OB/GYN and medical educator Dr. Amali Lokugamage talks with Adriana about how being pregnant propelled a paradigm shift in her ideas about birth, leading her to give birth at home. A champion of human rights in childbirth, she shares why birth recommendations have become so hospital-centric, and why it would benefit us all to embrace more family-centered, integrated, and collaborative models of care.
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- The evolution of an obstetrician: before and after being pregnant
- How pregnancy can heighten your intuition
- Trusting what your baby tells you
- The need to move away from a “one-size-fits-all” approach to medicine
- Ways OB care can evolve to encompass that intuition
- Organic Birth: getting medical students to be more comfortable with physiologic birth
- Creating a cooperative care between midwives and OBs
- “Intero-receptivity”: your inner sense of balance just may be increased by oxytocin
- The biochemistry of trust
- Your human right to autonomy over your body
- Some ways to increase your pregnancy intuition
- What her colleagues thought
- Decolonising ideas of healing in medical education, Journal of Medical Ethics
- Racism in UK maternity care risks safety of Black, Asian and mixed ethnicity women – study, The Guardian
- Biobehavioral responses to stress in females: tend-and-befriend, not fight-or-flight, Psychological Review
- Too far to walk: maternal mortality in context, PubMed, about the Three Delays Model
- Utility of the three-delays model and its potential for supporting a solution-based approach to accessing intrapartum care in low- and middle-income countries. A qualitative evidence synthesis, Global Health Action
- Birth Outcomes for Planned Home and Licensed Freestanding Birth Center Births in Washington State, Obstetrics & Gynecology, about a well-integrated perinatal care system in the U.S., more similar to perinatal healthcare in the U.K.
- Organic Birth movie
- The Heart in the Womb: An Exploration of the Roots of Human Love and Social Cohesion, by Amali Lokugamage
- Within the Pregnant Pause, by Amali Lokugamage
- Suzanne Arms interviews obstetrician Dr. Amali Lokugamage, via YouTube
- Obstetric violence and Human Rights presentation, via YouTube
- The Costs of Institutional Birth – Wake Up Call for Obstetricians lecture, via YouTube
- Birthlight Womb to World Conference 2013 – Dr Lokugamage Presentation and Panel, via YouTube
Related Birthful episodes:
Why an OB/GYN Chose to Have a Homebirth
Adriana: Welcome to Birthful, Mighty Parent or Parent-to-Be. I’m Adriana Lozada
Amali Lokugamage: Being an obstetrician, most of the births that I’d seen— because of the nature of the UK system of obstetricians only handling abnormal birth— my mind and my memory of births is full of medical problems. So having these two people that I trust, who I’ve observed have good results, was very beneficial for me— an antidote for my many years of immersion in problematic obstetrics.
Adriana: That’s Dr. Amali Lokugamage, who is a consultant obstetrician and gynecologist involved in medical education in London, U.K. And she’s talking about the connection that she developed with her midwives and some of the really deep work that she had to do after intuitively deciding that birthing at home was the best course of action for her and her baby, for this particular pregnancy.
Dr. Amali is also on the Board of Directors of the International MotherBaby Childbirth Organization and is a former member of the Advisory Board of Human Rights in Childbirth.
Now, this episode not only ties really nicely with our previous episode on homebirth, with Robina Khalid, but it also circles back to so many of the ideas that we’ve touched upon during this series on Models and Places of Birth.
My conversation with Dr. Amali was, in fact, one of the very first ones that I did for the podcast, and so I find it a very appropriate way to close out this series. Her unique perspective just really puts on a spotlight on both the theoretical and practical aspects of birth while also championing healthcare human rights, upholding the importance of autonomy and bodily integrity for true respectful care in pregnancy, and uplifting the value of connecting with your body, and with your intuition… which, is of course, is right up our alley.
You’re listening to Birthful, here to inform your intuition.
Dr. Amali, thank you for taking the time to talk here today.
Amali: Hi, Adriana. Nice to be with you on your show.
Adriana: So you also have a son who, while in-utero, led you to have a homebirth. Tell us a little bit more about that.
Amali: Well, let’s start off with the fact that before I got pregnant, I suppose I was always a broad-minded doctor, but I remember quite distinctly for most of my career that I thought a hospital birth was the best way and the safest way. And I remember— again, before I got pregnant— thinking that women who desired homebirth were misconceived, that I didn’t really understand why they should want to do it, y’know, a bit mad, but I think my pregnancy and the experience of pregnancy educated me.
I think in an average medical education, doctors are taught in an intellectual idea of birth and science (which is a very intellectual pursuit), but birth and the changes that occur in a woman during this very unusual time of life is a very physical and experiential experience.
It’s an immersion into an area— when some women described— there was a heightening of inner wisdom and an enhanced sense of intuitive decision-making. And, I think during my pregnancy, I— through some unpredictable conditions of pregnancy, not serious conditions, but conditions that kept me away from my usual place of work— I was allowed to, in fact, broaden my outlook, broaden my understanding, deprogram myself from some very fixed ideas about birth, and become very mindful and aware of my body and the baby growing within me (my son) and of an exchange of awareness and information between us both. And it wasn’t until halfway through my pregnancy that this intuitive connection started making me feel that my body was capable of birthing normally— and a subjective experience which can’t be scientifically evaluated, but nevertheless, a very strong feeling and a strong connective communication between my son to myself— that he wanted to have a homebirth because in those circumstances, he would know how to give birth and it would be the best place for me.
I think— being a very senior doctor within the NHS (the National Health Service)— I think a lot of my colleagues would quite naturally, if I’m in labor, be quite worried and have a lot of anticipatory anxiety about my birthing process.
So I felt that being at home and in the kind of heightened state of, I would say, an enhanced knowledge about myself and what was best for me, would be actually the safest place to give birth for me. Though, I have to say that, this decision-making was particular to my son and if I were to have had another baby and the baby were to say, “I need to go to hospital for a cesarean section,” or that would be that intuitive, very strong feeling, I would do that. So in this particular pregnancy, that was what I felt led to do through a kind of what I would say an “inner wisdom,” which I wasn’t really aware that a lot of women talk in those terms, but after my pregnancy reading around the subject, I realized that a lot of people actually talk about pregnancy in those terms.
Adriana: I think you’ve hit upon a key element that I like to explore more, which is how every pregnancy can be so unique and how the circumstances are very much, y’know, that intuitiveness and connection with baby can lead to different decisions and the importance of— on the side of the caregivers— of not applying sort of a cookie-cutter care, which is something that I… Do you feel that is more common within the obstetric care?
Amali: No, I think it’s throughout all of medicine. Over the last 15 years or so, or possibly a little bit longer than that, there has been a kind of one-size-fits-all flavor to medicine, where it’s felt that applying a certain way… a certain way of taking care of people to a whole population was the best way of achieving health for all.
But I think there is a movement away from that. There are certainly lots of very insightful publications from very high-ranking academic staff from all over the world publishing papers on evidence-based medicine. And the fact that, often rules and, well, guidelines and protocols map poorly to complex problems in patients. And there is that recognition that one has to tailor care. And also, that there should be the respect for autonomy in decision-making. But I have to say, in the U.K.— and I’m aware that there’s a difference between the U.K. and the States— homebirth is one of the sort of “average” options for women. It’s not thought of as a sort of a strange thing to do. And we have an integrated health care system where midwives and doctors communicate with each other and have a joint care over women. And that’s what I felt that I received in my particular case, so there was always that sort of team-working.
Adriana: And things are definitely a lot more disjointed over here in the U.S., where I’m at! What do you think would be a good way to get the doctor students to try to adapt this model a little bit more?
Amali: So part of my everyday role is with the medical school that I worked for in London, which is one of the sort of foremost ranking universities in the U.K. University College of London. And within that medical school, we have a component of training which is about the integration of psychology through every aspect of health, ethics, and law (what they call social determinants of health) interlaced with all of medicine. And within that kind of integrated health stream of education, I certainly deliver a regular syllabus to students on the psychobiological aspects of birth. For instance, I show my medical students each cohort (which come to me every four weeks) Debra Pascali Bonaro’s Organic Birth, which is the shorter form of Orgasmic Birth, so they can see that birth is not necessarily a difficult and painful experience, but can even be joyful and pleasurable for some. They get lectures on evidence-based medicine, risk and autonomy, and human rights. And so in my medical school, we certainly do deliver that type of education, and certainly there is hope for the future.
What I’ve noticed, that after you graduate as a doctor, there is a little bit of education on the psychobiological aspects of pregnancy, but not as much as I think the future doctors will bring to the table. So it’s more the older generation of doctors that probably haven’t had that type of education.
Adriana: Yeah, I’m just… I’m thinking and trying to figure out, because I find that not a lot of the doctors that are coming through the ranks get to experience a natural birth or get to see how it can develop without having to meddle with it, and like you were saying, maybe that the other colleagues around you, if you were to have the birth at the hospital, would be worried. And that there’s enough research that shows how the energy in the room and that worry can affect how the moms react to labor and how labor develops. So, I guess there, the essence is trying to get them to see films like Organic Birth, and to… it’s such a… requiring a paradigm shift in their minds of seeing it as a normal thing.
Amali: I think you’re right. I think I remember when I was in their shoes— oh, that’s probably about more than 27 years ago or more— I got more experience in normal birth. And my education, which was typical of medical students and my cohort of colleagues, is that I had to observe ten normal deliveries and then conduct or be involved in ten further deliveries. And now, because of the rise in cesarean section rate, it is much harder for medical students to actually gain that experience. And it’s quite conceivable that the average doctor who doesn’t end up doing obstetrics, will only have been exposed to perhaps one or two or three normal deliveries in their lifetime.
And most of them would have had some form of intervention, like an epidural. And that’s why I think it’s quite important, and something I’m pushing for, is for the use of audio-visual materials about normal birth. In my medical school, medical students could go to a homebirth if the timing was right, but because it’s rather difficult when fitting into a syllabus, the audio-visual and the video materials about homebirth is probably one of the best ways for them to get an idea of that type of birth, which is so, so different from a hospital setting.
And even if, say, a student doctor goes on to pursue the speciality of obstetrics, then in the U.K. where midwives deal with normal pregnancy and the doctors deal with the abnormal stuff, there’s even less opportunity to see a physiological birth, an undisturbed birth, and even more important for visual materials to be there for a doctor. So, it’s my hope that we can develop this sort of thing in the specialty training that occurs after your basic medical degree… but I think it will be a bit of a slow process, and I can see that the World Health Organization is very interested in respectful maternity care.
And they’ve even understood the word “obstetric violence,” and they’ve even understood the concept that in facility-based birth there can be a focus on intervention for no good reason. Of course, facilities have to be there for obstetric emergencies, and that’s one of the basic needs of a community. But certainly if the World Health Organization is understanding this, there is movement and understanding within medicine.
Adriana: And I’d like that there’s movement so that what you’re speaking to is the movement that happens at higher levels and institutionally, globally. And I think there’s also a movement on the consumer/individual basis, where moms are becoming more informed and trying to realize that they… that it’s their experience and they do have choices and they need to inform themselves so they can make the choices that are right for them.
But I also think it’s really important for them to hear things like what we’re talking about, sort of demystifying a little bit the authority— not authority, but the “physician as all-knowledgeable”— because if their wishes are to have a natural birth, it’s hard sometimes to have that intuition be heard and to find your voice to speak loudly when the person who very much is caring for your health may not necessarily trust what you’re feeling or have a relation or know what you’re feeling because there haven’t been exposed to it and just know the intervention part of it.
Amali: I think medicine still has a long way to go, in understanding— how should I say— in a wisdom, the body speaking. There are some scientific publications coming through, with a scientific concept of intero-receptivity, which means that the person becomes aware of what’s happening in their body, their inner sense of balance. And interestingly enough, there have been a few fledgling reports about how oxytocin increases intero-receptivity, increases your inner awareness of what is going on, so that’s interesting! I was actually amazed to hear that in my own university, as part of this integration of professional development module that I was talking about, that there was a lecture in second year of medical school on embodiment and the definition of that in psychological terms.
So again, there is some movement within academic centers. But that is definitely not a, sort of, a strong message that’s going out in the average education. So the only terms in which a woman can vocalize her needs by whatever means— whether she has intellectually thought about it or it’s through her intuitive reasoning— is human rights and her rights to autonomy over her body, and that is something that is recognized worldwide. And so that is probably the only avenue in which a woman could articulate the rights over her “body integrity,” which is another term that the World Health Organization had in their statement about respectful care in pregnancy.
So in my average antenatal clinic, which I hold weekly, when I hear women with these sort of requests, I use a multidisciplinary approach, but what I listen for— but again, this is just my perspective— is whether this decision has come from a place of inner wisdom and listening to their bodies, or whether it’s an intellectual pursuit (just for the principle of wanting an idea intellectually or for the principle of human rights or the principle of feminism). And then I have to admit, I feel a bit more uneasy because it’s coming from a place where the body hasn’t been listened to, but whatever it is and whatever the processes that are going on in my mind, I recognize that, fundamentally that a woman has autonomy and as long as things are discussed and from a hospital’s medical/legal perspective, documented— then I will organize a multidisciplinary team with senior midwives and we try to do the best that we can essentially. And that’s my personal practice, but I know that that isn’t the experience of all women, but those are the principles that I employ at my hospital.
Adriana: And so what would you say to moms— both from a professional and a personal point of view— in terms of how they can increase that tuning in and listening to their intuition?
Amali: Well, I… what helped me in my pregnancy was actually— and this is not a recipe for all, by any means— but what really helped me with slowing down. If you’re rushing around, if you’re at work, it’s harder to get there. But if you have no choice but to rush around, I did pregnancy yoga, which helped me sort of slow down, become very aware of my body. It had time for that connection to my baby. And certainly there are publications saying that the mindfulness practice in pregnancy yoga does reduce fear and apprehension of birth and gives you a sort of an awareness. So, that may not suit all people, but I think in a Western civilization that hasn’t been around for, y’know, eons, one has one’s body. And if you’re given the space and if there’s support in society, support of the partner, or if a woman can find a group where they can talk to other pregnant women, that can also help.
I think there is a study by an author called Taylor from UCLA that says when women gather together and talk in circles and share their concerns, their oxytocin levels go up and then their stress levels reduced as a result of that. So group circles of women would help. I’m not proposing a one-size-fits-all way to awareness…
Adriana: And I wouldn’t expect you to!
Amali: …yeah. But those are the things that helped me, and I think for individual women, they might… they may find their own solutions, but having some space to be with themselves, to explore themselves, and hopefully a bit of support so that they can get that space, is a way into that kind of sense of health balance/inner awareness. A doula is of course, I think, another way in, having support. Having continuity of midwifery care, I think that there’s something about the biochemistry of a trusted relationship and support that again, I think may have something to do with the biochemistry of trust— and we know oxytocin is involved in the biochemistry of trust— and then that would give you perhaps a sense of internal awareness. So, y’know, those sorts of things.
Adriana: I’m really liking that phrase “the biochemistry of trust,” because it really brings together the science and the intuition and mind and body and spirit and all of those components that make us whole!
Amali: Yes, I think that’s quite a topic in health, actually. That’s hopefully going to be expanded upon as I can see that colleagues are awakening to that in terms of decision-making.
Adriana: I’m going to start using it a lot more as a phrase. I think it conveys a lot. Now, in terms of the support that you were talking about when you made your decision, which was I’m sure unexpected even to you! How did the people around you react? How did you find the support? Or did you find surprise or astonishment?
Amali: I had continuity of midwifery care from, I suppose, midwives/senior midwives that were very good colleagues, so that was good. And they— I knew that two good colleagues were going to be there, two midwives, so I know you could say that maybe not all women would have that opportunity.
But being an obstetrician, most of the births that I’d seen— because of the nature of the U.K. system of obstetricians only handling abnormal birth— my mind and my memory of births is full of medical problems. So having these two people that I trust, who I’ve observed have good results, was very beneficial for me— an antidote for my many years of immersion in problematic obstetrics.
Some of my colleagues— not my immediate consultant colleague who looked after me, but, so, a couple of my male colleagues— were very concerned and I could hear them saying, “Oh, please do have a cesarean section, Amali!” Anyway, y’know, that’s their perspective and that’s where they’re coming from.
And I— y’know, with all the doctors that really have a lot of consternations about homebirth— I really understand their perspective. I completely get it, because I remember being in that position before. There’s a principle in global health, which I think has led to the WHO having their recommendation to the world saying that women should be directed towards facilities for birth, is a model in global health called the Three Delays Model. Are you familiar with that, Adriana?
Adriana: I am not.
Amali: So the three delays are: the first delay is the woman or her immediate caregiver not appreciating a problem in pregnancy, and not knowing that there is a problem means that they don’t seek the relevant medical healthcare.
The second delay is: once they have realized that there’s a problem, there may be infrastructural issues in terms of lack of transport or societal issues in developing countries— say, a woman has to gain permission from a village leader to travel to a hospital— and there can be delays at that level.
And then the third level of delay: is problems with the actual facility. In a developing country setting, perhaps it’s lack of blood transfusion or the necessary surgical expertise or any kind of that sort of stuff.
So there has been, on a global health level, a kind of worry about these three delays and that’s why they’ve recommended facility-based deliveries, but then now, and certainly the Safer Motherhood and U.S. Aid, have picked up the fact that facilities can’t cope with that many normal women in labor.
And that when you herd people into a sort of industrial model of health care, the humaneness of that care reduces, and that’s when you get the disrespectful care. So, I think, going back to the experience that has happened in England, that has led to the fact that we are now becoming more aware that we have to have compassion, which is an obvious thing! In the system, it’s because of the principles of medicine from a kind of political/infrastructural kind of perspective where there has been a thought that to make health efficient, you have to kind of have a factory line model, and human beings just don’t work that way. And I think this is now being recognized, so we have to see what comes forth. And I have no solution for every woman in terms of if she has difficulties with a healthcare provider, what she has to do, but look locally and see what the setup is in terms of support. That’s all I can suggest, really.
Adriana: And it’s a huge suggestion because I think the fact that we’re talking about this and women hearing that there are possibilities and options and choices, and that they can be encouraged to go and look a little deeper and listen to their intuition and to their bodies, will ultimately improve the whole system, both from the upper level and the consumer level. So I thank you so much for one, having listened to your intuition during pregnancy, and also for all the work that you do to try to make birth a better experience for all moms.
Amali: Thank you. Adriana. Lovely to talk to you.
That was consultant OB/GYN Dr. Amali Lokugamage. Her most recent book is called “Within the Pregnant Pause,” where she combines medical knowledge with mindfulness, beauty, and compassion. You can find Dr. Amali on Twitter @docamali
And you can connect with us on Instagram @BirthfulPodcast. In fact, we would love to hear what your biggest takeaway was from this episode, so, if you are not driving, please take a screenshot right now and post it to Instagram with your thoughts, and make sure to tag @BirthfulPodcast so we can see it and share it.
You can find the in-depth show notes and transcript of this episode at Birthful.com, where you can also learn more about my birth and postpartum preparation classes and download your free postpartum preparation plan.
Birthful is created and produced by me, Adriana Lozada, with production assistance from Aysia Platte.
Thank you so much for listening and sharing Birthful. Be sure to follow us on Goodpods, Apple Podcasts, Spotify, Amazon Music, and everywhere you listen.
Come back for more ways to inform your intuition.
Lozada, Adriana, host. “Why an OB/GYN Chose to Have a Homebirth” Birthful, Birthful, May 25, 2022. Birthful.com.
About Dr. Amali Lokugamage MBChB, BSc, MSc (Epidemiology), MD, FRCOG, SFHEA
Dr. Amali Lokugamage is a consultant obstetrician and gynecologist and involved in medical education in London, UK, who— through the process of having quite a revelatory pregnancy— ended up choosing to birth at home.
Dr. Amali’s main clinical interests lie in medical gynecology and general obstetrics with human rights in childbirth, normalizing birth, maternity acupuncture, and holistic gynecology. She has authored the acclaimed book The Heart in the Womb: An Exploration of the Roots of Human Love and Social Cohesion, and, more recently, Within the Pregnant Pause, which blossomed from the perspective of looking after pregnancy as an obstetrician & during the time of the pandemic restrictions.
She is on the Board of Directors of the International MotherBaby Childbirth Organization (which is a UN recognized NGO); a former member of the Advisory Board of Human Rights in Childbirth; and on the Editorial Board for the International Journal of Childbirth.
She is a champion for healthcare human rights and is involved in compassion and patient experience projects at her London hospital.
Dr. Lokugamage is an internationally invited speaker at many multidisciplinary Birth conferences promoting respectful care, dignity and autonomy in maternity services. She has a keen interest in Integrated Medicine and the psychobiological dimensions of diagnosis and treatment.
In London she leads an NHS maternity acupuncture service. She is a Trustee of the Birthlight Trust where she instigated a pregnancy yoga dance project. Dr. Lokugamage also has expertise in the treatment of chronic illness integrating both standard and complementary medicine modalities in a patient-centered approach.
You can connect with her on LinkedIn.
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