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    Don’t fear the patient with a birth plan


    Ultimately, the purpose of a birth plan is to promote communication and not to induce friction between providers and birthing mothers. A survey-based study reported that 65% of medical personnel but only 2% of pregnant women believed that having a birth plan predicted a worse obstetric outcome.6 Obstetricians and midwives are justifiably concerned that birth plans attempt to control a process that inherently cannot be controlled or planned.

    For a birth plan to be effective, it should not only take into account the unpredictable course of pregnancy and the dynamic process of labor, but also ensure continuous communication among all participants involved. Communication during the birthing process should acknowledge birth plans as fluid documents that “evolve” with the unpredictable nature of labor.

    Today in the United States, birth plans are still the outliers, not the norm. In Scotland, use of birth plans is endorsed at the national level and they are standardized to a national maternity record, which to some extent has normalized their use.7 Similarly, some institutions in the United States have also begun implementing such documents, allowing mothers to make informed choices based on reliable information. This streamlines the creation process and maximizes the potential of birth plans as tools for effective communication during labor.

    Next: Are we too quick to turn to cesarean delivery?

    I believe that physicians or midwives need to help integrate shared decision-making into the birth process to help women make use of the results of the best available research in reaching decisions about labor and delivery That counseling should incorporate medical evidence with respect to patients’ values, centered around flexibility to accommodate a patient’s needs and desires.

    Decision-making is not completely a rational process; it includes elements of personal value, trust, and confidence. Because the fulfillment of birth preferences appears to significantly affect patient experience, it may be useful to establish a standardized approach toward creating and implementing birth plans to avoid these rifts. Rather than relying on potentially unreliable information, streamlining the birth plan creation process could maximize its potential as a tool for effective communication during birth. Incorporating a universal birth preference document with a cascade of options as part of routine standard of care acknowledges birth plans as flexible documents. It ensures that providers learn to look for it, and learn to adapt their practice style to safely accommodate patient preferences.

    Birth cannot be planned, but preferences can be shared, and a provider must ensure that all parties are willing to adapt and be flexible, given the unpredictable nature of childbirth. I stand with the birthing community and believe the name “birth plan” is perhaps too restrictive. I propose renaming or marketing a “birth preference” document to emphasize the iterative nature of this process. Perhaps most importantly, providers need to be educated and encouraged to recognize that direct communication and shared decision-making is essential to facilitate and enhance women’s birth experiences.


    1. 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;56:376-381.

    2. Kuo SC, Lin KC, Hsu CH, Yang CC, Chang MY, 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;47:806-814.

     3. Lundgren I, Berg M, Lindmark G. Is the childbirth experience improved by a birth plan? J Midwifery Womens Health. 2003;48:322-328.

     4. 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;12:1-15.

    5. Mei J, Afshar Y, Gregory KD, Esakoff TD. Birth Plans: What Matters for Birth Experience Satisfaction. Birth. 2016;43(2):95-86.

    6. Grant R, Sueda A, Kaneshiro B. Expert opinion vs. patient perception of obstetrical outcomes in laboring women with birth plans. J Reprod Med. 2010;55:31-35.

     7. Whitford HM, Entwistle VA, van Teijlingen E, Aitchison PE, Davidson T, et al. Use of a birth plan within woman-held maternity records: a qualitative study with women and staff in northeast Scotland. Birth. 2014;41:283-289.

    Yalda Afshar, MD, PhD
    Dr. Afshar is a Maternal-Fetal Medicine Fellow in the Department of Obstetrics and Gynecology, University of California, Los Angeles

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      When I read 'birth plan' I always imagine a fetus trying to communicate with an obstetrician; either by sending a handwritten letter or, more up-to-date, a text message. Since women deliver and fetuses are born it is more appropriate to speak of a delivery plan.


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