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The Star Online: Lifestyle: Parenting

Home birth: Weighing the risks

Posted: 20 Mar 2014 09:00 AM PDT

The case of two women who died during unassisted home birth here recently highlights issues like the safety of delivering babies in a non-hospital setting and the support services available.

I'm a mum, just that my son's not with us now…" writes Lily Lai (not her real name) in her blog where she shares her birthing experience. What started as a joyous first pregnancy turned into a nightmare for the first-time mother when an unassisted home birth went awry.

She had learnt about natural childbirth and believed she could deliver her baby at home safely with the help of her hypnobirthing coach.

But 10 days after her first contractions started, Lai was rushed to the hospital only to find that her baby had died in her womb.

Late last year, two first-time mothers also had tragic unassisted home births; they died from excessive blood loss after delivering their babies.

National statistics for unassisted home births are not available but gentle birth advocates and doctors are saying the number is growing. A quick search on the Internet finds plenty of web sites, chat groups and links to books and home videos on the subject. Childbirth-related sites like HypnoBirthing Malaysia lists at least 90 unassisted home birth stories.

"A lot of times women are reluctant to come to hospital (to deliver their babies) because they feel their choices are taken away from them," says consultant obstetrician and gynaecologist at Pantai Hospital Kuala Lumpur Dr Paul Ng Hock Oon.

Since 2008, a support network for mothers, The Gentle Birthing Group Malaysia (GBG), has been advocating "gentle birth" – drug-free and natural birthing options

"But a gentle birth doesn't have to be natural birth, it can be a C-section if it's done with respect to the baby and the mother makes the decision. If she's happy with a medicalised birth (epidural, episiotomy and the whole works), it's her choice," says GBG representative Chrissy Steinhardt. "But when it's not her choice, the interventions can result in a traumatic birthing experience for the mother."

It doesn't help that the medicalisation of childbirth means what is a straightforward, natural process is now treated as a medical procedure. Caesarean rates in Malaysian government hospitals hover around 25% in 2008 compared to around 10% in early 2000. The figure is believed to be higher in private practice.

Something to think about: Is the medicalisation of childbirth pushing women into delivering at home?

Something to think about: Is the medicalisation of childbirth pushing women into delivering at home?

Doctors are medically and ethically obliged to ensure the safety of mother and baby, Dr Ng explains.

"That is why they sometimes go to the other extreme and in turn makes patients feel their choices are taken away from them," says Dr Ng who has more than 20 years' experience in obstetrics, including an 11-year stint in the UK.

Also, fear of litigation is scaring medical providers into defensive and often interventionist practices.

Home birth risks

But whilst women should tune in to their natural birth instinct, the risks of unassisted births should not be taken lightly.

A study published in 2010 in the American Journal Of Obstetrics & Gynecology found that planned home births involved less medical intervention but carried twice or thrice the risk of the baby dying.

First-time mothers were also far more likely to need last-minute transfer to a hospital, up to 37%, compared to only four to nine percent of home birthing women who had had at least one child. Reasons for transfers include lack of progress in labour, concerns about the foetus, hypertension, bleeding and a poorly positioned foetus.

Chances are, most low-risk women will have a safe, natural childbirth but it is the 10% that are worrying, especially when they don't have quick access to medical help, says Selayang Hospital's Head of Obstetrics and Gynaecology Dr Mohd Roslan Abd Halim.

"Even in hospitals, you can come in as a low-risk patient and end up as a high-risk patient. Things can change very fast during the labour process," says Dr Roslan who joined Selayang Hospital in 1999.

According to WHO, postpartum haemorrhage is the most common cause of maternal deaths worldwide. It can be caused by the failure of the uterus to contract, vaginal or cervical lacerations, uterine rupture or retained placental tissue.

Hence, the most risky time for the mother is after the baby is delivered.

"We've had patients who were wheeled into the hospital covered with blood from head to toe due to excessive blood loss after delivering at home," says Ng. "Their husbands or birth companions couldn't quantify the amount of bleeding or checked their pressures and pulse rates. Some had low haemoglobin level and required a blood transfusion."

Unlike The Netherlands where midwife-led deliveries are well established, Malaysia does not yet have a good support system, according to Dr Tang Boon Nee, president of the Obstetrical and Gynaecological Society of Malaysia (OGSM).

"In The Netherlands (where one third of births are assisted home births), things are done in a controlled fashion. The midwife goes to the house, assesses the situation, the ambulance is kept on standby and the ob-gyn is on alert," says Dr Tang. "Everything is set in that motion to prepare for the delivery in case something goes wrong."

Without the supervision of a qualified and experienced midwife or care provider during home births, most mothers and their birth companions can't recognise potential problem, asserts Dr Ng.

But women die giving birth in hospital, too.

"Of course, we haven't achieved zero mortality, our mortality rate is 27 over 100,000 (one of the best in the world)," Dr Tang explains. "We are losing patients because they are usually high-risk women who end up in hospitals with heart disease, multiple C-sections, pulmonary embolism and high-blood pressure during pregnancy.

"Yes, there are maternal deaths in hospital births, but there're many more unnecessary deaths for mothers and babies in unassisted home births."

Midwives needed

In Malaysia, assisted home births are legal and common in small towns or rural areas where access to a hospital is difficult. Based at health clinics, these certified midwives attend to the expectant mothers in their homes with equipment for monitoring foetal heart rate and resuscitation, and medications to stop bleeding. High-risk and emergency cases are transferred to the nearest hospital.

But in urban areas like the Klang Valley, women do not have adequate support for planned home births such as certified midwives who are confident enough or willing to assist in home births.

"If we don't provide the option to birth at home for women, they are going to have to choose between the devil and the deep blue sea. They feel they have no choice," says Nadine Ghows, one of the co-founders of GBG. Hence, the next big step for GBG is to push for midwifery care in Malaysia.

"We need to advocate for midwife-led birthing centres and not just about making hospitals more birth-friendly," says Ghows.

Midwives-led birthing centres, where women can experience a calmer, less invasive birth while in close proximity to a hospital in case of emergency, could be a solution.

Studies have found that midwife-led birth centres for low risk women are as safe as consultant-led care and are often associated with less intervention during labour and delivery, according to a 2013 Ministry of Health report by Hospital Tengku Ampuan Afzan in Kuantan, Pahang.

The Kuantan hospital is one of only three public hospitals in Malaysia that houses a low-risk birthing centre adjacent to the main hospital building. Managed by midwives and assisted by medical officers, the birth centre is equipped with delivery, antenatal beds and postnatal beds. The other two centres are in Hospital Tawau, Sabah and Hospital Sultanah Aminah, Johor Baru.

From 2009 to 2011, the figures for successful spontaneous vaginal delivery ranges from 96.1% to 98.6% compared to figures from the hospital's labour room that averages 68.99%. The centre also posted lower rates for instrumental delivery, episiotomy, C-section and neonatal admission to intensive care. The number of delivery in the birth centre is 20% (over 2,000 a year) of the total hospital delivery.

The study aims to promote the set-up of more low-risk birthing centres in Malaysia to address the problem of overcrowded obstetric facilities in government hospitals.

"What is important now is for us to be the bridge between mothers and care providers, to keep the dialogues going and advocate for more birth options," says Ghows.

Dr Mohd Roslan Abd Halim, Head of Gynaecology and Obstetrics Department at Selayang Hospital and consultant obstetrics and gynaecologist Dr Joy Poore showing us the private labour room.

Dr Mohd Roslan Abd Halim, head of Gynaecology and Obstetrics Department at Selayang Hospital and consultant obstetrics and gynaecologist Dr Joy Poore in the private labour room.

Making headway

On the bright side, public and private hospitals are making an effort to create a more welcoming and comfortable birthing environment, and address unnecessary obstetric interventions.

Recently, the Ministry of Health introduced the Mother-Friendly Care guidelines in hospitals nationwide, says Dr Roslan.

"Hospitals who want to attain the baby-friendly care status have to fulfil these guidelines which include: encouraging the use of non-drug pain relief like a massage or shower, allowing mothers to move about during labour and choosing a comfortable birthing position, and discouraging the use of invasive procedures like rupturing the membrane, episiotomy (a surgical cut made just before delivery to enlarge the vaginal opening) or induction of labour, unless medically necessary.

"If you've been practising interventionist obstetrics or midwifery for the longest time, it's not easy to change the mindset. It takes time but it can happen. "We need to also educate our nurses that women want to have a say in their delivery process. My dream is to make hospital delivery as homely as possible and for women to have safe and satisfying birthing experiences," he adds.

Communication is key

Sometimes a doctor's perceived (or not) patronising attitude can be a turn-off.

"There are many assumptions that medicine causes harm to baby and mother. But if doctors are too dismissive about patients' fears, they don't address the problem," Dr Ng admits. "Doctors should be open enough to let patients ask questions and patients should not be afraid to ask, even if you think it's a silly question."

In recent years, the number of women coming to their doctors with birth plans has shot up tremendously.

"Eighty per cent of these birth plans are very reasonable whilst the remaining 20% may require more discussion. For example, many don't want the routine injection to promote uterine contraction. I would explain the rationale behind the injection and if there's leeway to avoid it."

"I think it's just a matter of doctor being able to communicate those choices to the patient and to our own personal degree of comfort," adds Dr Ng.

And more often than not, most women are willing to listen.

"I had a patient who was beyond her due date by 28 days and refused an induction. I said, 'Well and fine, but do you mind staying in the hospital so that we can make sure the baby is fine?'" says Dr Roslan.

Eventually, the patient delivered a happy baby via natural childbirth.

The medical fraternity is open to more dialogues with advocacy groups to improve birthing options for women.

"We would like to work with advocacy groups that include doctors from private and government hospitals and the gentle birthing advocates to set standards of what is acceptable within a hospital setting," says Dr Ng.

"I believe that patients' positive experiences (in hospitals) will convince the medical fraternity that we perhaps need to rethink our perspective of obstetrics."

While doctors are prepared to listen, advocates have to be mindful of our standards and issues regarding risks too, he adds. "Hopefully, we can all move forward in a positive way."

As for Lai, she delivered a healthy baby at the hospital two months ago.

"Forums, doctors, books and birthing classes may offer a one-sided view of childbirth. It's best to choose an obstetrician you can trust and talk too, and go with his advice.

"Choose someone who appreciates life, isn't lackadaisical, has a sense of responsibility to take all precautions and is equipped with the experience and skills to ensure mother and baby will be safe," says Lai.

To read about Lily Lai's home childbirth experience, visit 

Related stories:

Natural and unaided

A midwife on standby

A gentle birth

The gentle birthing way


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