaining insurance at reasonable rates; arduous dialogue with the maternities supposed to welcome their patients in the event of a problem… “Everything is done to dissuade us”believes Floriane Stauffer-Obrecht, liberal midwife in Lunéville, in Meurthe-et-Moselle, since 2008, to the point that she sees her practice “as an act of civil disobedience”.
Since the Kouchner law of 2002, health professionals are required to obtain professional civil liability insurance. But liberal midwives practicing AAD are in a “vacuum”, since the contracts offered to them are equivalent to those of obstetrician-gynecologists, without them having the same practices or the same income. “Insurance premiums fluctuate between 20,000 and 30,000 euros a year… In the end, no one is insured”believes Etienne Tête, a lawyer who defends several midwives who are the subject of disciplinary proceedings by the Council of the Order.
The recent debates on obstetrical violence, as well as the closures of maternity wards, are however moving the lines in terms of childbirth. Witness the experiment launched in 2018 by obstetrician-gynecologist Jacky Nizard, at the Pitié-Salpêtrière hospital in Paris. Believing that home birth remained a political nonsense in France, despite the requests of women, he undertook to have a dialogue between the various medical actors concerned (midwives, SAMU and firefighters called in the event of transfer, attached hospital, etc.) . “If it goes wrong, it is us, at the public hospital, who welcome the complications. Might as well work upstream”, he explains. These actors now speak to each other on a monthly basis, and the patients followed by midwives practicing AAD are also examined, at the end of pregnancy, by Jacky Nizard. About fifty women are thus supported, both by a midwife and a hospital, in their home birth project.