Does a Birth Plan Buy You a Ticket to a High-Intervention Birth?
I recently received a very thoughtful set of questions from reader Rachael N.:
I keep hearing this idea that women who have birth plans are women who end up having c-sections. I actually first heard it from my freestanding birthing center midwife, when I asked if she would recommend that I write a birth plan. On the one hand, I imagine that there may be some women who become so attached to their plan that they are unprepared for the unpredictability of labor itself. On the other hand, it sounds far more likely that the birth plan may be a convenient target for blame on those occasions when it was actually the system that did not serve the woman well. So my questions are: What’s up with this myth? Is there any actual research showing what the outcomes are when women have birth plans? And how should a woman build some flexibility into her birth plan, given that childbirth is an unpredictable process??
I’ve also heard and seen people express this sentiment before: namely, that women with birth plans (and, especially, long birth plans) are the ones who will end up with the most birth interventions.
Like many sweeping generalizations, I find that some of these sentiments gloss over a lot of much-needed nuance and sensitivity and attention to detail. And this is troubling. In fact, it does little, if not nothing, to empower or even help women who are preparing for the birth of their babies.
For instance, when Taffy Brodesser-Akner talked to Dr. Kimberly D. Gregory in an article in Self magazine, Dr. Gregory expressed the following reservations about birth plans:
“I think that birth should be a beautiful experience,” says obstetrician Kimberly D. Gregory, M.D. She’s the vice chair of women’s health care quality and performance improvement at Cedars-Sinai Medical Center in L.A. “It should be exactly the way you want it, and doctors should intervene only to preserve the health or life of you or your baby.“
Naturally, one would assume that Dr. Gregory advocates birth plans. When I ask her this, she laughs. “We always say, ‘If you show up with a birth plan, just get the C-section room ready,’” she says. “You get everything on that list that you don’t want. It’s like a self-fulfilling prophecy.” Dr. Gregory led an unpublished study that compared women who took traditional hospital birth classes with those who employed Bradley-like training and a birth plan. The birth-plan group trended toward a higher C-section rate and more interventions. “There’s a certain personality type that tends to be more anxious. Maybe the anxiety hormones themselves put them at risk,” Dr. Gregory theorizes. “It seems that being open and honest and choosing the right doctor is probably a better option than writing everything down. Walking in with this list appears to set up an antagonistic relationship.”
For what it’s worth, I think that Dr. Gregory’s statements (which, to be fair,were probably edited for purposes of the article) include a mix of sweeping generalizations and helpful distinctions.
On the one hand, even if the hospital staff is joking when they claim that showing up with a birth plan entails a trip to the OR, the joke itself raises questions about just whose self-fulfilling prophesies are being fulfilled. Not all birth plans are created equally–some are the result of an online, cookie-cutter checklist, and others are the result of careful research that a woman and her partner have discussed with their care provider, the hospital staff, and their pediatrician.
On the other hand, Dr. Gregory’s points about the relationship between anxiety and labor and the importance of finding a supportive care provider are spot on. For if one envisions the hospital as a battle scene in which one must use a birth plan as a defensive shield, one might very well set oneself up for disappointment, and even the self-fulfilling prophesies to which Dr. Gregory alluded.
I was also able to dig up one published study that examined the disparities between patients’ and medical personnel’s perceptions of outcomes in women who use birth plan. (Note that this is different from the actual outcomes of women who use birth plans.) And the results were pretty fascinating:
Sixty-five percent of medical personnel vs. 2.4% of patients reported that patients with birth plans had overall worse obstetric outcomes than patients without a birth plan. There were 65.7% of health care providers vs, 8.7% of patients who reported that women with a birth plan had an increased rate of cesarean section. In addition, 53.4% of health care providers vs. 9.9% of antepartum patients reported a perceived increased rate of chorioamnionitis for women with birth plans. Statistically significant differences were also found between health care providers and patients in terms of their perceptions of the effect of birth plans on operative vaginal delivery, postpartum hemorrhage, episiotomy and length of hospital stay.
I do not doubt that these perceptions exist or that (as Dr. Gregory commented) birth plans created out of anxiety or antagonism can contribute to more complicated labors. (Fear or anxiety-based stress effects everything from pregnancy to birth to breastfeeding negatively.) But I also think that they/we need to make some clearer distinctions before drawing any hard and fast conclusions about the relative usefulness (or uselessness) of birth plans.
You see, I can understand why certain attitudes or expectations about birth plans might be more of a hindrance than a help to birthing women and their partners. But this is entirely different from claiming that birth plans themselves are somehow responsible for a higher rate of complications and/or medical interventions. And if this distinction (i.e. the one between attitudes and expectations about birth plans and birth plans themselves) is not made abundantly clear in the sort of statements described above, then women might be led to think that any and all articulation of their preferences for birth are counterproductive, useless, and even dangerous.
In my humble opinion, this thought is what is actually counterproductive, and even dangerous.
And that’s because there is a lot about birth plans that is a “good thing!”
Researching your birth preferences is a good thing.
(Who wants to find out the risks, benefits, and side effects of narcotic pain medication during a contraction, or, worse, while their baby is receiving medication because of the respiratory distress caused by the narcotic pain medication?)
Articulating your birth preferences is a good thing.
(How will your partner and/or the nurses know that you don’t want them to offer you pain medication unless you tell them so?)
And discussing these preferences (as early as possible) with your care provider, your hospital staff, and your pediatrician is an even better thing!
(Who wants to get to the hospital, in active labor, only to find out that their care provider doesn’t “allow” intermittent monitoring after all? Or that the hospital doesn’t have tubs in every labor and delivery room? Or that the staff will call Childrens Protective Services if parents refuse the erythromycin eye drops?)
But in order to create an effective birth plan–one that will communicate one’s wishes without working against one’s wishes–it is important to be mindful of the following:
1) A birth plan does not replace the need for birth preparation.
Going to an online “birth plan mill” and checking off a bunch of boxes (“yes” to the epidural! “no” to the episiotomy!) is not the same as preparing for birth.
A good childbirth education class can help you prepare for birth by helping you to discern what the protocols are in your chosen birth location, what the risks, benefits, and alternatives are of any birth intervention, and how you can cope with both the expected and unexpected during labor.
So can a good book (or set of books). (Please see my recommended reading list on the right sidebar.)
Or a good doula or other birth professional.
But a birth plan really doesn’t help all that much you if you haven’t yet determined why you want what you want–why you prefer intermittent monitoring over continuous monitoring, why you want to eat and drink during labor, why you want something different from your care provider’s or your hospital’s typical protocol.
2) A birth plan does not replace the need for a supportive care provider who is on board with your desires and preferences for your birth.
Even a well-researched birth plan will generally not stand up to a care provider who doesn’t allow anything stated on the birth plan. And this is why it is crucial to discuss your birth preferences–and even get your list of preferences signed–with your care provider well before labor begins.
For instance, if you would prefer to tear rather than to undergo an episiotomy, but your care provider has an 85% episiotomy rate, then you might consider finding a care provider who has a much lower rate.
If your care provider does not “allow” some of your birth preferences (such as intermittent monitoring, eating and drinking during labor, etc.), then you might consider asking if s/he will make an exception in your case (and sign your birth plan!), or you might consider finding another care provider who does support these preferences.
In other words, a birth plan itself will not magically change the way your care provider practices when it comes to your birth!
And a care provider who is on board with your preferences is worth much more than a piece of paper expressing these preferences.
3) A birth plan cannot plan your birth–but it can help you to articulate and express your desires and preferences for your birth.
This is why I (and many others) like to refer to birth plans as “birth preference lists.”
Birth is inherently unpredictable, whether you have an unexpected unassisted birth at home or an elective cesarean section that you have planned for from the moment you knew you were pregnant.
Thus, you cannot plan the birth you want–you can only plan for the sort of birth that you would like and remain open to the possibility that your plans and preferences might need to change in light of the particular circumstances of your birth.
This is not to say that articulating your birth desires and preferences is useless. To the contrary, this is an exceedingly useful exercise, one that can motivate you to research your options and to get a better feel for what you can expect from your care provider and from your birthing location.
But your attitudes about and expectations for your birth plan should reflect these sentiments: namely, that you cannot control your labor. You cannot control birth itself. But you can and even should empower yourself to make decisions about what you want for your birth, and how you would like others to accommodate your desires and preferences for your birth, and how you plan to remain flexible and open to the unpredictability of childbirth.
And care providers should be able to respect these sorts of preferences without pegging you as taking a one-way train to the operating room.
If you’re looking for a helpful guide on writing a birth plan, Melissa, the L&D nurse blogger from Nursing Birth, wrote two fabulous posts on birth plans: one covering the general topic of birth plans, and the other offering more specific tips and pointers for writing a birth plan/preference list.
I’m also interested in hearing your thoughts! Have you heard that “the women with birth plans end up with the most interventions”? Have you seen that in your experience as a birth professional? What advice would you/do you give to women about birth plans based on your experience?
You can see more of this discussion over on my Facebook fan page!