Does a Birth Plan Buy You a Ticket to a High-Intervention Birth?

Does a Birth Plan Buy You a Ticket to a High-Intervention Birth?

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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 Gregory led an unpublished study that compared women who took traditional hospital birth classes with those who employed Bradley-like training and a birth plan.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 website (such as Childbirth Connection, Lamaze International, or Mother’s Advocate).

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.

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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!



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18 Comments

  1. Ren
    Ren07-29-2010

    This is a great post, Kristen. I think it’s a really important topic.

    One of the smartest things I thought you pointed out was that a birth plan can’t be substitute for birth *preparation*. I have watched friends come up with a birth plan without doing research and without doing anything more than attending one hospital birth class – and they have been less happy with their birth experiences. But other friends (like yourself!) who have made birth plans based on careful research and in light of serious preparation have had really positive experiences. I think it’s essential to remember the plan isn’t the end OR the means, it’s just a map for both.

  2. Sharon Gourlay
    Sharon Gourlay07-29-2010

    Kristen, another great article, thank you for your insight. I would like to just say that in HypnoBirthing we call it Birth Preferences. We educate families to begin to research birth choices early. We empower parents to learn how to interview their Care Providers which is essential when preparing for your pregnancy and birth care. Many of these choices and preferences can be communicated through conversations but the strongest preferences should be written down. In HypnoBirthing we try to ensure that the birth companion feels capable of reviewing the birth preferences with hospital staff when needed. When I went on a tour of a recent hospital it was explained that many couples create a birth plan however they fail to communicate it to their care providers. That is an important link in this communication process. There is a place for written documents but there is also a place for verbal communication.
    The other idea I wanted to express is the mind and body connection is amazing. I have seen and encouraged many mothers to journal about how they would envision their birthing dream. They often are able to use the senses to make this journal entry jump up off of the pages. That element takes a birth preference and brings it alive in their minds eye. If they can see it (just like an olympic athlete) they can do it. So I love the idea of taking something that can be very analytical and seeing mothers bring it to life with their words, ideas, and even some of created collages that express what they want the birth to look like.

    I think those download pages of birth plans really has put a bad reputation on birth preferences. Many Cesarean Section mothers create a birth preference sheet….what are they setting themselve up for is my question?

    Warmly,
    Sharon

    • BirthingBeautifulIdeas
      BirthingBeautifulIdeas07-30-2010

      Sharon, I too encourage my doula clients to talk about what their “dream birth” would be like (and we also brainstorm how to respond to the “unexpected” in birth, of course)! But writing these things down in a journal might be even more helpful for some women–love that idea!

      Re: your question, are you asking about birth preferences for a planned cesarean? I actually think that it can be helpful for some women who are planning c-sections. I’ve even heard some say that it helps them to feel more in control of the process, as if they can really have some agency in their birth that they wouldn’t have otherwise.

      • Sharon Gourlay
        Sharon Gourlay07-30-2010

        I was just responding to the article that indicated women who had birth plans were setting themselves up for a C-section. I help women prepare a C-section birth preferences…I was just applying the same logic as the article….its probably more rhetorical than anything else. But what would those same professionals say to the C-section birth plan holder? What is she setting herself up for? :)!
        Thanks for the reply.
        Warmly,
        Sharon

  3. Rachael
    Rachael07-30-2010

    Thank you, Kristen! You answered my questions and so much more. With my first birth, my only plan was to trust my midwives, whom I must say were indeed trustworthy. I didn’t have much of a sense of how things might go, though, should a hospital transfer have become necessary. As it turned out, the birth went as beautifully as I could have hoped and, as planned, at the freestanding birthing center. But the next time I might do things differently (possibly a home birth), plus now I know so much more than I did then, plus I definitely tend to be anxious. It seems that the key for me and others like me may be to find ways to be prepared that feed our confidence rather than our anxiety — including our confidence to face the unexpected with openness, grace, and courage.

    Thanks again!

    • BirthingBeautifulIdeas
      BirthingBeautifulIdeas07-30-2010

      Thank YOU for your questions, Rachael! I think that this particular statement is fantastic: “It seems that the key for me and others like me may be to find ways to be prepared that feed our confidence rather than our anxiety — including our confidence to face the unexpected with openness, grace, and courage.”

      My thoughts exactly!

  4. Kiki
    Kiki07-30-2010

    I heard this before my first birth from the “midwife” at the hospital I had my daughter. I brought a list of my wishes at my 36 week appt and she said to me (I shit you not) “we have a saying here in the hospital, the longer the list the quicker we cut”. I should have known to RUN RUN RUN and find another provider at he last minute.

    Thank you for this post because I have thought about this statement a lot lately as I prepare for a VBAC in Feb 2011. It echoes in my head and all I can summize is that most hospitals (in NJ where I live at least) don’t know how to provide you with a natural birth. If you don’t want interventions they only know how to cut your baby out.

    I have a wonderful new midwife for this pregnancy. Out of network, independent of hospital ties. She told me that her Moms don’t need a birth plan. They are so in tune with each other by the time the birth comes everyone is on the same page and thery get the birth they desire. She has a 98% VBAC rate.

    I actually never took a birth plan to my first birth, I really thought they would respect my wishes. They ended up cutting me anyway unneccesarily. My daughter didn’t descend quick enough for them, she was head down, facing the right way but got stuck. Maybe if they had helped me to position her head correctly , instead of ignoring me and pushing pitocin every hour ), I would have ended up with a vaginal birth? The intervention rates at this hospital are sky high. They simply didn’t know what to do with me. Even the lovely nurse was baffled by me not wanting drugs. She said she’d never seen it before.

    So yes, I think it’s probably true that if you take a birth plan you’re more likely to get cut. it’s not the birth plan though, it’s the birth provider. They have already labelled you and don’t know how to help you have the birth you want. So they cut. If there was a real chance of natural birth in most hospitals in this country we wouldn’t even be discussing this.

    Love your blog !!

  5. Chris
    Chris07-31-2010

    Considering perceptions and expectations and such are definitely worthwhile, but I think the most important bits of this post are all in bold. My [wife’s] history has a good example.

    I remember when my wife and I started talking about birth plans during her first pregnancy. At a checkup well before her due date, she asked the OB/GYN about his opinions on birth plans. He told her that he doesn’t prefer them for a two-part reason. They take tools away from him, and he doesn’t use any kind of intervention unless it’s necessary. On one hand, he was largely saying, “I’d rather you just trust me.” On the other hand, we had chosen that doctor so that we could feel comfortable trusting the obstetrician who would deliver our children, and she was already establishing a dialogue about her preferences. We took his recommendation, keeping in mind that we would need to be verbal about what we wanted.

    As it happened, some intervention was required. In the final stages of labor, the doctor explained to us his plan. My wife told him what she wanted to do, he shifted his plan accordingly, and our son was born shortly thereafter.

    The baby was healthy. We were happy with outcome. The doctor commented a couple of times (with obvious satisfaction) that we used his expertise to make our own decision. I don’t recall how he put it, but he was clearly contrasting our approach to things like downloading birthing checklists.

    In our situation, the combination of advance preparation, the right care provider, and good communication proved much more important than a written birth plan.

  6. Renee
    Renee07-31-2010

    I’m so glad you addressed this question so beautifully! When I was interviewing a local hospital, while deciding whether to switch doctors or stick with the doctor who delivered my first child, the hospital “educator” that responded to my call said something like “Oh, DON’T TELL THE NURSES YOU HAVE A BIRTH PLAN!,” as though they would treat me as a lepper or something! I opted not to switch to that hospital, because I felt like that was the tone of all the responses to my questions. The person who was trying to “sell the hospital” to me gave me a “psh” attitude every time I asked a question based on research and serious concern!

    It is definitely a touchy subject, and I think that this time around I will take a little written list (as a reference) and have a bigger conversation with my doctor about it before my birth. Last time I think I was one of those women who kind of glossed over those questions/issues with my doctor and wrote a birth plan that we never fully discussed, resulting in a birth that was less than satisfactory (although totally successful and healthy in the grand scheme of things). I think my biggest concern was that I didn’t want to come off as pushy or a “smarty pants” talking to my doctor who definitely has more experience in the area of birth! This time I asked him at my first appointment if he would allow me to labor without a heplock (standard at all the local hospitals), and he has reservations, but said we could discuss it closer to the delivery in order to see if any risks arise or if he has any glaring concerns in later stages of the pregnancy. It isn’t his preference, but he is willing to have a discussion about it. I think approaching it early and as a humble request for consideration, he didn’t feel threatened by my question. Anyway, I am rambling. I’ve love reading your blog, and have added it to my “daily reads” bookmark tab!

  7. Best of the Birth Blogs – Week Ending August 1st | ICAN Blog
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    […] Birthing Beautiful Ideas is on a roll, with another great post this week, this time on the pros and cons of birth plans. […]

  8. Melissa
    Melissa08-29-2010

    Interesting read!!

    My first two sons were born in a hospital with epidural and other drugs. In my mind, I wanted intervention-free births, but they didn’t pan out that way.

    I then switched care providers…

    …and my new OB actually TOLD me to write up a birth plan. He said it sounded like I’d *finally* done my research, knew what I wanted, and how to go about achieving it. He also recommended I hire a doula. Together, we did up my birth plan, and he signed it and told me to bring it to the hospital with me. I ended up with exactly what I wanted AND needed – a completely intervention-free birth, with a speedy recovery, and a sense of “overcoming” the nay-sayers who said I couldn’t do it, not after two epidural births.

    I think informed birth plans are awesome, provided you have a care provider who will put his or her name behind it!!

    • BirthingBeautifulIdeas
      BirthingBeautifulIdeas08-30-2010

      Melissa, that sounds like a fabulous OB! What an empowering attitude he has about women and birth.

      And I love what you write at the end: “I think informed birth plans are awesome, provided you have a care provider who will put his or her name behind it!!” Yes!

  9. On My Mind
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    […] *   *Over at Birthing Beautiful Ideas, Kristen wrote a truly awesome post in response to some questions I had about birth plans. In short, she says: do your research, […]

  10. Liz
    Liz12-03-2010

    I was 39. We did Bradley. I had a birth plan.

    I gave birth in a hospital (special birthing ward, not regular OB, but still). Only husband, aunt, and nurses to assist…until about 10 minutes before the birth when the midwife finally showed up.

    Everything went great; I could hardly have asked for better. I didn’t get meds, my son was not circumcised, he BFed right away, etc.

    Because I knew what my choices were, what the possible occurrences were, and what the potential outcomes were, I didn’t have to make those choices during a time of altered, vulnerable consciousness.
    Liz´s last blog post ..The Big Kid

    • BirthingBeautifulIdeas
      BirthingBeautifulIdeas12-03-2010

      That’s such an important point about what birth plans can do–namely, they can allow a woman to know what her choices are (after researching them) and to make various decisions before labor rather than when she is in “a time of altered, vulnerable consciousness” (precisely!).

  11. Theresa
    Theresa01-16-2012

    I was glad to have found this article. A family friend who has several years of experience as a labor and delivery nurse told me tonight about the higher rate of c-sections for woman who have birth plans. My Dr has been completely supportive of my preferences, but I do not think others in the practice are. My first two were delivered in a freestanding birth center, and both were wonderful experiences. I’m now expecting twins, and reluctantly chose a hospital due to the higher risk with twins. I just gave my birth plan to my Dr today, and now wish I hadn’t. It’s really scary to think that stating my preferences will create a hostile relationship with the people who are supposed to be supporting me. Communicating well researched and reasonable preferences should not interpreted as an attack on the nurses/Dr’s expertise or role in the process.

    • BirthingBeautifulIdeas
      BirthingBeautifulIdeas01-17-2012

      HOPEFULLY, Theresa, your doctor won’t view your preferences that way. Again, I think it can be more about the way one approaches a birth plan. And it sounds like you’re approaching just as you should–as a communication of preferences!

      Good luck with the upcoming birth of your twins! As a doula, I’ve attended two BEAUTIFUL in-hospital twin births. I hope you have an absolutely beautiful birth too!

  12. Shared Decision Making in Maternity Care
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    […] is also why I frame birth plans as “birth preference lists.”  As I tell my clients, you can’t plan a birth, but you can articulate your preferences to your care provider and engage in meaningful discussion […]

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