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Don’t throw the birth plan out with the bath water!

by Hannah Dahlen and Bashi Hazard
02 August 2016
HEALTH AND MEDICINE
Birth plans aren’t new-age nonsense. They protect mothers’ medical rights, midwife Hannah Dahlen and lawyer Bashi Hazard say.
 
Hannah Dahlen – a midwife’s perspective
 
Just try mentioning ‘birth plans’ at a party and see what happens. Mia Freedman once wrote about a woman she met at a BBQ who asked what her plan was for her placenta. Freedman felt birth plans were “most useful when you set them on fire and use them to toast marshmallows”. She labelled people who make these plans as “birthzillas” arguing they’re more interested in having a birth than a baby.
 
In response, Tara Moss argued:
The majority of Australian women choose to birth in hospital and all hospitals do not have the same protocols. It is easy to imagine they would, but they don’t, not from state to state and not even from hospital to hospital in the same city. Even individual health practitioners in the same facility sometimes do not follow the same protocols.
 
Why the controversy over a woman and her partner writing down what they would like to have done or not done during their birth?  The debate seems not to be over the birth plan itself but rather over the issue of women taking control and ownership of their births and what happens to their bodies.
 
Some oppose birth plans on the basis that all experts should be trusted to have the best interests of both mother and baby in mind at all times. Others trust the mother as the person most concerned for her baby and believe women have the right to determine what happens to their bodies during this intimate, individual and significant life event.
 
As a midwife of some 26 years, I wish we didn’t need birth plans. I wish our maternity system provided women with continuity of care so by the time a woman gave birth her care provider would fully know and support her well-informed wishes. Unfortunately, most women do not have access to continuity of care. They deal with shift changes, colliding philosophical frameworks, busy maternity units and varying levels of skill and commitment from staff.
 
There are so many examples of interventions that are routine in maternity care which lack evidence or in some cases are outright harmful. These include immediate clamping and cutting of the umbilical cord at birth, episiotomy, continuous electronic foetal monitoring, labouring or giving birth laying down and unnecessary caesareans. Other deeply personal choices such as the use of immersion in water for labour and birth or having a natural birth of the placenta are often not presented as options, or are refused when requested.
 
The birth plan is a chance to raise and discuss your wishes with your health care provider. It provides insight into areas of further conversation before labour begins.
 
I once had a woman make three birth plans when she found out her baby was in a breech presentation at 36 weeks – one for a vaginal breech birth, one for a cesarean and one for a normal birth if the baby turned. The baby turned and the first two plans were ditched but she had been through each scenario and carved out what was important for her.
 
Bashi Hazard – a legal perspective
 
Birth plans were introduced in the 1980s by childbirth educators to help women shape their preferences in labour and to communicate with their care providers. Women say preparing birth plans increases their knowledge and ability to make informed choices, empowers them and promotes their sense of safety during childbirth. Some (including in Australia) report that their carefully laid plans are dismissed, overlooked or ignored.
 
There appears to be some confusion about the legal status or standing of birth plans which is not reflective of international human rights principles or domestic law. The right to informed consent is a fundamental principle of medical ethics and human rights law and is particularly relevant to the provision of medical treatment. In addition, our common law starts from the premise that every human body is inviolate and cannot be subject to medical treatment without autonomous, informed consent.
 
Pregnant women are no exception to this human rights principle or to the common law.
 
If you start from this legal and human rights premise, the authoritative status of a birth plan is very clear. It is the closest expression of informed consent that a woman can offer her caregiver prior to commencing labour. This is not to say she cannot or will not change her mind but it is the premise from which treatment or further discussion during labour or birth should begin. 
 
Once you accept that a woman has the right to stipulate the terms of her treatment, the focus turns to any hostility and pushback from care providers to the preferences a woman has the right to assert in relation to her care.

Mothers report their birth plans are criticised or outright rejected on the basis that birth is “unpredictable”. There is no logic in this.

 Care providers who understand the significance of the human and legal right to informed consent begin discussing a woman’s options in labour and birth with her as early as the first antenatal visit. These discussions are used to advise, inform and obtain an understanding of the woman’s preferences in the event of various contingencies. They build the trust needed to allow the care provider to safely and respectfully support the woman through pregnancy and childbirth. Such discussions are the cornerstone of woman-centred maternity healthcare.
 
Reports received by Human Rights in Childbirth indicate that care provider pushback and hostility towards birth plans occurs most in facilities with fragmented care or where policies are elevated over women’s individual needs. Mothers report their birth plans are criticised or outright rejected on the basis that birth is “unpredictable”. There is no logic in this. If anything, greater planning would facilitate smoother outcomes in the event of unanticipated eventualities.
 
In truth, it is not the case that these care providers don't have a birth plan. There is a birth plan – one driven purely by care providers and hospital protocols without discussion with the woman. This offends the legal and human rights of the woman concerned and has been identified as a systemic form of abuse and disrespect in childbirth, and as a subset of violence against women.  
 
It is essential that women express their intention to discuss and develop a birth plan with their care providers from the very first appointment. This is a precious opportunity to ascertain your care provider’s commitment to recognising and supporting your individual and diverse needs.
 
Gauge your care provider’s attitude to your questions as well as their responses. Expect to repeat those discussions until you are confident that your preferences will be supported. Be wary of care providers who are dismissive, vague or non-responsive. Most importantly, switch care providers if you have any concerns. The law is on your side. Use it.
 
Making a birth plan – some practical tips
  1. Talk it through with your lead care provider so they can discuss your plans and make sure you understand all your options and implications of your choices.
  2. Make sure your partner or any other support people know your plan so they can advocate for you and communicate your wishes.
  3. Going to antenatal classes can help you feel more informed about what is available and what the evidence is behind your different options.
  4. Talk to other women about what has worked well for them, but remember your needs might be different.
  5. Remember you can change your mind at any point in the labour and birth. What you say is final, regardless of what the plan says.
  6. Try not to be adversarial in your language – you want people working with you, not against you. End the plan with something like “Thank you so much for helping make our birth special”.
  7. Stick to the important stuff.
Some tips on the specific content of your birth plan are available here.
 
Hannah Dahlen is a professor of Midwifery at Western Sydney University and a practising midwife. Follow her on Twitter @hannahdahlen.
 
Bashi Hazard is a Human Rights and Consumer Lawyer, Principal of BWLaw and Director of Human Rights in Childbirth.

6 Comments

Comments
Catherine Bell
A 'Birth Plan' should cover various scenarios (so is never thrown out), it is the result of an informed preparation process. The Informed Decisions are made in advance - mostly as contingency, but in the event that the birth must be managed medically, a birth plan shows the considerations made for that event. Informed Consent can not be given in the moment. Encouraging women to create a birth plan (I call them Birth Maps, as they have pre-considered alternative routes) means that they are placed at the centre of the birth, where they should be. To ignore a birth plan is to disregard the time and consideration a woman has taken into her own health and options. Not all birth plans are focused on a 'natural' birth. Many women write birth plans for their planned caesareans. A birth plan written for the medical care provider included the points of Informed Consent/Refusal. But a woman might also include points in her plan that help the care providers understand her unique needs. Informed Birth Preparation is the process behind a written birth document. It is important that women are encouraged to do this, rather than print off a template or use a tick-box app that does not provide reasoning behind the options.
28/02/2017 1:48:09 PM

Ellen O'Keeffe
Great article. I concur; the debate seems not to be over the birth plan itself but rather over the issue of women taking control and ownership of their births and what happens.

The majority of women, when they decide to have a child are capable with appropriate support and education of making informed choices that influence the outcomes of their pregnancy and birth.

Considerable evidence indicates that respecting and partnering with consumers in their own care is associated with a better care experience. A better care experience is associated with better clinical outcomes, enhanced consumer safety and less use of health care. Caregivers, who listen to women, provide them with accurate information and respect their choices, make a fundamental contribution to a safe maternity service.

We only have to look to Kate Middleton as an example. Do you know that Kate Middleton had a birth plan? That Kate had a birth plan is of interest in itself. Kate would have had continuity of care, a care provider who knew and supported her well-informed wishes and access to best evidenced based birth practices. That Kate looked so good 12 hours after her birth is evidence a normal natural birth promotes the mother’s well-being.
This is a very clear message to us all. Let us take heed of her example.
6/08/2016 6:04:02 PM

Sarah
It's fine to have a birth plan but you have accept that sometimes things can go to hell in a hand basket and then the priority is getting baby here safely and make sure mum is ok. I would have loved to have skin to skin with my second child but I was too busy being whisked off to surgery to stop my severe post partum hemorrhage. Basically saving my life. Yes birth plans have a place but not the point where they interfere with important care or people grieve because birth didn't go the way they planned.
4/08/2016 9:04:43 PM

Joy Heads
Excellent discussion on Birth Plans, thank you.
It begs the question of what form of education do doctors and midwives receive in basic counselling and communication skills?
Having worked in maternity units (postnatal not birthing) for over 25 years - that was the biggest problem I encountered.
Statements like: ‘Don’t do that - do this’; ‘My goodness your breasts are small’; ‘Maybe you don’t have any milk’; ‘Your baby is very small/very big.’ All comments that actively undermine maternal confidence.
The only thing I would encourage parents to include in any Birth Plan would be uninterrupted skin-to-skin contact at birth. Coming from an era when babies were whisked away to be weighed then to the nursery before mothers could even meet them – still haunts me.
http://www.cochrane.org/CD003519/PREG_early-skin-to-skin-contact-for-mothers-and-their-healthy-newborn-infants
3/08/2016 11:28:39 AM

Allison whitehead
Great article dissecting 'the birth plan' in relation to informed consent, human rights and continuity of carer. Unfortunately nearly 40 years on Midwives and Doctors - albeit a minority few - consider 'the Birth Plan' to be a 'way out new age thing'.

I work on the birth suite at Lancashire Women and Newborn Centre in Burnley - the majority of women I meet have medical conditions or classified as 'high risk' - inductions of labour, pregnancy induced conditions, previous Caesarian Sections etc. I consider the Birth Plan an essential tool when caring women - and not been involved in any aspect of their pregnancy. Their Birth Plan facilitates open discussions and explores the various options to gain informed consent.

I will be displaying your article for staff to read - hopefully to dismiss a few myths surrounding 'The Birth Plan!'
2/08/2016 9:12:54 PM

Simon Hornstra
Thank you for this, this really helps us understand that the law is on our side.
And who is Mia Freedman to call my wife a 'Birthzilla' for wanting her body respected?
2/08/2016 12:00:45 PM

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