SEARCH

SEARCH BY CITATION

Keywords:

  • birth plan;
  • Mexico;
  • maternity care;
  • childbirth education

Abstract

  1. Top of page
  2. Abstract
  3. Methods
  4. Results
  5. Discussion and conclusions
  6. Acknowledgments
  7. References

ABSTRACT: Background: Increased medicalization of childbirth in Mexico has not always translated into more satisfactory childbirth experiences for women. In developed countries, pregnant women often prepare written birth plans, outlining how they would like their childbirth experiences to proceed. The notion of expressing childbirth desires with a birth plan is novel in the developing world. We conducted an exploratory study to assess the feasibility and acceptability of introducing birth plans in a hospital serving low–socioeconomic status Mexicans and to document women’s and health practitioners’ perspectives on the advantages and barriers in implementing a birth plan program. Methods: We invited 9 pregnant women to prepare birth plans during their antenatal care visits. The women also participated in interviews before and after childbirth. We also conducted in-depth interviews with 4 women who had given birth in the past year, and with 2 nurses, 2 social workers, and 1 physician to learn about their perspectives on the benefits and challenges of implementing a birth plan program. Results: All 9 women who completed a birth plan found the experience highly satisfying, despite the fact that in some cases, their childbirths did not proceed as they had specified in their plans. Interviewed practitioners believed that birth plans could improve the childbirth experience for women and health care practitioners, but facilities often lacked space and financial incentives for birth plan programs. Conclusions: Our findings suggest that birth plans are acceptable and feasible in this study population. Facility administrators would need to commit to provide the physical space and financial incentives necessary to ensure successful implementation. (BIRTH 34:1 March 2007)

In the past several decades, in part due to technical innovations and increased access to maternal health care services, childbirth in Mexico has become safer and perinatal and maternal mortality rates have decreased. Although 92 percent of women who gave birth between 1994 and 1997 received prenatal care and 82 percent of them delivered in health facilities (1), quality of care remains uneven, and previous studies have documented widespread use of questionable clinical practices, such as unnecessary cesarean deliveries and episiotomies. For example, the World Health Organization recommends that the cesarean delivery rate should not exceed 15 percent since clinically unjustified cesarean sections elevate health care costs and expose the mother and newborn to unnecessary health risks (2). Nevertheless, in 2003, the overall cesarean delivery rate in Mexico was 34 percent (3), and a recent study found that Mexican private hospitals had a 53 percent cesarean delivery rate (4).

Of particular concern to proponents of a humanized childbirth is that increased medicalization has not always translated into satisfactory birth experiences for Mexican women. On the contrary, in this atmosphere of sterile and often depersonalized care, practitioners do not always attend to the concerns, preferences, and emotional needs of pregnant women. Particularly in Latin American cultures, in which women are accustomed to play a passive, subservient role in the face of a seemingly all-knowing doctor, pregnant women may believe that they have neither the right nor the knowledge to communicate their desires or express doubts about clinical decisions. In a previous qualitative study conducted among women who had given birth in a Mexican hospital, participants thought that doctors delivered information in an authoritarian and confusing manner and that even in the face of poor treatment by medical staff, it was best to stay quiet because those who complained less were treated better (5). Rather than a rewarding and joyous occasion, childbirth for some women has become an anxiety-ridden, impersonal experience in which practitioners fail to take the patients’ opinions or feelings into account.

Beginning in the late 1970s, as a backlash to what they perceived as women’s diminishing participation in overmedicalized childbirth, birth activists in Western Europe began to push for the introduction of birth plans during antenatal care. A birth plan is a written document prepared by a woman during pregnancy, which outlines her preferences for the management of her labor and delivery (e.g., preferences with respect to whether to have a cesarean delivery, whether she wants pain medications, or whether she wishes to have her partner in the delivery room with her).

Generally completed with the assistance of a practitioner or a childbirth educator, the writing of birth plans is a process intended to educate a pregnant woman about available childbirth options, to empower her to communicate with her practitioner about her desires and needs, and to facilitate her participation in practitioner decisions about labor and delivery (6–9). Proponents believe that the birth plan has its greatest effect during labor, when a woman feels the least control and may feel vulnerable and particularly incapable of making decisions (9). For example, previous studies conducted in Sweden, England, and Scotland demonstrated that women found birth plans beneficial and that having a birth plan reduced anxiety during childbirth, even if not all the wishes of the women were fulfilled (6–9).

Our project was motivated by the critical need to improve quality of care and increase patient-practitioner communication in Mexican obstetric services. Researchers have documented the feasibility of birth plans in developed countries, where patient-practitioner communication is more the norm; but to our knowledge, no investigations of birth plans have been conducted in developing countries, where the notion of patient participation in health care decisions or of questioning a physician may be novel or unheard of. In addition, in developing country settings, women of low socioeconomic status may be even less likely to feel comfortable in actively communicating with their health care practitioners (10). Furthermore, women accustomed to play a passive role in health care decisions may not be comfortable with the prospect of communicating their childbearing desires, in which case birth plans may not be acceptable. Similarly, practitioners in these settings may resist the notion of having their patients be such active participants in clinical decisions.

We conducted a first-of-its-kind exploratory study at a private hospital that serves a low–socioeconomic status population in Ciudad Juárez, Mexico, with the objectives of: first, determining whether the implementation of a birth plan program would be feasible and acceptable for pregnant Mexican women and their physicians and second, documenting the perspectives and opinions of women and practitioners about the benefits, drawbacks, and challenges of implementing a birth plan program in the hospital.

Methods

  1. Top of page
  2. Abstract
  3. Methods
  4. Results
  5. Discussion and conclusions
  6. Acknowledgments
  7. References

Study setting

We conducted this study at the Hospital de la Familia in Ciudad Juárez, Mexico. Located across the border from El Paso, Texas, this hospital is the fourth largest in the city, with approximately 100 physicians (including 30 general practitioners and 13 obstetrician-gynecologists) and more than 500 deliveries per month (accounting for 17% of all births registered in Ciudad Juárez). Of particular note is that the Hospital de la Familia caters specifically to low-income populations. For example, in the past two decades, more than 80 percent of the Hospital de la Familia’s clientele have come from marginalized communities in the city (E. Suárez, personal communication, February 27, 2006; J. Servín, personal communication, August 9, 2004).

Health care practitioner training

In late 2003 and early 2004, we conducted training sessions on birth plans for practitioners at the Hospital de la Familia. The hospital medical director required all practitioners who worked with pregnant women to attend the training sessions (i.e., obstetrician-gynecologists, general practitioners, nurses, and social workers), and we held multiple sessions to accommodate practitioners’ shifts. In this hospital, obstetrician-gynecologists or general practitioners attend the deliveries; nurses, social workers, obstetrician-gynecologists, and general practitioners are all involved in providing antenatal care. Nurses and social workers, who provide prenatal counseling to pregnant women, were primarily responsible for facilitating birth plan preparation with the participants.

Training sessions were facilitated by a Mexican midwife and a perinatal educator with more than 25 years of international experience as a Lamaze-certified childbirth educator and doula and also with specific expertise in birth plan preparation. The educator led interactive sessions aimed at raising awareness about evidence-based maternal health care, followed by a subsequent training session that consisted of an introduction to birth plans and specific instructions on how to assist women in preparing them during their antenatal care sessions.

Birth plan participants

We recruited a convenience sample of eligible women to participate in a study in which they would complete a birth plan with the assistance of a trained antenatal caregiver. Twenty women were recruited during their prenatal visits and through intrahospital publicity about our study, and 9 met all the eligibility requirements. Eligible women were at least 18 years old and had experienced at least 1 previous childbirth, inclusion criteria that enabled us to recruit women who had a previous experience with which they could compare the current pregnancy and birth. We obtained informed consent from participants and asked them to participate in a baseline interview covering sociodemographic characteristics, previous birth experiences, and understanding of patients’ rights.

The birth plan consisted of 42 statements describing different procedures or scenarios that could arise during pregnancy, labor, and delivery. The statements fell under the following 6 categories: (1) before being admitted to the delivery room (e.g., use of pain medication, eating, or drinking); (2) on admission to the delivery room (e.g., vaginal delivery, wearing own clothes or pajamas, shaving pubic hair); (3) during labor (e.g., participating in decisions about procedures and interventions, using oxytocin, having a friend or relative present, having medical students present); (4) pain control (e.g., injected pain medications, epidural anesthesia, general anesthesia); (5) delivery (e.g., presence of friends or relatives, episiotomy, pushing from vertical position); and (6) postpartum (e.g., exclusive breastfeeding, seeing and touching the baby immediately after birth, family planning counseling).

After hearing each scenario or procedure, each woman specified whether she wanted to avoid it, whether she was neutral, or whether she would like to experience it. Participants completed their birth plans 4 weeks before their delivery dates, and study staff made 2 copies of the birth plan—one for the participant and the other for the patient file (to be referenced by the physician who was to attend the woman’s labor and delivery). One week after the delivery, the women returned to the hospital to participate in a follow-up interview on the same topics addressed at baseline and to document the women’s birth experiences after having filled out a birth plan.

In-depth interviews with women and practitioners

We also conducted individual in-depth interviews with 4 other women (who did not actually fill out birth plans), 2 social workers, 2 nurses, and 1 general practitioner to learn about their opinions on the acceptability of introducing birth plans. Women who had given birth in the past year and had received services through the Hospital de la Familia were eligible for participation in these interviews. Practitioners employed at the hospital and actively involved with prenatal care visits, labor and delivery, neonatal care, and postpartum care were eligible. Our practitioner sample was not representative of all practitioners in the hospital; our participants were selected because they expressed both interest in, and availability to, participate in an interview.

The interviewer explored both women’s and practitioners’ knowledge, experiences, and opinions about birth plans. All the interviews were conducted in Spanish using participant-specific interview guides; for example, the interview guide for women was distinct from those for social workers, nurses, or doctors.

Interviewers tape-recorded and transcribed all interviews. The first and second authors analyzed the transcripts initially by organizing information according to the main components of the interview guides and then analyzed relevant ideas and themes that emerged during analysis. The illustrative quotations cited here were translated into English. The protocol for this study was reviewed and approved in accordance with the requirements of the Population Council’s Institutional Review Board.

Results

  1. Top of page
  2. Abstract
  3. Methods
  4. Results
  5. Discussion and conclusions
  6. Acknowledgments
  7. References

Birth plan participants

Nine pregnant women participated in baseline interviews, prepared a birth plan, and participated in follow-up interviews. The women ranged in age from 18 to 40 years, all with middle school education or less (Table 1). None had previously heard of a birth plan. Below we describe the participants’ preferences, as described in their birth plans, with respect to medical interventions during labor and delivery, their preferences for the postpartum period, and their perspectives on what patients’ rights entailed before and after having prepared a birth plan.

Table 1. Demographic Characteristics of Women who Prepared Birth Plans (n = 9)
ParticipantAge (yr)EducationMarital StatusNumber of Previous Pregnancies
124Completed elementary schoolCohabitating3
229Completed middle schoolMarried4
318Incomplete middle schoolCohabitating2
440Completed elementary schoolMarried4
521Completed middle schoolCohabitating2
618Completed middle schoolCohabitating1
718Completed middle schoolCohabitating2
818Completed elementary schoolCohabitating5
933Incomplete elementary schoolSingle4

Medical interventions

All participants stated that they did not want to have a cesarean delivery if they had no complications. In the follow-up interview after they had given birth, 4 women reported having had cesarean deliveries. Two of these women reported that their cesarean sections were due to cephalopelvic disproportion, 1 woman said that the procedure was indicated due to breech presentation, and the fourth did not report a reason for the cesarean section. Eight of the 9 women did not want an intravenous feed unless it was clinically necessary, but after delivery, all 9 women reported having had an intravenous feed introduced during labor. In terms of fetal assessment during labor, all the participants said that they wished to have continuous fetal heart rate monitoring, and in all 9 cases, the women were connected to the electronic fetal monitor during birth.

With respect to several other medical interventions, the women said that it did not matter to them whether they did or did not undergo them. For example, 8 of the 9 women said that it did not matter to them if their physician performed an episiotomy, and all 9 said that it did not matter to them if their pubic hair was shaved, an enema was used, or labor induction drugs were administered.

At follow-up, 3 women said that they had undergone an episiotomy, 6 reported having had their pubic hair shaved, 1 reported the use of an enema, and 4 reported having had oxytocin to induce labor.

Postpartum care

Six of the 9 women expressed a desire to see and touch their newborns immediately after birth, with an equal number saying that they wished to put the baby to breast as soon as possible. At follow-up, 5 women stated that their babies were given to them immediately after birth and all 9 were allowed to breastfeed immediately. In terms of postpartum family planning counseling, 6 women had stated in their birth plans that it did not matter to them whether they received such advice after birth, and at follow-up, all 9 women reported that they had discussed postpartum family planning with their physician.

Awareness of patients’ rights

As part of the baseline and follow-up interviews before and after participating in the birth plan process, we asked women the following question about their knowledge of patients’ rights: “During pregnancy and birth, women have legal rights, including the right to accept or reject procedures, medications, or tests that are offered. Do you understand what these rights refer to?” At baseline, all the women stated that either they did not know that they had rights as a patient or they understood “somewhat” their rights. In contrast, at follow-up, 5 of these women stated that they knew “perfectly” what their rights were as patients and the other 4 reported that they knew “somewhat” what they were.

At baseline, 7 of the 9 women could describe what patients’ rights meant to them, mentioning “To be able to have an opinion about what is done to you,”“I have the right to express what I do and don’t want, for example in terms of medication,” and “To ask and decide about procedures that are done to me.” The 2 women who had responded “I don’t know” or “I have no idea” about patients’ rights at baseline were both able to articulate their ideas about patients’ rights at follow-up, stating “To decide what I want to be done to me or not, and to my baby as well” and “To have an opinion, ask all the questions about procedures and medications they want to give me.”

Acceptability of birth plans

All 9 participants said that they were totally satisfied with the experience of preparing a birth plan, despite the fact that their actual birth experiences did not always completely align with what they had specified in their plans. They mentioned that even the mere act of having written a document outlining their needs and preferences resulted in a gratifying, more personalized experience.

Interviews with women

We conducted in-depth interviews with 4 women: 2 older adolescents (aged 18 and 19 yr) and 2 adults (aged 28 and 37 yr). After hearing an explanation of what a birth plan is, all expressed positive opinions about the idea of preparing such a plan. They qualified their opinions with the caveat that the actual use of birth plans would depend on the practitioner assisting the women in preparing them and would depend on the woman herself:

I think birth plans would help, depending on [the person who helps the woman do it] and how they do it, so that she isn’t left with any doubts or anything, explain everything to her and help her … so that she will be more informed.

The women also believed that birth plans could positively influence practitioners in terms of their behavior with patients:

Yes, because sometimes they forget that you are a patient, and that we don’t know a lot, and sometimes they are really … very cold, like they are limited to doing their work and don’t pay much attention to you.

Yes, because sometimes … nurses are really annoyed and everything, no? Well, at night when they are on call they are like that and sometimes they are like that, sort of difficult, no? They seem like that to me ….

In terms of whether they saw advantages or disadvantages of a birth plan the women mostly thought that it had advantages. None of the women believed that it had any major disadvantages, with 1 woman specifying that the decision to plan a birth was up to the individual and another mentioning that things may not always go as planned, despite the preparation of a birth plan.

Interviews with practitioners

Among the practitioners interviewed, only 1, a nurse, knew someone who had made a birth plan. When asked about what they thought a birth plan was, most practitioners saw a birth plan as a tool to prepare financially for pregnancy. Some also recognized it as the decision-making process involved for women to determine how they wanted to give birth as an integral piece of the process.

When asked if they believed that birth plans could improve the quality of care patients received, practitioners generally agreed and cited the increased personal care women would receive, whereby their feelings and specific needs could be taken into consideration:

Just by informing them and by having a program that can inform them, it would guide women step by step so that when the moment comes when they give birth, they will know more. And yes this would help because [health care providers] would take into consideration more the woman and what she needs, be more attentive to what she needs. (Nurse)

It could be a more satisfying experience for them, because they would choose things that they want to happen during birth. And they also would be able to choose what they do not want in their birth, within the limitations of the services available. But they would feel a little better. (Social worker)

There has to be optimum quality, because not only does the attending doctor have to be very aware of each of the stages of birth, but the patient has to be aware of what is happening and what will happen … so I have to read [the birth plan] and inform myself more about what she will need ….” (General practitioner)

Similarly, when asked about how birth plans could benefit health care practitioners, interviewees mentioned the positive aspects of understanding patient needs and having the patient be more invested in the birth process:

[Doctors] would have information on how the patients want to be treated, because I think that a lot of times they try to give their best attention and this way they would already have some information on how the patient wants to be attended in that moment and that would help them in their work. (Social worker)

The advantages I would expect would be a better prognosis because the patient would be more serious, more cooperative from the moment she enters the hospital. The disadvantages would be time and space. (General practitioner)

When asked about barriers in implementing birth plans, the practitioners cited lack of time and inability to necessarily comply with all the desires of the women.

The main reason [a doctor would not want to use a birth plan] would be that some women would request things that maybe can’t be done because it would put the baby’s or mother’s health at risk, even if the woman had requested it in her birth plan. This would be a possibility that doctors would not accept. (Social worker)

One of the reasons [that a doctor would not want to use a birth plan] would be that it would require more space and time for each patient and this would obviously mean that we may not meet our economic expectations [because dedicating more time to each patient means we would have fewer patients to bill], and this would be something I would not like. (General practitioner)

Interviewees believed that hospital administration could support a birth plan program by responding to these challenges by making more space available in the hospital and by offering financial incentives for physicians to participate.

Maybe [one suggestion] would be providing [physical] space where a birth plan program could take place because, for example … the majority of women requested that someone be with them at the moment [of birth] and often space would be limited, so in this way the administration could help …. (Social worker)

[The administration could help] with more incentives to carry out these projects. (General practitioner)

Overall, the health care practitioners’ generally positive and supportive attitudes about birth plans were tempered by uncertainty about whether their implementation would be feasible on a large scale in this facility.

Discussion and conclusions

  1. Top of page
  2. Abstract
  3. Methods
  4. Results
  5. Discussion and conclusions
  6. Acknowledgments
  7. References

From the patient’s perspective, birth plans are highly acceptable, both among the women who prepared such plans and among the women who participated in the in-depth interviews. Consistent with previous reports on women’s experiences with birth plans (6–9), participants appreciated the value of documenting and discussing their birth desires with their health care practitioners, even if their actual birth experiences did not mirror the preferences outlined in the birth plan. Interestingly, despite the fact that the original impetus for the birth plan movement in the 1970s was the perceived overmedicalization of childbirth (11), the participants who prepared birth plans in our study expressed no preferences about most clinical procedures affecting the mother, including episiotomy or enemas. In contrast, when it came to interventions directly affecting the baby, such as continuous fetal heartbeat monitoring or touching and breastfeeding the infant immediately after birth, the women did express clear preferences. It appears that rather than being primarily concerned with medical interventions affecting themselves, the women were most interested in interventions that affected the newborn.

The women were, however, unanimous in their preference for a vaginal delivery. Nevertheless, they all still expressed satisfaction with the birth plan experience even after 4 of the 9 participants ended up having a cesarean delivery. Participants in the in-depth interview also recognized that childbirth may not always go as specified in a birth plan, but nevertheless, they saw the value of using a birth plan to improve communication with health care practitioners.

A common thread among all women was that they were extremely interested in having an informed, participatory childbirth contrary to the stereotype of the lower-middle-class Mexican woman who prefers to defer silently to the judgment of her clinicians. Women who prepared birth plans also demonstrated an awareness of patients’ rights, a perspective that has value in any clinical context, above and beyond this isolated childbirth experience.

The health care practitioners interviewed also agreed in theory that birth plans had many advantages for both the woman and the health care practitioner, but some expressed doubts about how feasible such a program would be without the strong backing of hospital administrators. For example, in this particular facility, administrators would have to make a concerted effort to provide adequate physical space (in the delivery room and for counseling sessions) and a financial incentive for practitioners—particularly physicians—to take the time to participate in such a program.

We were interested in women’s preferences and experiences with respect to the medical interventions during birth to assess concordance between their documented wishes and the reality, but we did not address the broader question of whether birth plans can affect clinical outcomes. Our study focused specifically on the acceptability of using a birth plan to have a satisfying, personalized childbirth experience, but future research should continue to investigate whether birth plans can, for example, lower rates of unnecessary cesarean delivery.

This small exploratory study serves as a preliminary step that has allowed us to identify issues and questions that remain to be addressed in future research. For example, our methodology did not allow us to evaluate the quality of information the women received while developing their birth plans during their antenatal care sessions, and future interventions should incorporate an observation or monitoring component to ensure that women develop their birth plans based on correct, current information on evidence-based practices. As a concrete example of why we must consider quality of information given during birth plan preparation, in our study, we were unable to explain why women did not have an opinion on whether an enema or labor induction drugs were used, yet they were opposed to having an intravenous feed. Future qualitative research among birth plan participants should probe women’s rationales and motivations for preferring or opposing the specific interventions and situations.

In addition, given the small scale of this intervention, the generalizability of our findings is limited. Nevertheless, no obvious differences between the women in our sample and those seeking prenatal care or birth services in the hospital overall existed. Given the low socioeconomic status of the hospital clientele and of the women in our sample, we could not draw conclusions about how birth plans would be perceived by middle or upper class Mexican women. In addition, due to financial and time constraints, our practitioner interviews took place among those practitioners who had expressed that they had the time and interest to dedicate to our study, and they likely were among the more receptive of the hospital practitioners as far as implementing a birth plan; the positive sentiments of interviewed practitioners about birth plans may be a reflection of this potential bias. Finally, absent from our interviews were obstetrician-gynecologists, for example, who typically have the most direct contact with women during labor and delivery. Future research should expand on this study by incorporating administrators’ and obstetrician-gynecologists’ perspectives, since these groups are arguably the most influential in terms of the feasibility and acceptability of scaling up a birth plan program.

One of our findings, in particular, that of the women expressing strong preferences about interventions affecting their babies, whereas expressing indifference about procedures that affected themselves, may be a reflection of stereotyped gender roles in Mexican society (12). In a culture that traditionally reveres self-sacrificing motherhood, perhaps it is to be expected that women would be extremely concerned about the well-being of their newborn, whereas simultaneously exhibiting little to no concern about interventions affecting themselves. These findings should be explored in future investigations on improving the quality of the birth experience among Mexican women.

The notion of a birth plan remains novel in the developing world, particularly among low–socioeconomic status women in cultures where patients typically play a passive role in clinical settings. Our exploratory study suggests that not only may birth plans be acceptable to low–socioeconomic status Mexican women but health care practitioners also see the benefit of actively involving women in birth planning. Future research should also investigate women’s priorities in terms of maternity services that affect their own health versus those that more directly affect the newborn, particularly in Latin American settings.

Acknowledgments

  1. Top of page
  2. Abstract
  3. Methods
  4. Results
  5. Discussion and conclusions
  6. Acknowledgments
  7. References

We would like to thank Jennifer Catino, Graciela de León, Gustavo Martínez, Alma Pérez, Jesus Servín, Enrique Suárez, Guadalupe Trueba, the women and health care practitioners who participated in this study, the Hospital de la Familia, and the Federación Mexicana de Asociaciones Privadas.

References

  1. Top of page
  2. Abstract
  3. Methods
  4. Results
  5. Discussion and conclusions
  6. Acknowledgments
  7. References
  • 1
    Consejo Nacional de Población (CONAPO). Cuadernos de salud reproductiva: La República de México (Reproductive Health Reports: The Republic of Mexico). Mexico: Author, 2000.
  • 2
    Shearer E. Cesarean section: Medical benefits and costs. Soc Sci Med 1993;37:12231231.
  • 3
    Secretaría de Salud (SSA). Boletín de Información Estadística 2003 [Statistical Information Bulletin 2003]. Mexico: Author, 2003.
  • 4
    Campero L, Hernández B, Osborne J, et al. Support from a prenatal instructor during childbirth is associated with reduced rates of caesarean section in a Mexican study. Midwifery 2004;20:312323.
  • 5
    Campero L, García C, Díaz C, et al. “Alone, I wouldn’t have known what to do:” a qualitative study on social support during labor and delivery in Mexico. Soc Sci Med 1998;47(3):395403.
  • 6
    Lundgren I, Berg M, Lindmark G. Is the childbirth experience improved by a birth plan? J Midwifery Womens Health 2003;48(5):322328.
  • 7
    Whitford HM, Hillan EM. Women’s perceptions of birth plans. Midwifery 1998;14:248253.
  • 8
    Ekeocha CE, Jackson P. The ‘birth plan’ experience. Br J Obstet Gynaecol 1985;92:97101.
  • 9
    Springer D. Birth plans: The effect on anxiety in pregnant women. Int J Childbirth Educ 1996;11(3):2025.
  • 10
    Kim YM, Kols A, Bonnin C, et al. Client communication behaviors with health care providers in Indonesia. Patient Educ Couns 2001;45(1):5968.
  • 11
    Simkin P. The Birth Plan. Seattle: Pennypress Inc., 1980.
  • 12
    Gil RM, Vasquez CI. The Maria Paradox. New York: Perigree Trade, 1996.