There seems to be a level of mythology associated with birth plans. On one hand are the advocates who insist the birth plan is a valuable tool to ensure the desired birth experience. On the other hand are the nurses whose experience has taught them that birth plans can rarely be followed as written, leaving women frustrated and worse off than if no birth plan had been written. Who is correct?
Birth Plans and Maternal Satisfaction
Birth plans are associated with maternal satisfaction, but the relationship is more complex than you may initially expect.1 For example, adhering to the items on the birth plan increases satisfaction with labor. In many cases the requests are easy for modern providers to fulfill. The number of women who need an episitomy or operative vaginal delivery is relatively small, so most women have a good chance of feeling their birth plan was followed for these items.
The flip side of this equation is that women who make more requests on their birth plan are less likely to feel satisfied with the birth experience. Why is that? It could be that many of the items women put in a birth plan are not “options” to practitioners, but the treatment of choice for specific problems. Birth plans reduced use of two interventions; erythromycin and vitamin K for the newborn. These interventions require specific consent anyway.
Birth Plans and Maternal Outcomes
So does that mean writing a birth plan requesting no epidural, no induction, and no cesarean is a waste of time? Maybe; this was one study in one hospital and in one specific population but it agrees with other studies that find low compliance with maternal requests.
But again, the relationship between birth plan and birth experience may be more complex. In this study from Spain, decreased compliance with birth plan requests was associated with increased use of cesarean AND poorer neonatal transition to extra-uterine life.2 In other words, it appears that deviation from the birth plan may be a clinically good decision the mother and midwife made together because the fetus was showing signs of a problem.
To be fair, It is possible to look at the study and assume it was deviation from the birth plan that caused a trajectory of poor outcomes. But it is also possible to look at the study and assume the midwife and woman were reacting to changing conditions to deviate from the plan one piece at a time to try to preserve as much of the plan as possible — so those who had a cesarean had the least “fulfilled” because they had done the most to try to prevent a cesarean (as opposed to performing cesarean at the first challenge).
I used to tell my childbirth education students that some of them would do nothing from their birth plan because labor would go so quickly they didn’t have time to try any of the comfort measures or positions they chose. Others would do everything from their birth plan, moving through their full hierarchy of pain management options, working their way through all ways to stimulate stronger contractions, and ending with a cesarean done according to their wishes.
The Future of Birth Plans
I believe in the power of a well written birth plan to improve communication. But birth plans may help in one other area: moving evidence into practice. Consider this study from Spain that found written birth plans were associated with increased use of skin to skin contact after delivery.3 During a time when baby friendly was a growing model of practice, having a birth plan increased the chances a woman received this evidence-based care.