Childbirth has had a long and winding history. This is understandable since it has literally been happening since the beginning of human time. Prior to 1950, many births happened in a familiar home setting attended by a midwife, overwhelmingly a group of female providers. For a fun and fairly accurate representation, enjoy a binge of “Call the Midwife” by the BBC. While often depicted in a romantic way, childbirth prior to the 1930s and 40s was dangerous – sepsis caused 40% of maternal deaths as most deliveries were performed without sterile technique and many women died of hemorrhage (severe bleeding) or preeclampsia and eclampsia (elevated blood pressures in pregnancy and seizures) (6).
As science and medicine progressed in the second half of the 20th century, new technologies and techniques moved delivery into a hospital setting attended by physicians, overwhelmingly a group of white male providers. Maternal death in the first quarter of the 20th century was quite common prior to this with as many as 7/100 deaths in the United States (6). While advancements in science and medicine and a shift towards hospital-based delivery improved maternal and fetal/neonatal morbidity and mortality, an unwanted side effect for many patients was the medicalization (and potentially over-medicalization) of the delivery experience (1). In addition, the culture of paternal medicine and the “doctor knows best” mentality meant that this shift encouraged a lack of communication and autonomy for patients.
Within bioethics, autonomy means the patient’s right to choose what happens to their body and to make well-informed choices about the plan for their medical care. Currently, the rate of home birth remains low – less than 1% of all births in the United States (2). However, patients want autonomy for what is arguably one of the most impactful experiences of one’s life – the birth of a child. In the 1970s, prenatal educators introduced the idea of the Birth Plan, a standardized document that sets out the values of a patient regarding their birth experience. In 1996 the World Health Organization advocated for use of the Birth Plan with the goal of increasing patient autonomy during birth (1). Studies have demonstrated that patients feel more empowered and using a birth plan is associated with increased patient satisfaction (3). No studies have been done that address providers’ interactions with Birth Plans, but anecdotally there are few obstetrics providers that look upon them favorably.
While Birth Plans have become commonplace or even an expected part of obstetric care, approximately 50% of pregnancies are unplanned and therefore occur while on a medication that is not safe in pregnancy or at a time in a woman’s life when their health is not optimized (7). Instead of planning the details of birth that will occur several months from now, effort spent ensuring pregnancy occurs at peak health is more important. A few years ago, the state of Oregon began something revolutionary—they began a campaign called “One Key Question.” This campaign focused on planned pregnancy and optimizing women’s health BEFORE attempting to conceive. Instead of scrambling to figure out how to improve a woman’s health while her body was growing a human, this campaign helped women plan ahead of time (8). It targeted all OB/GYNs, family medicine physicians, internists, specialists—any health provider seeing women for care, to ask one question “Are you planning a pregnancy in the next year?” The decision tree for what followed was even more important—if the answer was yes, then the patient received counseling regarding how to optimize health before becoming pregnant. If the answer was no, there was an opportunity for contraceptive counseling to prevent unintended pregnancies.
As a maternal-fetal medicine specialist in Milwaukee Wisconsin, I wonder: Why does society care so deeply about planning the birth, but not about women’s health and well-being? Why don’t we value women’s health until there is a fetus inside her uterus? Why are we so good at empowering women to develop a delivery plan, but terrible at empowering a woman to plan her reproductive timing? There is now evidence (thanks, Oregon!) that clearly extols that optimization of pre-pregnancy health improves pregnancy, birth, and childhood outcomes. The same cannot be said about Birth Plans. This kind of planning is much needed in women’s health. Women with underlying medical conditions, ones as simple as obesity or as complex as kidney failure—all benefit from pre-pregnancy planning. If you want a safer, healthier pregnancy, the planning starts before you conceive.
Trust and clear communication with your physician are the best way to ensure a safe birth, not what answers Google gives you (Public Domain).
Numerous websites offer templates and instructions for creation of Birth Plans. Some lay out options as if delivery is a diner menu and not a series of medical interventions or decisions that are to be made concomitantly with a physician. One template (the first to appear on Google) includes a preference about whether a patient would prefer to be awake or put asleep during a Cesarean. In most institutions, this is not a patient choice but rather a decision made based on if the patient has adequate pain control to do surgery (for example an epidural). Proposing such options are choices, rather than potential medical situations to navigate, at best increases entitlement for a “perfect vaginal delivery” but at worst increases life-threatening situations. While birth has become safer for patients and neonates, one does not get pregnant for their health – while women are no longer routinely dying of sepsis, hemorrhage, and preeclampsia, maternal morbidity rate from data in the last 5 years is ~14 deaths/100,000 live births (6). Nowhere on Birth Plan templates is a patient indication of whether they want intervention in the case of life-threatening hemorrhage or antibiotics for infection, situations that CAN occur. The expectation that a Plan prepares a patient for what is likely a completely unknown entity for nulliparous patients (patients that have never delivered a child before) is shrouded in the idea that part of becoming a “good mother” is preparing for birth (e.g. creating a Birth Plan). More eroding is the perpetuation of the view that being a “good mom” is about anything except actually being a good parent. A Birth Plan with the goal of unanesthetized vaginal birth as the standard sets up for failure the approximately 1/3 of women who end up requiring a cesarean section for birth (5). The idea that a patient is “weak” or less powerful if they choose pain control with an epidural is disheartening. Women who deal with postpartum mood concerns like postpartum depression or anxiety may identify delivery as the precipitation of negative emotions that sets up the maternal-child relationship for tension. The goal of patient autonomy, trust, and communication is challenged when a patient feels like a failure.
To further extrapolate on the issue of time wasted – physicians want patients to remember how WE spent our time to help them through the delivery process. As a general OBGYN one studies through medical school for four years and then trains in a residency program for another four. To specialize in high-risk obstetrics includes an additional three years of training. In total, that is fifteen years and thousands of hours learning to be an expert. It is unfair to expect that by virtue of being pregnant, a woman should feel it is her responsibility to know exactly what she wants for her birth. No amount of research on Google or reading “What to Expect When You are Expecting” can approach that level of knowledge. And it’s unfair to expect that! Having an open, trusting relationship with a physician is the best thing a patient can do to ensure safe and healthy delivery, and allowing a physician to be the guide through the experience is the safest option.
As part of my training, I have had the privilege to deliver babies in three other countries, ones that would be considered developing nations. These countries have far fewer resources than most of the United States. American women do not typically recognize how dangerous childbirth can be and that going home with a liveborn, healthy baby is a guarantee women in other parts of the world do not have. In fact, it was quite shocking to me when I realized that most women in the countries where I have worked don’t come to the hospital prepared with baby names or with many baby items. In many places in the world, the naming and announcement of birth come later, after a good outcome has occurred. While the U.S. has worked hard to improve maternal health, birth, and neonatal outcomes, we often do not realize the benefits we have compared to many other places around the world. When I think of some of my American patients demanding medically unimportant things as part of their Birth Plans or even choosing medically unsafe things in their plans, I am reminded of the things my patients in these other countries didn’t have—assurances of healthy birth and a healthy baby and a medical system that has evolved to reduce death and poor outcomes significantly during the 20th century. I would like to remind patients clinging to unsafe practices or desires as part of their Birth Plan that they are lucky—lucky to have well-trained doctors or midwives, appropriate nursing staff, clean or sterile hospital environments, near-unlimited access to medicines important in childbirth, and typically a well-stocked blood bank in case an emergency occurs. But they have not experienced the maternal and neonatal losses that I have in working in resource-poor labor and delivery units. They do not understand the wonderful privilege of modern medicine that is just normal in the U.S. So, I do not remind them of this, but instead patiently listen to their concerns and try to explain why a different option is likely better.
When I think of my own pregnancy and birth experience, I recall that I discussed becoming pregnant with my OB/GYN before I began trying to conceive. I was lucky that my health was optimal at that time. She prescribed me prenatal vitamins and wished me luck. I became pregnant as a brand new fellow in a city where I had lived less than a month and knew no one. In choosing my OB/GYN, I asked a labor and delivery nurse which physician delivered all the nurses, as I hoped this would likely match me up with a physician whose skills I trusted implicitly. I did not have a birth plan for my first child (who surprised us by delivering preterm) but certainly had some preferences. It was as I was pushing that I realized I had never even talked to my physician about my desires at all surrounding birth. At that moment, the fetal heart tracing wasn’t ideal, so I said “Hey, I know we haven’t talked about this, but I prefer forceps or vacuum to a cesarean if that’s safe and possible!” She laughed and told me if I just gave 1-2 more pushes I’d have a baby (and I did). I did not need a birth plan because I trusted my physician.
In examining the shift in medicine towards patient autonomy and away from paternalism, a shift we absolutely endorse, we have placed unfair expectations on women and their care teams. Most obstetricians want the very same things that most women do—an uncomplicated pregnancy and delivery and a healthy baby. We propose that instead of creating a birth plan at home, patients and their doctor should have open conversations regarding what is typical in their labor and delivery units and how they and their partners’ practice. Obstetricians have the expertise for a reason; they’ve devoted much of their life to learning the science and art of medicine. Working as a team to create a healthy birth environment should improve a patient’s experience, place further trust in the physician and medical systems, and ensure that a physician’s expertise and experience are used to effect optimal patient outcomes. Instead of placing yet another unfair expectation on women, the medical team can work together to empower women to prepare for birth and feel at peace with what may occur.
References
1. Medeiros RMK, Figueiredo G, Correa ÁCP, Barbieri M. Repercussions of using the birth plan in the parturition process. Rev Gaucha Enferm. 2019 Jun 6;40:e20180233. Portuguese, English. doi: 10.1590/1983-1447.2019.20180233. PMID: 31188973.
2. Snowden JM, Tilden EL, Snyder J, Quigley B, Caughey AB, Cheng YW. Planned Out-of-Hospital Birth and Birth Outcomes. N Engl J Med. 2015 Dec 31;373(27):2642-53. doi: 10.1056/NEJMsa1501738. PMID: 26716916; PMCID: PMC4791097.
3. Anderson CM, Monardo R, Soon R, Lum J, Tschann M, Kaneshiro B. Patient Communication, Satisfaction, and Trust Before and After Use of a Standardized Birth Plan. Hawaii J Med Public Health. 2017 Nov;76(11):305-309. PMID: 29164014; PMCID: PMC5694973.
4. DeBaets AM. From birth plan to birth partnership: enhancing communication in childbirth. Am J Obstet Gynecol. 2017 Jan;216(1):31.e1-31.e4. doi: 10.1016/j.ajog.2016.09.087. Epub 2016 Sep 21. PMID: 27664497.
5. Boyle A, Reddy UM. Epidemiology of cesarean delivery: the scope of the problem. Semin Perinatol. 2012 Oct;36(5):308-14. doi: 10.1053/j.semperi.2012.04.012. PMID: 23009961.
6. Ozimek JA, Kilpatrick SJ. Maternal Mortality in the Twenty-First Century. Obstet Gynecol Clin North Am. 2018 Jun;45(2):175-186. doi: 10.1016/j.ogc.2018.01.004. PMID: 29747724.
7. Finer LB and Zolna MR, Declines in unintended pregnancy in the United States, 2008–2011, New England Journal of Medicine, 2016, 374(9):843–852, doi:10.1056/NEJMsa1506575
8. Bellanca HK, Hunter MS. ONE KEY QUESTION®: Preventive reproductive health is part of high quality primary care. Contraception. 2013 Jul;88(1):3-6. doi: 10.1016/j.contraception.2013.05.003. Epub 2013 May 11. PMID: 23773527.
