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The utilisation of birth plans in childbirth and the expectations, experiences and perspectives of both women and healthcare professionals
Introduction (500 – 550 words)
Birth plans are written documents which encourage women to record in advance their desires, expectations and preferences for their care and support in labour (Lothian, 2006; Welsh and Symon, 2014; Whitford et al., 2014). It also enables women to become familiar with available options for labour and empowers women to communicate their preferences with healthcare professionals (Lothian, 2006; Welsh and Symon, 2014; Mei et al., 2016). It was introduced in the 1980s as a response to the increased rate of medicalisation in labour and to help women avoid unnecessary or unwanted intervention (Welsh and Symon, 2014; Whitford et al., 2014; DeBaets, 2016). There are different types of birth plan templates for instance, proforma birth plans which can provide headings, suggestions or structured questions about aspects of care (Whitford et al., 2014). Additionally, some templates list alternatives with tick boxes or women can initiate their own unique plan using a free text document (Welsh and Symon, 2014; Whitford et al., 2014; DeBaets, 2016). Moreover, birth plan templates can be incorporated within women’s handheld maternity notes and it can also be found in pregnancy and parenting books, on websites and included in antenatal education (Welsh and Symon, 2014; DeBaets, 2016). The type of information included within a birth plan consists of: methods for coping with pain, fetal monitoring, birth positions and postnatal care (Welsh and Symon, 2014; Whitford et al., 2014).
This topic was personally and professionally chosen due to the mixed positive and negative experiences observed within practice with regards to the utilisation of birth plans. Also the topic fits into the overall scheme of health and social care provision as it is practice orientated and is a professional issue within obstetric care. Additionally, women and healthcare professional’s expectations, experiences and perspectives of birth plans are the key issues that will be discussed within this assignment. Furthermore, by understanding the utilisation of birth plans within childbirth, this will help to facilitate informed choice, improve women’s childbirth experiences and improve wellbeing. This is because birth plans are a tool that can be used to empower and educate women, encourage shared decision making, initiate and develop trust between women and healthcare professionals and facilitate communication about women’s expectations (Pennell et al., 2011; Farahat et al., 2015). Also, according to Thomas (1998) childbirth should be more of a partnership which is what the birth plan aims to achieve. In addition, this essay will be structured by firstly explaining the literature review process and how evidence was collated within the methodology, secondly the literature review will explore the collected evidence in depth, then the key themes that were highlighted from the literature review will be analysed thoroughly within the discussion, lastly a conclusion will summarise the key points that were mentioned and conclude on the findings.
Methodology (300 – 330 words)
In order to obtain relevant literature a comprehensive review of qualitative research (Siu and Comerasamy, 2013) was utilised by using the following keywords ‘birth plan AND women’s OR professionals AND expectations OR experiences. This was applied to Google, Google Scholar, Maternity and Infant Care Database and Library search. It was important to choose appropriate words and terms in order to obtain relevant references (Moule and Hek, 2011). The search strategy used was successful as all the searches yielded good results. However, one search through Google yielded 9,310,000 results, making it impossible to review all the search results.
Moule and Hek (2011) state that a literature search should be carried out in a systematic way therefore, an inclusion and exclusion criteria was applied. The inclusion criteria consists of empirical research, policies, guidelines, reviews, opinion papers, patient group information, research written in English language and qualitative research. Furthermore, the exclusion criteria consists of research not written in English language and research focusing on the expectations, experiences and perspectives of the partners of women. The rationale for setting the above criteria was to create a focus for the literature search and to help identify the different types of data that will answer the research statement optimally (Polit-O’Hara and Beck, 2006; Siu and Comerasamy, 2013; Aveyard, 2014). Moreover, the Nursing and Midwifery Council (2015) state that professionals should use current evidence and knowledge in practice. Additionally, a common agreement within healthcare literature reviews is to set a 10 year limit (Goodman and Moule, 2009). Therefore, a year limit of 2007 to the present was used to ensure more practical and contemporaneous evidence was retrieved (Goodman and Moule, 2009; Aveyard, 2014). However, the search year limit had to be expanded in order to include seminal evidence due to inadequate and limited results. Consequently, making the earlier evidence useful in providing historical context. As a result, the earlier evidence cannot be transferred to today’s maternity care provision (Siu and Comerasamy, 2013; Aveyard, 2014).
Literature review (3200 – 3520 words)
(1600 – 1760 words each)
Theme 1: Women’s expectations, experiences and perspectives of birth plans
Following on from what was previously mentioned, a birth plan enables women to have a sense of control over childbirth and their birth satisfaction (Mei et al., 2016). It was introduced with the expectation that it would give women more control during childbirth (Lundgren and Lindmark, 2003). Evidence suggests that control is an influencing factor of birth satisfaction and how women assess the quality of their childbirth experience (Hauck et al., 2007; Kuo et al., 2010; Fair and Morrison, 2012). For instance, higher levels of personal control has been shown to link to higher satisfaction with the childbirth experience (Lundgren and Lindmark, 2003; Kuo et al., 2010). Women with expectations of control over the childbirth process have positively been linked with accomplishing control during childbirth and increased satisfaction (Kuo et al., 2010). However, results from a study highlighted the fact that birth plans did not improve women’s sense of control during childbirth (Lundgren and Lindmark, 2003). On the other hand, it can be argued that this evidence is out dated and does not apply to contemporary midwifery practice.
Childbirth preparation, such as birth plans have been proven to provide women with techniques to maintain control during labour, develop realistic expectations and increased satisfaction (Fair and Morrison, 2012). However, by utilising birth plans women expect to have control over events during childbirth. Evidence suggests that failure to meet control expectations can have a negative impact on a woman’s satisfaction with her birth experience (Fair and Morrison, 2012). Moreover, women who expect childbirth events to go exactly as planned in their birth plan are likely be dissatisfied (Fair and Morrison, 2012). As a result of unrealistic expectations, this may lead to a decline in birth satisfaction and may also increase women’s probability of postnatal depression (Hauck et al., 2007; Fair and Morrison, 2012). This is because childbirth is unpredictable, as it is predominantly controlled by the body’s natural mechanisms, and/ or medical interventions (Fair and Morrison, 2012). Therefore, women should recognise that birth plans are flexible documents that evolve according to the unpredictable nature of childbirth (Mei et al., 2016). This notion is supported by results from a study which highlighted the fact that birth plans can heighten childbirth experiences, if women understand that unexpected events can occur which may not be included in their plan (Aragon et al., 2013). Additionally, women with positive expectations for the childbirth experience tend to have higher birth satisfaction compared to women with negative expectations who tend to have lower satisfaction (Fair and Morrison, 2012). Antenatal childbirth expectations have an influence on the childbirth experience, as women with expectations achieved are more likely to have positive childbirth experiences and satisfaction (Hauck et al., 2007; Kuo et al., 2010).
Moreover, birth plans can positively impact on the implementation of childbirth expectations in the following ways, it may help women have realistic expectations, encourage them to think about how to maintain control during labour and it might also stimulate women to think about how to deal with the childbirth process (Kuo et al., 2010). For instance, common features in plans includes requests to have a supportive person in attendance, to stay mobile during labour, drink fluids and to have skin to skin contact with their baby after birth (Farahat et al., 2015). On the other hand, birth plans may also be utilised as a defensive tool, as some women see it as protection against what they perceive to be unnecessary interventions (Mei et al., 2016). This is because birth plans can be compared to protocols, as it is a document that women develop in order to reduce their fear and anxiety about uncontrollable situations or events during the childbirth process (Kuo et al., 2010). For example, common requests of things to avoid includes continuous fetal monitoring, pain medications, epidurals and episiotomies (Farahat et al., 2015).
Evidence suggests that even when women’s documented preferences in their birth plans are not achieved, they may still express satisfaction with utilising birth plans (Kuo et al., 2010; Whitford et al., 2014; Mei et al., 2016). This is because birth plans help to facilitate a discussion on the options that are available in labour which can be beneficial for women (Whitford et al., 2014; Mei et al., 2016). On the other hand, further evidence suggests that women who are inflexible with their birth plan preferences run a risk of being disappointed with their birth experience, when their requests cannot be implemented (Berg et al., 2003; Mei et al., 2016). Moreover, women can feel let down by professionals, if birth their plans are not obviously looked at or taken into consideration by professionals and they can feel like they have failed within childbirth (Mei et al., 2016). For instances, results from a survey emphasises that by having a high proportion of requests from the birth plan fulfilled, significantly related to greater overall satisfaction, feeling that expectations were met and feeling more in control (Mei et al., 2016). Furthermore, evidence has shown that birth plans have a positive impact on women’s level of satisfaction because it helps increase their understanding of childbirth, enables them to express their requirements and preferences for birth and improves the communication between women and healthcare professionals (Aragon et al., 2013). However despite this, the most common reason women write birth plans is for personal education and preparation (Pennell et al., 2011). Therefore, when requests on birth plans are not met, by just building a positive relationship with healthcare professionals and women having active participation within decision making can also result in feelings of satisfaction with the childbirth experience (Kuo et al., 2010).
Further evidence suggests that experienced control during childbirth is a significant predictor of birth satisfaction and that antenatal control or birth expectations do not have any predictive quality with regards to birth satisfaction (Fair and Morrison, 2012). However, results from a study show that women who created a birth plan described a more positive childbirth experience, their expectations were met and they perceived a higher sense of control compared to women who did not use birth plans (Kuo et al., 2010; Aragon et al., 2013). Birth satisfaction increases when women are empowered to take an active role in decision making such as, positions in labour, pain management and medical interventions (Fair and Morrison, 2012). Research shows that high levels of control during childbirth increases birth satisfaction and decreases the likelihood of traumatic perceptions of childbirth and postnatal depression (Fair and Morrison, 2012). On the other hand, many women hope for a self-regulated birthing experience, by doing so they choose the type of birth they would like to have and then take responsibility for planning and knowing how to achieve this outcome (Malacrida and Boulton, 2014). This is because the majority of women assume prior to giving birth, that they can choose and plan for a specific type of birth. However, their birthing experiences did not always align with their expectations. (Malacrida and Boulton, 2014). Moreover, women hope for and even expect that a birth plan would allow them some degree of certainty and control throughout the childbirth process (Malacrida and Boulton, 2014). Additionally, birth plans can be disappointing to women because it promises them a false sense of control and certainty, however it fails to provide any real guarantees regarding childbirth events (Malacrida and Boulton, 2014). On the other hand, birth plans empower women to be involved in decision making, resulting in increased control over the childbirth process therefore encouraging a more positive experience and higher overall satisfaction with childbirth (Kuo et al., 2010). Furthermore, birth plans encourage opportunities for women to learn about obstetric procedures, ask questions and receive answers with regards to their childbirth process and to consider matters which they have not yet contemplated, as a result enhancing their childbirth experience (Kuo et al., 2010).
In order to retrieve women’s perspectives of birth plans, online forums and application programs such as ‘Netmums’ were reviewed. Although it is recognised that sources such as this are not considered robust, however it provides the perspectives of women. For example, a forum thread regarding birth plan advice highlighted mixed opinions that women expressed on the use of birth plans (Netmums, 2013). Some women felt that birth plans are essential for putting their preferences across to professionals. On the other hand, the majority of women felt that women should not get fixated on the birth plan as childbirth is unpredictable (Netmums, 2013). Therefore, women should remain optimistic and flexible with their plan to avoid disappointment. This was also the case on the Pregnancy Forum (2011) and Cow & Gate baby club (2013) forum as there were mixed perspectives on whether to write a birth plan or not and the effectiveness of having one in place. On the other hand, women find the process of thinking about their preferences and completing a birth plan beneficial even though the plan does not affect the degree of control they attain in labour (Lundgren and Lindmark, 2003; White-Corey, 2013). Women report that creating a plan encourages them to think about options and their preferences for birth, while also letting them become familiar with choices that are available before labour commences (Lothian, 2006). Furthermore, women state that completing a birth plan offers an opportunity to have a discussion about their thoughts and feelings with their partners and start to clarify their requirements with them (Lothian, 2006). Although, women expressed feelings of betrayal and felt let down by professionals when their birth plans are ignored and not carried out, especially when the rationale is due to time constraints and staffing levels (Lothian, 2006).
Women usually accept that giving birth is not always straightforward and that medicines and interventions could be used if necessary (Thomas, 1998). But the majority of women did not want them to be used routinely (Thomas, 1998). Therefore, some women decide to not have a birth plan in place in order to avoid disappointment (Malacrida and Boulton, 2014). Evidence suggests women felt that birth plans could give them a false sense of control (Mei et al., 2016). On the other hand, some women feel that the philosophy held by their healthcare professional with regards to childbirth is important (Cook and Loomis, 2012). This is because if they both share the same attitudes towards childbirth this can help women to make birth related decisions (Cook and Loomis, 2012). For that reason, women use their plans to outline their ideal birthing experience but also making it clear they are not undermining the expertise, experience and ability of healthcare professionals (Thomas, 1998). They just want to ensure that if any problems occur during the childbirth process that they are kept informed and consulted with regards to any proposed plan of action (Thomas, 1998). Additionally, women state that they have requested for specific types of care and a wider range of choices but these were never undertaken (Thomas, 1998). Although this notion is outdated, it is supported by a recent poll carried out by the Positive Birth Movement (2017) which highlighted the fact that 42% of 2,000 women said their birth plan was not adhered to. Moreover, less than half of the women said their birth plans were read by professionals but no action was carried out (Positive Birth Movement, 2017). In addition, women believe that it is easy for everyone to think that birth plans are final and unalterable therefore, making it more difficult for women to remain flexible (Positive Birth Movement, 2017). Furthermore, as flexibility is a key element towards having a more satisfying birth experience, it may be more useful to think in terms of a ‘birth guideline’ as this insists more flexibility. However, Hill (2017) suggests that a birth plan is an opportunity for women and their partners to play an active role in their birth experience. This is done by enabling them to learn about the various options on offer and empowering them to decide on what they want, not just within their ideal birth but in every situation possible (Hill, 2017; Thompson; 2017).
Theme 2: Healthcare professional’s expectations, experiences and perspectives of birth plans
Although there is no scientific suggestion to support the notion that women with birth plans have worse outcomes. Evidence has shown that professionals believe that women who have birth plans are at a higher risk of caesarean section and an overall worse childbirth experience compared to women who do not have birth plans (White-Corey, 2013; Farahat et al., 2015; DeBaets, 2016). Also, varying cultural views form the attitudes of professionals towards how best to provide healthcare (Sheridan et al., 2011). As a result, it has been noted that some professionals have a strong dislike to birth plans and consider it to be a misfortune (White-Corey, 2013). Therefore, how a professional views birth plans and childbirth will impact on the options that are offered to women and on the decisions that women make before and during labour (Cook and Loomis, 2012). Furthermore, birth plans have been perceived to cause tensions between women and professionals which can trigger negative attitudes from professionals and eventually impact on the clinical care they provide to women (Welsh and Symon, 2014). This is important to highlight as this perception that professionals have might influence the way they care for women during labour (White-Corey, 2013). Wier (2008) states that a birth plan is regarded with hostility and apprehension by some midwives. Moreover, DeBaets (2016) suggests that professionals sometimes feel hostile towards women with birth plans, as a result this could lead into mistrust between both parties.
Although birth plans are supposed to improve relationships it has been noted to irritate healthcare professionals, which could adversely affect obstetric outcomes (Lothian, 2006; DeBaets, 2016). Moreover, birth plans can also become an unintended obstacle which can cause friction between professionals and women (Mei et al., 2016). On the other hand, a plan can help professionals to recognise women as individuals and appreciate their individuality more quickly, by knowing what is most important to the women and their needs (Lothian, 2006). Alternatively, some professionals assumed that because of time constraints they were allowed to make decisions for women without going through the process of discussing and negotiating, in order to find a plan that respects women’s wishes and requests (Lothian, 2006; DeBaets, 2016). Professionals also assume that women go into hospital with uninformed and unrealistic birth plans which provokes some degree of annoyance (DeBaets, 2016). Additionally, professionals often view women who have birth plans that focus on the interventions they want to avoid as difficult and demanding as professionals believe these plans are inflexible and unrealistic (Lothian, 2006; DeBaets, 2016). As a result, Professionals may become irritated and frustrated with women that go into hospital with a list of expectations but they have not prepared physically or emotionally for childbirth (White-Corey, 2013; Welsh and Symon, 2014; Farahat et al., 2015).
A primary aim for birth plans are to help build the woman and professional relationship moreover, they were introduced to assist with communication difficulties (Lundgren and Lindmark, 2003; Lothian, 2006). However, a study highlighted that a birth plan did not improve the relationship between women and midwives because midwives are already good at establishing caring relationships with women (Lundgren and Lindmark, 2003). Furthermore, the tool can be used to challenge and improve care that professionals provide as it requires professionals to consider the woman’s needs and expectations within childbirth (Wier, 2008). When women’s expectations are altered, the professional becomes crucially important in helping women negotiate changes and promote a positive birth experience (Cook and Loomis, 2012). This is because healthcare professionals influence women’s childbirth decisions by providing them with information or supporting a woman’s already established philosophy of childbirth (Cook and Loomis, 2012). Moreover, professional’s knowledge also impacts women’s birth planning and what happens when, during the birth changes are made to the initial birth plan (Cook and Loomis, 2012). Furthermore, healthcare professionals found that having an extended visit with women at approximately 34-36 weeks gestation is beneficial in discussing with women their values and preferences for the birthing process (DeBaets, 2016). However, professionals are not always able to discuss birth options and directly support women to complete their birth plans due to busy clinics and/or a lack of staff (Whitford et al., 2014).
Professionals are also regularly concerned that birth plans signify an effort to plan and control childbirth which inherently cannot be planned or controlled (Aragon, 2013; Mei et al., 2016). Furthermore, evidence suggests that birth plans do not always enhance a woman’s control during childbirth however, their outcomes were influenced by the insufficient time that professionals assigned to reading women’s birth plans (Kuo et al., 2010). Mei et al. (2016) states that professionals are less likely to read women’s birth plans and take them into consideration when creating a clinical plan of care as it might include outdated or inaccurate information. Moreover, practices such as episiotomies are no longer part of standard practice since 2006 (Mei et al., 2016). However, despite this nearly being obsolete within standard medical practice women are still requesting for no episiotomy within their birth plans (Mei et al., 2016). As a result this may be contributing towards professional’s negative attitudes and views towards birth plans (Mei et al., 2016). Lothian (2006) supported by Welsh and Symon (2014) state that professionals become institutionalised within their workplace which therefore limits their flexibility in accommodating women’s birth plan requests. Furthermore, it has been noted that due to the increase in medicalisation within childbirth, healthcare professionals do not always treat every woman as an individual and respect their right to be involved within decision making with regards to their care, also they do not show sensitivity to women’s desires and feelings (Kuo et al., 2010).
Evidence highlights that midwives views has been ignored with regards to the utilisation of birth plans (Welsh and Symon, 2014). This signifies a gap within evidence base as midwives play an integral role in discussing and trying to achieve the wishes and requests of women during childbirth (Welsh and Symon, 2014). However, according to Whitford et al. (2014) very few healthcare professionals had negative opinions and reservations regarding encouraging women to complete a birth plan. Professionals felt that birth plans could encourage beneficial discussions with women during pregnancy and labour (Whitford et al., 2014). Additionally, it can also be used to stimulate and guide discussions regarding options within the childbirth process in the antenatal period (Whitford et al., 2014). However, a study that looked at evaluating the effects of implementing birth plans to women in Taiwan received declines from obstetricians unwilling to participate (Kuo et al., 2010). The obstetricians stated they declined due to not having enough time to communicate with women moreover, they felt that the utilisation of birth plans was too tedious and complex (Kuo et al., 2010). On the other hand, some professionals suggested that completed birth plans might highlight areas of particular anxiety and worry for women. Therefore, this can help to tailor care especially when professionals do not know the woman (Whitford et al., 2014). Moreover, some professional’s felt that explicit reference to a woman’s personal plan could reassure women and improve communication (Whitford et al., 2014). This is because changes occur as women’s circumstance change therefore women need to learn and prepare for the unknown of childbirth (British Broadcasting Corporation, 2017). As preparation is key and women need to know what is available to them and why medical interventions may be needed (British Broadcasting Corporation, 2017).
Midwives recognise some women’s reluctance to make a list of plans and requests due to the unpredictability of labour (Whitford et al., 2014). Therefore, some midwives explained that during their antenatal discussions with women they emphasize the need to remain flexible within childbirth. While also reassuring women that plans can be changed during labour at any time when required (Whitford et al., 2014). Conversely, some healthcare professionals believe that women with birth plans have unrealistic expectations and become inflexible to making changes to their plan when required (Farahat et al., 2015). Midwives state that the term ‘birth plan’ causes some women to become inflexible with their expectations and gives them a false sense of control (Welsh and Symon, 2014). As a result, midwives are concerned that women are holding unrealistic expectations that they can plan their birth. Consequently, they feel this will increase women’s chances of feeling disappointed with their childbirth experience when their expectations are not met (Welsh and Symon, 2014). Although they view the term ‘birth plan’ to be misleading, midwives also state that birth plans are useful tools in encouraging communication with women. However, they feel awareness needs to be raised to women on the fact that birth plans should be flexible and adaptable (Welsh and Symon, 2014). Additionally some midwives feel that preparing for childbirth is not going to come from paperwork for example, birth plans (British Broadcasting Corporation, 2017).When birth does not go to plan, women should have a sense of control and they should know that their body is designed to give birth. Moreover, women should understand that childbirth does not always go to plan and they should be able to cope with this and healthcare professionals should support women to get through this experience (British Broadcasting Corporation, 2017).
Healthcare professionals state that birth plans provide women with a better understanding of what could occur during childbirth (Aragon et al., 2013). Furthermore, it encourages women to express their ideal wishes and desires in order to ensure everyone involved in the birthing process is thinking in a similar way with regards to care (Aragon et al., 2013). On the other hand, obstetricians expressed concerns about women using their plans to include requests that are part of standard care for example, requesting for good communication (Whitford et al., 2014). This could imply that good care would not be offered to women unless they explicitly requested it in their birth plans (Welsh and Symon, 2014; Whitford et al., 2014). As a result, this could cause some professionals to react negatively towards women and their plans as they are using it as a defensive tool (Welsh and Symon, 2014); Whitford et al., 2014). Conversely, professionals stated that they did not provide women with choice during childbirth because they never requested it in their birth plan (Thomas, 1998). Additionally, midwives have voiced the pressures they face because of birth plans as they feel compelled to facilitate women’s desired birth expectations and provide appropriate care (Welsh and Symon, 2014). Similarly, midwives also felt pressure from obstetric staff to get women to change their birth plan requests in order to conform to hospital policies as a result, midwives felt constrained to institutional requirements (Welsh and Symon, 2014). However, midwives also felt a sense of accomplishment and satisfaction when they were able to support women in attaining their ideal childbirth experience (Welsh and Symon, 2014).
Discussion (1500 – 1650 words)
The two themes, both women’s and healthcare professional’s expectations, experiences and perspectives of birth plans, highlight areas in which changes can be made to improve women and healthcare professionals experiences of birth plans within childbirth. Many authors have stated that women who write birth plans have more childbirth satisfaction (Lothian, 2006; Welsh and Symon, 2014; Whitford et al., 2014). Moreover, there is a significant gap in evidence on professional’s experiences and views of utilising birth plans with women during childbirth (Aragon et al., 2013; Welsh and Symon, 2014). Mei et al. (2016) recommends staff training and more time for proactive communication between professionals and women may be useful in helping to facilitate and enhance women’s awareness of professional responsiveness to women during their childbirth experience. As a result, the negative experiences raised within the two themes should be challenged in future practice so that women and healthcare professionals will have a more positive experience of birth planning.
Some authors have suggested that a birth plan may cause conflict when situations arise during labour, and this may inadvertently generate hostile relationships between women and healthcare professionals if women do not want to deviate from their birth plans (Aragon et al., 2013). Additionally, authors have highlighted concerns regarding birth plans causing conflict between women and professionals when there is mistrust or a lack of respect between them both (Aragon et al., 2013). Also, results for a study demonstrate that both women and professionals see the benefits and limitations of using birth plans (Aragon et al., 2013). Both women and professionals report that the birth plan can be useful as a communication and educational tool. Moreover, the act of creating a birth plan was an educational experience for women and the implementation of birth plans empowered them to articulate their expectations and preferences to their healthcare professionals (Aragon et al., 2013). However, most of the studies and evidence used have been limited by having small cohorts, and limited studies explored the advantages and disadvantages of using birth plans and the most important aspects of a birth plan among women and healthcare professionals.
The literature within this search has been sufficient enough to draw generalised themes and conclusions, however there are restrictions to some data. There were various limitations to the studies included within the literature review, for instance the majority of women sampled were mainly Caucasian, educated and some studies were from countries outside the United Kingdom. Moreover, there were several literature used within the review that were older than the 10 year limit, as suggested by Goodman and Moule (2009). Therefore, the overall evidence used in this review may be questionable. This is because the evidence used are not all contemporaneous, which is a requirement set by the Nursing and Midwifery Council (2015), in order for the evidence to be applied to current practice. Furthermore, internet sources such as ‘Mumsnet’ were used which are not robust sources and only provide insights into the topic reviewed from a woman’s perspective. Consequently, further future research will need to be carried out in order to validate these insights highlighted. Therefore, it is crucial to conduct further research into the perspectives of both women and healthcare professionals with regards to utilising birth plans in order to keep a contemporaneous evidence base and practice. Also, this literature review highlights mixed expectations, experiences and perspectives of both women and healthcare professionals with regards to the utilisation of birth plans in childbirth. As a result, this demonstrates the need for further in-depth research that focuses on this aspect of midwifery practice, in order to attain better understanding of the effectiveness of birth plans.
Local Trust Guideline (2014) states that at the booking visit woman and midwives discuss place of birth and all women at 34weeks gestation should discuss plans for labour and birth This discussion should include recognition of labour, pain relief and their issues and concerns with professionals moreover, professionals can give women further information (Local Trust Guideline, 2014). Moreover, the National Institute for Health and Care Excellence (2008) suggests that at 34 weeks gestation all pregnant women should be given information and the opportunity to discuss issues and ask questions. Then at 36weeks gestation women should complete their birth plans (Local Trust Guideline, 2014).This should be carried out by respecting women’s wishes and her involvement in decision making, which are essential to her care in pregnancy and labour (Department of Health, 2007; National Institute for Health and Care Excellence, 2008; The Royal College of Midwives, 2012). However, between 34-36weeks gestation the National Institute for Health and Care Excellence (2008) suggests that professionals encourage women to discuss preparation for childbirth and provide information about coping with pain in labour and the birth plan. Birth planning is a continuous part of antenatal care and this requires a focussed discussion about place of birth, at which women should receive clear, unbiased advice and be able to choose where they would like their baby to be born (Department of Health 2007; The Royal College of Midwives, 2012). The birth discussion and associated birth plan are essential opportunities for women and midwives to share information (National Institute for Health and Care Excellence, 2008; The Royal College of Midwives, 2012). The birth plan should be discussed in full with the midwife looking after the woman in labour. Women often find it difficult to ask questions, so midwives need to encourage them to do so, and to act as an advocate for their expressed wishes (The Royal College of Midwives, 2012). This is because control, or lack of it, was important to women’s experience of labour and their subsequent emotional well-being (The Royal College of Midwives, 2012). The Nursing and Midwifery Council (2015) states that professionals should treat women as individuals and uphold their dignity, listen to women and respond to their preferences and concerns. Moreover, ensure that a holistic approach is carried out when assessing and responding to women’s needs and professionals should always act in the best interests of women (Nursing and Midwifery Council, 2015). According to Birthrights (2013) a birth plan does not have any formal legal status but it should be respected by healthcare professionals unless the woman gives her consent to a different plan of care.
This literature review highlighted that having a birth plan section incorporated within standard maternity handheld notes has benefits (Whitford et al., 2014). However, these are not always realised within practice because woman my need to be actively empowered and encouraged to consider plans and complete them. There needs to be a process where it can be explained to women at an early stage (Whitford et al., 2014). Therefore, professionals should have more time and training to work more efficiently with women, so they can express their preferences and document their values and concerns (Mei et al., 2016, Whitford et al., 2014). On the other hand, it may be argued that by embedding birth plans into standard maternity notes implies the assumption that completing a birth plan is a standard thing to do (Whitford et al., 2014). However, it may be more valuable for women to have a supported opportunity to discuss options for labour rather than to ensure women complete birth plans (Whitford et al., 2014). This is because it may not necessarily be the birth plan itself that is important to women. It could just be having the opportunity to discuss concerns and choices for labour (Whitford et al., 2014; Mei et al., 2016). Additionally, as birth plans were created as a tool for women to communicate their preferences and choices in the childbirth process (DeBaets, 2016). It often does not function effectively due to reflecting inconsistent and outdated choices. As a result, birth plans can alienate healthcare professionals and cause breakdowns in communication instead of enhancement (DeBaets, 2016).Therefore, a better alternative could be a birth partnership, which can establish trust and effective communication between women and professionals through a process of shared education (DeBaets, 2016). Healthcare professionals will need to be enthusiastic enough to talk with women within their care, educate them on all the options that are available and take the time to listen to women’s values and concerns (DeBaets, 2016).
Since there is a widespread inconsistency in birth plan preparation it may be useful to develop a universal approach towards creating and implementing birth plans (Mei et al., 2016). For instance, inventing a standardised document which can be used nationwide across maternity. Also, in order for birth plans to provide improvements in communication and ensure women have the satisfactory childbirth experience they expect to have (Mei et al., 2016). Future research should highlight further factors that make birth plans effective at times and detrimental at others (Mei et al., 2016). Thus enabling birth plans to promote discussions about the complex nature of birth in a way that positively benefits both women and professionals. Furthermore, due to the term ‘birth plan’ being considered as inappropriate and contributing to women’s unrealistic expectations of childbirth, in particular the notion that birth can be planned (Welsh and Symon, 2014). A suggestion may be to change the term ‘birth plan’ into ‘birth guide’ or ‘birth preferences’ or ‘birth choices’ (Aragon et al., 2013; Welsh and Symon, 2014). In order to put emphasis on the need for women to remain flexible with their requests for labour, due to the dynamic and unpredictable nature of childbirth. The document should also be used as a prompt for discussion between women and professionals to promote understanding of events that can occur and procedures (Aragon et al., 2013).
Conclusion (500 – 550 words)
By carrying out this literature based study I have gained a better understanding of the utilisation of birth plans in childbirth and the expectations, experiences and perspectives of both women and healthcare professionals within midwifery practice. The rationale for the implementation of birth plans was to give women more control (Lundgren and Lindmark, 2003; Mei et al., 2016). This is crucial as control is a factor that effects how a woman perceives the quality of their childbirth experience (Hauck et al., 2007; Kuo et al., 2010; Fair and Morrison, 2012). Although arguments suggest that birth plans do not improve women’s sense of control during childbirth (Lundgren and Lindmark, 2003). This is because birth plans can cause dissatisfaction and postnatal depression when birth does not go exactly as planned (Hauck et al., 2007; Fair and Morrison, 2012). However, because childbirth can be unpredictable women should recognise that birth plans are flexible documents (Fair and Morrison, 2012; Mei et al., 2016). Furthermore birth plans can positively impact on the implementation of childbirth expectations (Kuo et al., 2010). It can be utilised as a defensive tool, as some women use it as protection against interventions (Mei et al., 2016).
Healthcare professionals believe women with birth plans are at a higher risk of caesarean section and worse childbirth experience, compared to women without birth plans (White-Corey, 2013; Farahat et al., 2015; DeBaets, 2016). Some professionals strongly dislike birth plans and consider it a misfortune (White-Corey, 2013). Moreover, it can trigger tensions between women and professionals and cause professionals to display negative attitudes, which can impact on women’s overall childbirth experience (Welsh and Symon, 2014). Some midwives approach birth plans with intimidation and apprehension as professionals sometimes feel hostile towards women with plans (Wier, 2008; DeBaets, 2016). Furthermore, birth plans can irritate healthcare professionals even though it is supposed to improve relationships (Lothian, 2006; DeBaets, 2016). This is because it can become a hindrance during the childbirth process and cause friction between professionals and women (Mei et al., 2016). However, birth plans can enable professionals to view women as individuals and allows them to know what is most important to women and their needs (Lothian, 2006).
The controversy surrounding the effectiveness of birth plans is still current within contemporary midwifery, as there are still unanswered questions as to whether it meets the intended aims or unintentionally promotes a hostile relationship between women and healthcare professionals (Wier, 2008; Pennell et al., 2011; Aragon et al., 2013). However, despite the controversy the popularity and acceptance of the birth plan continues to strengthen and increase (Pennell et al., 2011). Moreover, the evidence highlights that there are both positive and negative experiences and perspectives on the effectiveness of birth plans (Pregnancy Forum, 2011; Cow & Gate baby club, 2013; Netmums, 2013; Welsh and Symon, 2014). However, further research is needed into the effectiveness of birth plans in order to provide improvements in communication between women and healthcare professionals, and to ensure women have the satisfactory childbirth experience they expect to have (Mei et al., 2016).
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