I’m excited to welcome Ruth Greene back to The Prepared Expat to share her wisdom with you all. Ruth is a doula with over a decade of experience helping families navigate not only the complexities of giving birth, but doing so as an expat. She wrote Part 1 of this series about choosing where you will give birth (in your host country, passport country, a third country, etc.) and has come back to share her expertise about what to expect when you or your loved one is giving birth as an expat. Let’s dive in!

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Ten Assumptions About Giving Birth Abroad

Every day hundreds of thousands of women give birth around the world. While the physiological basics may be the same, the variety of options and experiences is vast! When choosing to give birth abroad, it can be easy to make assumptions about what pregnancy, birth, and postpartum may look like. Often, the stories we grow up hearing from our moms, aunts, friends, and sisters shape our view of birth, and it can be difficult to adjust our perspective. In my previous article on giving birth abroad, I covered several considerations when choosing your birth location. In this article, I address ten assumptions one might have about birth, and I offer a reminder that things may look very different than you expect.

A note before we begin: Even though the following is by no means exhaustive, the variety of options and topics to consider can feel overwhelming! In addition, every individual is different—some wish to know and plan every detail while others would rather not face a deluge of information. A doula working in your community can be an invaluable resource to help you here: a doula can tailor both the amount and the type of information to the individual, weeding out the excess and making pregnancy, birth, and postpartum less daunting. Find out more about what a doula is here and here.

Assumption 1: Maternity costs will be minimal or covered by insurance

Every country has a different medical system, and it is important to research and prepare for the costs of maternity and birth. Some countries have socialized medical care, and most costs can be covered, even for expats. Other countries have zero maternity assistance, and it will be necessary for the birthing mom to save money for the birth or enroll in a good insurance plan before even trying to conceive. 

It is extremely important to note that most insurance plans have a 9-18 month waiting period between the time the person enrolls and the time they become pregnant (not the time they give birth). In addition, not all insurance plans cover maternity and those which do may also have certain limitations on which hospitals they cover or which high risk costs are included. If you are planning to use insurance to cover your birth costs, consider contacting an insurance broker to discuss which plans will provide the coverage you need. (Helpful hint: brokers don’t charge the individual; their costs are covered by the various insurance companies they represent. Consulting a good insurance broker shouldn’t cost you anything and will hopefully save you money in the long run.)

Mark’s note: Check out the article Expat Health Insurance Demystified: Your Essential Guide to learn more about expat health insurance and even contact a broker I trust and recommend.

Assumption 2: I can choose where to give birth

Choosing where to give birth should be the right of the individual, correct? Not according to some governments. Many countries, such as the USA, have a wide range of options, from homebirth midwives, to free-standing birth centers, to hospitals. Even in the USA however, local regulations vary from state to state, restricting licensing and availability of midwives. Some providers have limited capacity and fill up quickly, so knowing what options you have before you even conceive can help you efficiently sort out your care. Other countries outright ban homebirth or have restrictive regulations that effectively exclude homebirth as an option.

In addition, depending on your pregnancy risk level, you may even be restricted in which hospital you can give birth in. As not all hospitals have the same level of emergency care, some individuals may find they “risk out” of their hospital or care practice of choice.

Assumption 3: Medical records are kept by the hospital

In our modern digital age, it may be surprising that some hospitals do not keep electronic records or even store your records at the hospital. In pregnancy, it may be expected that the birthing mom brings their test results and doctor notes to every prenatal, birth, and postpartum appointment. These may be the only copy of their medical records, so it is important that you don’t lose them.¹

Assumption 4: I can find out the gender of my baby.

In a world where creative gender reveal videos are a social norm, it is interesting to note that finding out the gender of the baby during pregnancy is actually illegal in some countries (notably China and India). While there may be “ways” of seeking out discreet methods (for example asking in “code”, or paying for a private sonographer), remember that you may be putting the sonographer, doctor, and/or hospital at legal risk.

Consider doing a “babymoon” to a country where doctors may disclose your baby’s gender, or make it a fun mystery until the baby is in your arms.

Assumption 5: Recommended vaccines are standardized and available

When I went back to my passport country to give birth to my fourth child, I was already in my 34th week of pregnancy. No one in my passport country thought to ask what vaccinations I had completed and, since all my other children had been born in China, I didn’t realize that the US and China had different vaccination recommendations and availability.

For example, the US CDC and many countries around the world now encourage giving Tdap early in the third trimester in order to pass some whooping cough immunity to the baby. However, in China, my host country, Tdap is not available and the alternative vaccine, Dtap, is only given to children.² When I returned to my passport country, I found out that the vaccination schedule I followed in my host country was different than that of my passport country.

If vaccination is an important topic to you or your loved ones, be sure to research what is available well in advance, as you may have to travel to another country to obtain it. Some other variations in vaccine availability and regulations include: 

• Polio—live vaccine versus inactivated vaccine
• Influenza—may not be offered to pregnant moms or be of an older strain
• BCG (tuberculosis)—discontinued in many western countries, yet commonly given at birth in countries that have a higher rate of active tuberculosis in the community

Assumption 6: My partner can be with me when I want

According to the WHO, the Human Rights ACT (UK), and many other organizations, having a companion of choice at birth is a basic human right. The WHO states:

When a woman has access to trusted emotional, psychological and practical support during labour and childbirth, evidence shows that both her experience of childbirth and her health outcomes can improve.

World Health Organization, “Every woman’s right to a companion of choice during childbirth“, 9 September 2020

And yet, many places around the world still deny the entry of a birth partner both to prenatal appointments and the labor ward, especially if the birth partner is male. This may be partially due to cultural beliefs about genders, overcrowding of hospitals (and therefore a lack of privacy in general), or simply hospital practice and policies.

In addition, different hospitals have different definitions of “at the birth.” Many of my clients are assured by their doctor that their husband can be at the birth, only to find out that their husband was only allowed to be present at the moment of pushing. The husband was banned from the labor ward while the birthing mom labored alone for hours. In other cases, partners were allowed into the labor ward but asked to leave for cervical checks, epidural insertion, or other medical procedures.

A better question to ask is this: “It is very important to us that my partner be with me at all times. Under which circumstances will they be asked to leave the room?”

Assumption 7: An epidural is always an option

Approximately 75% of US Americans, 42% of Australians, and 85% of French moms opt for epidurals during birth. Many people picture an epidural at the center of their birth plan. As a matter of fact, there are still places in the world where an epidural for a vaginal birth might not be standard or even available.

In addition, the dosage and combination of medication used in the epidural varies widely by practice. Perhaps you have heard of “walking epidurals” used by your friends in your home country, but your local acquaintances describe being completely numb and unable to move their legs after the epidural was placed. If you have always pictured using an epidural as your main comfort measure during labor, this is an important topic to consider when choosing where to give birth.

Assumption 8: I can choose when to be with my baby

Ever seen that adorable scene in the movies of the new dad looking though the glass window at their newborn baby sweetly sleeping in the hospital nursery? One might be surprised to hear that newborn nurseries are not always available. It’s often the norm and even expected that a newborn would “room in” with the mother, continuously staying in the same room as the mother. Some places have the option to pay for a nurse or nanny to help the parents during their hospital stay, or expect you to bring a relative to provide this type of care.

Other hospitals might not ALLOW the baby to be with the parents, especially in the first hours after birth. I have an expat friend in another country where all babies in the public hospital are sent to a nursery immediately after birth for observation, and are only brought back to the mom four hours later. Before you choose a birth location, inquire about what the postpartum stay will look like for mom and baby.

Additionally, many Neonatal Intensive Care Units (NICU) around the world completely ban parents from entering. As various studies around the world have shown the importance of parent involvement and proximity for babies struggling for survival, practices in many countries are slowly changing to allow at least one parent to be near the baby, even in NICUs. For healthcare systems that are often overwhelmed or understaffed, however, this may not be practical or common.

When a friend’s baby, struggling to breathe at birth, was transferred to a NICU at the public hospital, they were shocked to find out that the parents could not see, touch, or even visit their baby. They were only allowed to call once a day between the hours of 4 and 5pm. “If no one contacted them,” our friends were informed, “they could assume their baby was fine.” It can be hard to contemplate worst case scenarios, but one might consider researching what emergency procedures look like in case the unthinkable happens.

Assumption 9: Circumcisions are available worldwide

As a private, yet religiously and culturally sensitive subject, people rarely discuss infant circumcision. It can be easy to assume, therefore, that the procedure is available worldwide. Interestingly, infant circumcision is a highly regional practice. A high percentage of people in the USA and many African countries choose circumcisions, while the practice has been largely abandoned in many European countries.

In addition to knowing whether infant circumcision is “available” to you, it is very important to ask questions about the specific procedure that will be used. Some procedures are more invasive and carry higher risks than others (including full anesthesia and fasting for the infant). When weighing the cultural, religious, and physical benefits of any practice, it is important to assess the risks and implications of the particular procedure that is available to you, if any. 

One more important factor to consider is timing. The less invasive circumcision procedures such as “the ring” have a time limitation on them. Some hospitals require it to be done in the first three weeks after birth, others will perform the procedure up to six weeks after birth. If you wait past six weeks, then many places will require you to wait until the baby is six months old (when they are more safely able to undergo general anesthesia). If you hope to circumcise your newborn baby, do not wait until birth to figure out where and when to have it done. Especially in locations where the procedure is not commonplace, hospital appointments fill up fast and you might miss the window it is available to you.³

Assumption 10: The hospital will provide what I need

Recently, a client texted me a picture of the hospital “birth package” offered by a private hospital in China. One of the items provided in the birth package was toilet paper. As a Westerner, I laughed, but it was a great reminder that public hospitals here expect you to bring with you everything that you may need: absorbent bed liners, slippers, diapers/nappies, and, yes, even toilet paper.

Be sure to ask the hospital what they expect you to bring or if they have a recommended packing list. While most items can usually be purchased at the hospital store, if they have one, those stores are only open during certain hours. You may also be able to save money by ordering a birth bundle online. Be sure to prepare these items well in advance as you never know what time of day (or night!) your labor will begin!

Conclusion

From eating and drinking in labor, to birth positions, to maternity leave practices and laws, the list of things that may be different when giving birth overseas could go on indefinitely. Every country, every city, even every hospital, has its own practices, policies, and cultural undertow that influence a person’s birth experience. That is why it is so important to both Build Your Community and Seek Professional Help (see Birthing Without Boarders, Part 1). 

Social media groups can be fantastic sources of information, but they can also be overwhelming and entirely too public for private matters. That’s why we at Having a Baby in China (HABIC) started the HABIC Cohorts program.  These Cohorts are designed to join 3-6 families together with an experienced doula to help facilitate conversations and answer individual questions. If you are pregnant in China, contact us to be connected with a HABIC Cohort today!

Thanks Ruth!

I hope you appreciate the advice and expertise Ruth has generously shared with us. Make sure to read her first article, Babies Without Borders, Part 1: Preparing for Birth at Home or Abroad.

And I just want to put in a plug for Ruth’s HABIC Cohorts. If my wife and I were going to give birth in China, I’d definitely join a Cohort. One of the biggest challenges we faced when we were pregnant overseas was finding reliable, evidence-based suggestions that were relevant to our expat life. We could find resources in English for a U.S. American audience, but we found a lot of the advice was irrelevant because of how different our local hospital system was.

The HABIC Cohorts give you access to a doula who understands not just the medical information, but the local medical system. That’s an incredibly valuable resource and I recommend it to any of you who are pregnant in China. I only wish the groups were available worldwide!

Also, Ruth was generous enough to offer a discount to readers of The Prepared Expat, so definitely contact her and let her know that you learned about HABIC Cohorts from The Prepared Expat!

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Footnotes

1. Mark’s note: Medical records and proof of pregnancy are often also required when you apply for citizenship for your child, another good reason why you want to keep track of them! It’s not a bad habit, each time you get a new record, to make a digital copy for safekeeping and your convenience. ↩︎
2.  Pertussis (Whooping Cough) outbreaks happen around the world, and often it is the tiny babies too young for Dtap that are at the highest risk. The goal of giving Tdap in pregnancy is to provide the baby with some level of immunity in utero, so they will be protected until they are old enough to be vaccinated themselves. ↩︎
3. Mark’s note: After posting this article, an expat shared that he was unable to get his son circumcised at a hospital in his location, but he was able to contact a Jewish rabbi who was willing to perform the circumcision even for a non-Jew. So, if you’re in a location where circumcisions aren’t possible and you’d like one performed, consider whether there are non-medical options available to you like a rabbi. ↩︎