Archive for the ‘Advocacy & Evidence-based Practice’ Category

When I counsel mothers during their pregnancy, or when they attend one of our Healthy Mother Lamaze Programs, one of the first things I assure them is that I believe in their bodies’ ability to give birth naturally. I also tell them that I will spend as much time as they need to overcome their concerns, fears, and anxieties – not how much time I am able to spare for them on a given day.


I think that giving mothers the confidence in their bodies’ ability to give birth naturally starts with good prenatal care and counseling. The paramount factor in a normal birth and in obtaining a fulfilling outcome for mother and her baby is the ability of care providers to ensure continuity of care. As the relationship between the health care provider and mother develops during the course of prenatal care, a mutual trust between them brings a sense of safety, security and openness. When it comes to the time of birth, rarely do we have to deal with psychological issues which may stall or impede labor, since many fears and concerns have already been dealt with during the prenatal period. This is great comfort to a mother who is going to give birth for the first time and who has so many questions. Through the consultations and the prenatal sessions, we have not only taken care of most of their immediate needs, but we have also taught the mother what to expect during labor. In addition, we have given them the tools and techniques to overcome the challenges of labor. So, even when the going gets tougher, the mother – who by now knows that we will give her the best possible support – is free to focus on the task at hand – giving birth! Often, I have sat with a first-time, would-be mother in labor, when I can feel a particularly difficult wave of contraction coursing through her body, when I know she is in slight panic, and I know she is wondering if she will be able to complete the task that she started, I look straight into her eyes and say to her, “You have just a little further to go.” She grasps my hand a little harder, nods, breathes and blows through her contraction and replies, “OK”. Then, we manage the next contraction together. In fact, many a time, after giving birth my new mother will say “I don’t remember the pain – I just remember you saying “you are almost there” and this gave the strength to finish what I so strongly desired.”

The amount of time spent by us during prenatal visits, using our powers of observation is the second most important factor impacting a normal outcome. Most of today’s prenatal visits are assembly line in nature, and may be worse than no visit at all. This is particularly true when a woman has a condition that requires more frequent visits. Today’s routine prenatal exams in which the blood pressure is taken, fetal heart tones quickly found, a quick check done on the ultrasound monitor, and various tests ordered, may have little relevance in determining the normalcy of a woman’s pregnancy. Of course, it is important to do all of these as standard care practices. However, in my consultations and in my Lamaze classes, I am much more interested in how a mother carries herself. Does her back hurt? Can I teach her better ways to improve her posture, and teach her husband / family members some massages to help relieve her discomfort? Should she be adjusting the way she works at her workplace? Can I teach her ways to avoid pulling some of the muscles and ligaments that are lax during pregnancy? How’s her energy level? Perhaps she is anemic or depressed. How’s her self-esteem? Perhaps she is constantly being reminded that she has put on too much or too little weight. Is she anxious about something that she has perhaps been unable to voice? How is her appetite? Is she able to sleep well at night? Can I show her some comfort positions to use during sleep, or some relaxation and breathing exercises she can do before she goes to bed?


Then, when I examine her and feel her belly, it is wonderful to have a baby who responds to my touch – the personality of the tiny being is probably mirrored in the tenor of her prenatal movements! If the baby is found to be in the breech position (head up and buttocks down within the womb), I take time to teach the mother exercises and positions to try and invert the breech. More often than not, the baby does turn to the head down position within a week to ten days! All in all, it takes time to “tune in” with the mother’s pregnancy—to talk about nutrition, her groin strain, the things that she has heard from her cousin about cesareans, what her friend has told her about “how wonderful it was to have a “painless” epidural birth”, and many, many other things that are not a part of usual hospital case sheets and charts.


This does not mean that labor is not hard work for both the mother and for those of us who provide continuous labor support. However, in order to help each of my mothers and their families achieve the best possible labor and childbirth outcomes I try to spend the bulk of my energy during the prenatal period.

A final important factor in assuring that birth will proceed normally is the birthing environment. Where does the mother feel safe? With whom does she feel confident? A couple of years back, I was talking with my cousin’s daughter who had just finished her 3rd year physiotherapy exams. She was feeling very exhausted and yet was not satisfied with her performance. She had studied very hard and felt that she had a good grasp of the subject matter, yet when she went to take her practical exams in Electrotherapy, she had been overcome by feelings of fear and anxiety. Although she did well in all the other exams, she felt she should have done better in her “practical”, and that the marks that she got did not reflect her knowledge of the subject fairly. I asked her why she had suddenly developed feelings of fear, and she told me that the testing site was a room she had not been in before, and full of equipment with which she was not familiar. There were about thirty others being tested whom she did not know, and the invigilator was a stranger. To top it all, the room was very hot! As she was talking, I felt like she could be describing the conditions that are present when most women walk into a typical hospital for delivery! No wonder so many women have “failure to progress” when exposed to an unfamiliar environment. Recently, I read a wonderful article about the functioning of sphincters and privacy – it is commonsense – we all know that our bowel and bladder sphincters do not open up and release in public; they need privacy. Why would the “cervical sphincter” be any different? The article reinforced my belief about calm, quiet and privacy and familiarity that are needed to “progress” labor and to give birth.


It has been my experience that when the mother is able to labor in an environment of her choice, with people surrounding her who make her feel respected, loved and safe, she feels empowered to give birth to her baby, rather than be delivered. I have read some wonderful birth stories written by midwives in Europe and US, of short, almost painless labors that they were a part of. Although I used to be somewhat skeptical of these birth stories, I am starting to believe that they are probably true. Belief, faith and spirituality are in equal measures important for the wonderful transformation of a woman into a mother. I am left wondering how much of an effect does my belief in the mother have in her final birthing outcome? The more I believe that “mothers birth their babies”, the more I am able to facilitate mothers to have a better birthing experience.

My musings for today….. feel free to write in your thoughts and experiences…

Dr. Vijaya

Recently, I was talking to one of our Healthy Mother Labor and Childbirth program participants who had gone to her parents’ house in Kerala to spend the rest of her pregnancy. During a routine check up at the local hospital four weeks before her due date, her baby’s heart rate was seen to be fluctuant, accompanied by significant decelerations. Her OB suspected that there may be cord entanglement, and immediately admitted her to the hospital. With severe decelerations of the baby’s heart rate continuing, her doctors  decided to immediately take her for an emergency C-Section. Soon after her delivery, the doctors found that her baby had significant difficulty with breathing, and the pediatrician counseled the parents to admit him to the Neonatal Intensive Care Unit (NICU).

However, neither the hospital in which the baby was born, nor any other hospital in the vicinity, had NICU facilities. Thus began a ten day emotional and physical rollercoaster ride for mom and dad. The baby was shifted to the nearest hospital with NICU facilities, which was about 6 hours away. Mom could not be discharged from where she was for the next 3-4 days, and baby was 6 hours away in NICU. Dad shuttled between the 2 places daily, until mom was finally discharged and was able to see her baby. In adition, the hospital practices where the NICU was located were not mother-friendly, so mom was not allowed to touch or hold her baby for several days. She could only see her baby from outside the glass walls of the intensive care unit.

Finally the baby was discharged from the NICU in good health, and as I write this mom and baby have been at their home for several days, and both are doing well. Since the mother had continued to pump breastmilk while her baby was in the NICU, she is now nursing her baby without much difficulty. Way to go, mom!

As I was speaking to this couple, I thought I would re-emphasize the importance of choosing the right hospital for your baby’s birth. Not only is it important to choose a hospital that provides you with the best possible support and care that can promote a natural childbirth, but it is also important to check whether they have good emergency backup and post-delivery care infrastructure such as NICU facilities, should your baby need it. If not, at least you should check to see whether there are hospitals in the vicinity which offer NICU facilities, so that mother-baby separation can be kept to a minimum. Over and above this, there are several questions that you need to ask of your doctor and/or hospital, so that you can ensure the best possible birthing experience for you and your baby.

The Coalition for Improving Maternity Services (CIMS) is doing a remarkable job of advocating mother-baby friendly practices in US hospitals and medical facilities . I have adapted some of their recommendations in a document after making them relevant to the current Indian conditions. You can download the document here (Points to consider about your hospital).

In my next post, I will write about how Lamaze is helping women and their families in rethinking the different aspects of labor and childbirth.

Dr. Vijaya Krishnan

Recently I had the opportunity to read most of the 128-page report published by Childbirth Connection (www.childbirthconnection.org) the non-profit maternity care research and advocacy group, Milbank Foundation, a non-partisan endowment working in the health care field, and the RSG, a voluntary association of legislative leaders and policy makers in the US. Here is the link to the report – http://www.childbirthconnection.org/pdfs/evidence-based-maternity-care.pdf

The report is an excellent one, and gives credence to what maternity and newborn advocates have been saying for many years – procedures and practices which have been repeatedly known to cause harm, and which has been recommended to be used only in limited circumstances are today widely in use, and are often routine in most hospitals. As I kept reading, I could not help wonder that if the US health care system, with its watchdogs and numerous checks and balances can receive such an indictment then what are the implications for India, where advocacy is almost non-existent, and many hospitals have almost 80% c-section rates?

The report mentions that US hospital charges for maternal and newborn care in 2006 were $86 billion, a nearly 9% jump from 2005 figures. Of these, unnecessary c-sections took up $2.5 billion, representing almost 33% of all US deliveries. Further, I was surprised to note that a 2008 study conducted by Agency for Healthcare Research & Quality (AHRQ), looked at 2005 data and concluded that childbirth in the US was the leading cause of hospitalization, surpassing heart-failure, cancer, and stroke. Maternity care (pre and post-partum visits) was the third-most frequent reason for all outpatient visits. Further, at $79 billion, cost of hospitalization with respect to maternity care (women and new born) was by far the largest component of health care costs in the US, according to the same study conducted by AHRQ.

Private insurance paid 51% of costs of hospital stays in the US, with government Medicaid picking up 42%. It was also surprising to note that going by 2005 data, 49% of all hospital procedures done on the 18 to 44 year-old population were related to childbirth. Six of the 15 most commonly used procedures done on the entire US population involved childbirth, according to AHRQ. Some of these include medical induction (2nd), c-section (7th), fetal monitoring (13) and artificial rupture of membrane (14th).

So what does this mean to us in the Indian health care context? I would love to read such a report prepared for India that captures some of the same facts in the above report. I encourage anyone interested in creating such a research finding to get in touch with us so that we can collaborate or point us to good, existing  research data. I know of two not-so recent research studies, one conducted in Delhi and one near Chennai.

I would also imagine insurance companies, both government and private payers, would be interested in knowing where their money is being spent and how. Evidence-based research has shown repeatedly that physiological approach to childbirth without routine intervention provides the best outcomes for a healthy mother, and for her baby AND is less expensive for insurance companies, specifically by avoiding costs involved as a result of technology-led interventions, and post-partum issues that occur because of c-sections. I invite responses from Indian insurance company stakeholders on what their company’s view is. It would be interesting to note their take on the issue.

We at Healthy Mother believe in the power of physiological approach to childbirth and in the natural ability of a woman’s body to give birth without external intervention in most cases. In our classes we reinforce this confidence in the minds of women and their families and follow evidence-based practices that facilitate a fulfilling and healthy childbirth. It is our belief that a system that promotes normal childbirth with continuous labor support in the form of midwives/trained labor support personnel, and one which relies on medical intervention only as a backup, is more beneficial to families, society, and to the entire nation as a whole.

As usual please send me your comments…

I have been on an unintended hiatus for the past few weeks…. Reviewing the comments in response to my posts, I am surprised that almost all questions have been in the area of Cervical Insufficiency. Why is that? Granted this experience may not be statistically significant, it got me thinking as to why so many questions…

It is a fact that many women, by nature, have a hard time in asserting themselves. This is even more evident when they are vulnerable and stressed during the time of their pregnancy. Many expectant mothers often do not have much idea about how their body changes and the reason for and management of issues such as Cervical Insufficiency, low-lying placenta etc. Many a time, their doctor does not either have or take the time to explain fully all the implications of the issues.

I would think that giving more information is a good thing because women can have a better understanding of their body during pregnancy and will become more confident in their bodies’ ability to give birth. In our Healthy Mother program, we teach our would-be moms and dads how mother-nature has endowed a mother’s body with natural abilities to give birth and how to use this endowment with diligence and minimal external medication. While we are all for medical intervention during an emergency, we find that many would-be mothers and their families do not have the information that they have a right to, and are being subject to more-than-required levels of medical intervention.

The other day I met with a friend of mine, who is a well-known anesthesiologist. He specializes in “labor analgesia”, the sanitized term for epidural. While we were talking about his work, he said that there is an increasing trend among Indian women to prefer epidural during the early stages of labor. This surprised and troubled me – as the Indian economy expands and as people are exposed more to western cultures and practices, my guess is that some of the Indian traditions that deal with natural ways of pain relief and management during labor are being brushed aside. Studies have proven the long-term risks of epidural for the mother and have also proven the fact that the process of labor is actually good for both the mother and the baby. We are proponents of natural and healthy ways for pain relief, those that have been followed by women in many cultures through many generations – breathing, relaxation, rhythms, rituals. We follow the philosophies of Lamaze International and WHO to promote, support and protect normal birth, and so advise our participants to consent to epidural only as a last resort. Let me close by asking my readers their opinion about whether they would choose epidural if they were pregnant. How many of you actually chose epidural during your labor, and how many were actually informed of natural ways of pain relief by your medical team?

Keep those comments coming; and feel free to ask questions.

Dr. Vijaya Krishnan