Place of birth?
You need to thoroughly check whether the intended place of birth and attending obstetrician and midwives have the necessary measures in place to ensure a safe childbirth.
HOME birth was the norm until the advent of modern medicine in the 20th century. There were disastrous consequences for many mothers, and many babies delivered at home succumbed at the time of childbirth or soon after.
The overwhelming majority of women and babies in Malaysia are likely to have a safe delivery and birth. The neonatal mortality (deaths in the first four weeks of life) rate was 4.4 per 1,000 total births in 2009, compared to 14.77 per 1,000 total births in 1980.
This compares with two to four per 1,000 live births in 2009 in developed countries.
The maternal deaths, attributable to problems in pregnancy or at birth, were 28 per 100,000 maternities in 2009, compared to 59 per 100,000 maternities in 1980.
This compares with six to nine per 100,000 maternities in 2009 in developed countries.
The home birth rate declined from 50% in 1938 to less than 1% in 1955 in the United States; from about 80% of births in the 1920s, to about 2% in 2001 in the United Kingdom; and from 95% in 1950 to 1.2% in 1975 in Japan. The data in Malaysia is sparse.
There has been a resurgence of interest in home birth in some developed countries, with an increasing number of women willing to consider this option.
The Changing Childbirth report (2003) of the Department of Health of the United Kingdom reported that it is believed that if women had true choice, the home birth rate would be around 8–10%, and not 2%.
However, in Holland, which always had the highest home birth rate in Europe, there has been a decline of 34% to 24% in the past decade, especially since 2009.
With the relative increase in home births in developed countries, data about its risks and benefits in the modern-day setting will grow, thereby enabling doctors to provide the relevant information to assist women make an informed decision about the place of birth.
Hospital birth
Most Malaysian women give birth in a hospital, with nursing care provided by trained midwives. Normal deliveries in public hospitals are usually carried out by midwives, and on some occasions, medical students and trainee midwives.
Doctors, including specialists, are available for any problems that may arise. Depending on the seniority and experience of the doctors, they will perform assisted vaginal deliveries, Caesarean sections, and manage any problem(s) that the patients might have.
The majority of normal deliveries, as well as all assisted vaginal deliveries and Caesarean sections in private hospitals, are done by specialists, who also manage any problem(s) that may arise.
The advantages of hospital birth include having direct access to specialists like obstetricians, anaesthetists and paediatricians or neonatologists, who are specialists in the care of the newborn; access to epidurals or spinals for pain relief; and availability of a special care baby unit if the newborn has any problems.
These advantages are available in the Health Ministry’s general hospitals, university hospitals, armed forces hospitals and the bigger private hospitals.
Although these facilities are limited in some of the Health Ministry’s district hospitals, there is a referral system in place for any mother in labour who has complications, to be transferred to a hospital where such facilities are available.
Choices of the type of care are available in the private hospitals and the majority of the Health Ministry’s general hospitals, university hospitals and armed forces hospitals.
Doctors and midwives will provide information about what is available. If it is not done, the patient and her relatives have a right to request for such information.
The patient has the choice of a private hospital. It may be one that is near home or one where her regular obstetrician practises. In the case of public hospitals, the choice is usually limited to one that is near the patient’s home.
Different midwives will provide care during labour in all hospitals. Different doctors will also be attending to labouring patients in the Health Ministry’s general hospitals, university hospitals and armed forces hospitals, unlike in private hospitals, where it is usually the same doctor who has provided care during pregnancy.
The mother who has delivered in a public hospital is often moved from the labour ward to a postnatal ward, and sometimes may be discharged early if there are no problems because of the need for beds in these hospitals, which have a high workload.
The situation is different in a private hospital where the patient can stay in the same room for as long as she likes, depending on the willingness to pay.
Home birth
If the pregnancy has been uncomplicated and both mother and foetus are well, the mother may opt to have a home birth.
The labour and delivery in a home birth is no different from that of a hospital birth.
The supporters of home birth often quote the 24% home birth rate of Holland, which has the highest home birth rate in Europe. However, there is a need to remember that the Dutch healthcare delivery system is able to support home birth.
Although the risk of death to babies in planned home births has been reported to be double or thrice that of planned hospital births, the overall risk of death is low.
The advantages of home birth include being in a familiar and relaxing environment, which enables the mother to cope better with labour; no separation from spouse or children; care by a midwife with whom one is familiar with; immediate bonding with the newborn and the family; and lower cost.
Studies of home birth experiences report an increased sense of control, empowerment and self-esteem, and an overwhelming preference for home birth.
Home birth is not suitable if the mother has diabetes, high blood pressure or any other chronic medical condition; had a previous Caesarean section; developed pregnancy complica-
tions like anaemia, high blood pressure or pre-term labour; multiple pregnancy; the foetus is not presenting by the head; or the pregnancy is past the due date.
It is important to remember that complications may develop during labour despite an uncomplicated pregnancy, and transfer to hospital will also be necessary if labour is not progressing.
There could be delay in such a transfer, which may expose the foetus to risks.
A study in the United Kingdom reported that about 40% of first time mothers and 10% of women who have previously given birth are transferred to the hospital from planned home birth.
The reasons include maternal exhaustion, premature rupture of membranes, high blood pressure, failure to progress, non-reassuring foetal status, cord prolapse and haemorrhage.
A successful home birth will require a team comprising an experienced midwife and an obstetrician.
An alternative plan must be in place should transfer to a hospital be necessary (and the availability of a paediatrician who will examine the baby within 24 hours of birth).
It is vital that the midwife is competent within the home birth environment, and that the obstetrician has made a careful assessment of the patient’s suitability for home birth.
Planning for a home birth will require a detailed discussion with the midwife and obstetrician.
Maternity homes are operated by doctors or midwives in the private sector, and birth centres by the Health Ministry. The facilities and advantages are somewhat between that of hospital and the home.
Questions to ask
It is often stated that the most dangerous journey a human being takes is at the time of birth.
There are about 450,000 to 500,000 births annually in Malaysia. Whilst the vast majority have happy outcomes, there are some in which there are tears of sadness rather than tears of joy.
The basic questions when deciding on where to give birth that all pregnant women need to have answers to include:
Are the physical facilities designed for safety?
How long does it take to be transferred from the place of delivery to the operating theatre?
Are there adequate equipment for monitoring in labour and normal delivery, and the immediate management of complications in mother and baby?
Is an obstetrician involved in the care, and what is his or her name?
Is an anaesthetist and/or paediatrician available, and what is his or her name?
Are there sufficient skilled midwives employed and deployed effectively?
Does the medical and midwifery staff have the right skills to deal with emergencies?
What pain relief modalities are available?
What if a complication happens in labour?
What if an instrumental vaginal delivery or Caesarean section is required?
Are there written policies, standards, procedures and guidelines for obstetric emergencies?
Will there be an opportunity to develop a personal birth plan?
What are the costs of antenatal care and delivery, and the treatment of complications?
Most health care facilities, obstetricians and midwives would provide answers willingly. Otherwise, the pregnant woman has to actively seek them.
If there is reluctance to provide answers to legitimate concerns or the answers are unsatisfactory, it may be prudent to consider changing to another healthcare facility and/or obstetrician and/or midwife.
The pregnant women’s choice of where to give birth can influence whether she and baby have a happy or sad outcome.
Healthcare facilities, obstetricians and midwives who put a premium on patient safety and quality of care are less likely to have poor outcomes for both mother and baby.
Having a baby is a huge responsibility.
The parents-to-be owe it to themselves and their unborn child to check thoroughly whether the intended place of birth, and the attending obstetrician and midwives have the necessary measures in place to ensure pregnancy and childbirth is as safe as it can possibly be.
Dr Milton Lum is a member of the board of Medical Defence Malaysia. This article is not intended to replace, dictate or define evaluation by a qualified doctor. The views expressed do not represent that of any organisation the writer is associated with. For further information, email starhealth@thestar.com.my. The information provided is for educational and communication purposes only and it should not be construed as personal medical advice. Information published in this article is not intended to replace, supplant or augment a consultation with a health professional regarding the reader’s own medical care. The Star does not give any warranty on accuracy, completeness, functionality, usefulness or other assurances as to the content appearing in this column. The Star disclaims all responsibility for any losses, damage to property or personal injury suffered directly or indirectly from reliance on such information.