Don’t fear the patient with a birth plan

On L&D units throughout the country, more and more women are being admitted with birth plans. Birth plans have become an increasingly common part of women’s prenatal preparation. Women cite these documents as an opportunity for educating, empowering, and developing confidence about childbirth. My residency at a busy urban hospital piqued my interest in patient birth preferences and birth plans. However, despite the high proportion of women with birth plans, there was an unspoken negative perception of them by many L&D staff. The clear disconnect between obstetricians and patients was baffling. What happened to shared-decision making and patient-centered care? What was lost in creating this “informed consent,” this personal manifesto, and “(living) labor will”? Where are the power struggles?

Birth plans are often created in childbirth education classes to share preferences for birth and perhaps exert control over events during labor (which, as we obstetricians know, cannot truly be planned). A staggering 39% of birth plan content is drawn from the Internet, which occasionally includes websites of questionable medical accuracy.¹ Many of us have seen birth plans printed from the Internet that include requests to avoid outdated procedures such as prophylactic enemas or routine episiotomies. At times, rather than acting as an effective communication tool, birth plans can create unintended obstacles. They can cause women to be perceived as inflexible and feel disappointed with their birth experience when their plans cannot be implemented.

Birth plans were introduced in the 1970s to combat an overly medicalized view of pregnancy. A randomized controlled trial in Taiwan compared women with birth plans to those without, and found that women with birth plans had improved childbirth experiences, fulfilled childbirth expectations, and improved feelings of mastery and participation.² The results suggest that birth plans are an effective means of fulfilling expectations, affording a larger degree of control, and fostering a positive birth experience.

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A Swedish study of postpartum women found that women who had used a birth plan were less satisfied with their provider’s support and guidance than those who did not complete a birth plan.³ For high-risk pregnancies in particular, it has been shown that a birth plan actually intensifies negative feelings towards the birth experience.⁴

Despite the well-intentioned goals of birth plans, rarely is the approach to creating one streamlined and organized, largely due to the varied sources people use. We looked at women with birth plans and discovered that having a higher number of specific birth plan requests fulfilled correlated with greater overall satisfaction, higher chance of expectations being met, and feeling more in control.⁵ However, we also showed that having a high number of requests was associated with an 80% reduction in overall satisfaction with the birth experience. It is unclear if this discrepancy is due to women having higher expectations or a biased medical perspective. Perhaps there is a “paradox of choice” phenomenon in that too many choices have a proven detriment to our emotional wellbeing whereas a lack of choices leads to contentment, the framework that makes In-N-Out and Trader Joe’s (versus most grocery stores) so successful.

Ultimately, the purpose of a birth plan is to promote communication and not to induce friction between providers and birthing mothers. A survey-based study reported that 65% of medical personnel but only 2% of pregnant women believed that having a birth plan predicted a worse obstetric outcome.⁶ Obstetricians and midwives are justifiably concerned that birth plans attempt to control a process that inherently cannot be controlled or planned.

For a birth plan to be effective, it should not only take into account the unpredictable course of pregnancy and the dynamic process of labor, but also ensure continuous communication among all participants involved. Communication during the birthing process should acknowledge birth plans as fluid documents that “evolve” with the unpredictable nature of labor.

Today in the United States, birth plans are still the outliers, not the norm. In Scotland, use of birth plans is endorsed at the national level and they are standardized to a national maternity record, which to some extent has normalized their use.⁷ Similarly, some institutions in the United States have also begun implementing such documents, allowing mothers to make informed choices based on reliable information. This streamlines the creation process and maximizes the potential of birth plans as tools for effective communication during labor.

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I believe that physicians or midwives need to help integrate shared decision-making into the birth process to help women make use of the results of the best available research in reaching decisions about labor and delivery That counseling should incorporate medical evidence with respect to patients’ values, centered around flexibility to accommodate a patient’s needs and desires.

Decision-making is not completely a rational process; it includes elements of personal value, trust, and confidence. Because the fulfillment of birth preferences appears to significantly affect patient experience, it may be useful to establish a standardized approach toward creating and implementing birth plans to avoid these rifts. Rather than relying on potentially unreliable information, streamlining the birth plan creation process could maximize its potential as a tool for effective communication during birth. Incorporating a universal birth preference document with a cascade of options as part of routine standard of care acknowledges birth plans as flexible documents. It ensures that providers learn to look for it, and learn to adapt their practice style to safely accommodate patient preferences.

Birth cannot be planned, but preferences can be shared, and a provider must ensure that all parties are willing to adapt and be flexible, given the unpredictable nature of childbirth. I stand with the birthing community and believe the name “birth plan” is perhaps too restrictive. I propose renaming or marketing a “birth preference” document to emphasize the iterative nature of this process. Perhaps most importantly, providers need to be educated and encouraged to recognize that direct communication and shared decision-making is essential to facilitate and enhance women’s birth experiences.

References

1. Pennell A, Salo-Coombs V, Herring A, Spielman F, Fecho K. Anesthesia and analgesia-related preferences and outcomes of women who have birth plans. J Midwifery Womens Health. 2011;56:376-381.

2. Kuo SC, Lin KC, Hsu CH, Yang CC, Chang MY, et al. Evaluation of the effects of a birth plan on Taiwanese women's childbirth experiences, control and expectations fulfilment: a randomised controlled trial. Int J Nurs Stud. 2010;47:806-814.

 3. Lundgren I, Berg M, Lindmark G. Is the childbirth experience improved by a birth plan? J Midwifery Womens Health. 2003;48:322-328.

 4. Berg M, Lundgren I, Lindmark G. Childbirth experience in women at high risk: is it improved by use of a birth plan? J Perinat Educ. 2003;12:1-15.

5. Mei J, Afshar Y, Gregory KD, Esakoff TD. Birth Plans: What Matters for Birth Experience Satisfaction. Birth. 2016;43(2):95-86.

6. Grant R, Sueda A, Kaneshiro B. Expert opinion vs. patient perception of obstetrical outcomes in laboring women with birth plans. J Reprod Med. 2010;55:31-35.

 7. Whitford HM, Entwistle VA, van Teijlingen E, Aitchison PE, Davidson T, et al. Use of a birth plan within woman-held maternity records: a qualitative study with women and staff in northeast Scotland. Birth. 2014;41:283-289.