Midwife's Musings - Maternity care abroad
So you’re pregnant overseas? Congratulations!
At times it can be easy to feel like you’re on this journey alone, but really you’re part of a club of women who have decided to expand their families outside of their passport country, and ultimately, you’re also part of a global community of women navigating pregnancy, birth and new parenting. I don’t know about you, but I often find situations and experiences less daunting when I know I’m not on my own and that actually, I’m part of a bustling community.
I’m also aware that every maternity journey is different and this can be hugely impacted by access to maternity care. You may be living in a bustling town or city filled with medical facilities or you could be in a more rural location with limited access to medical help. Whatever situation you’re in, it’s important that you are confident about your maternity care.
Here are some handy pointers that might help:
Find a maternity team you trust
Having a great medical team (midwife, delivery nurse, doctor etc.) that you trust is crucial. It is important that you feel that whatever might happen, you have a team who have your back and will keep you and your baby safe. An important thing to be aware of is that not all doctors are qualified or have experience in obstetrics, so it's good to make sure the person caring for you has the necessary experience and qualifications.
Research is so important here. Ask around and seek out recommendations. It is very unlikely that you will be the only expat who has given birth in your location. Ask friends, look online for any forums where people may have shared their experiences and make appointments to see a medical team. When you are confident in your team, a huge weight will be lifted, I promise!
Explore your options
You may be able to access all maternity care from conception right through to postnatal care near your home, or you may need to travel further. If you live in a remote location, you may need to travel for all your appointments or you may be able to mix and match.
Many smaller clinics (if not all) would be able to provide full antenatal and postnatal checks including blood pressure, urine checks, blood tests, measuring your stomach and listening into the baby.
If you decide to have a mixture of different health providers, it is really important to make sure you have good communication so each team knows what care you are receiving where, and to take any notes you are given to each appointment. Choose a provider you would like to be overseeing your care (doctor or midwife) and ask them how many appointments they would like with you in person and what they would recommend. They may also be able to offer some appointments on the phone and they may want to check in with you after each appointment that another health worker saw you.
If you plan to give birth further afield, it is important to consider where you can stay close to the hospital before the baby is born. It may be a more expensive option but as babies are usually born between 38-42 weeks of pregnancy, with little warning, finding accommodation is crucial. From someone who has been there before, there are few things as stressful as a race against the clock to get to a hospital! If you ask around you may find there are ministries, organisations or co-workers who can help. You won’t be the first person in this position.
As a midwife, I do feel I need to stress the importance of antenatal care, but if you genuinely cannot find anyone who can offer maternity services locally, and are unable to travel for all appointments, it is worth seeing if you could have phone appointments with a doctor/midwife and to ask if they know anywhere that could provide these checks or failing that ask if they could teach you how to check your own urine and blood pressure. Of course the gold standard is for someone medically trained to do this, but if there is no other way, then this is better than not having any monitoring at all.
Schedule of care
I’m going to begin with a bit of a caveat here. Every country and even different hospitals within the same country will have different schedules of care. I’ve mostly worked clinically in the UK, and so I can only really speak into this. It might be helpful for you to research care that is usually available in your passport country to make sure you are getting the care that you are happy with. If you are in doubt as to whether something is possible, please do ask, as investigations are often available privately (at a cost) if they aren’t routine.
If you’re in a more rural location, it may be tempting to think, ‘what can I cut’. I totally understand this. It is hard and expensive to travel for appointments, but from a midwifery perspective, I can tell you that everything we offer is evidenced based and is important in it’s own way to support you and to ensure yours and your baby’s safety.
We usually recommend two of these in the UK. Whilst it is a really special moment for parent’s to meet their babies, they also have medical importance:
Dating/Nuchal scan - 10-14 weeks – This scan measures the baby’s size and helps us to have an accurate idea of when the baby is due. Everybody’s cycle is different so dates can be up to two weeks out. At this scan, screening for Down’s Syndrome, Edward’s Syndrome and Patau’s Syndrome are also offered.
Anomaly scan – 18-10 weeks- Most babies are perfectly happy and healthy but the purpose of this scan is to check for any abnormalities. The baby, amniotic fluid levels and the placenta are checked and any abnormalities spotted can be further investigated throughout the pregnancy. For example, if it is known that a baby has a problem with their heart, the cardiac team can offer further specialist scans and make arrangements and plan for any care the baby may need after they are born. If something like this were the case, it may alter your decision about place of delivery, to ensure you have the necessary support available.
Regular appointments are scheduled to ensure the health of mum and baby and whilst routine checks such as blood pressure and urine, may seem to be of little significance, they are actually hugely important. Whilst the majority of mothers will have healthy pregnancies, that is not always the case and since the introduction of routine antenatal appointments, rates of maternal mortality and morbidity drastically reduced. It is usually midwives who lead these appointments, but they can also be performed by doctors.
During each appointment your blood pressure and urine will be checked to make sure that you aren’t developing a condition called pre-eclampsia and from 25 weeks they will measure your stomach to check the growth of the baby, check for the baby’s position and listen into the baby’s heart rate. They will also check in with how the pregnancy is going, making sure there are no problems and helping to prepare you for the birth.
Schedule of appointments
As said above, these can vary but I hope this gives you an idea.
Booking appointment- 10-12 weeks – This is the first appointment and is longer. We talk through your medical and family history in case there is anything that could affect your pregnancy. We also offer to take bloods for HIV, Hepatitis B, Syphilis, Sickle cell, Thalassaemia, your blood group (you usually require two samples throughout pregnancy in case you need a blood transfusion) and a full blood count (iron and clotting levels in particular). If you have had one, we will review your dating/nuchal scan report.
16 weeks- Blood results and scan reports are reviewed (although you would have been contacted earlier if there is a problem) and follow up is arranged if needed.
25 weeks- (usually with the doctor) – This is often the first time you will see the doctor during your pregnancy. They ask how the pregnancy is going, look at your scan reports and conduct the routine tests.
28 weeks - A blood test is offered to check iron levels (they tend to reduce at this stage in pregnancy so we can offer iron supplements if needed) and the second blood group. The anomaly scan report is reviewed and follow up arranged if needed with a consultant obstetrician. Anti-D injection is offered to women whose blood type is rhesus negative to protect any future pregnancies.
31 weeks (Usually just for first time mothers) – Results of blood tests are discussed and we chat generally about how the pregnancy is going.
34 weeks (Usually with the doctor) – Results of all scans and blood tests are reviewed as well as the routine tests.
36 weeks – We pay more attention to the position of the baby. If the baby is breech (bottom first) we would talk about ways to help the baby to turn ready for birth. We also talk about your preparations and plans for birth.
38 weeks (Usually with the doctor) – The doctor will speak to you about what they will recommend if the baby is not born by 41 weeks as we aim for all babies to be born by 42 weeks to make sure that the baby is still receiving a good blood supply from the placenta.
40 weeks (Usually just for first time mothers) – If you would like an internal examination, a ‘cervical sweep’ can be performed which encourages the start of labour. We will also discuss again what we will advise if pregnancy continues.
41 weeks (For those who have not given birth) – A ‘cervical sweep’ will be offered again and induction of labour will also be offered.
It is important to talk to your maternity team to ask what they would advise for your care once your baby is born. If you give birth in another location, they will probably want to check on you a few times before you leave. Local clinics will also often be able to provide this care, so if you do decide to give birth in a larger facility in another location, it may be possible to return home after a few days (depending on yours and your baby’s health) and to continue care from there.
In the UK if everything is going smoothly, there are usually 3-5 appointments and most mums and babies are discharged at 10 days old with numbers of someone to contact if needed. Throughout these appointments we will ask how you are feeling and your general wellbeing, check your blood pressure, temperature, pulse and breathing rate, have a feel of your tummy and check that your uterus is reducing in size, check your wound if you had a cesarean or stitches if you tore, ask about your bleeding and ask about your legs. We will also ask to see your baby, check their soft spots on their heads, check they aren’t developing jaundice, their heart rate, temperature and breathing rate and we will ask about feeding as well as how often they are passing urine and opening their bowels. We can offer feeding support with either breast or formula feeding and we will weigh the baby to make sure that the baby is gaining weight well.
In the UK we offer a screening called the ‘Newborn Blood Spot’ or ‘Heal Prick’ test that is usually done when the baby is 5 days old. It screens for 9 conditions such as sickle cell disease and metabolic diseases like maple syrup urine disease. Most results come back completely normal but the conditions it screens for can be serious and so, testing enables us to give your baby the best support possible. For example, some of the metabolic conditions can have long-term consequences on babies brain development if diet is not changed appropriately. This test would be a great one to look into doing, although it may well be a private test.
Know when to contact medical help
Outside the usual schedule of care, you may need further assistance. I’ll include this in another post as this is getting long (!) but if in doubt please do ask for help. Your maternity team is there to support you and will only be pleased to help. If in doubt, we would always rather hear from you, even if it is so we can reassure you!