Becoming a parent is always challenging, but giving birth while living abroad presents an added list of difficulties.

When Amber McKinnon realized she was pregnant, she didn’t know what to expect.

The American relocated to Taiwan three years ago in search of positive change. Now 39, McKinnon appreciates her “charmed life in Taiwan.” She has since found work as an English teacher, met her Taiwanese partner, gotten married, and recently gave birth to a daughter.

But the couple’s journey to parenthood wasn’t straightforward, further complicated by the fact that Amber McKinnon had to navigate a healthcare system alien to her.

Her advice to all expectant parents: “Do the research. Know what potentially could happen and have an idea of how you would like it to go.”

For McKinnon and her partner, the first pregnancy ended in a miscarriage, a painful experience that only amplified the couple’s longing for a child. Once their obstetrician had discovered the cause of the loss – a pregnancy-related autoimmune disorder –  McKinnon and her partner conceived again. She says she appreciates the care provided at the Chang Gung Memorial Hospital’s OB department.

“The blood test for the disorder is normally only done after three consecutive losses in most Western countries,” says McKinnon. “I was really glad to be here and with the obstetrician I was with, who ran the blood work right away, so I didn’t have to go through that again.”

With adequate treatment, McKinnon’s second pregnancy progressed well. By the end of the second trimester, she started looking into options for giving birth.

“I started thinking, this baby is going to have to come out one way or another,” she says, laughing. “I was doing a lot of research, and I was not excited about a lot of the things that I found out.”

McKinnon was shocked by Taiwan’s high rate of episiotomy, the surgical cutting of the perineum to facilitate the child’s exit through the vagina. In 2021, Taiwan reported episiotomies performed in 99.87% of all births. The WHO considers episiotomies as medically necessary in about 10% of all births – a shocking contrast.

Episiotomies and inductions are standard practice

McKinnon was still digesting that information when her doctor brought up scheduling an induction date.

“I was like, ‘I don’t want to have an induction,’” she says. “But he was like, ‘it’s safer for the baby,’ and he had nothing to tell me about why. It was just, ‘it’s safer, we’re doing this, so what date works for you?’”

Scheduled medical inductions and cesarean sections are popular with many Taiwanese families. In 2021, 37.64% of newborns were delivered via c-section. There is an appeal to the predictability of a scheduled birth – and the option to have a child on an “auspicious” date.

But for Amber McKinnon, this was not an option. She hoped for a spontaneous, natural delivery and felt the hospital where she was receiving her prenatal care was not equipped for what she wanted.

“I figured, if the doctor didn’t want to listen to or care about how I felt about induction, he wasn’t going to care about anything I had to say during the labor and delivery process either,” she says. She never returned to her provider. Instead, McKinnon embarked on a search for her ideal place to give birth in Taiwan.

In Mandarin, natural or low-intervention delivery is called wenrou shengchan (溫柔生產), or “gentle birth.” One of its biggest advocates here is 48-year-old OB-GYN Chen Yu-ping. In her coffee shop cum birth class center, “Belly Daily,” near Da’an Park, she explains that Taiwan’s delivery standards are difficult to change. Episiotomies are standard in almost all hospitals, and most doctors have never witnessed a natural birth without medical intervention.

Having had two hospital births herself, Chen knows first-hand how the vaginal cut can affect the body long term. For her, the tight scar tissue impacted her range of motion and the alignment of her hips for years, and she says she knows of “worse cases.”

Creating a good birth experience

Chen has taken it upon herself to offer an alternative birthing experience. In 2016, she founded the platform monisclassroom.com, where she promotes a holistic approach to labor and delivery. Chen’s café hides a cozy, quiet room with a bed and a sofa, a large tub, and a birthing ball. Overhead projectors light up the walls with a calming 180-degree nature scene. A plush tree on the wall counts all babies born here, one leaf for every delivery.

Since Chen started creating her “gentle birthing” ecosystem in 2016, her team has delivered more than 400 babies. Families can choose between a midwife-assisted delivery in the birthing room or at home, or at Taipei Union Hospital for Women and Children, where Chen practices as an OB-GYN. But there is one drawback:

“For a delivery at home or in the birth room, you should be able to speak Chinese,” says Chen. Her midwifery team works in Chinese only, and expecting parents are required to complete Chinese-language birthing classes before delivery.

As for many foreign nationals in Taiwan, this was not an option for Amber McKinnon. During her research, she instead came across Angela Chang.

Chang is a certified birth doula (person providing guidance and support during and after labor) who will accompany and advocate for the birthing person vis-à-vis their medical team. McKinnon calls her a “lifesaver,” and Chang says she knows McKinnon’s situation all too well.

“A lot of my expat clients are feeling anxiety about giving birth in a country they are unfamiliar with, in a system they are unfamiliar with, in a language they are unfamiliar with,” says Chang. With 15 years of experience, and over 500 babies born on her watch, the Canadian may be the single best source for foreign nationals preparing to have a child in Taiwan.

When she first received her training as a birth doula, postpartum doula, and childbirth educator, Chang had no idea her services would be in such high demand. “I thought that it would be a hobby,” she says. Instead, Chang soon averaged between one and three births a month.

For a package fee of NT$35,000, her clients get two prenatal meetings, round-the-clock support during labor and delivery, and one postpartum consultation. Chang supports births all over Northern Taiwan, assisting with translation, sharing her experiences with different providers, and helping women have the best possible birth.

“A good birth for me doesn’t mean that it’s an all-natural, vaginal water birth,” says Chang. “Even if it ends up being an epidural, vacuum or cesarean section – in a good birth, each step along the way the mother was supported, received information, and made that decision herself.”

A mother of three herself, the doula believes in choice and informed consent during birth. She wants couples to know their options when giving birth in Taiwan. Therefore, she holds birth classes for English speakers every two to three months.

What to consider when choosing a provider

On a sunny November afternoon, seven couples have gathered in a small conference room in Taipei. Their faces reveal both anxiety and excitement. The parents-to-be practice birthing positions, review signs and stages of labor, and learn what to check for when choosing a birthing provider:

Has the doctor ever delivered a baby without an episiotomy? How common are the use of fundal pressure, vacuum deliveries, and cesarean sections at that site? Is there a room for labor, delivery, and recovery, or do women have to switch rooms when fully dilated?

Is the fetal heart rate monitored constantly or intermittently? Does the provider adhere to delayed umbilical cord clamping, and will the child stay with the mother after delivery? Does the provider have a lactation consultant on staff?   

These are important questions to ask since international recommendations may differ from Taiwanese standards of labor and delivery care. How much room there is for individual birthing preferences also depends on the hospital and the attending physician.

In Taipei, Taiwan Adventist Hospital and Taipei Veterans General Hospital are most used to working with foreign nationals. They are privately operated and may charge more than public hospitals like Taipei City Renai Hospital. In all cases, there is a co-payment of NT$3,000-5,000 for each delivery, with medically necessary interventions like c-sections and induction of labor covered by NHI.

Most hospitals offer so-called walking epidurals that allow women to move around. Mother and newborn will be monitored for three days postpartum for a vaginal delivery and five days for cesarean delivery, with extra charges if they choose a private room. Since NHI only covers either a doctor’s or a midwife’s fee, hospitals only employ specially trained nurses, and midwifery has become a vanishing craft.

Choosing a place for “gentle birthing”

If women opt for a less medicalized birthing experience, costs will be higher. But at least there are options now, says Chang. When she had her third child 15 years ago, Taiwan’s first birthing center had just opened. There, Chang had a positive birthing experience that prompted her to train as a doula.

Located in Xinzhuang district, Loving Care Maternity was set up with a low-intervention approach and was the first place in Taiwan to offer waterbirths. Chang continues to recommend Loving Care to her clients.

“They are very much on board with natural birth, and they do keep track of their cesarean rate, which varies between 9 and 19%,” she says. “They also have implemented standards of care like delayed cord clamping, and baby staying with mother after birth, and not being whisked away.”

The experienced doula says it is a more affordable option than the newer, fancier Dianthus clinic, another popular choice among her clients. Many international insurance policies include Dianthus in their coverage.

Dianthus operates several clinics in Taipei and Taoyuan. An English-speaking nurse will accompany foreign patients to every check-up for a fee of NT$2,000 per visit. Patients on NHI will have to pay out of pocket for all additional services, like the labor and delivery room with midwife assistance and waterbirth option.

As a third option, Chang is happy to refer parents to the few English-speaking midwives in Taipei that offer home births.

Expectant mom Amber McKinnon eventually decided on Loving Care Maternity for her delivery. It cost her NT$45,000 out of pocket, but she feels it was well spent – even though her birth did not go according to plan.

Due to a swelling of the cervix that caused a lot of additional pain, McKinnon opted for an epidural, even if that meant that she could no longer labor in the birth tub. Each new dose of the medication brought on painful nausea and vomiting for her, and the 26 hours of labor blend together in her memory. Still, she felt well cared for throughout the duration of the birth.

McKinnon was able to enjoy immediate skin-to-skin contact with her daughter after she was born. Meanwhile, doula Angela Chang checked the baby’s latch and ensured that the breastfeeding relationship was off to a good start. McKinnon says she’s glad she invested all this time and energy in making a conscious, informed choice about her birth. She says:

 “In the moment, I was like, ‘this sucks.’ A lot of things didn’t go the way I wanted them to, but I actually don’t feel negatively about it.”