There has been a lot of discussion on twitter over the last week or so about the various merits and pitfalls of Birth Plans. This debate has included extensive discussion about the terminology – should we talk about Birth Plans or Birth Preferences? Is it better to use free text, checklist options or visual presentations? In creating a birth plan are women setting themselves up to be disappointed if things don’t go “according to plan”? How can we help women to achieve their plan? The arguments on all sides are persuasive but at the end of the day its not up to us – it’s down to the women and birth plans will mean different things to different people. They are not interested in semantics, regardless of the power of language, they just want to tell us how they would like their birth to go. They just want us to listen to them. Whatever a woman requests and however she presents the information the “plan” is only as good as the listening skills of the person who needs to help “action the plan”.
Birth plans and birth planning formed an integral part of #TheatreChallenge as talking to women about their options and choices is viewed as an essential part of care which is often neglected when women transfer to theatre but which has the power to transform birth experience. You can see the film about Theatre Birth Plans here. However I’d like to reflect more on the wider role of birth planning between health professionals and the women we care for.
There is plenty of evidence to support the fact that women want more say in their care. I use discussion of the woman’s birth plan as a key part of any admission, a way of getting to know the woman and her partner and what they are hoping to happen during their labour and birth and beyond from the moment I meet them. Its the perfect ice-breaker, a means of creating conversations, exploring expectations and putting a sense of control firmly with the woman from the word go.
So what is the evidence relating to birth plans? A recent study by Afshar et al (2017) found no difference in the incidence of LSCS for women with birth plans and no difference in length of labour. Women with birth plans were less likely to receive oxytocin, undergo ARM, or have epidural but were also less likely to be satisfied with their birth experience and felt less in control. Of course these results say nothing about staff attitudes towards the birth plans. Fink (2017) discusses a survey where only 26% of staff had a favourable view of birth plans and 1/3 believed that birth plans were predictors of poor outcome. Such attitudes are hardly likely to contribute to positive patient experience regardless of outcome. It may well not be the plan that leads to dis-satisfaction but attitudes and response to that plan in an unfolding situation. A 2012 study by Cook & Loomis concluded that positive and negative birth experiences related more to feelings of control and choice than specific elements of their birth plan.
I regret to say that time and again as a health professional I have seen women ridiculed for having a birth plan, especially if there is lots of detail or more unusual requests. For my own part I am grateful when a woman has taken the time to explore the options open to her and document her preferences before she is distracted by pain and fatigue. I wonder if a woman does not have any form of birth plan if she has been let down ante-natally in that she has not been provided with the information she needs to make informed decisions about her care. I also take exception to the idea that someone with a birth plan is inflexible. Just because someone has written down what they would like to happen does not mean they are not aware that plans may change. That is just what life is like! It does not mean we shouldn’t make plans in the first place.
At the recent RCM conference women’s expectations were explored. There was a suggestion that these expectations were inappropriate and that women expected too much from a service stretched to breaking point which simply could not deliver to a standard expected by women. Whilst reference to difficult staffing levels and workload is undoubtedly true I do not agree that women should alter their expectations of the care they wish to receive. Most women recognise the pressures faced by staff and do not complain. But this is why it is so important to discuss birth planning with women both before and during labour so women know what they can expect and can help themselves in the best ways possible. Ante-natal education plays a huge part in birth planning.
NICE guidelines require us to support women in their choices just as much as they set out time frames for delivery based on category of LSCS. Yet sadly the role of birth planning is given much less attention and women may remain oblivious to some of the options open to them, especially if such options are viewed as trivial and the situation is escalating. Yet this is the very time that we need to communicate best and try to impart a sense of control back to the woman.
Much of the discussion around birth plans revolves around whether or not a woman presents her midwife with her written birth plan when she attends in labour. Yet this debate seems to miss the point – Birth Planning is part of our role as midwives, not the job of the woman and her family! If a woman attends without a written birth plan that does not mean she does not have a birth plan, it just means she’s not written it down or that she is not yet aware of her options. Ask some midwives about birth plans and they may raise their eye-brows or roll their eyes, however ask a midwife about whether she sees herself as an advocate for women, with a duty to gain consent for procedures and most will be passionate in their response. I cannot see how this differs from birth planning! Every time we ask a woman a question about her labour we are essentially exploring her birth plan whether she presents it as such or not.
Birth planning goes far beyond a written document. Birth planning is about conversations, informed choice, empowering women. Its about dignity and respect. Its about ensuring that women are aware of their options. Some women spend lots of time researching their options and ensuring they are up to date with current practices and recommendations. Other women do not have access to the resources which empower them to make decisions about their care. And some women do not wish to make choices. They prefer to leave such decisions to the care givers who they believe will make the best choices on their behalf. But this in itself is a birth choice and should be respected as such. Others may not have been given the opportunity to engage in conversations. Part of our role as midwives is to create these conversations, ideally during the ante-natal period, but if not, then at the earliest opportunity, even if this is when the woman attends in labour.
Women who do attend with a written birth plan are often viewed with suspicion – how will they react if things don’t go according to the plan? They are often viewed as being inflexible just because they have written what they would like to happen down. This is an unjustified response. Written birth plans are starting points for conversations and most women will be grateful to any professional who takes the time to explore their plan, even if this is to suggest that elements of it may not be possible due to a specific situation or hospital policy. However if we are saying something is not possible then we really do need to think about why we are saying no, and at the end of the day we do need consent for anything we do or chose not to do as practitioners. We also need to support women in their choices and decision-making. We are there to guide and inform but ultimately choices are down to the woman and as practitioners we need to advocate for the women in our care. Sometimes it is easier to say something is not possible than to push boundaries, go against the norm or risk getting into trouble for breaking the rules.
I have no idea what the quote below refers to. I’m pretty sure its not to do with birth plans but it is an interesting concept. Society encourages us to set goals and plans in our lives from an early age. What do we want to be when we grow up? Think about family planning! Have you made plans for retirement? What are your holiday plans this year? People are encouraged to write their goals down to make them real and to share them with other people to create a support network which will allow them to achieve their goals. From the star chart for the toddler, and the promise of treats to the child that scores well in a test, to structured plans such as Weight Watchers or a personal fitness programme in adulthood or the making of a will, we all create plans and we all present them in some way. But when it comes to a woman making a plan for one of the most important events in her life, when she sets out her aspirations, her targets, her goals for her birth experience, she is often met with criticism and the plan itself is viewed as negative, as if it somehow tempts fate and inevitably leads to deviation and distress. Why would it be right to plan for all other aspects of our lives but not birth?
For women who go to theatre birth planning is just as important. Women may or may not be aware of their options in theatre. They may feel that everything has suddenly moved beyond their control. This can be disempowering and is a significant contributor to poor patient experience. Placing a degree of control back with the woman can be liberating and empowering in a time of emotional stress.
Birth plans incorporate many different elements of a birth. Women may express preferences about mode of birth, pain relief options, episiotomy or feeding choices. They may also reflect the importance of practices such as skin to skin or optimal cord clamping. Or they may simply reflect who they want as a birth partner or what music they want to play.
As health professionals there is a temptation to give priority to the things we rate as most significant and play down other aspects of a birth plan. Some professionals may see skin to skin as less important for example simply because it is not a priority in their unit and focus instead on pain relief options. However we need to recognize that if a woman has included it in her birth plan then it is important to her. Furthermore if things don’t go “according to plan” then other aspects which did not seem important before may suddenly gain importance and have the power to return a sense of control to a women.
For example a woman who was planning a pool birth went on to develop complications which resulted in an emergency LSCS at 29 weeks. Her plans for waterbirth, skin to skin and optimal cord clamping could not be supported but she was happy to do what was recommended for her baby at the time. In an effort to return an element of control the midwife asked if she would like music playing at the birth. The woman chose to have reggae playing. This small decision left her feeling empowered and gave her something else to focus on, contributing positively to her birth experience despite the difficult circumstances. This did not form part of her original plan as she did not “plan” to go to theatre but the on-going process of birth planning by her midwife meant that the plan adapted to the situation. Little things can have a big impact.
To conclude then I really don’t think we should use the term “birth plan” or “birth preference” – this relates to a noun. A fixed entity which implies something which has been completed. In contrast birth planning is a process which adapts and evolves with changing situations. Planning is a verb. To quote my old English teacher “its a doing word” – it reflects an ongoing discussion between the woman and her health care professionals which needs to continue throughout the birth experience and beyond. Birth planning can relate to ideas presented by the woman as her preferred choices for birth but can also include elements that the woman might not be aware of as options and can adapt to changing situations around birth. Birth Planning is an essential part of our role as midwives and its importance should never be under-estimated.
Thank-you for reading
♥ Katherine ♥