3 problems with birth plans (and why you should write one anyway)
Birth plans have become a rite of passage in pregnancy. Everyone from your friendly neighbourhood hypnobirthing teacher to the NHS recommends them, Google ‘birth plan template’ and you’ll get at least 815,000,000 results (yes, really).
There’s an inconsistency here, though, because the refrain I hear most frequently about birth plans is ‘…it all goes out the window once labour starts’. Only last week a mother of 3 shared with me that her advice to pregnant women is not to waste time writing one because no-one bothers to look at them, and even if they do, birth is never what you had expected.
It’s not just anecdotes from our friends and relatives that suggest birth plans are a bit ‘over-promise, under-deliver’. There’s ample evidence that birth plans are not correlated with what happens during your birth, or how your baby comes out of your body[i]. This inconsistency has a knock-on effect of its own; in one 2016 study[ii] 65% of maternity care providers wrongly believed that mothers with birth plans had worse outcomes than those without them. Even the NCT, those staunch advocates of women’s knowledge about and active engagement in birth, note that it is ‘…not clear yet whether birth plans can actually improve your birth experience…’ (NCT, 2019).
So what’s going wrong? Why do birth plans have such a bad reputation, and why do mothers keep writing them? My experience of working with mothers, and my research, suggest these 3 fundamental problems.
Birth Plans don’t fully reflect the planning & decision-making mothers do
To start at the beginning, what is a birth plan? The NHS describes them as ‘...a record of what you would like to happen...’ (2021) and the NCT say they ‘...help mums decide how they’d like birth to be’ (2019). This suggests that when mothers write a birth plan, they’re forecasting what they want to happen, setting a fixed intention for the outcome they most want. As if committing the best-case scenario to paper will somehow make it more likely to happen (in fact, this is what was an intention setting exercise recommended to me when I was pregnant with my first child; write the story of your birth as you’d like it to be). This is one of the reasons birth plans have a bad reputation; they’re accused of setting mothers up to fail by giving unrealistic expectations of what can and can’t be controlled.
For the women I work with, though, ‘The Birth Plan’ is less a charm to ward off ‘bad birth vibes’ and more of a practical ‘birth-hack’. While the focus is on the birth plan, in truth it’s just the tip of the iceberg, the visible out-put of all the knowledge acquisition, discussion, planning and decision making they’ve done throughout their pregnancies. For them, a birth plan is not a separate and disconnected document, but the hard copy result of an iterative process that makes for more confident, easier decision-making during the physical and emotional intensity of labour and birth. Understood like this, the birth plan is a way of essentialising your attitudes and approach. A short-hand way to tell care providers (who you probably won’t have met before) who you are, and how you’d like to approach your births. Not a forecast of what’s to come, but the beginning of a conversation with your care providers.
Birth Plans aren’t a realistic reflection of what happens in birth rooms
The idea of ‘The Birth Plan’ is based on a fundamental misunderstanding of how the birth room works. The whole idea of the birth plan is based on the idea that you can create a ‘good birth’ experience by stacking up the right decisions in the right order, like some sort of modular, LEGO™ set. Follow the instructions correctly and you’ll get a great outcome.
Birth, though, is far more nuanced and connected than that. Mothers cannot control all the variable factors that potentially affect their births, and it’s not reasonable to make mothers responsible for doing that. There’s no ‘Sliding Doors’ decision-making method that allows you to determine which of your options is the best. Decisions are not simple binaries of consent/decline, in the way birth plans often present them. Rather they are risk/benefit analyses in which there is often not a clear, objective ‘right’ answer.
In my experience, despite what might appear to be inflexible, choices, made in advance and determined in their birth plans, mothers know this at some level. The mothers in my study (and the women I’ve supported as a doula) are really flexible and are quite prepared to adapt plans if there’s a good reason to do so (care providers, it’s worth noting that your ability to build an authentic rapport based on mutual trust really, really improves the ability of mothers to lean on your judgement and recommendations).
When birth plans are written in the belief that birth can be wholly managed or controlled, they are in truth a little unrealistic. Birth plans would be a good deal more credible and appropriate if they were formulated to account for usual adaptations and flex that birth requires of us.
Birth Plans don’t really describe what mothers want
The idea that ‘Choice and Control’ are the lynchpins of satisfactory maternity care goes back a long way. It was noted the 1983 Changing Childbirth report, and has stayed with us since. I’m here to suggest that ‘Choice and control’ don’t effectively communicate what mothers want from their care providers, and that this is another flaw in the birth plan.
As with all things, history matters, and it’s important to understand that the idea that ‘choice + control = better childbirth experience’ came about within particular political and social conditions. In the 1950s and 1960s women had little or no control over their birth experiences. Medicine was heavily paternalistic, and mothers were expected to yield to the professional judgement of doctors (it’s worth remembering that women had only had the vote since 1918, well within living memory, so that male/female hierarchy and power dynamics were still firmly in place). The establishment of the NHS prompted the migration of birth into the physical estate of the NHS, culminating in the 1971 Peel Report, which recommended that 100% of births should happen in hospital. The establishment of the NCT and AIMs in the UK, in 1956 and 1960 respectively, and the US Women’s Health Movement in the 1960s and 1970s, moved to challenge this, and to centralise women themselves in decision-making about their own bodies and their own fertility (it’s no coincidence that the Roe vs Wade ruling in the US came in 1973; this was part of the same feminist battle).
In this context ‘choice and control’ made sense. Fast-forward 40-odd years to 2022 and ‘choice and control’ as axes for positive birth experience seems both anachronistic and unhelpfully fashionable. Anachronistic because attitudes and practice in maternity care has moved on significantly. While it remains true that consent remains complicated by power dynamics we are well past the expectation that maternal compliance should be standard and enforceable. Fashionable because neo-liberal attitudes to personal responsibility and the primacy of the individual tie neatly into the idea of mothers as rational consumers of healthcare, and justify the ‘branding’ of ways to do birth. These unrealistic characterisations of individuality in birth suggest that mothers aren’t just doing it for themselves, but by themselves – yet the truth is that birth is not an individual pursuit but a communal endeavour. While there’s something of an echo of feminist theories of bodily control in neo-liberalism, they’re not entirely synonymous.
In my experience mothers who write birth plans do not intent to reject the counsel of midwives and obstetricians in favour of controlling their own choices because they think they know better (and this is how the birth plan is sometimes interpreted by care providers). What women are actually saying in their birth plan is that don’t want to be hurled onto the conveyor belt of maternity care which standardises their uniquely personal experience. They are rejecting bureaucratised care which does not reflect them as individual, fully realised whole humans. What the women I work with really want, far more than unmediated choice or sovereign control, is compassionate care from midwives who recognise & respond to them ‘in their own world’.
…but write one anyway
With all this in mind, why do I still recommend going to the effort of writing a birth plan? Well, the planning matters. Although 84% of women will have a baby by the time they are 45 (source: ONS) and 100% of us are born, birth remains tucked away and rarely witnessed in our culture. Talking about what you think you might want and need from your partner(s) matters. Getting acquainted with what birth can look and feel like (rather than how it usually looks and feels in a fragmented model of institutionalised care) gives you options and opportunities you may not previously have considered.
Having something to share with your care providers on the day matters too, because respectful and honest communication matters, and as you have to start somewhere you may as well start with something they’re expecting to receive. However, your birth plan doesn’t have to follow the same old tired format. Your birth plan doesn’t have to be a chronology of what you think you’ll accept and what you think you’ll decline. Feel free to ditch the tired idea of what a birth plan should look like and think instead about what you want to say to the people who’ll be caring for you when you’ll be at your most vulnerable, on a day you want to remember positively for the rest of your life.
[i] Including Judith Lothian in 2006 (‘Birth Plans: The Good, the Bad, and the Future’ in Journal of obstetric, gynecologic, and neonatal nursing), Lundgren et al in 2003 (‘Is the childbirth experience improved by a birth plan?’, in Journal of midwifery & women's health) and Whitford and Hillan in 1998 (‘Women's perceptions of birth plans’, in the journal Midwifery). Contact me for full references and links to these papers. [ii] DeBaets, Amy Michelle, PhD, (2016). From birth plan to birth partnership: enhancing communication in childbirth. American journal of obstetrics and gynecology, 216(1), pp.31.e1–31.e4.
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