Ditch the Birth Plan!

Birth PlanWhen women are able to experience self-determination, rather than control or a perfect plan, they will succeed at having a birth that is aligned with their vision. The key, shares Nicole Deggins of Sista Midwife Productions, is that mamas tap into their intuition and develop a birth philosophy. In this pieces, she offers the key questions to ask your clients on their journey.

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“They didn’t follow anything in my birth plan!” she cried as she was wheeled down the hall from the operating room into recovery.  She is distraught, shocked, frustrated and angry.  How could this have happened? Why didn’t they follow her plan!?

This is unfortunately the scene seen many times over on labor and delivery units across the country. Birth plans, once believed to be the holy grail of an educated and empowered birth have become virtually useless.  Where did this plan come from? Why doesn’t it work? And what can women do instead?
In 1980 Penny Simkin and Carla Reinke published Planning Your Baby’s Birth. This pamphlet presented a new concept; the idea that a woman could create a birth plan as a way to open communication with her provider.  For some women, birth plans became a wonderful addition to the medical record.  They became a tool for conversation and a viable way for women to discuss options.  In many hospitals today however, birth plans are considered a thorn in the side of labor and delivery staff.  Women with birth plans are often seen as difficult patients and are treated with smug attitudes. They are often the butt of jokes at the nurses’ station especially when things don’t go as planned. In spite of having well written birth plans women continue to find themselves dissatisfied, feeling like they have had little say in how they give birth.
The dissatisfaction often comes from the fact that for many women, writing a birth plan is about finding a way to control their birth process. Regardless of the fact that true control is not possible, the literature is full of evidence that control, or the notion of perceived control, is significant to childbearing women as it relates to birth satisfaction.  As a result, birth plans continue to be used under the guise that they are a vehicle of control.  Namey and Lyerly (2010)1 spoke with women about their ideas of what it means to have control during their labor and birth.  From their research, self-determination emerged as the most prominent meaning of control. They defined self-determination as “the ability to have a birth that is shaped and guided by ones’ own inclination and values rather than those of others.” How do we take this idea of self-determination to help women create the birth experiences they deserve?
Birth Plan

While the process of creating a birth plan can be educational and empowering, it’s important to understand that birth plans have many limitations so we have to learn to create an atmosphere for realizing self-determination without one.  Instead of a birth plan, I encourage women, to begin their journey by developing a personal birth philosophy.  Dictionary.com tells us a philosophy is the critical study of the basic principles and concepts of a particular branch of knowledge.”  Merriam Webster says simply that a philosophy is “a set of ideas about how to do something” i.e. birth. If we combine these definitions we see that developing a birth philosophy means a woman has done some critical study of the basic principles of birth and has developed an idea about how she wants to do it.

Ideally a woman would create a birth philosophy before she is pregnant. Unfortunately many women don’t. As a result it’s critical that as early as possible they examine their thoughts on what I consider some of the very basic principles of birth. She must determine her preference between the midwifery and medical model of care, hospital or out of hospital birth, the use of pain medications or natural pain relief and induction or spontaneous labor.  As she learns about each of these basic tenets, she can slowly begin to develop ideas about specifics like medications, fetal monitoring, intravenous fluids etc.  She must examine not only which she prefers but why she prefers it.
As women develop their philosophy, we must encourage them to continue to evolve their thinking.  She must understand that everything is filtered through, and influenced by, a number of things including: personal experiences, experiences of others, what she sees in the media, and the expectations of the community she belong to.  Birth philosophies, just like birth itself, can be fluid and we should continue to provide evidence based information and guidance to continue their critical study without overwhelming them with too much information in the process.  We must help them to remember, there are a lot of options between having a “free birth” and scheduling an elective cesarean section during a second prenatal visit.  And we want to remind her to include an examination of her beliefs about the emotional, spiritual and metaphysical side of birth.
While certainly not an all-inclusive list, some questions that can be used to help a woman cultivate her birth philosophy include:

  • Do you see birth as a big extended family celebration or a small three person private party?
  • How do you find peace after a stressful situation?
  • Is it important that you have an intimate/close relationship with your primary birth attendant?
  • Who takes care of things in an emergency?  How do you respond? What role does your partner play?
  • When you are sick or in pain what brings you comfort?
  • What did you like most/least about your last pregnancy and birth experience?
  • Is the gender of your primary birth attendant important?
  • Can you trust your partner or support person to act confidently on your behalf?
  • Do you consider yourself high risk? Why?
  • How do you celebrate something very special?
  • When you have a bad day how do you react and what makes you feel better?
  • Do you trust your intuition?
  • Would you rather trust the word of your provider or the word of your partner?

The process of philosophy creation is about growing, learning, moving and sharing. It’s not about creating the “perfect” birth. It’s about learning and understanding options. It’s about realizing what things are really important and then using that information to guide conversations and decisions.  Having a solid birth philosophy can give a woman more confidence when speaking with her provider and other members of her birth team.  Developing a birth philosophy can help a woman determine if her provider is the right one for her.  Are their philosophies similar or are they worlds apart?  Is this a good fit? Or should she consider changing providers, which ultimately can be one of the most critical steps in creating an empowered birth experience.

Finally, in working with women to create a birth philosophy, we must encourage them to get in touch with their intuition.  We must remind them as Dr. Benjamin Spock told us:  “Trust yourself. You know more than you think you do.” And “Don’t take too seriously all that the neighbors say. Don’t be overawed by what the experts say. Don’t be afraid to trust your own common sense.”

What research tells us and what I have seen to be true, is that when given factual information free from coercion, women will make the best decisions for themselves and their families.  And when they are able to experience self-determination, not control or a perfect plan, with the freedom to be a knowledgeable player in the decision making process, they will succeed at having a birth that fits into their birth philosophy regardless of writing a birth plan and often regardless of the type of birth they ultimately have.

1 Namey & Lyerly.  The meaning of “control” for childbearing women in the US.  Social Science & Medicine. 2010 Aug;71(4):769-76

Nicole Deggins, CNM, MSN, MPH is a masters prepared certified nurse midwife, author and educator and with more than 20 years of experience in women’s health care, advocacy, and empowerment. Nicole has practiced as a midwife in Washington DC, Mississippi, and Louisiana and has worked as a labor and delivery nurse in numerous public and private settings throughout the country. Today, Ms. Deggins works as the founder and CEO of Sista Midwife Productions (SMP). Through her work with SMP Ms. Deggins is dedicated to bringing transparency to prenatal education and helping women understand their rights as they navigate the medical obstetrical system. 

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