Birth plans: Managing patients' expectations [Podcast]

To read: Don't fear the patient with a birth plan

Susan Olmstead: I’m Susan Olmstead, editorial director of Contemporary OB/GYN. And today, I’m speaking with Dr. Yalda Afshar, who is a blogger for us and who is a maternal-fetal medicine fellow in the Department of Obstetrics and Gynecology at UCLA. So thanks for talking with us, Yalda.

Yalda Afshar: Thanks so much for the invitation to be here, Susan.

Susan Olmstead: As an OB, tell me about how you feel about birth plans.

Yalda Afshar: Okay, so I think even more than how I feel about birth plans, I really just support women’s decision to prepare for pregnancy, for childbirth, their experience in a way that they feel empowered. And if that includes writing a physical birth plan, then so be it. I’ll support her decision. I mean, the other caveat is that women that have birth plans, that cohort is actually increasing on labor and deliveries throughout the country. So we have to be cognizant of that. And I’ll speak a little bit later how perhaps, I think, the name birth plan is pretty restrictive. And I’m trying to use birth preference more so, in that we know birth really can’t be planned. So these preferences can be shared.

Susan Olmstead: I see. So, that’s a very good point. Well, I’ll start by asking, do you encourage patients to write out birth preferences or do you wait for them to bring up the topic? How does that work, typically?

Yalda Afshar: So, I definitely don’t bring it up. But I bring up – I don’t bring up the topic of a birth plan, per se, but I bring up birth choices. I love to discuss it prenatally, antenatally, before they present in active labor. And that’s really what I think the whole point of a birth preference document should be. It should kind of heighten the therapeutic alliance between the mom and the provider. And it should be a little bit of back and forth, some shared decision making.

So, I don’t encourage anyone to write it, but if they write it, I support their decision. More so, I kind of steer them towards more evidence-based decision making in creating one. And the other thing is, in the US, birth plans aren’t the norm on L and D. They’re outliers. In other countries, in the UK, in Scotland, they’re part of the national maternity record and it’s a standard of care. So it’s a little different.

Susan Olmstead: I didn’t realize that. That’s interesting. So there’s a national form that’s used universally?

Yalda Afshar: Yeah. A universal standardized kind of birth-preparedness document.

Susan Olmstead: Interesting. So, what if a patient does write up a birth plan and – you touched on this, but what if her expectations are unrealistic? You said you help steer toward more realistic expectations of birth?

Yalda Afshar: Yes. So that’s actually a big issue in this era of shared decision-making. We know that women who have a higher number of birth plan requests, they are less satisfied with their birth experience. The less things that are fulfilled from their birth document, the more unsatisfied they are. I think what’s important is that if someone has something that’s unrealistic, not part of the standard of care, we discuss that.

And that’s an issue with a lot of the birth plans that are found on the internet. They include a lot of outdated procedures. Things like prophylactic enemas, routine episiotomies. ACOG has had a stance against both of those for a while now. So helping to make things a little more tangible, real, and in touch with the day-to-day labor and delivery.

And I think it brings a good point. I use this topic of birth preparedness to say, “Hey, I come to work every single day saying, ‘How can I make the life of moms in labor better? How can I insure a safe pregnancy outcome for the mom and the baby?’” And I think that if that is spelled out between the two, there’s a little more trust. Sure, a birth document is just one kind of module to help bridge that.

Susan Olmstead: Well I’m sure that helps patients feel a lot more confident and comfortable. So if you were to develop the ideal plan, one that you would hope a patient might come to you with, what would it include?

Yalda Afshar: So we’ve actually started doing this at a couple institutions now. I think the ideal plan, for me, would be providing a patient a decision-making tool. So saying, “The evidence shows that having a hep-lock xyz. What is your preference about that?” “The evidence shows that a vaginal delivery is associated with better outcomes for xyz.” And then having them choose.

So it’s really decision-making tools. It’s evidence-based practice recommendations. And then really three arms: labor, birth, and newborn. One page, very simple. And again, a tool.

Susan Olmstead: Right. And I’m sure with the understanding that this is a changeable document. And I’m sure you help patients understand that labor is unpredictable and things happen that may certainly cause things to – cause the plan to shift. Is that right?

Yalda Afshar: Absolutely. You know, labor is dynamic. And that is one of the most important discussions to have is that neither the provider nor the mom has any control over the course of labor. So we can try to optimize some preferences, but really, in the end, labor kind of pans out. So, preparedness is important.

Susan Olmstead: Well, it sounds like you’re very in touch with what moms want and eager to work with them. So I suppose that’s the takeaway message.

Yalda Afshar: Yeah. And I think that we looked at this at a larger, provider-level recently. We did a national online survey that was distributed through professional societies and social media. We heard from about 600 providers. I mean, I’m sorry, 76 percent were obstetricians, the rest were midwives. To see, what do they think about plans and childbirth education. And it was pretty surprising.

Only 26 percent of the providers had favorable views on birth plans. And about 67 percent actually did not recommend birth plans. 30 percent felt they were predictors of poor obstetrical outcome. And then kind of the caveats are: and then, with more practice years, they had more favorable views on birth plans. And with higher obstetrical volume, they also had more favorable views.

So this is definitely not a national sentiment. I think that it’s a trendy topic. Moms are asking for it. And it’s important that if we believe in this therapeutic alliance and shared decision-making, as OBs, we start bridging that gap on our end.

Susan Olmstead: Dr. Afshar, thank you so much for talking with us. We really appreciate it. We’re glad to have you as a blogger for us, as well.

Yalda Afshar: A privilege. Thank you so much for your time.

Susan Olmstead: Thank you, bye-bye.