Homebirth in Malaysia: Are we there yet?

The death of two home birthed mother has arises an alert among the public and the healthcare providers in Malaysia. The trending of homebirth is arising with the establishment of some support group of natural birthing in Malaysia.

The idea of this writing is to educate the healthcare professionals in regards to homebirth and its safety issues as well as the public to be well-informed about homebirth in developed countries and the perspectives of it in our Malaysian context.

Because developed countries like Australia, United Kingdom, The United States and New Zealand does allow homebirth, many Malaysian women wanted a similar option of birth. These women voices out their concern and demand by challenging the Malaysian health care system.  

There are many reasons why these women may aggressively fighting their rights to do homebirth…reasons like..

a)      to be able to have own empowerment towards own body without any interference from medical staff and technology interventions meaning greater degree of self-determination

b)      to deliver at their own comfort in a familiar environment with a more quiet, peaceful and privacy moments for themselves

c)      freedom from institutional needs and restraint

d)      attitude of more significant others

e)      more involvement of partner/ husband

f)        no need to leave other children behind

g)      privacy away from any male attendants including male professional doctors (that’s where religious reason comes in and the issue of aurah is brought in

h)      women who strongly believe about natural birthing (like natural parenting – kelahiran fitrah, kelahiran alami) which does not need any involvement of unnatural interventions other than natural instinct

i)        women who previously had caesarean that was told by their obstetrician  that they are not fit for VBAC (vaginal birth after caesarean)/ trial of scar due to the risks they posses but they strongly want the VBAC so they defaulted and opted for homebirth

j)        women who traumatised by previous experience in the hospital setting

k)      cheaper option

the list goes on….

Before we start arguing about base on our emotions and logical thinking…let us talk about facts and figures.

Let us has a glimpse of what is homebirth like in Australia, what is their stand, how their medical system work and why it is possible in Australia, why it is more promising there…

Why Australia as the ground of discussion? Because I was trained there and had experience in learning gentle birthing/ homebirthing there.

Homebirth is very well established in the Australian health care system due to the existence of guidelines and policies. They have a national body for homebirth which is call Homebirth Australia that empower the women of Australia to op for homebirth (if they are in the low risk group). This national body involve consumers, midwives and related health professional whom committed to ensuring survival of homebirth as birth option to Australian women. They hold onto the stand that was made by the Royal College Obstetrician and Royal College of Midwives of the United Kingdom.

Royal College of Obstetricians and Royal College of Midwives Joint Position Statement on Homebirth
“The Royal College of Midwives (RCM) and the Royal College of Obstetricians and Gynaecologists (RCOG) support home birth for women with uncomplicated pregnancies. There is no reason why home birth should not be offered to women at low risk of complications and it may confer considerable benefits for them and their families. There is ample evidence showing that labouring at home increases a woman’s likelihood of a birth that is both satisfying and safe, with implications for her health and that of her baby.^“

Please read it all…do not take this statement partially…. “homebirth…for women with uncomplicated pregnancies……low risk of complications”

However the Royal Australian and New Zealand College of Obstetrician and Gynaecologist had made decision that planned homebirth should not be offered as a model of care and that collaborative care between midwives and Obstetrician in a hospital setting is considered the best model of maternity care due to high perinatal deaths in a planned homebirth.

This statement is made based on several studies.

The most recent meta-analysis of planned homebirth in Western countries identified 12 studies of suitable quality for inclusion, providing a comparison of 342056 planned homebirths with 207551 planned hospital births. The overall neonatal death rate (NND) was almost three times higher for babies born without congenital anomalies in the homebirth group. Since that study was published, an additional paper from the United States has reviewed planned homebirths during the period 1989 to 2005 in Missouri, and also reported and increased relative risk for perinatal death in the planned homebirth group.

Australia is aiming for a lower frequency of homebirth due to it geographically diverse country and poorly developed infrastructure for planned homebirth. The geography does not suit itself to obstetric “flying squads” that are readily available to retrieve mothers from home when problems have arisen during labour and birth. Australia has the dual problems of vast distances in rural settings, and heavy city traffic in Melbourne and Sydney. Evidence is that approximately 12 to 43% of those identified as “low risk” in pregnancy will develop a complication necessitating transfer to care in a conventional birth suite setting. In many locations in Australia this cannot be accomplished expeditiously.

For low risk women planning for homebirth published studies show about 7.4 – 30% of women will be transferred during antenatal period due to preterm labour, preterm premature rupture of membranes, malpresentation, antepartum haemorrhage. 1.5 – 13% will require transfer after onset of labour common problem due to failure to progress in labour, concern about fetal wellbeing and maternal request for analgesia. 0.7-6.7% transfer due to postpartum problems like postpartum haemorrhage, , retained placenta, surturing of perineal lacerations. 0.06-1.4% neonates require transfer after due to respiratory problems or assessment of anomalies.

States like South Australia and Western Australia readily made policies for the healthcare professionals and midwives to guide these qualified practitioners when caring form women who make an informed choice to give birth at home.

 In these policies, midwives and health professionals that involved in giving homebirth services must fulfill the prerequisite requirements to assure the competency of the workforce involved. The policies also gave clear guidelines for determining which mother can safely opted for homebirth and which is not. 

In which a case a mother should not be allowed to do homebirth but she strongly wants one and that she has been fully informed about the pros and cons and considered making an informed choice, she needs to sign in the consent form and healthcare professionals can decline to continue their care if they felt that they have to practice outside their scope, ability, skills and competencies. So this mother must hire a private midwife still not allowing her to do homebirth unattended/ unassisted.

I have been informed by lay person that sometimes health care providers like to scare of their patients by informing “scary” stories of risks. Birth is neither a sickness nor an illness. It’s a natural process that should be described as an amazing painless process and as a happy moment in life but healthcares like to talk about risks. Most mommies out there feel intimidated by the overwhelming facts. However, mommies should be aware that health professionals have the legal, medical and social responsibility towards the women and community to inform the other side of the story so these mommies are able to make an informed choice.

What is informed choice? Informed decision?

Its when the women has the AUTONOMY and control to make decisions about her care AFTER a process INFORMATION EXCHANGE that involves providing her with SUFFICIENT EVIDENCE BASED INFORMATION about all options for her care in the ABSENCE OF COERCION by any party and WITHOUT WITHOLDING INFORMATION about any options. So women can make a decision in absences of coercion that reflects her self-determination, autonomy and control.

During my medical student time.. I have seen consultation done between mothers and healthcare professionals in regards to their birthing plans… things that normally discussed are like where they want to deliver, how (normal/ lscs – after assessing the risk and need), when (if planning for induction/ lscs), what analgesia do they want etc. if they opted for homebirth, who are the professionals involved (also after discussion of individual risks)…they discuss about everything about their concern and then make an informed choice then.

So what it is like in the Malaysian context?

In Malaysia, the issue of informed choice has been argued because in the last few mortality/ morbidity cases, workforce that involve in the care of mothers’ who opted for homebirth e.g doulas, support personnel are not medically and professionally trained personnel. They may be unaware of the current risks of the mother involved and the fact that the choice is made one sided as most mothers who opted for homebirth rarely discuss in details with their health professionals. So information normally received from one end only.  

The fact is that homebirth is not being offered as an option for the model of care for mothers in Malaysia yet. It may be one day but not near future. People would say… “my grandmas, my long long grandmas delivered at home..so what do you mean by not an option in Malaysia?”

Learn the statistics…our older generations had most their deliveries at home but this is also associated with higher mortality and morbidity rate.

Since 1960’s till current, the death toll rate from maternal mortality has decline significantly from a number of 170 deaths in 100 000 populations (1966) to 70 deaths in 100 000 in 1976 to 30-40 deaths in early 2000 and currently the MMR (maternal mortality ratio) is 27 deaths in 100 000 populations. This is due to an internationally initiatives introduced in the late 1980’s which is called Safe Motherhood Initiatives.

Is planned Homebirth achievable in Malaysia? What is the prospect?

As mentioned above, countries like Australia has its own healthcare policy in regards to planned homebirth which outline the requirements needed before deciding for one. The mother must receive regular antenatal check up with health professionals, is free from pre-existing medical and pregnancy complications, at the time of labour must have a singleton pregnancy with cephalic presentation, lives no further than 30 minutes from supporting hospital facility etc. The competency of workforce is reinforced. In Australia, planned homebirth should be attended by 2 qualified practitioners (registered midwife/ medical practitioner) who have reasonably appropriate experience of childbirth, awareness of contraindications, able to identify medical emergencies, competent in obstetrics emergency procedures and neonatal resuscitation and availability of emergency resuscitation equipment ready to use.

However there is no specific policy right now in Malaysia allowing planned homebirth as an alternative model of care for mother. Besides that, the main issue arises from workforce that is available in our health care system and the relative to the fertility and birth rate in our country.

 

	Australia	Malaysia	New Zealand	UK	US
Worldbank data Nurses/midwives ratio (per 1000 people) in 2010	9.6	3.3	10.9	10.1	9.8
KFF nurses/midwives ratio (per 10 000 population) fr 2005 - 2012	95.9	32.8	108.7	94.7	98.2
Worldbank data Physicians (per 1000 people) 2010	3.9	1.3	2.7	2.7	2.4
KFF Physicians (per 10 000 populations) 2005 - 2012	38.5	12	27.4	27.7	24.2
Worldbank data Fertility rate (birth per women) 2011	1.9	2.0	2.1	2.0	1.9
Worldbank data Birth rate (per 1000 people) 2011	13	18	14	13	13
KFF Birth rate (per 1000 people) 2013	12.3	20.41	13.48	12.26	13.36

From the above table, we can see that the number of health professionals overall in developed countries like Australia and UK is three time fold the number available in Malaysia but the birth rate of Malaysia is about 1.5 greater. To achieve a well-establish planned homebirth in Malaysia is still difficult to achieve with the high rates of birth yet our medical health professional are still understaffed. We are unable to give full participation and assistant in homebirths. Mind me but doula are professional support group but they cannot replace medically professional staff. In the case of emergency, as claim by our doula, they cannot recognized red flag signs of emergency and not readily aware if their clients’ medical and pregnancy complication and potential risks.

Perhaps, another way to ease the situation is to offer gentle birthing in our local hospital, atleast to give the Malaysian women to choose to be in a better labour environment (better than the usual hectic labour room)…to allow our women to have more control over their labour, self empowerment rather than going thru a conventional labour process… small tiny rooms with partitions, very little privacy, screaming of staff and other patients can easily be heard etc.

Like as told before, in Australia… usually, they will discuss the birth plan. How they want it to be? Where they want it to be? What analgesia? When it is going to be (if planned for lscs/ induction in the possession of riks)…Mothers can have gentle birthing not just at home but also in the hospital settings where some rooms were set up like home…one of the rooms in a district hosp has a queen size bed. They can have gym balls, hot bath/ shower, TENS, epidural but allow for mobility…

However this arises another issue…our current labour room are not constructed to fit this need…so this mean there is a need of reconstructing our labour room to be more home-like rooms which will take up extra cost.

So having said all that, it is not easy to allow planned homebirths in Malaysia due to the availability of health care staff to attend homebirths. Besides that the issue of transportation, availability of local ambulances to assist transfer to tertiary hospital in the case of emergency is another rolling issue to think of. It is not a work of a day or two. A better way is to look at a more gentle birthing method, to emphasis among healthcare the importance of communication and having the share care between professionals and patients, not a one-sided, paternalistic care like we used to have, meaning allowing the women to practice their autonomy and rights to choose but in a control, safer environment and under the advise and supervision of health professionals. Mother must also understand that medical interventions are not there to harm you but they are there to assist and facilitate labour in the case where it would be risky for the mother to be allowed to labour alone.. This is parallel to the need of maqasid al syariat and qawaid al syariat.

This is not a one-man show, labour cannot be single handedly…be it on the health care side, the patients’s side or doula/ supporting group. Maternal care involved collaboration of all parties to ensure the the best level of care is given to our clients. Keep in mind that no matter what we do, what we are aiming for, the safety of the maternal and neonatal is the main priority. Do no harm is best to hold. And everything else, we rest it to the Al-Mighty.

Narrates Hazrat Anas Bin Malik one day Prophet Muhammad noticed a Bedouin leaving his camel without tying it. He asked the Bedouin, "Why don't you tie down your camel?" The Bedouin answered, "I put my trust in Allah."
The Prophet then said, "Tie your camel first, and then put your trust in Allah."Sunan At-Tirmizi, 1981.

Wallahu’alam.

References:

1. homebirthaustralia.org/‎
2. http://www.rcog.org.uk/womens-health/clinical-guidance/home-births
3. Women’s and Newborns Health Network: Policy for Publicly Funded Homebirths including Guidance for Consumers, Health Professionals and Health Services, February 2012, Department of Health, State of Western Australia
4. Policy for planned birth at home in South Australia, 4^th July 2007, Department of Health, Government of South Australia
5. data.worldbank.org
6. http://kff.org/global-indicator/