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Perspectives of Expectant Women and Health Care Providers on Birth Plans
OBSTETRICS
Perspectives of Expectant Women and Health Care Providers on Birth Plans Melissa Aragon, MA,1 Erica Chhoa, MPH,1 Riki Dayan, BSc,1 Amy Kluftinger, BSc,1 Zoe Lohn, MSc,2 Karen Buhler, MD, CCFP1,3 1
Department of Family Practice, University of British Columbia, Vancouver BC
2
Women’s Health Research Institute, Vancouver BC
3
Department of Family Practice, British Columbia Women’s Hospital, Vancouver BC
Abstract
Résumé
Objective: A birth plan is a document detailing a woman’s preferences and expectations related to labour and delivery. Empirical research exploring the value of birth plans has shown conflicting findings about whether birth plans have a positive or negative effect on labour and delivery, suggesting a need for further study. This study aimed to understand the perspectives of women, health care providers, and support persons regarding the use of birth plans.
Objective : Un plan d’accouchement est un document détaillant les préférences et les attentes d’une femme à l’égard du travail et de l’accouchement. Les recherches empiriques explorant la valeur des plans d’accouchement ont obtenu des résultats contradictoires quant à la question de savoir si ces derniers exercent un effet positif ou négatif sur le travail et l’accouchement, ce qui semble souligner la nécessité de procéder à d’autres études sur le sujet. Cette étude avait pour but de comprendre les points de vue des femmes, des fournisseurs de soins et des accompagnateurs à l’égard de l’utilisation de plans d’accouchement.
Methods: A cross-sectional questionnaire was distributed to a convenience sample of expectant or postpartum women, health care providers, and support persons from January 2012 to March 2012 in British Columbia. Results: In total, 122 women and 110 health care providers and support persons completed the questionnaire. Both women and their attendants viewed the birth plan as being valuable for acting as both a communication and education tool. However, the respondents noted that women may be disappointed or dissatisfied if a birth plan cannot be implemented. The most important elements of a birth plan identified included pain management, comfort measures (e.g., mobility during labour), postpartum preferences (e.g., breastfeeding), atmosphere (e.g., privacy), and birthing beliefs (e.g., cultural views). Conclusion: This is the first study to identify advantages and disadvantages of using a birth plan as well as the most important aspects of a birth plan from the perspectives of both women and their attendants in Canada. The findings could be applied to optimize the efficacy of birth plans in Canada and potentially internationally as well.
Méthodes : Un questionnaire transversal a été distribué à un échantillon de commodité de femmes enceintes ou ayant accouché, de fournisseurs de soins et d’accompagnateurs entre janvier 2012 et mars 2012 en Colombie-Britannique. Résultats : En tout, 122 femmes et 110 fournisseurs de soins de santé et accompagnateurs ont rempli le questionnaire. Tant les femmes que leurs fournisseurs de soins et de soutien estimaient que le plan d’accouchement était utile à titre d’outil de communication et d’éducation. Toutefois, les répondants ont souligné que les femmes pourraient être déçues ou mécontentes dans les cas où la mise en œuvre du plan d’accouchement s’avère impossible. Parmi les plus importants éléments du plan d’accouchement qui ont été identifiés, on trouvait la maîtrise de la douleur, les mesures visant le confort (p. ex. mobilité pendant le travail), les préférences postpartum (p. ex. allaitement), l’atmosphère (p. ex. intimité) et les croyances quant à l’accouchement (p. ex. aspects culturels). Conclusion : Il s’agit de la première étude à identifier les avantages et les désavantages de l’utilisation d’un plan d’accouchement, ainsi que les aspects les plus importants d’un tel plan, et ce, tant du point de vue des femmes que de celui de leurs fournisseurs de soins et de soutien au Canada. Les résultats pourraient être utilisés aux fins de l’optimisation de l’efficacité des plans d’accouchement au Canada et (potentiellement) à l’étranger.
Key Words: Women’s health, pregnancy, childbirth, labour, birth Competing Interests: None declared. Received on May 6, 2013 Accepted on July 5, 2013 J Obstet Gynaecol Can 2013;35(11):979–985
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INTRODUCTION
S
ince their inception in the 1970s, birth plans have become increasingly popular in Western countries to improve advocacy for women’s autonomy during childbirth.1,2 A birth plan is a document detailing a woman’s preferences and expectations related to labour and delivery. The precise content of a birth plan varies, but may include preferences and expectations for obstetrical management, newborn care, conduct during emergencies, and cultural considerations.3–5 The aim of a birth plan is to improve women’s satisfaction with labour and delivery by promoting participation, informed decision-making, and empowerment. However, birth plans have been criticized for being rigid and unrealistic, which may adversely affect obstetrical outcomes and contribute to a negative experience.2,3,6 Previous research exploring the impact of birth plans has revealed mixed results. Several studies have shown that birth plans have a positive impact on women’s level of satisfaction by increasing their understanding of labour and delivery, allowing women to express their needs and preferences, and improving communication between women and care providers.7–12 One group found that 66% to 80% of Canadian women surveyed across various care provider groups believed that a birth plan was “a good idea for pregnant women.”13 To date, one randomized control trial has been conducted to assess the use of birth plans: Kuo and colleagues found that nulliparous women in Taiwan who created a birth plan reported a more positive childbirth experience and higher perceived control over the childbirth experience than women who did not use a birth plan.14 Other studies have shown that birth plans have a more modest effect on the labour and delivery process, no effect at all, or in fact, a negative effect. For example, women surveyed in Sweden15,16 and Australia17,18 reported that a birth plan did not improve their level of satisfaction with labour and delivery. One half of the women surveyed in another study stated that a birth plan did not make any difference in the amount of control that they felt during labour, suggesting that the birth plan did not meet one of its intended goals.10 Interestingly, one study conducted in the United States found that there was no difference in rates of Caesarean section or episiotomy between women who had a birth plan and those who did not; however, women with a birth plan had epidural anaesthesia less often than women without a birth plan.19 A study conducted in Sweden found that the use of a birth plan intensified negative emotions among pregnant women at high risk.15 980 l NOVEMBER JOGC NOVEMBRE 2013
Together, these findings indicate that it is unclear whether there are benefits to using a birth plan. Further, some authors have suggested that a birth plan may conflict with the circumstances that arise during labour, and this may inadvertently generate hostile relationships between women and care providers if women do not want to deviate from their birth plan.3,5 Other authors have raised concerns about birth plans causing conflict between patients and care providers when there is mistrust or a lack of respect between women and their attendants.20 There is clear disparity between the findings of individual studies of birth plans, with conflicting findings even arising within the same study.10,16,17 Further, most studies have been limited by having small cohorts, and no study has explored the advantages and disadvantages of using a birth plan or the most important aspects of a birth plan among women, care providers, and support persons within the sociocultural landscape of Canada.14 We therefore conducted a survey to examine the attitudes and perceptions of women and their attendants regarding birth plans. This information could potentially be used to improve the birth plans currently in use in Canada and internationally. METHODS
In Canada, pregnant women receive obstetrical care from family physicians, obstetricians, or midwives, and some women receive care from a combination of these providers. Women may also choose to be supported by a doula, most often paid for privately, during the labour process. Birth plan templates may be given to women by their care providers, or women may seek out birth plans online. The birth plans that are used can vary in their content, but typically include sections to be completed by the expectant woman (and possibly her family) regarding her preferences for pain management options, specific procedures (e.g., fetal monitoring, use of vacuum or forceps, Caesarean section), unexpected events, newborn care, and the role of her partner. We developed a questionnaire after reviewing the literature concerning birth plans (Appendix).1,3,4,11,14 The resulting crosssectional questionnaire asked participants two open-ended questions to ascertain the advantages and disadvantages of using a birth plan: 1. “What are some of the pros of using a birth plan?” and 2. “What are some of the cons of using a birth plan?” In addition, participants were asked about the most important aspects of a birth plan: “If a birth plan had to be limited to one page, what aspects do you feel are the most important to be communicated to on-call staff ?”
Perspectives of Expectant Women and Health Care Providers on Birth Plans
and “What three aspects of a birth plan do you feel are the most important?” In addition to these questions, the care providers and support persons were asked to indicate their specific role (i.e., obstetrician, family physician, nurse, midwife, doula), and the women were asked which care providers and support persons were following them through their pregnancy, whether they had used or were planning to use a birth plan, and location of delivery. The online questionnaire consisted of both open-ended and multiple-choice questions. The anonymous questionnaire was distributed to a convenience sample of women, care providers, and support persons between January 2012 and March 2012. Expectant and postpartum women, care providers, and support persons were recruited from birth-related social networking websites (e.g., Facebook pages related to midwifery in British Columbia). In addition, the study was advertised to care providers at departmental meetings at British Columbia Women’s Hospital and Health Centre in Vancouver, and through the University of British Columbia Faculty of Medicine’s email list serve. The Google Docs program was used to collect the data. Quantitative data were analyzed descriptively. With respect to qualitative data, text responses were annotated by four investigators (R.D., M.A., E.C., A.K.) independently in short sections (1 to 2 sentences) for codes, which were then discussed among the investigators to identify prominent themes. Main themes emerged based on descriptive analysis.21 Verbatim quotations from participants were selected to illustrate key points. RESULTS
A total of 122 postpartum or expectant women and 110 care providers and support persons completed the questionnaire. Most women (55%, n = 68) identified a midwife as their primary care provider, while only some women identified a family physician (27%, n = 34) or obstetrician (11%, n = 13) (Table 1). Most women (70%, n = 86) indicated that they had used or were planning to use a birth plan during their most recent pregnancy. The care providers and support persons identified a variety of roles, mostly nurses (27%, n = 30) and family physicians (23%, n = 25) (Table 1). Two major benefits of birth plans were reported by participants. First, 53% (n = 65) of the women and 57% (n = 63) of their attendants stated that birth plans acted as a communication tool, allowing the woman’s partner, family, and care providers to understand the woman’s expectations and preferences for labour and delivery. Some women reported that the birth plan acts as a discussion
piece during prenatal appointments. According to one practitioner, birth plans bring: “greater understanding of what may happen in labour and birth and a great way to express one’s ideal desires so that all involved in her birthing can be on the same page.” Second, 47% (n = 57) of the women and 41% (n = 45) of their attendants indicated that a birth plan was useful for educational purposes. Women reported that the knowledge gained through the process of creating a birth plan was very beneficial, allowing them to consider their options, become aware of hospital policies, and address areas of concern. One woman stated: “Being prepared and educated increases success in everything we do. It should especially be encouraged and supported in pregnancy and delivery. Having knowledge is empowering and enabling.” Additional advantages cited by the participants included the following: 18% (n = 22) of the women and 20% (n = 22) of their attendants stated that birth plans enhance autonomy and informed decision-making; 20% (n = 24) of the women and 4% (n = 4) of the attendants stated that birth plans helped to foster a positive outlook towards the birth; 19% (n = 23) of the women and 9% (n = 10) of the attendants stated that the use of birth plans increased the expectant mother’s feelings of control and empowerment. None of the women and 4% (n = 4) of their attendants indicated that there are no advantages to using a birth plan. Forty-three percent (n = 52) of the women and 47% (n = 52) of their attendants reported that the greatest disadvantage of having a birth plan was the secondary effect of negative emotions such as disappointment or dissatisfaction arising when a birth plan could not be followed, particularly if this is combined with unrealistic expectations. One woman explained: “I knew that if I wrote it down I would be mentally committed to it and it might be harder to ‘roll with’ whatever the birth may bring.” One third (n = 40) of the women and 26% (n = 29) of their attendants indicated that birth plans could lead to inflexibility and rigidity, potentially leading to poor outcomes. For example, one woman explained: “You can stick to them too rigidly, or it may make you feel angry at yourself if you were not able to stick to what you had written or wanted.” A care provider stated: “Some patients want to stick rigidly to the plan—despite how their labour is progressing.” Similarly, 29% (n = 35) of the women and 14% (n = 15) of their attendants felt that birth plans could give a false sense of control and might not allow women to prepare for the unexpected. Many women emphasized the importance NOVEMBER JOGC NOVEMBRE 2013 l 981
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Table 1. Characteristics of women and health care providers n (%) Characteristics of women (n = 122) Primary care provider/support person
Midwife
68 (55)
Family physician
34 (27)
Obstetrician
13 (11)
Multiple births with different health care providers
3 (3)
Midwife and family physician
1 (1)
Fertility specialist
1 (1)
Did not indicate
2 (2)
Use of a birth plan
Yes
86 (70)
No
28 (23)
Did not indicate
8 (7)
Location of delivery
Hospital
61 (50)
Home
32 (26)
Different locations for multiple births Did not indicate
8 (7) 21 (17)
Characteristics of health care providers and support persons (n = 110) Health care provider profession
Nurse
30 (27)
Family physician
25 (23)
Midwife
21 (19)
Obstetrician
18 (16)
Support person profession
Doula
16 (15)
of the birth plan not being a “plan,” but rather a guide or intention. Additional disadvantages cited by the participants included the following: 13% (n = 14) of the attendants felt that birth plans were not useful because they were too detailed or restrictive; 6% (n = 7) of both the women and their attendants stated that birth plans may actually be harmful to patient care, indicating that they may interfere with clinical care or increase the mother’s stress and anxiety during labour; 13% (n = 16) of the women and 14% (n = 15) of their attendants noted that birth plans may elicit negative reactions from health care providers. Thirteen women (11%) and five of their attendants (5%) stated that they did not see any disadvantages to having a birth plan. With regard to the most important components of a birth plan, pain management was the component most commonly cited by both the women (59%, n = 72) and 982 l NOVEMBER JOGC NOVEMBRE 2013
their attendants (42%, n = 47) (Table 2). In addition to pain management, four themes were identified by more than 20% of the women: comfort measures (30%, n = 36), postpartum preferences (29%, n = 35), interventions (26%, n = 32), and control of atmosphere (21%, n = 25). Similarly, in addition to pain management, three themes were identified by more than 20% of the care providers and support persons: instructions contradicting the standard of care (26%, n = 29), beliefs about birth (24%, n = 27), and postpartum preferences (23%, n = 26). Two components were mentioned by the care providers and support persons but not mentioned by the women at all: the presence or absence of prenatal education (4%, n = 4), and statement of hospital policy (3%, n = 3). Regarding components of a birth plan spontaneously mentioned by the participants, more women (30%, n = 36) than attendants (9%, n = 10) indicated that comfort measures were important. Second, more women (26%, n = 32) than attendants (11%, n = 12) indicated spontaneously that the use of interventions was important. Third, more attendants (26%, n = 29) than women (12%, n = 15) stated that instructions contradicting the standard of care were important. Finally, more attendants (24%, n = 27) than women (5%, n = 6) indicated that beliefs about birth were important. DISCUSSION
This is the first study to report the advantages and disadvantages of using a birth plan, as well as the most important aspects of a birth plan from the perspectives of women, their care providers, and support persons in Canada. These results add important information in this area, and could be applied to develop an effective birth plan template that would be useful for women and their attendants. Most of the women in the current study received their primary maternity care from a midwife, and were planning to use or had used a birth plan. This is in keeping with other studies characterizing the population of women who use birth plans, which also found that most women choosing to use a birth plan were being cared for by a midwife.12,17 The results from this study demonstrate that both pregnant women and their attendants see benefits and drawbacks in using a birth plan. The main benefits reported by participants included the role of a birth plan as a communication and educational tool. The act of creating a birth plan was an educational process for women, and the implementation of a birth plan empowered them to express their expectations and preferences, which could
Perspectives of Expectant Women and Health Care Providers on Birth Plans
Table 2. The most important components of a birth plan Birth plan component
Women n (%)
Health care providers and support persons n (%)
Pain management (e.g., pharmacological options)
72 (59)
47 (42)
Comfort measurements (e.g., mobility, pushing preferences)
36 (30)
10 (9)
Postpartum preferences (e.g., who should cut the cord, breastfeeding)
35 (29)
26 (23)
Use of interventions (e.g., episiotomy, forceps, vacuum)
32 (26)
12 (11)
Control of atmosphere (e.g., privacy, lighting)
25 (21)
18 (16)
Identification and role of support people
22 (18)
16 (14)
Postpartum instructions contradicting standard of care (e.g., refusal of erythromycin, vitamin K, newborn screening)
15 (12)
29 (26)
Type and frequency of assessments
10 (8)
2 (2)
Birth and delivery instructions (e.g., positions, water birth, spontaneous vs. coached)
10 (8)
5 (5)
Emergency plan
10 (8)
7 (6)
Beliefs about birth (e.g., cultural and religious factors, hypnosis)
6 (5)
27 (24)
Psychosocial and emotional factors to consider
2 (2)
9 (8)
Presence or absence of prenatal education
0 (0)
4 (4)
Statement of hospital policy
0 (0)
3 (3)
be communicated to their attendants. These findings are consistent with several studies that found the use of a birth plan promoted active participation in the delivery,8,14 clarified women’s opinions about labour and delivery options,12 and facilitated communication between the women and their care providers.7,11,12 Notably, all of the women in the current study indicated that there were advantages to having a birth plan, and 11% indicated that there were no disadvantages to having a birth plan, indicating that overall, the women viewed birth plans positively. This has also been noted by another group.13 Although the women and their attendants described multiple advantages of using a birth plan, many feared that birth plans could potentially lead to dissatisfaction, inflexibility, and a false sense of control if a birth plan was not carried out as outlined. These concerns have been raised by other authors and corroborated by studies showing that women whose delivery did not follow their birth plan were less satisfied with the process than women who were able to follow their birth plan.3,5 For example, Kannan and colleagues found that women who had requested an un-medicated delivery but who had epidural anaesthesia were less satisfied with their experience than women who had planned on having an epidural.22 Other studies found that women felt disappointed23 or betrayed8 by their care providers when a birth plan was not carried out. However, two groups found that women described the use of a birth plan as satisfying despite the fact that some of their deliveries did not go as planned.12,24 Together, these findings suggest that women should not feel bound
to their birth plans, but rather should be flexible to account for the unpredictable nature of childbirth. Pain management was most commonly cited by the women and their attendants as the most important aspect of a birth plan. Other important aspects cited included postpartum preferences, comfort measures, beliefs about birth, control of atmosphere, interventions, and instructions contradicting the standard of care. These results are consistent with the findings of a study conducted by Deering and colleagues, who found that the most common requests included by women in a birth plan involved pain management interventions (e.g., regarding epidural anaesthesia), comfort measures (e.g., regarding walking during labour) and obstetrical interventions (e.g., regarding episiotomy).25 Similarly, another study found that analgesic preferences were reported to be the most common birth plan items.1 The women and their attendants appeared to differ slightly in their opinions about the most important components to include in a birth plan. Specifically, more care providers and support persons than women indicated that beliefs about birth and instructions contradicting the standard of care were important to consider in a birth plan. More women than their attendants indicated that comfort measures and the use of interventions were important. These differences may reflect different priorities, or different opinions regarding the factors that a woman can influence during delivery. For example, attendants may feel comfortable with the medical issues surrounding childbirth, but may NOVEMBER JOGC NOVEMBRE 2013 l 983
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feel less sure and more inquisitive about the women’s personal beliefs and culture. The results of this study indicate that birth plans can enhance the experience of labour and delivery, if women understand that unexpected circumstances can arise during labour that may not be consistent with the birth plan. Furthermore, the success of a birth plan depends on open communication between women and care providers and an environment that empowers women to make informed choices.8 These data could be used to develop a birth plan template, ideally a concise document to facilitate reference by care providers during delivery.4 As indicated by the participants in this study, key sections of a birth plan should include pain management, postpartum preferences, control of atmosphere, comfort measures, beliefs about birth, interventions, and instructions contradicting the standard of care. A birth plan should include acknowledgement of the unpredictable nature of childbirth, and that women’s preferences should be open to change. Moreover, the birth plan has been described as a “living document”3 and an “evolving document,”4 suggesting that it should be modified according to new information and changing circumstances. This study suggests that the term “birth plan” should be replaced by “birth guide” to emphasize the need for flexibility due to the dynamic nature of childbirth. A birth guide can be used as a point of discussion between women and care providers to promote understanding of procedures.11 The recommendations described here have the potential to promote communication between women and their attendants to increase women’s satisfaction and comfort with their labour and delivery. Further exploration of the attitudes of women and their attendants towards the use of birth plans among different cultural groups would be valuable. Additionally, further research should be instigated to assess the efficacy of birth plans critically. Our study has several limitations. Recruitment of participants focused on women and their attendants residing within British Columbia; the responses are likely not representative of other areas. Sampling bias may have affected recruitment because about one half of the women recruited were receiving midwifery care, yet in the fiscal year of 2007–2008 only 6% of women delivered under the care of a midwife.26 Further, the proportion of midwives in the care providers and support persons group did not match the proportion of women receiving midwifery care. Future studies may specifically explore the relationship between midwives and the use of a birth plan. The questionnaire was available only in English, so the results may be limited by cultural and ethnic perspectives. The lack of demographic variables collected prevents 984 l NOVEMBER JOGC NOVEMBRE 2013
generalizing or extrapolating the results of this study to other populations. Finally, the term “birth plan” was not defined on the questionnaire, so individual respondents may have interpreted this term differently. CONCLUSION
While many participants in this study indicated that a birth plan is a valuable educational and communication tool, the participants also acknowledged that a birth plan may promote a false sense of control or lead to disappointment if it is not fully implemented. Women emphasized the need to be flexible in making requests because a birth plan may not be implemented as desired. The study identified the important aspects of a birth plan that could used to help a woman develop or modify one. Ultimately, we believe that birth plans have the potential to play an integral role in conveying women’s preferences effectively, and thereby facilitate informed decisions and a satisfactory experience for both women and their care providers. ACKNOWLEDGEMENTS
The authors would like to thank those who participated in this study and the Fir Square Doulas of 2011–2012. Melissa Aragon, Amy Kluftinger, Riki Dayan, and Erica Chhoa were students in the Faculty of Medicine at the University of British Columbia when this study was conducted. This project was supported by the Family Practice Initiative Fund. REFERENCES 1. Simkin P. Birth plans: after 25 years, women still want to be heard. Birth 2007;34(1):49–51. 2. Kitzinger S. Letter from England—birth plans. Birth 1992;19(1):36–7. 3. Lothian J. Birth plans: the good, the bad, and the future. J Obstet Gynecol Neonatal Nurs 2006;35(2):295–303. 4. Kaufman T. Evolution of the birth plan. J Perinat Educ 2007;16(3):47–52. 5. Bailey JM, Crane P, Nugent CE. Childbirth education and birth plans. Obstet Gynecol Clin North Am 2008;35(3):497–509. 6. Perez PG, Capitulo KL. Birth plans: are they really necessary? Pro and con. MCN Am J Matern Child Nurs 2005;30(5):288–9. 7. Moore M, Hopper U. Do birth plans empower women? Evaluation of a hospital birth plan. Birth 1995;22(1):29–36. 8. Too SK. Do birthplans empower women? A study of midwives’ views. Nurs Stand 1996;10(32):44–8. 9. Too SK. Do birthplans empower women? A study of their views. Nurs Stand 1996;10(31):33–7. 10. Whitford HM, Hillan EM. Women’s perceptions of birth plans. Midwifery 1998;14(4):248–53. 11. Sham A, Chan L, Yiu KL, Ng CW, Ng J, Tang PL. Effectiveness of the use of birth plan in Hong Kong Chinese women: a qualitative exploratory research. Hong Kong J Gynaecol Obstet Midwifery 2007;7:30–4.
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12. Pennell A, Salo-Coombs V, Herring A, Spielman F, Fecho K. Anesthesia and analgesia-related preferences and outcomes of women who have birth plans. J Midwifery Womens Health 2011;56(4):376–81. 13. Klein MC, Kaczorowski J, Hearps SJ, Tomkinson J, Baradaran N, Hall WA, et al. Birth technology and maternal roles in birth: knowledge and attitudes of Canadian women approaching childbirth for the first time. J Obstet Gynaecol Can 2011;33(6):598–608. 14. Kuo SC, Lin KC, Hsu CH, Yang CC, Chang MY, Tsao CM, et al. Evaluation of the effects of a birth plan on Taiwanese women’s childbirth experiences, control and expectations fulfilment: a randomised controlled trial. Int J Nurs Stud 2010;47(7):806–14. 15. Berg M, Lundgren I, Lindmark G. Childbirth experience in women at high risk: is it improved by use of a birth plan? J Perinat Educ 2003;12(2):1–15. 16. Lundgren I, Berg M, Lindmark G. Is the childbirth experience improved by a birth plan? J Midwifery Womens Health 2003;48(5):322–8. 17. Brown SJ, Lumley J. Communication and decision-making in labour: do birth plans make a difference? Health Expect 1998;1(2):106–16. 18. Peart K. Birth planning—is it beneficial to pregnant women? Aust J Midwifery 2004;17(1):27–9.
20. Perry C, Quinn L, Nelson L. Birth plans and professional autonomy. Hastings Cent Rep 2002;32(2):12. 21. Neergaard MA, Olesen F, Andersen RS, Sondergaard J. Qualitative description—the poor cousin of health research? BMC Med Res Methodol 2009;9:52. doi:10.1186/1471–2288–9–52. 22. Kannan S, Jamison RN, Datta S. Maternal satisfaction and pain control in women electing natural childbirth. Reg Anesth Pain Med 2001;26(5):468–72. 23. Carlton T, Callister LC, Stoneman E. Decision making in laboring women: ethical issues for perinatal nurses. J Perinat Neonatal Nurs 2005;19(2):145–54. 24. Yam EA, Grossman AA, Goldman LA, Garcia SG. Introducing birth plans in Mexico: an exploratory study in a hospital serving low-income Mexicans. Birth 2007;34(1):42–8. 25. Deering MA, Heller J, McGaha K, Heaton J, Satin AJ. Patients presenting with birth plans in a military tertiary care hospital: a descriptive study of plans and outcomes. Mil Med 2006;171(8):778–80. 26. British Columbia Perinatal Health Program. Perinatal Health Report 2008. 2010. Available at: http://www.perinatalservicesbc.ca/ NR/rdonlyres/3DEC78D6-BDC3–4602-B09B-FB0EE1C7B7D9/0/ SurveillanceAnnualReport2008.pdf. Accessed May 18, 2013.
19. Deering SH, Zaret J, McGaha K, Satin AJ. Patients presenting with birth plans: a case-control study of delivery outcomes. J Reprod Med 2007;52(10):884–7.
APPENDIX Questionnaire for health care providers and support persons 1)
I am a(n) (circle one):
obstetrician
family physician
midwife
nurse
doula
02) What are some of the pros of using a birth plan? 03) What are some of the cons of using a birth plan? 04) If a birth plan had to be limited to one page, what aspects do you feel are the most important to be communicated to on-call staff?
Questionnaire for women: 01) Are you expecting or have you previously given birth? 02) Did you (or will you) use a birth plan for this pregnancy? 03) In your opinion, what are the possible limitations of a birth plan? 04) What 3 aspects of a birth plan do you feel are the most important? 05) Did you (or will you) use a doula? 06) What do you think are the pros of having a birth plan? 07) What do you think are the cons of having a birth plan? 08) My main health care provider for this pregnancy is/was a:
a. Midwife
b. Family physician
c. Obstetrician
d. Other
0 09) Where did you (or will you) plan on delivering? 10) If your birth plan had to be limited to one page, what aspects do you feel are the most important to be communicated to the on-call staff?
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Perspectives of Expectant Women and Health Care Providers on Birth Plans Melissa Aragon, MA,1 Erica Chhoa, MPH,1 Riki Dayan, BSc,1 Amy Kluftinger, BSc,1 Zoe Lohn, MSc,2 Karen Buhler, MD, CCFP1,3 1
Department of Family Practice, University of British Columbia, Vancouver BC
2
Women’s Health Research Institute, Vancouver BC
3
Department of Family Practice, British Columbia Women’s Hospital, Vancouver BC
Abstract
Résumé
Objective: A birth plan is a document detailing a woman’s preferences and expectations related to labour and delivery. Empirical research exploring the value of birth plans has shown conflicting findings about whether birth plans have a positive or negative effect on labour and delivery, suggesting a need for further study. This study aimed to understand the perspectives of women, health care providers, and support persons regarding the use of birth plans.
Objective : Un plan d’accouchement est un document détaillant les préférences et les attentes d’une femme à l’égard du travail et de l’accouchement. Les recherches empiriques explorant la valeur des plans d’accouchement ont obtenu des résultats contradictoires quant à la question de savoir si ces derniers exercent un effet positif ou négatif sur le travail et l’accouchement, ce qui semble souligner la nécessité de procéder à d’autres études sur le sujet. Cette étude avait pour but de comprendre les points de vue des femmes, des fournisseurs de soins et des accompagnateurs à l’égard de l’utilisation de plans d’accouchement.
Methods: A cross-sectional questionnaire was distributed to a convenience sample of expectant or postpartum women, health care providers, and support persons from January 2012 to March 2012 in British Columbia. Results: In total, 122 women and 110 health care providers and support persons completed the questionnaire. Both women and their attendants viewed the birth plan as being valuable for acting as both a communication and education tool. However, the respondents noted that women may be disappointed or dissatisfied if a birth plan cannot be implemented. The most important elements of a birth plan identified included pain management, comfort measures (e.g., mobility during labour), postpartum preferences (e.g., breastfeeding), atmosphere (e.g., privacy), and birthing beliefs (e.g., cultural views). Conclusion: This is the first study to identify advantages and disadvantages of using a birth plan as well as the most important aspects of a birth plan from the perspectives of both women and their attendants in Canada. The findings could be applied to optimize the efficacy of birth plans in Canada and potentially internationally as well.
Méthodes : Un questionnaire transversal a été distribué à un échantillon de commodité de femmes enceintes ou ayant accouché, de fournisseurs de soins et d’accompagnateurs entre janvier 2012 et mars 2012 en Colombie-Britannique. Résultats : En tout, 122 femmes et 110 fournisseurs de soins de santé et accompagnateurs ont rempli le questionnaire. Tant les femmes que leurs fournisseurs de soins et de soutien estimaient que le plan d’accouchement était utile à titre d’outil de communication et d’éducation. Toutefois, les répondants ont souligné que les femmes pourraient être déçues ou mécontentes dans les cas où la mise en œuvre du plan d’accouchement s’avère impossible. Parmi les plus importants éléments du plan d’accouchement qui ont été identifiés, on trouvait la maîtrise de la douleur, les mesures visant le confort (p. ex. mobilité pendant le travail), les préférences postpartum (p. ex. allaitement), l’atmosphère (p. ex. intimité) et les croyances quant à l’accouchement (p. ex. aspects culturels). Conclusion : Il s’agit de la première étude à identifier les avantages et les désavantages de l’utilisation d’un plan d’accouchement, ainsi que les aspects les plus importants d’un tel plan, et ce, tant du point de vue des femmes que de celui de leurs fournisseurs de soins et de soutien au Canada. Les résultats pourraient être utilisés aux fins de l’optimisation de l’efficacité des plans d’accouchement au Canada et (potentiellement) à l’étranger.
Key Words: Women’s health, pregnancy, childbirth, labour, birth Competing Interests: None declared. Received on May 6, 2013 Accepted on July 5, 2013 J Obstet Gynaecol Can 2013;35(11):979–985
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INTRODUCTION
S
ince their inception in the 1970s, birth plans have become increasingly popular in Western countries to improve advocacy for women’s autonomy during childbirth.1,2 A birth plan is a document detailing a woman’s preferences and expectations related to labour and delivery. The precise content of a birth plan varies, but may include preferences and expectations for obstetrical management, newborn care, conduct during emergencies, and cultural considerations.3–5 The aim of a birth plan is to improve women’s satisfaction with labour and delivery by promoting participation, informed decision-making, and empowerment. However, birth plans have been criticized for being rigid and unrealistic, which may adversely affect obstetrical outcomes and contribute to a negative experience.2,3,6 Previous research exploring the impact of birth plans has revealed mixed results. Several studies have shown that birth plans have a positive impact on women’s level of satisfaction by increasing their understanding of labour and delivery, allowing women to express their needs and preferences, and improving communication between women and care providers.7–12 One group found that 66% to 80% of Canadian women surveyed across various care provider groups believed that a birth plan was “a good idea for pregnant women.”13 To date, one randomized control trial has been conducted to assess the use of birth plans: Kuo and colleagues found that nulliparous women in Taiwan who created a birth plan reported a more positive childbirth experience and higher perceived control over the childbirth experience than women who did not use a birth plan.14 Other studies have shown that birth plans have a more modest effect on the labour and delivery process, no effect at all, or in fact, a negative effect. For example, women surveyed in Sweden15,16 and Australia17,18 reported that a birth plan did not improve their level of satisfaction with labour and delivery. One half of the women surveyed in another study stated that a birth plan did not make any difference in the amount of control that they felt during labour, suggesting that the birth plan did not meet one of its intended goals.10 Interestingly, one study conducted in the United States found that there was no difference in rates of Caesarean section or episiotomy between women who had a birth plan and those who did not; however, women with a birth plan had epidural anaesthesia less often than women without a birth plan.19 A study conducted in Sweden found that the use of a birth plan intensified negative emotions among pregnant women at high risk.15 980 l NOVEMBER JOGC NOVEMBRE 2013
Together, these findings indicate that it is unclear whether there are benefits to using a birth plan. Further, some authors have suggested that a birth plan may conflict with the circumstances that arise during labour, and this may inadvertently generate hostile relationships between women and care providers if women do not want to deviate from their birth plan.3,5 Other authors have raised concerns about birth plans causing conflict between patients and care providers when there is mistrust or a lack of respect between women and their attendants.20 There is clear disparity between the findings of individual studies of birth plans, with conflicting findings even arising within the same study.10,16,17 Further, most studies have been limited by having small cohorts, and no study has explored the advantages and disadvantages of using a birth plan or the most important aspects of a birth plan among women, care providers, and support persons within the sociocultural landscape of Canada.14 We therefore conducted a survey to examine the attitudes and perceptions of women and their attendants regarding birth plans. This information could potentially be used to improve the birth plans currently in use in Canada and internationally. METHODS
In Canada, pregnant women receive obstetrical care from family physicians, obstetricians, or midwives, and some women receive care from a combination of these providers. Women may also choose to be supported by a doula, most often paid for privately, during the labour process. Birth plan templates may be given to women by their care providers, or women may seek out birth plans online. The birth plans that are used can vary in their content, but typically include sections to be completed by the expectant woman (and possibly her family) regarding her preferences for pain management options, specific procedures (e.g., fetal monitoring, use of vacuum or forceps, Caesarean section), unexpected events, newborn care, and the role of her partner. We developed a questionnaire after reviewing the literature concerning birth plans (Appendix).1,3,4,11,14 The resulting crosssectional questionnaire asked participants two open-ended questions to ascertain the advantages and disadvantages of using a birth plan: 1. “What are some of the pros of using a birth plan?” and 2. “What are some of the cons of using a birth plan?” In addition, participants were asked about the most important aspects of a birth plan: “If a birth plan had to be limited to one page, what aspects do you feel are the most important to be communicated to on-call staff ?”
Perspectives of Expectant Women and Health Care Providers on Birth Plans
and “What three aspects of a birth plan do you feel are the most important?” In addition to these questions, the care providers and support persons were asked to indicate their specific role (i.e., obstetrician, family physician, nurse, midwife, doula), and the women were asked which care providers and support persons were following them through their pregnancy, whether they had used or were planning to use a birth plan, and location of delivery. The online questionnaire consisted of both open-ended and multiple-choice questions. The anonymous questionnaire was distributed to a convenience sample of women, care providers, and support persons between January 2012 and March 2012. Expectant and postpartum women, care providers, and support persons were recruited from birth-related social networking websites (e.g., Facebook pages related to midwifery in British Columbia). In addition, the study was advertised to care providers at departmental meetings at British Columbia Women’s Hospital and Health Centre in Vancouver, and through the University of British Columbia Faculty of Medicine’s email list serve. The Google Docs program was used to collect the data. Quantitative data were analyzed descriptively. With respect to qualitative data, text responses were annotated by four investigators (R.D., M.A., E.C., A.K.) independently in short sections (1 to 2 sentences) for codes, which were then discussed among the investigators to identify prominent themes. Main themes emerged based on descriptive analysis.21 Verbatim quotations from participants were selected to illustrate key points. RESULTS
A total of 122 postpartum or expectant women and 110 care providers and support persons completed the questionnaire. Most women (55%, n = 68) identified a midwife as their primary care provider, while only some women identified a family physician (27%, n = 34) or obstetrician (11%, n = 13) (Table 1). Most women (70%, n = 86) indicated that they had used or were planning to use a birth plan during their most recent pregnancy. The care providers and support persons identified a variety of roles, mostly nurses (27%, n = 30) and family physicians (23%, n = 25) (Table 1). Two major benefits of birth plans were reported by participants. First, 53% (n = 65) of the women and 57% (n = 63) of their attendants stated that birth plans acted as a communication tool, allowing the woman’s partner, family, and care providers to understand the woman’s expectations and preferences for labour and delivery. Some women reported that the birth plan acts as a discussion
piece during prenatal appointments. According to one practitioner, birth plans bring: “greater understanding of what may happen in labour and birth and a great way to express one’s ideal desires so that all involved in her birthing can be on the same page.” Second, 47% (n = 57) of the women and 41% (n = 45) of their attendants indicated that a birth plan was useful for educational purposes. Women reported that the knowledge gained through the process of creating a birth plan was very beneficial, allowing them to consider their options, become aware of hospital policies, and address areas of concern. One woman stated: “Being prepared and educated increases success in everything we do. It should especially be encouraged and supported in pregnancy and delivery. Having knowledge is empowering and enabling.” Additional advantages cited by the participants included the following: 18% (n = 22) of the women and 20% (n = 22) of their attendants stated that birth plans enhance autonomy and informed decision-making; 20% (n = 24) of the women and 4% (n = 4) of the attendants stated that birth plans helped to foster a positive outlook towards the birth; 19% (n = 23) of the women and 9% (n = 10) of the attendants stated that the use of birth plans increased the expectant mother’s feelings of control and empowerment. None of the women and 4% (n = 4) of their attendants indicated that there are no advantages to using a birth plan. Forty-three percent (n = 52) of the women and 47% (n = 52) of their attendants reported that the greatest disadvantage of having a birth plan was the secondary effect of negative emotions such as disappointment or dissatisfaction arising when a birth plan could not be followed, particularly if this is combined with unrealistic expectations. One woman explained: “I knew that if I wrote it down I would be mentally committed to it and it might be harder to ‘roll with’ whatever the birth may bring.” One third (n = 40) of the women and 26% (n = 29) of their attendants indicated that birth plans could lead to inflexibility and rigidity, potentially leading to poor outcomes. For example, one woman explained: “You can stick to them too rigidly, or it may make you feel angry at yourself if you were not able to stick to what you had written or wanted.” A care provider stated: “Some patients want to stick rigidly to the plan—despite how their labour is progressing.” Similarly, 29% (n = 35) of the women and 14% (n = 15) of their attendants felt that birth plans could give a false sense of control and might not allow women to prepare for the unexpected. Many women emphasized the importance NOVEMBER JOGC NOVEMBRE 2013 l 981
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Table 1. Characteristics of women and health care providers n (%) Characteristics of women (n = 122) Primary care provider/support person
Midwife
68 (55)
Family physician
34 (27)
Obstetrician
13 (11)
Multiple births with different health care providers
3 (3)
Midwife and family physician
1 (1)
Fertility specialist
1 (1)
Did not indicate
2 (2)
Use of a birth plan
Yes
86 (70)
No
28 (23)
Did not indicate
8 (7)
Location of delivery
Hospital
61 (50)
Home
32 (26)
Different locations for multiple births Did not indicate
8 (7) 21 (17)
Characteristics of health care providers and support persons (n = 110) Health care provider profession
Nurse
30 (27)
Family physician
25 (23)
Midwife
21 (19)
Obstetrician
18 (16)
Support person profession
Doula
16 (15)
of the birth plan not being a “plan,” but rather a guide or intention. Additional disadvantages cited by the participants included the following: 13% (n = 14) of the attendants felt that birth plans were not useful because they were too detailed or restrictive; 6% (n = 7) of both the women and their attendants stated that birth plans may actually be harmful to patient care, indicating that they may interfere with clinical care or increase the mother’s stress and anxiety during labour; 13% (n = 16) of the women and 14% (n = 15) of their attendants noted that birth plans may elicit negative reactions from health care providers. Thirteen women (11%) and five of their attendants (5%) stated that they did not see any disadvantages to having a birth plan. With regard to the most important components of a birth plan, pain management was the component most commonly cited by both the women (59%, n = 72) and 982 l NOVEMBER JOGC NOVEMBRE 2013
their attendants (42%, n = 47) (Table 2). In addition to pain management, four themes were identified by more than 20% of the women: comfort measures (30%, n = 36), postpartum preferences (29%, n = 35), interventions (26%, n = 32), and control of atmosphere (21%, n = 25). Similarly, in addition to pain management, three themes were identified by more than 20% of the care providers and support persons: instructions contradicting the standard of care (26%, n = 29), beliefs about birth (24%, n = 27), and postpartum preferences (23%, n = 26). Two components were mentioned by the care providers and support persons but not mentioned by the women at all: the presence or absence of prenatal education (4%, n = 4), and statement of hospital policy (3%, n = 3). Regarding components of a birth plan spontaneously mentioned by the participants, more women (30%, n = 36) than attendants (9%, n = 10) indicated that comfort measures were important. Second, more women (26%, n = 32) than attendants (11%, n = 12) indicated spontaneously that the use of interventions was important. Third, more attendants (26%, n = 29) than women (12%, n = 15) stated that instructions contradicting the standard of care were important. Finally, more attendants (24%, n = 27) than women (5%, n = 6) indicated that beliefs about birth were important. DISCUSSION
This is the first study to report the advantages and disadvantages of using a birth plan, as well as the most important aspects of a birth plan from the perspectives of women, their care providers, and support persons in Canada. These results add important information in this area, and could be applied to develop an effective birth plan template that would be useful for women and their attendants. Most of the women in the current study received their primary maternity care from a midwife, and were planning to use or had used a birth plan. This is in keeping with other studies characterizing the population of women who use birth plans, which also found that most women choosing to use a birth plan were being cared for by a midwife.12,17 The results from this study demonstrate that both pregnant women and their attendants see benefits and drawbacks in using a birth plan. The main benefits reported by participants included the role of a birth plan as a communication and educational tool. The act of creating a birth plan was an educational process for women, and the implementation of a birth plan empowered them to express their expectations and preferences, which could
Perspectives of Expectant Women and Health Care Providers on Birth Plans
Table 2. The most important components of a birth plan Birth plan component
Women n (%)
Health care providers and support persons n (%)
Pain management (e.g., pharmacological options)
72 (59)
47 (42)
Comfort measurements (e.g., mobility, pushing preferences)
36 (30)
10 (9)
Postpartum preferences (e.g., who should cut the cord, breastfeeding)
35 (29)
26 (23)
Use of interventions (e.g., episiotomy, forceps, vacuum)
32 (26)
12 (11)
Control of atmosphere (e.g., privacy, lighting)
25 (21)
18 (16)
Identification and role of support people
22 (18)
16 (14)
Postpartum instructions contradicting standard of care (e.g., refusal of erythromycin, vitamin K, newborn screening)
15 (12)
29 (26)
Type and frequency of assessments
10 (8)
2 (2)
Birth and delivery instructions (e.g., positions, water birth, spontaneous vs. coached)
10 (8)
5 (5)
Emergency plan
10 (8)
7 (6)
Beliefs about birth (e.g., cultural and religious factors, hypnosis)
6 (5)
27 (24)
Psychosocial and emotional factors to consider
2 (2)
9 (8)
Presence or absence of prenatal education
0 (0)
4 (4)
Statement of hospital policy
0 (0)
3 (3)
be communicated to their attendants. These findings are consistent with several studies that found the use of a birth plan promoted active participation in the delivery,8,14 clarified women’s opinions about labour and delivery options,12 and facilitated communication between the women and their care providers.7,11,12 Notably, all of the women in the current study indicated that there were advantages to having a birth plan, and 11% indicated that there were no disadvantages to having a birth plan, indicating that overall, the women viewed birth plans positively. This has also been noted by another group.13 Although the women and their attendants described multiple advantages of using a birth plan, many feared that birth plans could potentially lead to dissatisfaction, inflexibility, and a false sense of control if a birth plan was not carried out as outlined. These concerns have been raised by other authors and corroborated by studies showing that women whose delivery did not follow their birth plan were less satisfied with the process than women who were able to follow their birth plan.3,5 For example, Kannan and colleagues found that women who had requested an un-medicated delivery but who had epidural anaesthesia were less satisfied with their experience than women who had planned on having an epidural.22 Other studies found that women felt disappointed23 or betrayed8 by their care providers when a birth plan was not carried out. However, two groups found that women described the use of a birth plan as satisfying despite the fact that some of their deliveries did not go as planned.12,24 Together, these findings suggest that women should not feel bound
to their birth plans, but rather should be flexible to account for the unpredictable nature of childbirth. Pain management was most commonly cited by the women and their attendants as the most important aspect of a birth plan. Other important aspects cited included postpartum preferences, comfort measures, beliefs about birth, control of atmosphere, interventions, and instructions contradicting the standard of care. These results are consistent with the findings of a study conducted by Deering and colleagues, who found that the most common requests included by women in a birth plan involved pain management interventions (e.g., regarding epidural anaesthesia), comfort measures (e.g., regarding walking during labour) and obstetrical interventions (e.g., regarding episiotomy).25 Similarly, another study found that analgesic preferences were reported to be the most common birth plan items.1 The women and their attendants appeared to differ slightly in their opinions about the most important components to include in a birth plan. Specifically, more care providers and support persons than women indicated that beliefs about birth and instructions contradicting the standard of care were important to consider in a birth plan. More women than their attendants indicated that comfort measures and the use of interventions were important. These differences may reflect different priorities, or different opinions regarding the factors that a woman can influence during delivery. For example, attendants may feel comfortable with the medical issues surrounding childbirth, but may NOVEMBER JOGC NOVEMBRE 2013 l 983
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feel less sure and more inquisitive about the women’s personal beliefs and culture. The results of this study indicate that birth plans can enhance the experience of labour and delivery, if women understand that unexpected circumstances can arise during labour that may not be consistent with the birth plan. Furthermore, the success of a birth plan depends on open communication between women and care providers and an environment that empowers women to make informed choices.8 These data could be used to develop a birth plan template, ideally a concise document to facilitate reference by care providers during delivery.4 As indicated by the participants in this study, key sections of a birth plan should include pain management, postpartum preferences, control of atmosphere, comfort measures, beliefs about birth, interventions, and instructions contradicting the standard of care. A birth plan should include acknowledgement of the unpredictable nature of childbirth, and that women’s preferences should be open to change. Moreover, the birth plan has been described as a “living document”3 and an “evolving document,”4 suggesting that it should be modified according to new information and changing circumstances. This study suggests that the term “birth plan” should be replaced by “birth guide” to emphasize the need for flexibility due to the dynamic nature of childbirth. A birth guide can be used as a point of discussion between women and care providers to promote understanding of procedures.11 The recommendations described here have the potential to promote communication between women and their attendants to increase women’s satisfaction and comfort with their labour and delivery. Further exploration of the attitudes of women and their attendants towards the use of birth plans among different cultural groups would be valuable. Additionally, further research should be instigated to assess the efficacy of birth plans critically. Our study has several limitations. Recruitment of participants focused on women and their attendants residing within British Columbia; the responses are likely not representative of other areas. Sampling bias may have affected recruitment because about one half of the women recruited were receiving midwifery care, yet in the fiscal year of 2007–2008 only 6% of women delivered under the care of a midwife.26 Further, the proportion of midwives in the care providers and support persons group did not match the proportion of women receiving midwifery care. Future studies may specifically explore the relationship between midwives and the use of a birth plan. The questionnaire was available only in English, so the results may be limited by cultural and ethnic perspectives. The lack of demographic variables collected prevents 984 l NOVEMBER JOGC NOVEMBRE 2013
generalizing or extrapolating the results of this study to other populations. Finally, the term “birth plan” was not defined on the questionnaire, so individual respondents may have interpreted this term differently. CONCLUSION
While many participants in this study indicated that a birth plan is a valuable educational and communication tool, the participants also acknowledged that a birth plan may promote a false sense of control or lead to disappointment if it is not fully implemented. Women emphasized the need to be flexible in making requests because a birth plan may not be implemented as desired. The study identified the important aspects of a birth plan that could used to help a woman develop or modify one. Ultimately, we believe that birth plans have the potential to play an integral role in conveying women’s preferences effectively, and thereby facilitate informed decisions and a satisfactory experience for both women and their care providers. ACKNOWLEDGEMENTS
The authors would like to thank those who participated in this study and the Fir Square Doulas of 2011–2012. Melissa Aragon, Amy Kluftinger, Riki Dayan, and Erica Chhoa were students in the Faculty of Medicine at the University of British Columbia when this study was conducted. This project was supported by the Family Practice Initiative Fund. REFERENCES 1. Simkin P. Birth plans: after 25 years, women still want to be heard. Birth 2007;34(1):49–51. 2. Kitzinger S. Letter from England—birth plans. Birth 1992;19(1):36–7. 3. Lothian J. Birth plans: the good, the bad, and the future. J Obstet Gynecol Neonatal Nurs 2006;35(2):295–303. 4. Kaufman T. Evolution of the birth plan. J Perinat Educ 2007;16(3):47–52. 5. Bailey JM, Crane P, Nugent CE. Childbirth education and birth plans. Obstet Gynecol Clin North Am 2008;35(3):497–509. 6. Perez PG, Capitulo KL. Birth plans: are they really necessary? Pro and con. MCN Am J Matern Child Nurs 2005;30(5):288–9. 7. Moore M, Hopper U. Do birth plans empower women? Evaluation of a hospital birth plan. Birth 1995;22(1):29–36. 8. Too SK. Do birthplans empower women? A study of midwives’ views. Nurs Stand 1996;10(32):44–8. 9. Too SK. Do birthplans empower women? A study of their views. Nurs Stand 1996;10(31):33–7. 10. Whitford HM, Hillan EM. Women’s perceptions of birth plans. Midwifery 1998;14(4):248–53. 11. Sham A, Chan L, Yiu KL, Ng CW, Ng J, Tang PL. Effectiveness of the use of birth plan in Hong Kong Chinese women: a qualitative exploratory research. Hong Kong J Gynaecol Obstet Midwifery 2007;7:30–4.
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12. Pennell A, Salo-Coombs V, Herring A, Spielman F, Fecho K. Anesthesia and analgesia-related preferences and outcomes of women who have birth plans. J Midwifery Womens Health 2011;56(4):376–81. 13. Klein MC, Kaczorowski J, Hearps SJ, Tomkinson J, Baradaran N, Hall WA, et al. Birth technology and maternal roles in birth: knowledge and attitudes of Canadian women approaching childbirth for the first time. J Obstet Gynaecol Can 2011;33(6):598–608. 14. Kuo SC, Lin KC, Hsu CH, Yang CC, Chang MY, Tsao CM, et al. Evaluation of the effects of a birth plan on Taiwanese women’s childbirth experiences, control and expectations fulfilment: a randomised controlled trial. Int J Nurs Stud 2010;47(7):806–14. 15. Berg M, Lundgren I, Lindmark G. Childbirth experience in women at high risk: is it improved by use of a birth plan? J Perinat Educ 2003;12(2):1–15. 16. Lundgren I, Berg M, Lindmark G. Is the childbirth experience improved by a birth plan? J Midwifery Womens Health 2003;48(5):322–8. 17. Brown SJ, Lumley J. Communication and decision-making in labour: do birth plans make a difference? Health Expect 1998;1(2):106–16. 18. Peart K. Birth planning—is it beneficial to pregnant women? Aust J Midwifery 2004;17(1):27–9.
20. Perry C, Quinn L, Nelson L. Birth plans and professional autonomy. Hastings Cent Rep 2002;32(2):12. 21. Neergaard MA, Olesen F, Andersen RS, Sondergaard J. Qualitative description—the poor cousin of health research? BMC Med Res Methodol 2009;9:52. doi:10.1186/1471–2288–9–52. 22. Kannan S, Jamison RN, Datta S. Maternal satisfaction and pain control in women electing natural childbirth. Reg Anesth Pain Med 2001;26(5):468–72. 23. Carlton T, Callister LC, Stoneman E. Decision making in laboring women: ethical issues for perinatal nurses. J Perinat Neonatal Nurs 2005;19(2):145–54. 24. Yam EA, Grossman AA, Goldman LA, Garcia SG. Introducing birth plans in Mexico: an exploratory study in a hospital serving low-income Mexicans. Birth 2007;34(1):42–8. 25. Deering MA, Heller J, McGaha K, Heaton J, Satin AJ. Patients presenting with birth plans in a military tertiary care hospital: a descriptive study of plans and outcomes. Mil Med 2006;171(8):778–80. 26. British Columbia Perinatal Health Program. Perinatal Health Report 2008. 2010. Available at: http://www.perinatalservicesbc.ca/ NR/rdonlyres/3DEC78D6-BDC3–4602-B09B-FB0EE1C7B7D9/0/ SurveillanceAnnualReport2008.pdf. Accessed May 18, 2013.
19. Deering SH, Zaret J, McGaha K, Satin AJ. Patients presenting with birth plans: a case-control study of delivery outcomes. J Reprod Med 2007;52(10):884–7.
APPENDIX Questionnaire for health care providers and support persons 1)
I am a(n) (circle one):
obstetrician
family physician
midwife
nurse
doula
02) What are some of the pros of using a birth plan? 03) What are some of the cons of using a birth plan? 04) If a birth plan had to be limited to one page, what aspects do you feel are the most important to be communicated to on-call staff?
Questionnaire for women: 01) Are you expecting or have you previously given birth? 02) Did you (or will you) use a birth plan for this pregnancy? 03) In your opinion, what are the possible limitations of a birth plan? 04) What 3 aspects of a birth plan do you feel are the most important? 05) Did you (or will you) use a doula? 06) What do you think are the pros of having a birth plan? 07) What do you think are the cons of having a birth plan? 08) My main health care provider for this pregnancy is/was a:
a. Midwife
b. Family physician
c. Obstetrician
d. Other
0 09) Where did you (or will you) plan on delivering? 10) If your birth plan had to be limited to one page, what aspects do you feel are the most important to be communicated to the on-call staff?
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