SUNDAY, April 21, 2024
All the reasons Thailand needs to urgently reform its approach to maternity care
By Wanrug Dowson, Faculty of Liberal Arts, Thammasat University

In December last year, the Public Health Ministry initiated the “Give Birth, Great World” campaign. This is part of an urgent national agenda to boost fertility in a country where the number of births has slumped in recent years, with 2023 seeing the lowest birth rate in 71 years.

If nothing is done, Thailand’s population will reportedly drop by half, hitting 33 million in 60 years, with the number of senior citizens outnumbering the rest of the population.

The government has announced plans to tackle this demographic shift, ranging from providing access to reproductive technology for parents, including single women and the LGBTQ+ community, to increasing rights and flexibility related to childcare such as longer paid parental leave, and sharing expenses and burdens of raising children. While these measures are still under revision and formulation by policymakers and stakeholders (the Public Health Ministry is set to make a big announcement next month), it seems the will is there.

However, what seems to be lacking in public discussion and government discourse is the focus on what I see as the “emotional” dimension of bearing, birthing and raising a child, which could be addressed by maternity care via a woman or patient-centred approach.

While the National Health Assembly (NHA), a platform for developing participatory public policy, proposed “promoting quality births and child growth” in its assembly last year, its report focusing on the “quality” aspect, however, failed to address this transformative approach which many countries, especially those in Europe, see as key to the improvement of health outcomes, patient satisfaction and promotion of positive healthcare.

This is a major blind spot in Thailand’s maternity care where many women and parents I know have had a very contrasting experience in that the clinical staff-centred service tends to overlook and undermine women’s needs, perspectives and preferences.

It is shocking that in the 21st century, state hospitals still keep the father out of the delivery room, as if childbirth were a women’s-only affair. Having experienced a complicated childbirth myself, my partner’s physical presence was the most precious emotional support to me during our first’s birth. For him, the experience was transformative and life-changing.

It is important for the partner to be able to assist physically and emotionally in the long labour of childbirth should the mother wish so. It fosters a healthy and positive foundation for a lifelong relationship between two people who are bound together when raising a child.

Thailand has a lot to improve in terms of gender equality, not least in maternity services, where dads should not be relegated to the hospital corridors. He should instead be encouraged to take up a shared parental role starting from prenatal care and childbirth. How can we ensure “quality” child growth and “warm” families when fathers are not even included at the beginning of the process?

Moving back to prenatal care before childbirth, information about “birth wishes” is quite poor, if non-existent in Thailand. In many countries, birth wishes usually come in the form of a series of questions and answers related to the whole process of delivery and childbirth: the key people the parents want involved, the type of environment they want, pain management preferences, preferences for birthing positions, clinical processes they wish or do not wish to be performed (perineal incision, ventouse, forceps, etc), their preferences for “skin to skin” contact with the newborn right after birth even with C-section, etc.

This baby-friendly initiative has been promoted by UNICEF, especially for its important role in “breastfeeding triggering” and the baby’s microbiome, but is non-existent in maternity care discourse and practice in Thailand. My obstetrician-gynaecologist informed me that this is because guidelines from the Public Health Ministry do not allow the staff to do so. Writing birth wishes helps the care team know what is important to the parents, instead of letting the medical team make decisions for us in the delivery room where unexpected complications can happen without consultation or prior knowledge of parents’ wishes.

In the UK for example, a variety of birth positions are encouraged by the National Health Service (NHS) – all fours, yogi squat etc – while lying on the back, which has been proven to be one of the most difficult birth positions, is still being promoted in the Thai Public Health Ministry’s “red book”. The red book is given by state medical authorities for recording information about maternity services, childbirth and the baby’s health.

While in the UK the delivery room in state hospitals provides all sorts of devices to support natural and active birth such as yoga balls, relaxing lights and sounds, and even a birth pool when the pregnancy is considered low risk, Thai state hospitals provide only a bed, giving child labour a medicalised, mainstream approach – an approach that WHO guidelines warn as creating a lack of choice for birthing women. In a country where news about stillbirths and maternity care failure looms large, “birth wishes” need to be introduced by the Public Health Ministry as one of the urgent tools, if Thailand wants to gain trust in the quality of quality of maternity care and confidence in its support system for raising children.

My sister recounted an undesirable experience she underwent at one of the leading university hospitals in Thailand. While in the hospital for post-partum recovery, her newborn was taken away for vaccination while she was asleep, even though she had specifically told the nurses that they had to inform her before doing anything with the baby.

This is not an exception, but a telling example of how Thai parents are left feeling helpless and disrespected by their healthcare providers and how Thailand’s maternity services and medical services, in general, are considered by its users as unmodern, apathetic and lacking in collaborative communication.

Pregnancy and childbirth is a Janus-faced experience. For many fathers and mothers, this experience is a mixture of bliss and dread, joy and anxiety, happiness and distress. How can many of us using state hospitals and tackling long waiting hours, overcrowded waiting areas, lack of communication between staff and patients, say that our experience in maternity service is a “positive” and memorable one?

As long as we don’t address this blind spot and promote a women-centred approach with personalised care in maternity services, prenatal as well as post-partum care, we won’t be able to convince Thais to “Give Birth”, let alone build a “Great World”. The decision to have children is personal and has nothing to do with the national or global situation.