Abstract
In answer to a reader's question, the author of this column discusses moving birth plans beyond a check list of options to a plan of evolving confidence, support-building, and comfort.
Keywords: birth plans, childbirth educators, natural birth
Question: I encourage the women in my Lamaze class to create birth plans. However, when they discuss their plan with either their health care provider or the staff at the hospital, the response is either outright animosity or assurance that their plan will be respected, but this does not happen. I wonder whether or not birth plans are useful?
Answer: I firmly believe that birth plans are helpful, but—like you—I have wondered about the usefulness of the “birth plan” in its current form. I have struggled over the last few years to figure out why I am dissatisfied, and I have tried to come up with an alternative. My thinking was helped along by the spirited discussion of the participants in the Labor Support Workshop held in Morristown, New Jersey, on November 30 and December 1, 1999. So, my answer to your question reflects their thinking and ideas as well as my own.
Women have always planned for the birth of their babies—who would be with them, where the birth would take place, what they would do in labor and in the days and weeks after birth. Some birthing practices (e.g., the upright position for birth and the support of other women) are remarkably similar across cultures, but other practices are unique. However, within the context of the traditional practices of a culture, it seems reasonable to believe that birthing women planned and chose among many options before and during labor. Birth rituals for the most part facilitated normal, natural birth and insured that the mother would be supported and comforted through labor and in the days and weeks after her baby's birth. Birth rituals reflected trust in women's inherent ability to birth their babies and deep confidence in the process itself. Hospital, physician-directed birth changed all that. The hospital rituals—where the woman must stay in bed, remain attached to intravenous lines and fetal monitors, have food and drink withheld from her, and be routinely separated from her baby—interfere with the normal, natural process of birth, maternal-infant attachment, and breastfeeding. In a very real sense, another birth ritual has been created: the epidural. The modern birth plan was intended to encourage women to think about birth practices, communicate with the health care provider, and ultimately make informed decisions. In reality, the birth plan often pits the birthing woman and the health care provider and hospital staff against each other. The result, unfortunately, can be frustration on both sides.
In reality, the birth plan often pits the birthing woman and the health care provider and hospital staff against each other.
The birth plan in its typical format is a choice of options that are intimately interwoven with physician practice and hospital culture rather than embedded in the context of nature's simple and elegant plan for birth. Planning for birth is a process that should start with learning not about “options” but first about normal, natural birth and the rituals, including comfort strategies, that women have found helpful across time and cultures. Women need to know that they have within themselves the ability to give birth, and that their own inner wisdom will guide them through birth. Your Lamaze class may be the very first time they have ever heard this! Women also need to know the philosophical differences between the medical and midwifery models of care. Women have made the choice of health care provider and place of birth months before they attend your Lamaze class, but it is critical that they understand how these choices will influence future choices, and how the differences in philosophy and patterns of care will shape their experience in ways that will either enhance or diminish their confidence and ability. These choices will, and should, shape planning for birth. Women need to know the influence that even simple interventions (e.g., restrictions on movement and intravenous) have on the normal, natural process of labor and birth. All of this knowledge becomes the foundation for developing a personal birth plan.
What will a useful birth plan look like? The birth plan is no longer a check list of “options” or “choices” but rather a personal plan for a safe, satisfying experience. An abundance of ancient and contemporary research suggests that both safety and satisfaction are enhanced by facilitating rather than interfering with the natural process of labor, birth, breastfeeding, and mother-infant interaction. Three simple things help: confidence in one's own abilities, the freedom to tap into inner wisdom, and the physical and emotional support of family, friends, and professionals. Rather than a checklist of medically focused options, the birth plan develops as three questions are answered:
How can I become and remain confident in my own abilities?
How can I have the freedom I need to find comfort during labor and birth, and to mother my baby?
Who will provide the physical and emotional support that I will need?
Certainly, women have to think about fetal monitors, episiotomies, and rooming-in. However, medical interventions and hospital policies are important only within the context of their effect on a woman's confidence, her freedom to tap into her inner wisdom, and the support she will need. Planning for confidence, freedom, and support becomes the framework for the birth plan.
As each woman's personal plan evolves, the question “Is it possible?” has to be asked. Discussions with the health care provider focus on discussing preferences, negotiating to find compromises, and finding ways of getting what is needed (confidence, freedom, and support) within the context of the reality. Of course, the challenge continues to be helping women find or create options where there appear to be none.
As each woman's personal plan evolves, the question “Is it possible?” has to be asked.
At the Labor Support Workshop, we brainstormed what the birth plan using this framework might look like. Following is a sampling of the possibilities that we discussed.
What will I do during the rest of my pregnancy, in labor and after my baby is born to develop and then maintain confidence in my own abilities? These are some examples of what women's plans might be:
I will talk to my grandmother about her births.
I will talk to other women who have had positive, empowering birth experiences.
I will only read birth stories that are positive.
I will recite birth affirmations every day (“I am strong and competent.” “My body knows how to give birth.” “I am part of the endless cycle of women giving birth”).
I will create birth art that affirms my strength and power.
I will remember that being attached to a fetal monitor does not mean that there is a problem with me or my baby.
I will stay at home in early labor.
I will learn and practice relaxation techniques.
I will attend childbirth classes taught by an educator who has confidence in birth and in me.
I will keep my baby with me after birth.
We acknowledged that, in general—but not always—women who give birth outside the hospital and are attended by midwives are likely to be quite confident. Women who will give birth in a hospital attended by a physician may be quite confident but have to develop ways of maintaining confidence in the hospital environment. And for some women, confidence will be intimately connected to the “safety” of physician and hospital and medical technology.
Who will provide the emotional and physical support I will need during labor and birth and in the days and weeks after my baby is born? Who will I feel safe with? Who is able to comfort me during the hard work of labor, and the challenging work of being a new mother? Here are some examples of women's planning:
I will ask my mother to be with me in labor.
I will interview and hire a professional doula.
My husband will support me in labor.
My mother and sister will come and stay with me after the baby is born.
I will buy paper plates and prepare meals ahead of time so that I will not have to cook and do dishes in the first few weeks after my baby is born.
I will attend a La Leche League meeting.
Because of the restrictions in many hospital environments, women giving birth in a hospital must plan especially carefully for continuous emotional and physical support. Women who give birth in a birthing center return home quickly, so plans must be made for extra support at home. Women who give birth at home need to plan carefully for ongoing housework such as cooking and cleaning.
How can I plan for the freedom I need to find comfort during labor and birth, and to mother my baby? Planning for the freedom necessary to respond to her contractions, and to tap into inner wisdom during labor and after the baby is born is challenging. The differences in the midwifery and medical models of health care delivery are most evident in this arena. Hospital practices, such as staying in bed during labor and separation of mother and baby, dramatically restrict women's freedom. Even so, the limitations can be moderated. Here are some possible examples of women's planning:
I will stay at home in early labor.
I will change positions frequently even if I am confined to bed.
I will buy a birth ball.
I will talk to my physician about intermittent fetal monitoring.
If I must be on a fetal monitor, I will feel free to move and moan in response to my contractions.
I will have my hair brushed and my feet massaged in labor.
I will relax in the shower or bathtub during labor at home even if this is not a possibility at the hospital.
I will keep my baby with me after birth.
I will nurse my baby in response to early infant feeding cues.
I think the major benefit of creating a birth plan in this way is that the focus moves away from the medical approach to birth and in a realistic way focuses women's planning on facilitating normal, natural birth. The planning includes not only labor, birth, and hospital practices but also late pregnancy and the weeks after the baby is born. Planning is within the context of each woman's “reality”—her lifestyle, her personal preferences, her health care provider, and place of birth. Planning in this way moves women beyond thinking of the physician and hospital as gatekeepers and to the understanding that her choices of both may require her to shape her plans somewhat differently. In creating her plans, she negotiates “reality” with the goal of minimizing negative effects on the normal, natural process of birth and maximizing the potential for facilitating normal, natural birth.
… the major benefit of creating a birth plan in this way is that the focus moves away from the medical approach to birth and in a realistic way focuses women's planning on facilitating normal, natural birth.
Author's Note: A special thank you to Debby Amis and the participants of the Labor Support Workshop in Morristown, New Jersey, for their contribution and wisdom. I would love to hear what you, the reader, think about these ideas!
