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    Don’t fear the patient with a birth plan


    On L&D units throughout the country, more and more women are being admitted with birth plans. Birth plans have become an increasingly common part of women’s prenatal preparation. Women cite these documents as an opportunity for educating, empowering, and developing confidence about childbirth. My residency at a busy urban hospital piqued my interest in patient birth preferences and birth plans. However, despite the high proportion of women with birth plans, there was an unspoken negative perception of them by many L&D staff. The clear disconnect between obstetricians and patients was baffling. What happened to shared-decision making and patient-centered care? What was lost in creating this “informed consent,” this personal manifesto, and “(living) labor will”? Where are the power struggles?

    Birth plans are often created in childbirth education classes to share preferences for birth and perhaps exert control over events during labor (which, as we obstetricians know, cannot truly be planned). A staggering 39% of birth plan content is drawn from the Internet, which occasionally includes websites of questionable medical accuracy.1 Many of us have seen birth plans printed from the Internet that include requests to avoid outdated procedures such as prophylactic enemas or routine episiotomies. At times, rather than acting as an effective communication tool, birth plans can create unintended obstacles. They can cause women to be perceived as inflexible and feel disappointed with their birth experience when their plans cannot be implemented.

    Birth plans were introduced in the 1970s to combat an overly medicalized view of pregnancy. A randomized controlled trial in Taiwan compared women with birth plans to those without, and found that women with birth plans had improved childbirth experiences, fulfilled childbirth expectations, and improved feelings of mastery and participation.2 The results suggest that birth plans are an effective means of fulfilling expectations, affording a larger degree of control, and fostering a positive birth experience.

    More: Why not induce everyone at 39 weeks?

    A Swedish study of postpartum women found that women who had used a birth plan were less satisfied with their provider’s support and guidance than those who did not complete a birth plan.3 For high-risk pregnancies in particular, it has been shown that a birth plan actually intensifies negative feelings towards the birth experience.4

    Despite the well-intentioned goals of birth plans, rarely is the approach to creating one streamlined and organized, largely due to the varied sources people use. We looked at women with birth plans and discovered that having a higher number of specific birth plan requests fulfilled correlated with greater overall satisfaction, higher chance of expectations being met, and feeling more in control.5 However, we also showed that having a high number of requests was associated with an 80% reduction in overall satisfaction with the birth experience. It is unclear if this discrepancy is due to women having higher expectations or a biased medical perspective. Perhaps there is a “paradox of choice” phenomenon in that too many choices have a proven detriment to our emotional wellbeing whereas a lack of choices leads to contentment, the framework that makes In-N-Out and Trader Joe’s (versus most grocery stores) so successful.


    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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