Birth plans: worse than useless

Yesterday I wrote about birthzillas, pregnant women who are hypersensitive, obsessively controlling, and rude to healthcare providers. They justify their behavior with the all purpose excuse "It's my special day."

Several commenters took umbrage at the idea that a birth plan is the hallmark of a birthzilla. What's wrong with making a birth plan they ask? The answer: a lot.

Birth plans engender hostility from the staff, are usually filled with outdated and irrelevant preferences, and create unrealistic expectations among expectant mothers. But the worst thing about birth plans is they don't work. They don't accomplish their purported purpose, make no difference in birth outcomes, and, ironically, predispose women to be less happy with the birth than women who didn't have birth plans.

Birth plans were instituted based on the philosophy of various natural childbirth advocates such as Penny Simkin and Lamaze International. They basically made up what they thought would improve the birth experience for women without any study at all about what actually improves birth experience for women.

Joanne Motino Bailey, CNM et al. write in Childbirth Education and Birth Plans, Obstetrics and Gynecology Clinics - Volume 35, Issue 3 (September 2008):

Advocates of birth plans claim that they can improve communication with staff, enhance choice and control during labor, and make women more aware of available options for their birthing experience. Too raised concerns that birth plans offer meaningless choices and “create an atmosphere of distrust between patient and physician or have the opposite effect by setting up the patient for a sense of ‘failure’ if the birth does not go as planned.”

There are no randomized controlled trials that analyze birth plans and the literature that does exist reaches varying conclusions ... Lundgren and colleagues found “although a birth plan did not improve the experience of childbirth in the overall group, there may be beneficial effects with regard to fear, pain, and concerns about the newborn for certain subgroups of women.” Brown and Lumley stated that “women who made use of a birth plan were more likely to be satisfied with pain relief, but did not differ from women not completing a birth plan in terms of overall rating of intrapartum care, or involvement in decision making about their care.” Whitford and Hillan found that most women who completed a birth plan found it useful and stated they would write another birth plan in a future pregnancy, although most did not believe it made any difference in the amount of control they felt during labor and many did not think enough attention had been paid to what they had written.

Why are birth plans ineffective?

1. Most birth plans are filled with outdated and irrelevant preferences. As childbirth educator Tamara Kaufman writes in Evolution of the Birth Plan (J Perinat Educ. 2007 Summer; 16(3): 47–52):

... [Women] identify the Internet as the resource they use most frequently to gather information about pregnancy, birth, and birth plans... [M]any of the birth plans detailed on these sites are outdated. For example, several on-line, interactive tools start with questions regarding being shaved or receiving an enema. Because these procedures are no longer routine in most areas, such details may cause parents to devote too much attention to unimportant issues and cause the hospital staff to dismiss the couple as being uneducated regarding routine hospital procedures...

2. Birth plans are gratuitously provocative, as Kaufman notes:

On-line birth plans are frequently more than one page in length, which may inhibit the hospital staff from closely reading the plan. On-line birth plans also have a tendency to use phrases such as “unless absolutely or medically necessary”—a phrase that is not always useful when caregivers usually believe the intervention they recommend is medically necessary at the time ...

3. Birth plans have no impact on outcomes. The most important component of any birth plan is requests around the issue of pain relief. As Pennell et al, point out in Anesthesia and Analgesia–Related Preferences and Outcomes of Women Who Have Birth Plans:

Women who elected birth plans were primarily white, college-educated, primigravida, and under the care of a certified nurse-midwife. One-third of births were induced, 10% required instrumentation, and 29% were cesarean births. Nearly every birth was associated with at least 1 labor and birth complication, although most complications were minor. Analgesic preferences were reported to be the most important birth plan request. Greater than 50% of women requested to avoid epidural analgesia; however, 65% of women received epidural analgesia. On follow-up, greater than 90% of women who received epidural analgesia reported being pleased. The majority of women agreed that the birth plan enhanced their birth experiences, added control, clarified their thoughts, and improved communication with their health care providers.

4. Birth plans encourage unrealistic expectations. Just the idea itself is unrealistic. There is very little that can be planned about birth: not the timing, not the length of labor, not the amount of pain experienced, not the relative size of the baby's head and the bony pelvis, not the adequacy of contractions and not how well the baby tolerates labor. Yet all birth plans implicitly assume that labor with fall in the normal range in every possible parameter. Disappointment is inevitable.

In Is the Childbirth Experience Improved by a Birth Plan?, Lundgren et al. were surprised to find:

... A questionnaire at the end of pregnancy, followed by a birth plan, was not effective in improving women's experiences of childbirth. In the birth plan group, women gave significantly lower scores for the relationship to the first midwife they met during delivery, with respect to listening and paying attention to needs and desires, support, guiding, and respect.

It appears that the birth plan may have actually set women up to be disappointed with their birth experience.

5. It is not really surprising that birth plans fail to achieve their stated aims when you consider that they are not plans for births. No one writes in their birth plan that they want to have a 16 gauge IV in each arm at all times; no one demands active management of labor; no one insists on extra blood tests for the baby. A more accurate name for birth plans would be "I refuse all these things regardless of whether they are routine and/or medically indicated because I know much more about the scientific evidence than any obstetrician or nurse." In other words, birth plans are an extended tantrum in written form.

Why do women write absurd ultimatums? Why do they think their a priori refusal of medically indicated interventions is remotely appropriate? Why do they think they have a better understanding of the scientific evidence than the professionals who create it, read it faithfully and are legally responsible for being completely up to date on it? Because people like Henci Goer (who has never delivered a single baby) and Ina May Gaskin (a woman with no training in midwifery, who let her own baby die, and who believes that birth is controlled by invisible "forces") told them so.

Why do they write these extended tantrums ("I'm not gonna and you can't make me!)? Because they've completely lost sight of the goal. Doctors and nurses are HEALTHCARE providers whose goal is to make sure that mothers' pregnancy complications are treated or prevented and that they give birth to healthy babies. Their role is not to facilitate birth goddess fantasies. Women know so little about birth, and are so sure (erroneously) that complications are vanishingly rare that they've confused birth with a piece of performance art. Birth plans are not about birth; they're about creating the most esthetically pleasing tableau.

That's why NCB and homebirth advocates can, with a straight face, have arguments about whether a C-section is actually a birth. It makes sense when you realize that for them birth is not about the baby being transferred from inside the uterus out to independent life. For them, a birth is an intricately choreographed performance that follows a pre-approved script. Deviate in any way, and the performance is ruined.

Ultimately, birth plans are not merely useless for their stated goal of achieving control over birth. They are worse than useless because they are filled with outdated nonsense, alienate providers, fail to achieve their stated aims and, through unrealistic expectations, encourage disappointment.

By all means share your most important preferences with your providers, but think long and hard before you present your provider with a list of refusals and ultimatums. Birth plans have been encouraged by ancillary birth personnel (childbirth educators, doulas) as a thumb in the eye of obstetricians. They accomplish nothing besides gratifying a desire to defy authority.