I wrote Birth plans: worse than useless over 5 years ago but it remains one of the most read, most commented upon pieces on this blog.
A new paper in the “journal” Birth (owned by Lamaze International), Birth plans—Impact on mode of delivery, obstetrical interventions, and birth experience satisfaction: A prospective cohort study by Afshar et al. shows that birth plans are still worse than useless, not merely failures on their own terms, but actually making women feel less satisfied than they would have without birth plans.
[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Having a birth plan is as effective as having a weather plan for the day of birth.[/pullquote]
Three hundred women were recruited: 143 (48%) had a birth plan. There was no significant difference in the risk of cesarean delivery for women with a birth plan compared with those without a birth plan (21% vs 16%, adjusted odds ratio [adjOR] 1.11 [95% confidence interval (CI) 0.61-2.04]). Women with a birth plan were 28% less likely to receive oxytocin (P < .01), 29% less likely to undergo artificial rupture of membranes (P < .01), and 31% less likely to have an epidural (P < .01). There was no difference in the length of labor (P = .12). Women with a birth plan were less satisfied (P < .01) and felt less in control (P < .01) of their birth experience than those without a birth plan.
It’s really not surprising when you consider that birth plans, like most of natural childbirth philosophy, was conjured from thin air, with no investigation as to whether they worked or if the assumptions behind them were accurate.
… Birth plans were originally introduced in the 1970s as a communication tool. In the 1980s, after criticism of an overly “medicalized” view of childbirth, the World Health Organization went on to classify birth plans in the top category of recommended practices for making pregnancy safer…
But the truth is that birth plans were created by birth paraprofessionals as a way empower themselves and stick a proverbial finger in the eye of obstetricians. Birth plans engender hostility from the staff, are usually filled with outdated and irrelevant preferences, and create unrealistic expectations among expectant mothers. And they don’t work.
This is not news.
Joanne Motino Bailey, CNM et al. in Childbirth Education and Birth Plans, noted:
There are no randomized controlled trials that analyze birth plans …
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.
Birth plans do not improve outcomes. As Pennell et al, pointed out in Anesthesia and Analgesia–Related Preferences and Outcomes of Women Who Have Birth Plans:
…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…
But most importantly, birth plans increase disappointment. 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…
Yet in 2017, people keep studying them, apparently hoping that this time the results will be different. Afshar et al. found weren’t:
The World Health Organization, American College of Obstetricians and Gynecologists, and the American Academy of Pediatrics have suggested that birth plans may be a vehicle for women to communicate what their preferences for childbirth are and that birth plans may be associated with improved patient safety and satisfaction. Despite these recommendations, there is little data with respect to the role of the birth plan in facilitating patient-provider communication or the efficacy of the birth plan with respect to mode of delivery.
And:
…[D]espite receiving care consistent with their birth plan, women with birth plans described not feeling in control and were less satisfied with their birth experience than those women without birth plans.
The authors evince surprise about this results, but they shouldn’t. Having a birth plan is like having a weather plan for the day of birth. It is utterly ineffective and very likely to end in disappointment.
Birth plans reflect the fundamental fraud at the heart of natural childbirth advocacy, the insistence that a woman’s experience of childbirth is all in her head and that by planning and directing her thoughts appropriately she can have whatever experience she wants. That makes as much sense as claiming that the weather is all in one’s head and that by planning and directing your thoughts you can have whatever weather you desire.
Birth plans don’t merely fail in their stated aim, there’s no way that they could ever succeed. The key to a safe, satisfying birth experience is flexibility based on the understand that no one can control childbirth. Anything else will inevitably lead to increasing disappointment, not preventing it.
