Plans, preferences, maps: Getting the birth you want

I have a love-hate relationship with birth plans (by any name). Progressive standardisation of care means a woman entering maternity care systems risk being swept along with the current, her body being used to meet the organisation’s goals and priorities, not her own. Women who dare to hope for something different might be told they have “unrealistic expectations of the control they will have over the experience”, as the New South Wales Branch of the Australian Medical Association (AMA) wrote in their submission to the Birth Trauma enquiry. This argument seems to assume women ask for things like: “I’d like a vaginal birth in room 6 at my local hospital at 7:13 am on a Wednesday on a rainy day, while my favourite radio station plays something by Adele”, in their birth plans. I have heard and read many women’s expressed plans for their births and none of them have ever been like this. Instead, it has been my experience that women use birth plans to put in writing their desire to be consulted on issues that impact on them, and to set out their priorities for their birth.

Why do I hate them?

What I hate about birth plans is that they are needed. I am deeply bothered by flaws in maternity care systems that make the existence of a birth plan necessary. In a perfect world, women would be taken seriously. Significant time and effort would be taken by maternity professionals to understand what women want, and each woman’s care would be designed to best meet her specific needs. This time and effort would be built into the system, rather than something that might happen by chance on a good day. In this perfect world, birth plans would be superfluous because ALL of her maternity care would be planned by the woman.

Why do I love them?

We are some way away from achieving perfection in maternity care systems, so having a mechanism by which women can have their voices heard by maternity professionals is an excellent idea. Birth plans remind maternity professionals that this is a woman who wants to make decisions about her care. They provide insights into women’s concerns and their knowledge about particular issues that might arise during pregnancy. When working clinically as an obstetrician, I always appreciated having a birth plan to quickly orient me the woman’s priorities, particularly when I had no prior relationship with the woman and it looked like the time for a discussion about an intervention was approaching.

There are a range of options for what that communication mechanism might look like, each with its own strengths and weaknesses. Catherine Bell and co-authors have clearly set these out, supported by research about decision-making in maternity care, in a recent editorial “Finding a way forward for the birth plan and maternal decision making: A discussion paper” (Bell, et al., 2023).

They point out the shortcomings of checklists or templates produced by professional organisations, that ultimately limit rather than support choice. The term birth “plans” appear to be perceived as threatening by maternity professionals so other alternatives have been suggested. Birth “preferences” or “guides” might not challenge maternity professionals but they hardly shout “treat me with dignity and respect!” from the treetops.

Bell’s own preference is for birth maps (her website provides details and examples). She describes birth maps as initiated by women in order to open communication channels with maternity professionals, and retaining flexibility to accomodate unexpected events during birth. She centres birth mapping in a framework of respectful maternity care, effective communication, and supported (not shared) decision-making.

So here’s the thing….

Birth maps, like plans, preferences, and guides, seem to be a good option but they still require a maternity professional and a maternity system that is ready to hear, and to act on, women’s decisions about their care. When we get to the place where women’s birth maps (or plans, or whatever they decide to name them) are always greeted enthusiastically and women’s decisions are respected, we will have reached a point where they are no longer needed.

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Reference

Bell, C. H., Dahlen, H. G., & Davis, D. (2023). Finding a way forward for the birth plan and maternal decision making: A discussion paper. Midwifery, 126. https://doi.org/10.1016/j.midw.2023.103806