Yam et al described their exploratory study of the introduction of birth plans to low-income women in Mexico (1). Although small and inconclusive, the authors made a notable effort to discover whether they could “improve quality of care and increase patient-practitioner communication” by assisting women to prepare birth plans and conducting training sessions on birth plans for all the practitioners who worked with the women. The 9 women who participated in the study found the experience of preparing a birth plan “highly satisfying, despite the fact that in some cases their childbirths did not proceed as they had specified in their birth plans.”
As I read this manuscript, I was taken back to 1980, when I, with Carla Reinke, published what I believe was the first document describing the birth plan as a way to encourage both informed decision-making by childbearing women and communication and cooperation among caregivers and clients (2). In that pamphlet, we advised expectant parents to become informed about birth options and to use language that is not only polite and friendly but also flexible, so that the birth plan would apply in both straightforward and difficult labors. Preparation of a birth plan included discussion between the woman and her caregiver and subsequent placement in the woman’s chart for other staff members to consult. Thousands of copies of the pamphlet were sold and the concept of birth plans spread.
In 1982, in the pages of this journal, Richards, a British social scientist, published a commentary The Trouble With ‘Choice’ In Childbirth (3). He listed maternity care practices that severely limit parents’ choices and suggested ways to remedy the situation, including “altering the fundamental relationship of mother and birth attendants.” He pointedly rejected the birth plan, however, referring to our pamphlet as an example of “a fashionable approach in America ….” He said, “My own reaction to such documents is very negative. They seem to illustrate the lack of trust and erosion of confidence between mother and attendant.” I was stunned and puzzled at that time, having expected him to support birth plans as a constructive way to address the very goals that he had eloquently expressed in his paper—of improving client-caregiver relationships and expanding childbirth choices. I had naively assumed that if women were tactful and informed, they would be welcomed to participate in their care as team members.
Three issues of the journal later, in 1983, due to considerable discussion of the article by Richards, Birth followed up with “More on the Trouble with ‘Choice’ in Childbirth,” which, among the 6 commentaries, included 1 by me, in which I explained my intention that the birth plan would be a “vehicle for trust and communication”(4). I believe that was the first description of the birth plan to appear in a major journal.
The birth plan has continued to create tension in client-caregiver-nurse relationships over these 27 years, and the differing reactions by practitioners and recipients of obstetric care to birth plans represent the age-old gulf between them. Over the years and today, most childbirth books written for the public have included discussions on birth plans. One recent book is devoted to the creation of a meaningful birth plan that will be heeded by the caregiving staff (5).
The question being addressed today, as in the past, remains: Should women have a right to directly express their concerns and preferences and have them heeded by their clinical caregivers? The paper by Yam et al asks that question on behalf of poor, underserved women (1), and Lothian asked the same on behalf of all women, especially those in the middle class (6). Unfortunately, it appears that expressing preferences may have an effect opposite from enhancing communication. Yam et al found that it seemed to have little influence on the women’s care. Lothian reviewed the literature on birth plans and concluded that “rather than improving relationships, birth plans may irritate the staff, which adversely affects obstetric outcomes”(6).
With some notable exceptions, the reception given to birth plans by practitioners has been anything but enthusiastic over the years. As the popularity of birth plans grew, many hospitals and provider groups countered by devising their own checklist versions of birth plans, in which they included only options that were available in their institution. Parents could still believe that they were participating but would not have the option of requesting options that departed from embedded routines. These birth plans created an illusion of choice but were impersonal and meaningless.
In recent years, various web sites on the Internet have become sources of advice on birth plans and checklists to aid in preparation. In fact, when I searched the Internet recently for “birth plan,” my search engine reported 91 million results (which may indicate something about the controversy over women’s desire to have a say in their care!). Although some of the checklists are comprehensive in the options listed, others in widespread use are based on the assumption that women who write birth plans want only medication- and intervention-free childbirth and include no options for interventions such as continuous electronic fetal monitoring, episiotomy, and elective cesarean section, which many parents nevertheless want, even though they are not evidence-based procedures. They also provide no opportunity for parents to offer personal information to introduce themselves and/or disclose any fears, issues, or concerns—the kind of information that aids nurses in becoming acquainted and providing individualized care. In effect, many of the web-based birth plans restrict choices just as the hospital-generated birth plan checklists do. Birth plans based on such checklists are often not taken very seriously. In fact, in my extensive travels around North America, speaking with maternity care professionals and paraprofessionals, I encountered mostly negative attitudes, ranging from making women who write birth plans the brunt of jokes (“the next cesarean”; “we’ll see how long this lasts”) to open hostility toward women who bring them into the hospital (“why does she even come to the hospital if she knows it all?”), to humoring the women (“it‘s fine for her to write a birth plan, but we’ll do what we think is best”).
One notable exception to these negative attitudes is in Seattle, Washington, where a more positive attitude toward birth plans is found. Most of the Seattle area’s busiest and most popular obstetricians, family doctors, and midwives encourage birth plans. Many schedule a longer prenatal appointment at 36 weeks to discuss the birth plan, suggest modifications, and hold firm and explain their position if unacceptable or unsafe options are listed. They are flexible and find that birth plans usually enhance the relationship, but they can also help identify women with fear, ignorance, or trust issues before labor. Contrary to the stereotype held by many, birth plans in Seattle are not always asking for a “hands-off” approach to birth; in fact, some very concerned and educated women request numerous unnecessary interventions for their peace of mind. When a woman arrives in labor, she is often greeted by the nurse with, “I’ve had a chance to look over your birth plan, and it looks very do-able. I will keep it in mind as we go along, and I’ll try to keep you informed if we feel there is a need to depart from it.” What welcome words for the couple to hear!
Two brief anecdotes illustrate the positive attitude toward birth plans in Seattle. In the first, a woman arrived in labor without a birth plan. The nurse asked her doula to accompany her out of the room, where she asked, “What does she want? We don’t know how she wants us to care for her!”
In the second, a woman, in great distress, entered the hospital at 37 weeks’ gestation. Her membranes had ruptured, and she was group B strep positive. She did not want to be induced, but agreed to it once she understood the risks. She had a needle phobia and required intravenous antibiotics and Pitocin. She was distraught, crying, and thought that her birth experience was ruined. When her nurse asked for her birth plan, the woman did not want to show it to her, replying, “It’s too late. It’s already fouled up.” The nurse kindly persisted, and the woman finally relented, tearfully handing over her birth plan, with, “It’s just a joke now.” The nurse looked it over and said, “There’s a lot here that we can still do. Did you bring the sign that you want to post on the door (‘Please knock before entering, and explain your reason for wanting to come in’)?” The woman answered, “No, I didn‘t have time to make it!” The nurse replied, “Well why don’t I just make that sign now and tape it to your door?” Suddenly, the woman felt validated and heard and began to trust the staff. Despite the rough beginning, this woman had a very positive birth experience and was most appreciative of the nurse, who reached out to the woman, even though she did not have to do so.
It is very sad when caregivers dismiss birth plans and the purpose behind them. To me, it seems that in effect, they are saying, “We do not want to know you or what is important to you. You will be treated like everyone else.” They do not understand that the way a woman is treated during labor and whether she feels in control or not will influence the way she remembers her birth experience (and the staff) for years to come (7).
Women in all socioeconomic groups have little opportunity to communicate their preferences and concerns and expect them to be taken seriously. Those 9 low-income women in Mexico, who prepared a birth plan, found the process very satisfying, but their caregivers seemed to have paid little attention to their wishes. We see this in maternity care everywhere. Women’s voices are largely ignored. Yam et al trained all the professionals who provided services to pregnant and laboring women (1). They were wise to educate both sides—practitioners and recipients of maternity care. Usually, all the information on birth plans is directed to the consumer and that is not working. Ongoing training sessions—in medical and nursing school and later, in which women’s (all patients’) information and preferences are presented as a integral component of their own care—are the key for changing the culture around choice and client participation. This is a global concern—one that we all must address if maternity care is to become safer and more satisfying.