Comparing Singaporean and American pregnancy guides

One of the questions I get a lot is “how is pregnancy different in Singapore than in the US?”

Today I’m going to attempt to answer that at least in part–I purchased a local pregnancy guide “The Essential Guide for First-time Asian Mums and Dads from pregnancy to pre-school,” which is the only Singapore-based book I’ve found (as opposed to the usual suspects, which are omnipresent–“What to Expect When You’re Expecting” is apparently universal) and I want to compare the way that pregnancy is presented here to the way it is presented (marketed?) in the US.

A few caveats–

  • I am not an OB.  Do not take anything I say here as medical advice
  • There is no “one true way” or “set in stone” approach in either Singapore or the US.  I’m going to make some sweeping generalizations.  You’ve been warned.
  • I am a high risk diabetic pregnancy.  I have never had a “normal” pregnancy.  Your mileage may vary.  I am writing from MY experiences, MY discussions with friends/community bulletin boards/etc.

The first thing I noticed about the first-time Asian mums/dads book is that it covers “pregnancy to pre-school” in approximate the same number of pages (or fewer) that What to Expect requires to address just pregnancy.  This actually a very good summary of the differences in style between the two countries.

Singapore takes a far more relaxed approach to pregnancy–the over-arcing assumption is that things will be FINE and just calm down already; you don’t need to know about all those “could happen” scenarios. 

The United States, perhaps in response to the very true stereotype that we are a litigious people, tends to skew to over-informing, nixing of anything that might be even a little bit risky and hyper conscious of “risk,” real or imagined.

A good example, from my personal experience is my diabetic status and what sorts of protocols that triggered.  In the US, my “regular” ob kicked me out of her practice at 5 weeks pregnant and referred me into a high risk program run jointly between Beth Israel’s Maternal Fetal Medicine department (staffed entirely by perinatologists–OB’s with further education/training specific in “high risk” pregnancy conditions like diabetes, high blood pressure, etc) and the Joslin Diabetes Clinic, a world leader in diabetes research and treatment.  Part of this, of course, was because I lived in Boston and that option was maybe 10 minutes further away than my former OB’s office.  I saw my perinatologist on a “regular” schedule, but I had far lengthier appointments than my low-risk friends, and I got an ultrasound at every appointment when insurance usually only covers 2-3 over the entire pregnancy for normal/low-risk cases.  However, I was also emailing/faxing in weekly spreadsheets of my blood sugar and insulin.  I saw my endocrinologist about every 6 weeks, one of her two nurses every 2-4 weeks, and a nutritionist a few times throughout the pregnancy…which had me in the office for diabetes related stuff every two weeks or so.  I was constantly giving bodily fluids for testing.  I had to get a special heart ultrasound at 23/24 weeks.  I had ante-natal testing regularly  at 28 weeks, then weekly from 32-35 weeks, and twice weekly from 36 weeks until I delivered Elanor.  My pregnancy was VERY closely monitored, and highly medicalized, including a necessary induction at 39 weeks because my blood pressure was spiking and I was showing signs of developing pre-eclampsia (a dangerous condition that can turn life-threatening).

Some women might have found the level of care I received in the US to be stifling or overly invasive.  Personally, I found it comforting, as I knew if there was anything that wasn’t quite right, we’d know right away and have adequate time to prepare for whatever might be coming our way.  (Ironically, of course, no one could foresee the infection that almost took her life, so there goes the theory that you can plan for what’s coming your way.)

In Singapore, there are few to no perinatologists.  Being diabetic isn’t really seen as that big a deal, and while diabetic control in early pregnancy is crucial to safe fetal development, that’s really mostly between you and your endocrinologist.  As for the endocrinologists, the two I’ve worked with had radically different notions of what “acceptable” blood sugars were for a pregnant woman–my first thought that the Joslin’s numbers were too restrictive, and my current thinks they’re appropriate (one of the reasons I switched, as I feel comfortable following the protocols that got E out safely).  Here, doctors and not hospitals set policy, so one of my big screening questions was to find an OB who didn’t just want to initiate a C-section at 37 weeks (which there is no reason to do in a highly monitored otherwise healthy diabetic pregnancy).  Another was to find a doctor who didn’t think that my wanting all the “unnecessary” additional testing was crazy and was willing to indulge me.

I think that part of the reason that the additional testing is seen as “unnecessary” as well as the overall more laid-back approach to pregnancy in Singapore is that there isn’t really insurance as Americans think of it.  As I understand it (and locals step in and explain, please!) people have a savings account that can be used towards medical care, and with the birth of each child, there is a small “baby bonus” given to the parents to help cover the cost of the delivery.  But realistically, most people are paying largely/completely out of pocket for pre-natal expenses.  So additional testing isn’t just something you do since the hospital wants it and your insurance will cover it…people have to seriously contemplate if the benefit of the additional testing is worth the additional out of pocket expenses.

With that in mind, I opened my book

There are a few pages that cover pre-conception, addressing things like nutrition/vitamins, etc.  There are two pages that address potential fertility issues, but there’s no standard definition of “infertility”–in the US, I believe most guides are clear that if you’re trying to get pregnant for 12 months without success, you should make an appointment with a reproductive endocrinologist.  While weight is cited as a potential infertility cause, there’s no mention of PCOS (poly-cystic ovarian syndrome) a not-uncommon issue for plus sized and insulin resistant women (and given that the local stats on diabetes are somewhat alarming, I would expect there to be).

The first trimester is deftly covered in about 6 pages (including a full page on gestational diabetes, which is interesting as GD isn’t technically the  diagnosis if you develop it prior to 28 weeks…that’s why I’m considered a type 2; that I develop diabetes too early in pregnancy…and the risks for a GD mom who develops it late in pregnancy are RADICALLY different and far less severe than for a woman who is diabetic in the first trimester, where uncontrolled sugars can cause heart defects, spina bifida, etc.).  The baby’s development is covered in about three short paragraphs, which is quite different from the US…where one of the most widely read pregnancy guides (based on my own informal polling) is the equivalent of “your pregnancy week by week.”

Both Singapore and the US do the nuchal fold translucency test (an early Down’s Syndrome test done with ultrasound and blood work), but the US does a great number more blood tests.  It is considered standard to do a full STD/STI workup in the US, and not in Singapore.  I got a strange look when I asked for it (no, I had no new risk factors, but let’s rule out stuff–a quintessentially American sentiment).

The second trimester is covered in 6 pages and covers everything from tips for a pregnancy wardrobe to fetal (foetal) development, and a two page discussion of pre-eclampsia (although there is no mention of the more severe form of pre-e, HELLP syndrome).  One interesting difference between US and Singapore pre-natal care…the level 2 ultrasound (also known as the fetal anomaly scan), which is done between 18 and 22 weeks is done by your OB here in Singapore, whereas in the US it is outsourced to a radiologist.

The third trimester merits 4 pages that cover everything from vericose (aka spider) veins, the joys of late pregnancy (backache, heartburn, shortness of breath) and discharge, swelling and other physical changes.  A few paragraphs about baby’s late development (note, viability–the youngest age that a child is considered to have a fighting change of survival is 24 weeks in the US and 28 weeks in Singapore).  However, at this point there is no actual discussion of viability (I learned the dates from my OB) whereas in a US guide, there’s a detailed discussion of viability and what prematurity risks.

There’s a small section about prenatal testing; meaning the Nuchal Fold (or OSCAR) test, the triple screen (in US quad screen), amnio and CVS assessments.  There is no mention of non-stress tests, biophysical profiles (both routinely done for high risk moms and mentioned in most books in the US), no mention of fetal alpha protein scans (which checks for some birth defects including spina bifida), or any of the other assorted tests you can get done.  There’s no mention of why you give urine at every appointment, or what blood work might be done.

There’s a two page spread about a twin birth, but no discussion of a larger multiple pregnancy.  I don’t know if there are laws here restricting the number of eggs a woman can receive during IVF and I’ve certainly not seen a mum out with more than 2 (and twins seem super rare here…in my part of MA they were quite common due to the number of women who delay fertility).  Perhaps that’s also because it’s more common to have an only child household in Singapore?

There’s a few pages about nutrition, weight gain and exercise.  What I find interesting is that weight gain for women here is far more generous in the US, which was the opposite of what I’d expected given what I’d heard about Asian doctors from expats who delivered in other Asian countries, especially Japan, where it’s not uncommon if you’re plus sized to have a doctor tell you to not gain ANY weight or to lose weight (an ill advised move that can put your body into ketosis, and potentially cause issues for the baby–I know from whence I speak–as someone who loses weight, and not by choice, it’s something we’re always on the lookout for).

There’s a two page spread about sex during pregnancy.  As someone who works in sex education and who wants to specialize in sexuality during and post pregnancy, this section was particularly troublesome for me.  It does at least say that sex isn’t a bad thing when pregnant.  Then it mostly addresses avoiding sex during pregnancy.  No mention of  which positions may be better suited for the pregnant body, no real discussion of how sexual desire often increases thanks to increased blood flow, and no positive reinforcement that sex is a great way to stay close to your partner (and that intercourse isn’t the only way to stay intimate).

What to take to the hospital–This was enlightening.  Apparently the hospital provides nothing.  A US hospital will give you stretchy guazy panties, maternity pads, a sitz bath, etc.  In Singapore, you bring your own.  You also need a ton of paperwork to process the baby’s birth certificate (which we then get to follow with taking it to the US Embassy, getting a certificate of foreign birth, a passport, and a dependent pass for the little girl).  Among the things they don’t list that would be standard in an American book–cell phone & charger,  camera & charger, laptop & charger.

“Normal Labour”–by which they mean vaginal gets 4 pages.  There is, however, no discussion of when to go to the hospital.  In the US, there’s a guideline of a specific number of contractions, lasting a specific amount of time, over the course of an hour that’s supposed to signal when you go to the hospital.  Since I had an induction with E, and sort of always knew that it was going to happen (same as this time) it’s not something I paid a ton of attention to.  This section also scared the crap out of me because they say it’s routine for you go to in, get your pelvic region shaved and to receive an enema, and stated that episiotomies are still routine–three practices that have long since been discontinued in the US.  I actually showed up at my OB’s office with 3-5 studies on each subject stating that they weren’t beneficial.  Luckily, it’s something your doctor has control over and you can refuse.  (thankfully!)

The pages on pain relief were interesting to me as there are options here like gas and tens unit therapy, which are not standard in the US.  I’ll meet with a anesthesiologist before I go home and then get my US team’s opinions as to which are acceptable in my case.  It does, however, seem like there is far less stigma attached to pain relief in Singapore than there is in the US.

Finally there are a few pages on C sections.  I hear they’re quite common here (although I’m hoping to avoid one) and they talk about not walking for 24 hours post delivery.  Am I mistaken or did doctors make you ladies get up and walk as soon as humanly possible in the US?

We’ll save the rest of the hospital stay and taking baby home for another day.

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10 Responses to Comparing Singaporean and American pregnancy guides

  1. I had a c-section for the second set of twins I had (when I was a surrogate), and they had me up ASAP. I ended up walking laps around the L&D ward.

    • Crystal says:

      That was what I thought I remember in terms of what my OB said regarding a C and what my friends said about theirs…that as soon as they had feeling, they were up and walking.

  2. Dawn says:

    Re: walking – I had a vaginal birth, and a 1st-degree tear, which needed to be stitched up. I also had an epidural, so walking wasn’t really an option just post-birth, but since it was taken out before I started pushing, it wasn’t long before it wasn’t an issue. After they wheeled me into the recovery room and took F away (with T) to the nursery to get her check-up, I got out of bed and went to the doorway, because I’d heard crying and I was wondering if it was my baby and also missing her already. When I asked which way to go to get to the nursery, I got yelled at by the nurses for being out of bed (let alone walking around) and ordered to get back in. I was, however, encouraged to get up & go to the bathroom frequently (as it was necessary). But no, I was not “made to get up and walk as soon as humanly possible” – in fact, quite the opposite. During labor was a different story, though – they wanted me to walk as much as possible to hasten the delivery, until I needed the IV and epidural (about 10 hours after being induced) and couldn’t walk anymore.

    And by the way, although I am not a “high-risk pregnancy,” I have enough (mostly psychological) difficulty with pregnancy that the midwives do spend extra time with me, both on the phone and in the office. Since they’re not problems that pose significant risk to the baby, they didn’t kick me out and make me see an OB or anything – however, a friend of mine who did have some physical issues that threatened the baby started off with the same midwife practice, got kicked out and sent to an OB, and then got kicked out of the OB’s office and sent to a specialist – and all of that still didn’t save her baby; he was born at 28 weeks without enough lung tissue to survive (but don’t worry about that outcome; the mom had plenty of warning that might happen).

    Also, my understanding is that any ultrasounds are covered as long as there are medical reasons for them – this pregnancy I had one at 9 weeks (ostensibly to “check the age” since my periods had been irregular – but really to reassure me that my baby was ok since I was already having problems with panic attacks), the nuchal folds at 12 weeks, the fetal survey at 18 weeks, and a follow-up at 24 weeks to check for placenta previa (it had been close, but moved out of the way, thank goodness) and monitor my ovarian cyst (which they discovered at the 9-week ultrasound and since then has shrunk). With F, I had the 12 and 18-week US’s, a follow-up at 20 weeks because F did not cooperate at 18 weeks, and none more until the very end, after the standard 36-week US showed my fluid levels were low and they scheduled two NS tests per week, one of which came with a quick US. The funny thing was, though, since F hadn’t cooperated at 18/20 weeks, we didn’t know the gender, and then at the late-term US’s, they refused to tell us because we “had waited that long.”

    • Crystal says:

      US insurance does cover any and all “medically necessary” ultrasounds–hence why I have over 25 with E. But if you’re low risk, it’s like 2-3.

      There is a specific reason (something about air in the abdomen? don’t remember) that C sections HAVE to get up and walk very soon (within a few hours post-birth.

      • Dawn says:

        I’m not sure about that. Friends who see an OB as opposed to a midwife seem to get an ultrasound at every visit. I can’t imagine they’re paying out of pocket for that (though there’s a whole business of recreational ultrasounds, so maybe they’re just not very expensive).

      • Dawn says:

        As for the C-section walking, I just looked it up and it’s apparently to prevent deep vein thrombosis. However, the only timeline I saw was “encouraged to start walking short distances within 24 hours of surgery.” Within a few hours seems unrealistic given that most C-sections involve a lot of anesthesia plus there’s a risk of reopening the wound.

  3. TENS and Nitrous Oxide are two wonderful adjuncts to a natural birth that have no negative side effects and don’t enter your blood stream or affect the fetus/baby. We’re lobbying and hoping to have “air and gas” available here in the us as they are used in England and other countries. TENS is technically available here in the US but good luck finding available to use when you need it in labor.

    • Crystal says:

      Thanks, Nancy! Glad you chimed in…I love tens therapy for my bad back, so I thought it might be really good in terms of labor pain.

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