Photo by Carolyn Brown
Birth Plan: Does the Path Still Fit the Objective? Do the Means Still Fulfill the Purpose?
Midwifery Today, Issue 146, Summer 2023.
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Abstract: The usual birth plan tends to focus more on the medical practices and interventions and less on women’s needs, such as the perceived safety and assistance of the medical staff in helping women meet their needs and explore new alternative strategies to the concerns which may arise. Medical birth support has fixed structures, standardized procedures, and guidelines for medical safety and security. However, it often cannot be reconciled with the personal and individual needs of women, such as the feeling of safety and body awareness. Current studies suggest that although a birth plan helps women become more aware of their wishes, it does not improve communication or relationships with caregivers, does not increase women’s involvement in decisions during labor, and, overall, women are more dissatisfied with midwives’ listening, support, guidance, and respect. Birth plans that include communication about the mother’s most important needs and safety, as well as a linkage of the skills and competencies of the mother and medical staff, may create a welcoming and trusting atmosphere.
In the process of establishing a birth plan in the ’80s in the US and Europe, an effort was made to make women aware of their choices during labor. It took about 50 years—two whole generations—until women started to face the medical interventions while exploring their own possibilities during childbirth. The formally written birth plan was introduced in the 1980s as part of childbirth preparation to help women avoid escalating interventions (Lothian 2006). Kitzinger (1992) described this in the 1980s as “a rediscovery and restoration of women’s traditional control over the birth environment.” In the following 20 years, childbirth education classes became the medical and medical-led standard. According to Ondek (2000), they are used to market obstetric programs and control the content being taught and, thus, the expectations of birthing women. As a result, the birth plan was quickly institutionalized and birth plan templates were developed to reflect available options.
Today, interventions are an almost inseparable part of childbirth, and birth plans are likely to reflect the desire for interventions, including epidural, elective induction, and c-section, while expressing women’s demands to avoid unnecessary interventions (Lothian 2006). Kitzinger (1992) claimed that “[t]he more restrictive a hospital’s policies, the more likely women were to submit birth plans that were checklists of medical interventions.” Birth plans often suppress communication rather than encourage it, and provoke mistrust between women and caregivers, on the one hand, and women and birthkeepers on the other.
Despite the original expectations, numerous studies have shown that the use of a written handover plan is not significantly related to the level of participation in decision-making (e.g., Brown 1998). Although women find written birth plans helpful (Brown and Lumley 1998; Whitford and Hillan 1998), most research suggests that there are no differences between women who have a written birth plan and those who do not, in terms of anxiety, pain, or general experience (Brown and Lumley 1998; Lundgren et al. 2003) or sense of control (Brown and Lumley1998; Lundgren et al. 2003; Whitford and Hillan 1998). Pickrell and Marshall (1989) reported a fourfold increase in the risk of operative delivery among women who use birth plans. In a qualitative study of empowerment and birth plans by Tools (1996), women perceived their choices as illusory and largely superficial; birth plans “did not enable women to have more control over birth.” Feelings of being undervalued and unsupported were largely the result of ineffective, authoritarian, paternalistic communication that did not help develop confidence, set goals, or make choices (Toos 1996). The lack of conversation about their birth plans by their caregiver made the women in the sample feel disempowered. Lundgren et al. (2003) found that pregnant Swedish women who had been asked to complete a birth plan were less satisfied with the midwives’ listening, support, guidance, and respect after birth than women who did not complete a birth plan.
In health care, interaction and interpersonal behavior are of great importance and strongly influence experience. For example, birth-related traumatic stress sequelae are often related to the perceived or actual interpersonal behavior of health care professionals (Ford 2011). Most women indicated that the birth plan should receive more attention from the professional during birth (Alba-Rodriguez 2022). At the same time, midwives often perceive pressure regarding birth plans (Welsh 2014). According to Jones et al. (1998), birth plans do not improve relationships but rather irritate staff and negatively affect obstetric outcomes. The tensions between health care professionals and clients caused by birth plans reflect current broader issues in prenatal care, such as conflicting beliefs about birth, perceptions of safety and effective care, and ethical issues related to informed consent and informed refusal (Lothian 2006).
Some of the more recent studies further focus on the goals that a birth plan should pursue. It should be a living document that reflects increasing information, changing circumstances, and ongoing communication (Lothian 2006). According to Perry and Collective (2002), the birth plan is not intended to be simply a list of wishes, but rather a tool to facilitate the exchange of information between women and those who care for them during birth. Communication includes an ongoing dialogue during pregnancy and childbirth to promote trust, respect, autonomy, and integrity for all parties involved (Perry et al. 2002). In the study of Brown and Lumley (1998) women reported that writing a birth plan allows them to discuss their feelings and thoughts with their birth partners and clarify their needs and desires with them, thereby initiating the development of a strong support network.
One leading midwife told me two years ago: “If the woman comes in with a detailed and lengthy birth plan, I do not need to read it because I know, as a midwife in a birth clinic, that I am not in a position to fulfil it, even if I wanted to. Almost all points listed in the birth plan are part of my competence as a midwife. So, why is she here? But this plan leaves no room for discussion. Every time I see a plan like that, I know that it will have a different outcome than that.”
In a case study analysis, ethicists Perry et al. (2002) described a lack of communication as an important barrier to birth plan success and informed decision-making. On the one hand, pregnant women have a need to prepare themselves for labor and to communicate their preferences and wishes trustfully. On the other hand, midwives are birth experts with wide competencies, supporting women through natural labor and complications. Furthermore, there is also the birth plan—one of their first communications/contacts when the woman arrives in the hospital. Then the midwife immediately reads which techniques, interventions, and sometimes some (or all) of the competences she is not supposed to use. At the same time, she also knows that the labor may bring situations that need flexible handling and occasionally rescheduling.
The research of Brown (1998) clearly states that “[t]he lack of an association between the use of a written birth plan and variables assessing women’s views about intrapartum care suggests that there is insufficient rationale for continuing to advocate for policies that encourage pregnant women to complete written birth plans.” (Brown 1998) In the last three years, for example, in Germany, women giving birth have been encouraged to write a living will for the birth, which should preserve their rights, possibly leading to even more pressure and tension between the medical staff and them. Therefore, it would be beneficial to think about how the general view of the birth plan could change and what can be fulfilled.
We usually constitute birth plans using our logical and cognitive mind, to inform us about the birth process and available options and create a list of our informed decisions. The ability to answer questions regarding individual preferences, perceived safety, and wellbeing-related concerns is connected to the relationship we have to our self and body. Some women might demand counselling and support for core needs and emotions felt in their body that they identify by listening to their inner voice. Birth is a body-centered process. Therefore, we also need to listen to the body’s inner sense about its preferences and concerns, for example, about trusting the medical staff and the new environment . Otherwise, this inner sense may remain uninvolved or, much worse, ignored.
While a woman may aim for a safe and personally satisfying birth, unfortunately, “medical guidelines assign a more significant role to the cognitive notion of safety than to what is felt.” (Porges 2017) Moreover, birth plans consistently do the same. Birth plans that were initially created to prevent interventions and help women meet their choices have become a tool to focus just on the available medical options.
“The question is the prelude to more, it is the beginning of a togetherness that only ends when the questions run out.” (Kindl-Beilfuß 2011)
The common birth plan focuses on the future and predicts what the future self is willing to achieve. How much latitude do parents—who are dealing with the process of childbirth and their needs—have in weighing the options for medical interventions beforehand? How free are they to make decisions when the birth begins? Finding out and communicating the core needs for such a situation like labor is not possible without concentrating on the present. Most women are just aware of superficial concerns such as identifying their preference for giving birth in the water or not, or with or without medication. If a woman cannot or does not know whether to trust medical staff, it might be even more important for her to write a long and very detailed birth plan. She might also have some expectations not only about the plan but also about it being followed. Furthermore, it should be questioned whether the focus is on her core needs and preferences or on her anxiety and hidden concerns. The distrust is a result of another event that has nothing to do with the experience of giving birth and what future mothers might need.
One client of mine taught me how important it is to be willing to change the point of view. We were talking about her previous labor and the moment when she started to feel unsafe and was not able to be aware of the situation. Her midwife told her: “It will never work like this.” She gave up and agreed to a caesarean delivery, blaming herself. I asked her if she had had similar experience in the past. Without thinking much, she agreed and told me that she had never been trusted by the people surrounding her. Her sister was, but she never was. And it is still like that.
I asked her: “Is there a need to be trusted? Would you consider letting the midwife know about your need for a change?” She agreed completely. So, I asked: “How can you let the midwife know about that need in your birth plan?” Then, step by step, we created a list of her personal values instead of a plan. It was a collection of her personal needs with a request that a midwife support her in this way.
Beautiful speech is like a magic tool in dealing with other people. Using a language that is inviting and asking for support, respecting, and being open to the receiver to make his or her own choice can be very beneficial for both—women and midwives—to build a trustworthy relationship even if they are seeing each other for the first time. It is a great opportunity for a woman in labor to use this language and encourage a connection to the midwife, as she is kindly asked to support the woman to feel safe and comfortable. The midwife can obtain such important information and continue the communication with the woman throughout the labor.
Communication that leads to compassion and empathy in other people is powerful. It is actually what non-violent communication promotes and brings to people. It is important to ask the midwife if she is ready to hear what the client would like to ask for. From the beginning, the midwife is the expert with medical competence in the labor process. She is completely different from the obstetrician, who is focused more on avoiding pathological situations. The midwife supports a woman in labor with her competence in deep understanding of the process and skills regarding soft, non-medical or medical interventions that contribute to the natural progress of the labor. With only a list of bullet points or do’s and dont’s, her expertise cannot be honored. The conversation and exchange that are useful for building a trustful relationship, and possibly for a search for solutions and alternatives, are not encouraged.
If a birth plan aims for a safe and personally satisfying birth, the focus should expand from “these are the medical interventions I do not [or do] want” to “this is what I need, in order to experience as normal and safe a birth as possible for me, even if labor presents the unexpected.” (Lothian 2006) Being flexible, focusing on “I can” instead of “I can’t” and being a good team with support staff can make a huge difference not only for the outcome but also the way in which the woman experiences the labor. If there is something she “cannot do this way,” there is always another way she can. It is useful to be aware of this difference and support women to find their ability, even when they think the opposite is true.
It also makes a difference how a woman thinks about birth and its possibilities as she prepares for it. Therefore, the birth plan is not just to communicate the values important to the woman individually; it also can be a way to set expectations. Her assumptions and previous experiences and expectations can determine not only what she wants in a birth plan, but with the inner attitude, openness, and motivation with which she meets her midwife, doctors, and clinic staff. If a midwife assumes from the birth plan that the woman is open or willing or skeptical and distrustful regarding eventualities, interventions, and possibly also of her work, she can consider which offer might be most useful. Yet, the less leeway and flexibility there is in the woman’s ideas, the less offer the midwife is likely to see as useful. Therefore, it might be significant to look at what preconception the woman has about the clinic, midwives, doctors, and the medical system in general and how it is reflected in her birth plan. Avoidance strategies are usually linked to the feelings of fear, discomfort, anger, helplessness, etc., and are typically not helpful in transforming the previously associated experience into something positive or different. In most cases, they reproduce the same feelings repeatedly because the original trigger has not been conscious or seen.
A colleague of mine told me once: “Women should go to the hospital with confidence and trust.” It is an encouragement, a mantra, but it is also clearly too much to ask. I think it is much more important to think about how to build a trustworthy relationship with the midwife and medical staff. By taking the chance to identify our motives, expectations, and core needs during the labor when writing a birth plan, we open the room for better communication and trust with the medical staff, which might also help us to create a mindset toward more openness and flexibility and less avoidance, fear, or distrust. It is a big chance to find a way to build a great and supportive network that might create a trustworthy atmosphere the woman can feel safe in.
Communicating needs and adopting inviting language can be an important part of the process of creating trust, as well as self-reflection about gathered assumptions, previous experiences, and expectations. When a woman is aware of her needs and concerns and communicates them with openness—asking for support and maybe offering alternative procedures or looking for a solution with the midwife—the midwife can respond to those needs and concerns and search for alternatives and solutions together with the woman. Birth plans that include communication of the mother’s most important needs and safety comfort as well as linkage of the skills and competencies of the mother and medical staff can create a welcoming and trustworthy atmosphere.
For two years, I have been working and developing individual birth plans with my clients. By focusing on core needs and ways to fulfil them, the perspectives and expectations with which the women go into birth change. The process of creating a birth plan alone shapes my clients’ minds and the focus switches to something more essential than, e.g., avoidance strategies. Sometimes there is a well-known pattern. Frequently the focus on their own resources and strategies—which worked very well in the past, e.g., in one stressful life event—can be helpful. Also, the concentration on flexibility and ability of the woman brings new perspectives: “Where is my client flexible and where not? What does she need to become flexible again?” I experience with every client how they profit from the process of creating this kind of a birth plan. Very often we are able to find their personal Craft-Sentence—their personal mantra that is extremely strong because it comes out of them.
In the end, it also makes a difference for me, knowing not only the wishes but also the core needs behind those wishes. When we get in touch with each other and create a good connection, everyone is seen and listened to in an equal way. Everybody profits, allowing for creation of connections within the birth plan, also.
I am aware that the name “Birth Plan” or “Preference List” does not fit any more. Therefore, I am still looking for a new one. If you have any idea, please let me know.
I have developed a guide for the parents that may help them to create an individual birth plan. It is now in the testing phase. If you would like to test this guide with your clients, do not hesitate to contact me for the details.
References:
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