Travelling while pregnant

Air ambulance

Dr Lee Collier, Medical Director for Lia’s Wings and Neonatal Clinical Lead for Capital Air Ambulance, talks to us about medical care for preterm babies and pregnant women when travelling

Over 13 million babies are born prematurely each year worldwide, defined as birth before 37 completed weeks of pregnancy, and a small number of these will occur when the mother is travelling. Most airlines allow travel up to 36 weeks’ gestation and the available evidence suggests that risk to the unborn baby is minimal. This article outlines the medical care of preterm babies, highlights the gap in insurance products for pregnant travellers, and explores considerations for repatriation.

Medical care for preterm babies

Alveolar surfactant lines the air sacs in the lungs, lowering the pressure required to take a breath. Its absence causes respiratory distress syndrome (RDS), requiring treatment with artificial surfactant and usually ventilation. Adequate production begins from 32 weeks; however, infection is a major cause of prematurity and may cause surfactant deficiency at any gestation. Babies born at 32–36 weeks often need significant care, and represent 26% of neonatal intensive care unit (NICU) admissions in the UK.

Results from search engines and insurance comparison websites are at best confusing and at times misleading

In addition to respiratory support, the other main treatments are an incubator to maintain body temperature, and support to establish milk feeds. Key complications include:

  • Intraventricular haemorrhage (IVH): bleeding in the brain that may lead to hydrocephalus, sometimes requiring neurosurgery
  • Necrotising enterocolitis (NEC): inflammation in the gut that may require bowel surgery with stoma formation
  • Infection, which may lead to reintubation and ventilation
  • Patent ductus arteriosus (PDA), which may cause prolonged need for respiratory support, and sometimes requires cardiac surgery
  • Bronchopulmonary dysplasia (BPD), also known as chronic lung disease (CLD), requiring long-term oxygen therapy.

The mean length of stay for adults in ICU is four days. Conversely, a baby may stay in NICU until their due date, meaning a 16-week admission for a 24-week-gestation baby. Complications will extend this, and in the case of bowel surgery recovery, may take many months. Babies may be discharged with ongoing oxygen therapy or nasogastric feeding.

Insurance products

Following reports from the charity’s clients, we investigated the insurance products available for pregnant travellers. A search was performed using a UK insurance comparison website for a 33-year-old woman requiring a single-trip policy. The policy wording for the first 20 results was similar, including:

  • Cover for complications of pregnancy and childbirth including premature labour up to 32 weeks
  • Cut-off for multiple (twin) pregnancy varied between 24 and 28 weeks
  • No details of what treatments would be covered for the premature baby
  • No details of whether repatriation would be covered for the premature baby
  • One policy stated “childbirth in or after the 32nd week … is not a complication and is not covered under any section of this policy”.

Next, a search engine was used with the phrase ‘travel insurance pregnant’. The first results page consisted of advice pages from four comparison websites and four insurance providers, a UK National Health Service (NHS) advice page, and a result for ‘specialist pregnancy travel insurance’. The advice pages were very similar:

  • Most highlighted the 32-week cut-off for insurance and 36-week cut-off for flying
  • Only one site explained that the 32-week cut-off meant the end of the trip, not the beginning
  • None specified what would happen if a delay in the return trip breached the 32-week cut-off
  • One insurer’s advice page implied that they had no gestation cut-off, but the detailed policy had no wording about pregnancy or prematurity at all
  • The NHS web page did not highlight the common 32-week cut-off.

The ‘specialist pregnancy travel insurance’ result led to an insurance provider’s website describing a product that appeared to be no different from the other policies reviewed.

Finally, we tried to find the same advice pages directly on the insurance provider or comparison website. We discovered that:

  • The advice pages were difficult or impossible to find on the website menus
  • Despite entering details for a 33-year-old woman, no sites offered a link to the advice page on the main search results or policy information page.

Our findings highlight the gap between insurance cover to 32 weeks, and the 36-week airline cut-off. Choosing 32 weeks is at odds with the medical definition of preterm labour and risks leaving babies without the care they require.

Results from search engines and insurance comparison websites are at best confusing and at times misleading, in particular the ‘specialist pregnancy travel insurance’ that appeared to be no different from any other policy is concerning.

Caring for the family

The prospect of a prolonged admission followed by full recovery and unassisted travel home is almost unique to premature babies. However, the approach of waiting for discharge then a low-dependency or unescorted flight home entails a two to three month stay in a foreign country for the mother, and much longer if complications occur. This will have a significant impact on the mother’s mental health. Her partner is likely to need to return home and go back to work, and she will be separated from other children, extended family and community support. A crucial part of neonatal care is facilitating the transition from medical care to being under the care of the mother and her partner, and this is severely hampered by language and cultural barriers.

Emma, the mother of Jack, a 1 kilogram 27 + 5-week baby repatriated to the UK at 20 days, told us: “We had one translator, but she was only in certain days, so we could only see Jack on those days, and that made it really hard. The main thing was getting home to family for the support we needed and knowing that at home we would be able to actually hold Jack. Within half an hour of being in the air I was allowed to sit with Jack and I sat with him the whole journey holding my son’s hand, just gently talking to him, and he was calm for the whole flight.”

Where a baby is born preterm, we advocate hearing the voices of parents and neonatal transport experts calling for consideration of early repatriation home

mother with a premature baby on a plane

Early repatriation

It is outside the scope of this article to discuss risk assessment in detail; however, research evidence and decades of experience in the UK gives us confidence that air ambulance repatriation can be safely offered to many preterm babies within the first two to three weeks of life. This is our approach when arranging charity or privately funded repatriation, and we suggest this should be the default approach for all premature babies. This offers the best possible start for the baby by expediting the return to normal family life, ensures any significant complications are treated in the home country, facilitates a relationship with the local hospital and paediatricians, and offers cost containment for the insurer.

Conclusions

Premature deliveries make up a small but important part of the workload for insurers and medical assistance providers, and no doubt all involved strive to offer the best possible products and services to pregnant travellers. We have outlined gaps in the products available, and issues with the information offered when selecting a policy. This represents an opportunity to offer clearer information and genuine specialist products for pregnant travellers. Where a baby is born preterm, we advocate hearing the voices of parents and neonatal transport experts calling for consideration of early repatriation home.