Early births and misleading statistics

The times they are a-changing, and with them so is our entire approach to the delicate issue of childbirth. Professor Mark Brincat, chairman of the Gynaecology and Obstetrics Department at Mater Dei Hospital, invites me to consider the enormity of the changes Malta has experienced over the past century or so.

“We no longer have six or seven children, where the loss of one child is acceptable. Today, an average of 1.7 babies are born to every couple, so the loss of even one baby is unacceptable.”

Medical science has also evolved in step with the higher infant life expectancy.  Nowadays, again with the help of medical intervention, women are getting pregnant who would never have been able to in the past: people with diabetes, transplant patients as well as women who have put off having children until later on in life.

Extending pregnancy beyond 40 weeks increases the risk of perinatal mortality (still births and death of the infant within the first week of life) due to ageing of the placenta that ceases to transfer sufficient nutrients to the foetus.

Brincat explains that such high-risk patients need more monitoring and in the event that pregnancy goes over the recommended 40 weeks, then taking further risks is not recommended.

“We try to decide on the best strategy to end up with a favourable outcome that is to discharge a healthy mother and baby. Our motivation to perform an induction is a genuine concern.”

The issue of inducing early childbirth has been in the news of late, with the Malta Union of Midwives and Nurses claiming that doctors were sometimes recommending induction ‘unnecessarily’. Brincat however insists that labour is only induced when there is a medical reason to do so. Still, at a time when couples are having fewer children, the mothers expectations of a good experience are higher.

“When making a decision about whether to induce or not we also have the mother-to-be’s opinion to take into consideration. Some are keen to be started to have the baby sooner while others are keen to wait until labour comes naturally. Unless there is fundamental risk, we will always respect the mother’s opinion.”

Scepticism however lingers, and critics often point towards reports which suggest that Malta has the highest rate of induction in Europe.

Brincat acknowledges the point, but expresses reservations about both the statistics themselves, and the wisdom of comparing statistics between countries.

“The statistic being quoted in the media of 37.9% of births in Malta being induced is taken off a report that is two years old. The current statistic is closer to 30%.”

Statistics are also very dangerous to play around with, he claims – especially in a country like Malta where 10 or 12 births can change percentage rates significantly.

“Also when comparing these statistics to other countries it is important to take into consideration the rural populations. In rural areas (of other countries), people don’t have access to specialists and medical intervention in the form of induced labour will not be commonplace. These areas of the country will pull the average induced birth rate down considerably.”
The situation in Malta is not analogous. “In Malta, we have easy access to specialists and, where it is necessary, medical intervention can improve the situation of many mothers. It would be more appropriate to compare statistics of induced birth to Paris rather than to the whole of France.”

However, standards and procedures followed in Malta are similar to ones adopted in other European hospitals and Prof. Brincat says that both he and the rest of his staff are perfectly capable of working in European hospitals abroad.

“Most of our doctors have been trained abroad and we have checks with foreign boards to ensure our procedures are consistent with European standards. It is comforting that though we have a wide range of doctors who have trained at different colleges through different generations, we all practice in more or less the same way.” 

If customer satisfaction were taken into consideration, it would turn out that the maternity service at Mater Dei Hospital is second to none. Malta in fact registers some of the best results in the whole of Europe with regards to perinatal mortality. When deciding whether to give birth at a private hospital or at Mater Dei, it is Mater Dei that is the most common choice. Despite declining birth rates, admissions to the maternity ward at Mater Dei have increased by 20% last year and a further 20% over the previous year.

“The labour ward is equipped with intensive care equipment just in case something goes wrong. We have successfully aided the births of 26 and 28 week old babies, something that could never have happened in a natural scenario. We encourage natural practices with the back up of technology.”

The industry of obstetrics is a fluctuating one. There are times when the maternity wards are packed solid, and other times when everything seems relatively quiet.

“Our doctors and consultants worked throughout the Christmas period with very little time off and no overtime. There is no money changing hands as a result of the decisions we are making; therefore there is no reason to assume that doctors are inducing labour for convenience’s sake.

“When we decide an induction is necessary there is usually very little notice, sometimes it may be two or three days but other times it is necessary to start labour within a few hours. Our job is all about timing and we try to get the timing right to induce labour that will progress as naturally as possible.”

Whilst on the subject of natural labour, Prof. Brincat is quick to point out that though natural labour is what doctors are aiming to achieve the natural route is not always the best solution for mother and child.

“A still birth is still classified as a natural birth. As specialists we often make the decision to start labour if it does not come within a normal timeframe as risk of waiting for it to start naturally increases the probability of having a still birth.”