On childbirth in Taiwan: Taiwanese women, why aren't you angry?

The following article is about the state of the childbirth process in Taiwan. The article comes from issue 52 of Common Health Magazine, which is from March 2003. The article is no longer online at the website, but it has been posted in forums and on blogs. One example is here.

The article details the routine practices for childbirth in Taiwan. It laments that practices are 20 years out of date. Although it was written five years ago, I think the article is as relevant and important now as it was then. These same things are going on at almost all hospitals.

I considered writing a rant about this topic, but I instead translated this article because it is well-researched and is more authoritative than the rant I would have written. It is the longest post yet on this blog and also one of the most important.

When I had a chance to talk to the doctor about some of these issues, I first wanted to know about episiotomies. Is it possible to wait and see if it's necessary to perform an episiotomy, or do you have to do it? The doctor gave the standard reasoning for performing the operation, just like that described in the article. However, it's an explanation that isn't based on evidence. The doctor acknowledged that in other countries some people advocate against routine episiotomies, but dismissed that by saying, "This is how we do it in Taiwan." It was not optional. Maybe he had never even delivered a baby without cutting the perineum, so he probably wouldn't be patient enough to wait the extra time the delivery would require. After that, I sensed that the doctor didn't care if I had any opinion on the topic, so I didn't have the heart to ask him about all the other standard procedures.

The situation described in the article also makes me worry about other medical practices in Taiwan other than childbirth. I've had mostly positive experiences with doctors so far, so I would prefer to trust them, but this article makes me wonder: Are practices based on inductive reasoning and tradition or are they based on clinical evidence? Do doctors keep up-to-date with the recommendations of foreign medical organizations or do they ignore research done outside the country?

For another perspective, a perspective that I think is lacking in evidence, the article is followed with the translation of some comments of a forum member who criticized the article. But please read the article first for the more well-researched side.

For more information, see the guide mentioned in the article: Care in normal birth: a practical guide, published by the World Health Organization.

---

Taiwanese women, why aren't you angry?

By Si Yanfang

Taiwan's birthing situation lags 20 years in the past. The rate of Cesarean births is third highest in the world, and almost 100% of women are given an enema, an IV, an episiotomy, and half of deliveries use pharmacological intervention [by labor-stimulating or labor-inducing drugs]. Standard birthing procedures are almost completely counter to the recommendations of the World Health Organization, moving in the opposite direction of world trends. Are the great number of medical interventions in childbirth in Taiwan performed at the cost of the well-being of mother?

When thirty-three-year-old Jane (real name withheld) recalls giving birth to her second child in October of last year, she is still fearful. She promises that next time she will have a Cesarean. She just wants it to be over as soon as possible; she absolutely does not want to be in the hospital for too long.

When Jane entered the hospital, she was taken to have her pubic hair shaved, given an enema and IV, then she labored from 9 am until 4 pm, lying flat on the hospital bed for seven hours. Because she had a fetal monitoring device strapped around her belly and an IV connected to her arm, it was difficult even to turn her body. She wasn't used to using the bedpan to relieve herself while lying in bed, but when she wanted to get out of bed to go to the restroom, the nurse loudly berated her, "What are you doing! What's going to happen if we miss monitoring the baby's heartbeat?"

From the time she enters the hospital, Jane is not allowed to eat anything. She isn't even allowed to drink water. By afternoon, she feels like she's about to collapse, but the contractions are getting closer and more intense. She doesn't have any energy; even the command to breath is too much for her. She cries out in pain. The nurse coldly tells her, "Who hasn't given birth? How can you be so afraid of pain?"

In the seven hours of labor, not once does the doctor appear. When Jane feels the baby crowning, the nurse uses her fingers to hold back the baby's head, unwilling to let the baby come out. The nurse insists that she "wait until the assigned delivery physician arrives." Jane begs piteously, any doctor will do, she even yells at the nurse, "Get your hands away, I'll give birth by myself!" In this way, she is deadlocked with the nurse for over twenty minutes until the doctor finally arrives. To her surprise, the doctor uses his fingers to push the baby's head back in, then cuts her perineum before he will allow the baby to come out. The doctor's words clearly enter her ears: "Come on! Is it that painful? You make it sound like I can't deliver a baby."

After Jane returned home for her "month of sitting," she cried whenever she thought of the pain and humiliation of giving birth. She cried for the whole month.

＊＊＊＊＊＊＊＊＊

In Taiwan, Jane's birth experience cannot be considered an exception. Many women have similar memories of pain and feeling wronged. In Taiwan today, 99% of women give birth in hospitals. Former World Health Organization director of women's and children's health Marsden Wagner points to the numbers for each item in the survey of operating procedures at obstetrics departments in Taiwan, saying "Your births have many unnecessary medical interventions." He was responsible for evaluating the health of women in children in 45 industrialized nations around the world for 15 years. Looking at Taiwan's rate of Cesarean sections, episiotomies, and other items, he shakes his head saying, "This is the worst situation I have seen!" But when reporters hold these statistics and ask obstetricians in Taiwan for an explanation, the doctors speak reasonably and at length saying, "Birth is a dangerous matter. The greatest consideration in all this medical intervention is the health of the mother and child." But are the many medical interventions during birth in Taiwan performed at the cost of the well-being of mother? I'm afraid the answer is unsettling.

While infant mortality in other countries is dropping year by year, the mortality rate in Taiwan has risen from 5.3 in 1000 in 1990 to 6 in 1000 in 2001, and the mortality rate for mothers has been hovering at around 7 per 10,000, the same as seven years ago. The most apparent example of medical intervention in birth is the Cesarean section. Taking 2000 as an example, Taiwan's Cesarean rate was 34.5%, ranking third in the world behind only Chile and Brazil, which means that one in every three mothers gives birth by Cesarean section. The WHO recommends a rate of 10-15%. Scientific evidence supports a rate that should be controlled at 12%; only then can the numbers for mother and infant mortality drop to a minimum. But Taiwan's Cesarean rate is a full double that rate. Wagner emphasizes, "Check the disparity between what is currently being practiced and what is supported by scientific evidence. This is why the mortality rate during birth for mothers and babies in Taiwan hasn't improved."

Episiotomies: A difficult cut for Taiwanese women to avoid?

In Taiwan, pregnant mothers routinely have their pubic hair shaved for the sake of having an episiotomy. It is seen as decreasing the chance of infection to the perineum and for convenience in suturing the cut, but this explanation has no basis in scientific evidence. In fact, in its 1996 publication "Care in Normal Birth: A Practical Guide," the WHO states that routine shaving of pubic hair does not decrease the chance of infection, and can even increase the chance of infection with HIV and hepatitis for the mother and for caregivers. The episiotomy is performed for fear that the perineum with block the baby's head from coming out, leaving the baby stuck in the birth canal without oxygen for too long. Clinical evidence, however, shows that less than 20% of women require an episiotomy. According to a survey, 98% of births in Taiwan include an episiotomy. Dr. Wagner questions, "Do doctors in Taiwan really believe that all women need the cut's help to be able to give birth? That is simply outdated by 20 years."

Taiwanese doctors universally believe that if the perineum is not cut then it will tear, and the wound created by a natural tear is harder to suture than the wound made by cutting, and will more easily lead to involuntary urination. Some doctors blame it on Taiwanese women, saying that Taiwanese women have tighter vaginas than the women in other countries, and they don't like to do exercises before giving birth, making the perineum less elastic, and furthermore pregnant mothers fear the pain [of tearing] so they ask the doctor to cut it.

But the rate of episiotomies in other countries is dropping yearly. In England, the rate has dropped from 50% 20 years ago to just 14%. In the US, the rate has dropped from 100% 25 years ago to 70% 10 years ago, and has continued to drop to the current level of 33%. Three years ago, the American College of Obstetricians and Gynecologists recommended against routinely performing episiotomies. The American "Obstetrics and Gynecology" journal criticized the US's 30% episiotomy rate, saying the operation was still overused. As early as 1993, the medical journal "The Lancet" indicated that routine episiotomies (performed in every case) more often lead to tears than elective episiotomies (performed only when necessary), and lead to more pain after delivery. Many studies have proved that women who had episiotomies have a higher incidence of pain during intercourse three months after delivery compared to women who for whom the perineum tore naturally, and a higher rate of urinary incontinence because the muscles in the urinary tract and the pelvis weaken.

Because of this, Taiwan performed its own study. The results were consistent: the lacerations caused by routine episiotomies were more severe and more painful 24 hours after birth. Liu Yifang of the Graduate Institute of Nurse-Midwifery at The National Taipei College of Nursing, found that in a study of 64 mothers performed by Tang Yunlong, director of the obstetrics and gynecology at Taoyuan's Lixin Hospital, routinely performed episiotomies primarily result in second-degree lacerations, wounding the muscle layer and requiring stitches. Performing episiotomies only as necessary, on the other hand, primarily resulted in level-one wounds, hurting only the skin and not requiring stitches. The pain index for routine episiotomies was also markedly higher than the elective episiotomy group. There was no difference in the health score of the babies of the two groups.

Director Tang Yunlong, who participated in this study for three months, and who has twelve years experience in obstetrics and gynecology, said, "In the past I was used to performing the cut, because ever since medical school, the teachers have taught to do it that way." But now he avoids the cut as much as possible. "It takes courage to change," he says. "It wasn't until I learned that the study showed that not cutting was better, that I dared to change, because the wound is on the mother's body." Director Tang takes on 20 cases a month. Last year he tried not cutting in a few cases, but found that the tearing was severe. As he had to spend an hour or two stitching the wound, he felt irritated, thinking, "If I had known it would be like this, I would have cut it." But after a month he found he had the heart to to try it, and he got the hang of the technique; delivering without an episiotomy wasn't so difficult after all. "It's like golfing. After a while, you pick up the feel for it." Dr. Tang expressed that the key is waiting, so that the perineum becomes more stretchable, because natural labor is a slow process. "Actually, the pregnant mother on the delivery bed is in such pain that she loses rationality, and she doesn't have the strength to bother with whether or not the doctor is making the cut." In the past, he was used to spending only two to three minutes to perform an episiotomy and deliver a baby, but now that he wants to help mother protect their perineum and wait until it is necessary to cut, he waits around five to ten minutes.

Are routine enemas necessary?

In Taiwan, in addition to episiotomies, enemas, IVs, and prohibiting eating are considered routine operating procedure for birthing. Doctors say that babies are fighting a bloody battle for survival; if you don't give an enema, the mother will defecate as soon as she strains herself, drawing the feces into the battle and becoming a source of infection for mother and child.

Assistant Professor Gao Meiling of the nursing department at National Taipei College of Nursing recalls years ago when she gave birth to her first child. As soon as she entered the hospital she was given an enema, but after being in labor for two days without result, she was forced to have a Cesarean. But before surgery, there was no need to have another enema. "Entering the hospital, I had an enema for no reason," she states.

Studies in the 1980s showed that for the vast majority of mothers, not having an enema does not lead to incontinence during delivery. Incontinence occurs in only a very small minority of cases and does not lead to infection of mother's wound on the perineum or of the child. English obstetrician Dr. Ye Xueyuan states that he has never heard that it is necessary to administer an enema. "Not giving an enema does not affect the rate of infection for mother or child, so why do all mothers need an enema? What's the point?" She states that if a mother happens to have a bowel movement on the delivery bed, at worst it will affect cleanliness but it is unrelated to the safety of mother and child. To actually give enemas to all mothers, the price is too high. The WHO considers routine enemas as harmful to mothers and finds them ineffective, even saying the practice should be eliminated.

Taiwanese women give birth while in hunger

Taiwanese doctors universally believe that mothers should give birth on an empty stomach because they consider birth as something dangerous in which a Cesarean section could be required at any moment. If the mother does not have an empty stomach, it will increase the risk of anesthesia. However, anesthesiologist Wang Mingju of National Taiwan University states that it is enough to stop eating eight hours before a Cesarean section. It's unreasonable that for a small number of mothers who need an emergency Cesarean, mothers for whom there are no signs of danger are prohibited from eating.

Taking the Taipei Municipal Women and Children's Hospital as an example, a poster outside the doorway of the labor room explains what mothers "need to know about food and drink during labor." It encourages women to drink more liquids, such as soy milk and milk. Head nurse Huang Yingman asks, "If you don't eat or drink, where do you get the strength to give birth?" And the further a mother is into labor, the more she needs strength. First-time mothers take 12-14 hours on average [to give birth], and women who have given birth before take 6-8 hours. When a mother exerts herself, this often leads to a dry mouth. If she can have a drink to moisten her mouth she will be more comfortable. "But doctors' prohibition on eating and drinking even extends to drinking water," states assistant professor Gao Meiling. "It's actually quite cruel."

Routine IVs: Is it necessary to go under the needle?

When an expectant mother enters the hospital she must begin fasting--neither food nor drink is allowed. No one knows exactly when the mother will give birth, so doctors use an intravenous drip to replenish her energy and to avoid dehydration. The drip is glucose water. "If the mother can drink water, why does she need an IV?," Gao Meiling asks. In Taiwan, 99% of mothers are given an IV. It's worrisome to note that because of this, mother and baby must undergo an unnecessary risk. Studies show that intravenous glucose water causes the mother's blood sugar level to rise, also causing the fetus's plasma glucose level to rise. It also can causes blood in the umbilical artery to decrease in pH. If, during the course of delivery, over 25 grams of glucose is administered by IV, it can spur excess secretion of insulin in the fetus, which means that after birth, the baby can be hypoglycemic and have high levels of blood lactate. Because of this, the WHO views routine IVs as harmful and ineffective, and the practice should be eliminated.

For whose benefit is routine and continuous fetal monitoring performed?

In Taiwan, mothers have an IV coming out of their arm and an electronic fetal monitor strapped around their belly. Because of the monitor, mothers cannot labor in any position other than lying flat on their backs. Doctors explain that this is for constant monitoring of the fetus. A director of a hospital's obstetrics and gynecology department candidly explains his feelings saying, "The key thing is that I'm afraid of being sued. If something goes wrong, I'll have evidence to show that I did all I can do."

The fetal monitor is used to record the fetus's heartbeat and the contractions of the uterus. For high-risk births it is necessary to have monitoring constantly available, but Dr. Wagner states that, "The constant monitoring used for all mothers in Taiwan is unnecessary and has no benefits." He says that the way this is done in Taiwan will only increase the incidence of Cesarean sections.

In Sweden, for one year all mothers were equipped with a fetal monitor. That year, the rate of performing Cesarean sections doubled. The next year, with the elimination of this practice, the rate of C-sections returned to the original level. Even in America, where over 80% of obstetricians have been sued at least once, the American College of Obstetricians and Gynecologists does not recommend the routine use of continuous fetal monitoring.

The worst consequence is that the fetal monitor ties the mother to the bed. Lying on the back during labor is the position most likely to increase pain for a mother, and it decreases the degree of contraction of the uterus, making it disadvantageous for the progress of labor. The WHO recommends that if the fetus's heartbeat is normal, the heartbeat should be checked once every 15 to 30 minutes. Only in cases where the mother's water has broken and the fetus's position is not settled does she need to lie down. If the fetus's position is fixed, even if the mother's water has broken, she can still change positions as she likes, and the mother should be encouraged not to lie down. Standing up or lying on one's side are both helpful for the expansion of the cervix. Whatever position is comfortable should be used in labor.

Is your position good for giving birth?

Dr. Wagner states, "In evaluating whether the obstetrics department of a hospital has made progress, you can tell just by looking at what position mothers use to give birth." In Taiwan, mothers lie flat on their backs with their legs raised. Twenty-five years ago, it was already proved that this is the most painful and uncomfortable position for mothers and it is not good for the fetus. When the mother lies on her back, the fetus's head constricts the blood vessels connected to the uterus and reduces the amount of oxygen and nutrients supplied to the fetus.

Guo Suzhen, head of the obstetrics department at the Taipei College of Nursing takes out slides she photographed last year in Venice, loudly saying, "Look, the European-made delivery chair even has armrests. Women overseas can give birth sitting or squatting. Can Taiwanese women do that?" On the delivery bed, mothers often hear, "Push hard, push hard, just like you're pushing hard to poop." The birthing chair has a hole in the middle, like a toilet's lid, making it convenient to exert one's self while giving birth either sitting or squatting.

Research shows that entering the second stage of labor, if the mother's upper body is sitting upright, allowing her to see her belly, giving birth in this upright position is more helpful in reducing pain, perineal tearing and infection. The WHO recommends that other than lying on one's back, women should use any position that is comfortable.

Does your birth use drugs?

Another risk of giving birth in Taiwan is that posed by the use of labor-stimulating and labor-inducing drugs. Jian Yuha is a mother who has conscientiously prepared. She and her husband attended the hospital's complete childbirth education course and they watched videos at home for practice. For her previous two births she relied on drugs to stimulate labor and reduce pain. "I don't think I could bear the pain of natural labor without the help of drugs," she says.

Three years ago, she entered the hospital to give birth to her second child. Not long after going into labor, the doctor said, "It's too slow. Let's apply some drugs to help move things along, okay?" After applying the drug, contractions came quickly. Her Lamaze breathing couldn't keep up with it. The pain completely overwhelmed her. Yuhua yelled out, "I can't take it! I can't take it!" A nurse ran over and asked, "Do you want an injection of pain-reliever? It will take away some of your suffering." She immediately agreed, but as soon as she received the injection, the baby was already crowning. She hurriedly switched beds, coping with her large belly, and was sent to the delivery bed in the delivery room. In bewilderment she asked the nurse, "Miss, can my husband come in?" The nurse answer, "There's no need. If we wait for him to come, you'll already have given birth by the time he gets here." At the time, Yuhua was helpless and her family wasn't by her side. She felt stupid. After spending so much time practicing for this, now she wasn't able to put that practice to use. After she gave birth, the pain-reliever began to wear off. She was deep asleep from 1 pm until the middle of night, when she was woken by the 9/21 earthquake.

A survey shows that 64% of women in Taiwan use drugs to stimulate or induce labor. Dr. Wagner says, "This is extremely dangerous. Taiwan's doctors actually believe that over half of all births require drugs. They don't trust Taiwanese women have the ability to give birth on their own." But doctors in Taiwan, assured in their reasoning, explain this away saying that doctors can't wait in the delivery room the whole time. No one knows when exactly the mother will give birth. If you don't use drugs, how can you control the timing? If everyone is crowded in the delivery room and she doesn't deliver, how will the next mother come in? Should I go home? Dr. Wagner responds by asking, do your doctors clearly inform mothers of the side effects of labor-stimulating drugs? These drugs can cause the uterus to contract too much and to tear. Then the baby can't get enough oxygen and dies. He points out that the drugs also cause women to suffer. Labor-stimulating drugs speed up the labor and can easily cause electronic fetal monitors to show an abnormal reading, increasing the chance of Cesarean section. "If you go into labor on your own, you're more likely to come out on your own. If you use drugs to induce labor from the beginning, you are more likely to depend on medical intervention to get you out." says Ye Xueyuan, fellow of the UK's Royal Association of Obstetrics and Gynecology [lit. trans.].

Although inducing labor is usually considered safe, it can result in increasing the length of labor and infection of placental membranes and amniotic fluid, as well as stillbirths, cardiovascular disease and other complications. There is also the danger of tearing the uterus for mothers who have previously given birth by Cesarean section. In the UK, careful evaluation is required before using labor-inducing drugs. The UK Association of Obstetrics and Gynecology [lit. trans.] recommends that when pregnancy extends beyond the expected 40 weeks, doctors should consult with the mother and wait for 7 to 10 days before inducing labor.

Are Cesarean sections safe for mother and child?

When an infant is brought into the newborn intensive care unit, neonatologists are most afraid of hearing the huffing sound of labored breathing, then flipping through the infant's case information to find that it was born by Cesarean section. Although the infant's birth weight and gestation period are normal, neonatologists worry about these newborns who have not been squeezed through the birth canal in a natural birth, whose lungs are still soaked in amniotic fluid when they are removed from their mother's belly, which can result in labored breathing and lead to persistent pulmonary hypertension. Pediatrician Mu Shuqi of Xinguang Hospital says, "According to the standard of neonatal care in Taiwan, the mortality rate for persistent pulmonary hypertension is one in three." She recommends pregnant mothers consider natural birth as their first choice. If the mother's situation indicates Cesarean birth, it's still best to wait for the baby to tell mother, "I'm ready. I want to come out now," by contractions, the water breaking or by blood-tinged discharge.

In emergency situations, Cesarean birth can save the lives of mother and child, but there are risks. From a 1998 report on the mortality rate of mothers in England, the mortality rate for mothers is six times as high for Caesarean births compared to natural births. Even for elective Cesarean births in which there is no indication for it, the mortality rate is still two or more times that of natural birth. In addition, the loss of blood is greater, the rate of infection of wounds is greater, and the post-delivery recovery time is greater. Also, Caesarean birth increases the risk of uterine adhesion and ectopic pregnancy, and can lead to infertility.

Giving birth is not being sick

One Saturday afternoon, over a hundred people were assembled for a mother's training class. Speaking was the director of obstetrics of a medical center. He said that the Cesarean section has become an increasingly advanced, safe and carefree operation. His wife's three births were all done this way. [Speaking about the standard birthing procedure in Taiwan,] one medical center obstetrician says, "Even for my wife, she would go through this set of procedures in a natural birth. I'm not willing for any uncertain factor to occur during her birth. For example, if the weather report forecasts cloudy skies, then I'll prepare an umbrella." The two nurses sitting next to the doctor, who have years of experience in birthing care, nod their heads repeatedly in agreement. "Shaving the pubic hair, having an enema, having an IV, keeping the fetal monitor strapped on, going without food, etc. Our own birth will be done like this."

Dr. Ye Xueyuan, who graduated from Cambridge University and who served last year for nine months at Taipei city's Baby-Friendly Hospital, recalls that when he allowed women in labor to drink water, he was loudly berated by other members of the care staff. He asked, "Why can't she drink water in labor?" The answer he got was, "This is the practice at our hospital." "Taiwan's doctors and nurses don't know what a birth without medical intervention looks like," says Dr. Wagner. He shakes his head and sighs, "They don't see the far-reaching effects of the measures that they uses. They are like a fish in the water who can't see the water."

The enormous waste in birthing

In Dr. Wagner's eyes, Taiwan's routine birthing procedure, which is done in the name of safety, not only has no scientific basis but it actually harmful to mother and child and is a huge waste of medical treatment. In 2000, there were 300,000 newborns in Taiwan. The rate of Cesareans was close to 35%. He points out that among those, 69,000 were unnecessary Cesareans. Medical insurance wasted NT$1 billion on these unnecessary operations. Academia Sinica and the R.O.C. Department of health have asked medical associations of obstetricians to implement a local study of "the number of unnecessary Cesarean sections and their cost." Scholars in Taiwan conservatively estimate that unnecessary Caesarean sections in Taiwan reach 35,000, wasting over NT$3.5 billion. When Dr. Wagner meets Weng Ruixiang, director of Taiwan's Bureau of Health Promotion, he strongly recommends that Director Weng thoroughly investigate why over half of the mothers in Taiwan need labor-stimulating drugs, and see how many are actually unneeded wastes of medicine. Furthermore, the almost 100% rate of enemas and IVs represents the unnecessary use of close to 300,00 glycerin ball enemas, IVs, and needles. Also, 234,000 mothers received unnecessary episiotomies, suffering in vain the pain of the cut to the perineum.

"Birth by Cesarean, electric fetal monitors, episiotomies, etc., these medical techniques can be used, but why not carefully evaluate each mother's situation and wait until it's necessary to use them?" Dr. Ye Xueyuan asks. "Birth is not a sickness," he emphasizes. Is it really necessary to treat every pregnant mother as a high-risk case? He asks, does Taiwan give pregnant mothers first-rate service? Are the needs of pregnant mothers satisfied?

In 1994, the UK Department of Health issued a policy paper on childbirth care titled "Changing Childbirth." It emphasized treating mothers as the focal point, providing them with information and helping them make decisions. Two years later, WHO put forth "Care in normal birth: a practical guide," which also emphasized focusing on the mother and providing her with sufficient information and explanation, allowing her to decide on what she wants and does not want in the process of giving birth. Dr. Ye explains, giving mothers the power to make their own decisions means letting them make decisions, not just doing whatever the doctor is used to doing. In the process of birth, has the pain, worry, and discontent of mothers been resolved? Other than Cesarean sections and drugs, what can Taiwan's doctors offer pregnant mothers?

Childbirth is up to you

In 2001, there were around 260,00 newborns in Taiwan, which is equivalent to 712 per day. Have Taiwan's mothers received proper guidance on birthing? Are mothers comfortable during the process of giving birth? In answer to the above questions, Taiwan's obstetricians without exception give one of two answers: "I can't do anything about that" or "That's none of my business." A professor of obstetrics who teaches at Taiwan's number-one ranked medical school says, I agree that birthing in Taiwan is overly medicalized, but doctors are not the only ones who should take responsibility. His student, a council member of the Taiwan Association of Obstetrics and Gynecology, points out that changing routine practices in Taiwan's obstetrics departments is not the work of the association. Dr. Wagner says, "The only ones who can change the overly medicalized nature of birth in Taiwan are Taiwanese women." He takes New Zealand as an example; fifteen years ago, the rate of Cesareans in New Zealand was 20%, but now they have dropped by half to 10%. Episiotomies were practiced in 50% of cases, but are now down to 20%. The credit for all of this goes to power of women rallying together to change to the medical system. Women's groups in New Zealand have unceasingly fought for and defended their health and rights in childbirth.

When more and more Taiwanese women ask, "What do I want for my birth? What kind of birth experience do I hope to have?", and when they are willing to spend time preparing and actively participating in childbirth, Taiwan's doctors will begin to provide accurate and sufficient information to mothers and let mothers decide what they want and do not want in their birth process, providing a safe and comfortable childbirth process and environment.

* * * * * * * * *

---

This article has understandably angered some caregivers. For just a tiny bit of their perspective, I translated some of the comments of a forum member (musclenet) who called the article inappropriate and misleading. Here are some of his objections:

1. If you don't connect an IV line and you experience a sudden loss of blood, no one will be able to connect an IV line. If you say the incidence of this is very low so there is no need, then I ask you, if you don't give an IV and as a result a small number of people die, should the care staff take responsibility for that? Be more fair to patients. Many preparations are made just in cases. If you think that you don't need to give an IV and there won't be any problems then that's just wishful thinking.

I didn't see this issue addressed in the WHO guide, but it seems that if the only reason you need an IV is just in case, can't you connect the catheter without connecting the IV line the whole time?

2. If you don't care how much pain the patient goes through, then yes, you don't have to stimulate labor, but the problem is: you have to go through pain for a long time! After a few hours of labor, many mothers can't take it any more. If you've been in a delivery ward then you'll understand. You don't need to experience it for yourself, but just look at the experiences of all the mothers. Waiting too long without stimulating labor can also be dangerous for the fetus.

This response involves something that this article did not mention: controlling pain. If the pain isn't relieved, stimulating labor will just increase the pain, although it will hopefully last for a shorter duration. Also, a lot of these issues are tied together. If mothers weren't required to lie on their backs, then maybe fewer of them would need stimulation.

3. Don't think that the way they do things overseas is always right. Doctors overseas can wait because there are less women giving birth. If there are few in one day then that's a lot. In Taiwan's hospitals, there can be twenty or thirty in one day.

You can argue that the standard operating procedure in Taiwan is the best hospitals can do with limited resources, but you can't argue that the necessity of the practices therefore make them the safest or the best for mother and child.

The moon isn't really any rounder in other countries. Take some association or some foreign society of physicians and it sounds authoritative. Practices have to be different for different locations. In other countries, mothers don't "sit a month" after giving birth, but what about Taiwan? This article should be cut because it's misleading.

It's true that it sounds impressive to take a bunch of foreign societies of physicians, but does that mean that no organization is authoritative? The article relies heavily on the WHO recommendations. If that isn't satisfactory, what organization should be trusted? Then, musclenet uses the example of mothers in Taiwan "sitting a month" to bolster his point. This isn't very convincing. Just because practices are different in different places doesn't mean they are the best for each place or that we shouldn't try to improve things.

Speaking about the quote that making mothers go without food and water during labor is cruel, musclenet says:

This kind of description is really that of an outsider. If this wasn't quoted out of context, then the speaker is not professional. You should be asking, "Why must they fast?", not describing how uncomfortable it is or how they dislike it. If fasting doesn't make any difference, why are we making the mothers fast? Do you think it's for fun? Of course it isn't. You've got to be prepared for operation or for emergency intubation. (If you don't fast it can lead to aspiration pneumonia.)

This issue is addressed in the WHO guide. It's a valid concern, but the WHO guide points out that fasting doesn't necessarily prevent the risk of aspiration. Speaking about episiotomies, musclenet says:

Of course you don't have to make the cut, but the problem is that if not cutting occasionally causes a tear that extends to the rectum, the mother is facing incontinence for the rest of her life. If 97% don't need it, that doesn't mean that we can encourage the other 2-3% not to have it, especially when you don't know who the unlucky 2-3% are.

This comment does not appear to be based on clinical studies, but on conjecture. According to the WHO report,

In an observational study of 56,471 deliveries attended by midwives the incidence of third-degree tears was 0.4% if no episiotomy was made, and the same with a mediolateral episiotomy; the incidence with a midline episiotomy was 1.2% (Pel and Heres 1995).

Here is musclenet's conclusion:

This article thoroughly shows the trend of sensational reporting in Taiwan. The original source for this article has it's own secondary motives. (For midwives to gain the trust of pregnant mothers to get a greater income.) I suggest moderators deducts points or lock this topic.