TO THE OR? Shelley White-Corey, MSN, RN. 2.1 ANCC Contact Hours BIRTH PLANS: Tickets

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1 2.1 ANCC Contact Hours BIRTH PLANS: Tickets TO THE OR? Shelley White-Corey, MSN, RN Abstract Although some nurses and physicians might suggest that women who write birth plans are at greater risk of a cesarean birth, research has not supported this myth. The research studies on this topic have suggested, actually, that women who write birth plans do not have higher cesarean rates or worse obstetric outcomes. Birth plans have been shown to inform and empower women, and lead to more satisfaction with their birth experiences. The purpose of this article is to present the existing evidence on perinatal outcomes in women with birth plans and to explore the phenomenon of divergent perceptions among care givers. Key words: Birth plan; Childbirth preparation; Childbirth satisfaction; Perinatal outcomes. 268 volume 38 number 5 September/October 2013

2 Not all of the care we give is truly based on evidence. Some of it, we know, is based on the way we ve always done it, and some is not based on any evidence at all. One of these gray areas of care for perinatal nurses is the birth plan. Some physicians and nurses seem to believe that women who enter the healthcare system carrying birth plans are at greater risk of a cesarean birth. In some institutions, these negative attitudes toward women with birth plans are pervasive, ranging from making these women the brunt of jokes, to outright hostility (Simkin, 2007). Birth plans were intended to be a tool to create trust and improve healthcare provider patient relationships, but instead, in some institutions and settings, they seem to have created animosity, tension, and power struggles (Lothian, 2006). A study by Grant, Sueda, and Kaneshiro (2010) compared the perceptions of obstetric physicians and nurses and antepartum patients regarding outcomes in women with birth plans. They found that 65% of caregivers believed that patients with birth plans had an overall worse obstetric outcome, whereas only 2.4% of patients held that belief. Sixtyfive percent of healthcare providers thought that women with birth plans were more likely to have a cesarean birth, whereas only 8.7% of the patients interviewed believed this to be true. Carlton, Callister, Christiaens, and Walker (2009), in their study of obstetric nurses perceptions, reported that nurses have an aversion to birth plans and consider them a jinx. One nurse stated that she believes that 75% of her patients with birth plans end up having a cesarean, and that the patients are setting themselves up for failure. Many doctors and nurses believe that patients with birth plans have unrealistic expectations and are inflexible in making changes to their plan when necessary (Carlton et al., 2009; Kaufman, 2007). According to Lothian (2006), the tension that has resulted from the creation of the birth plan may be related to a divergence of philosophies. One perspective holds that birth is a natural process, and that women possess the capability of birthing without intervention. This view is the one held by the World Health Organization (1996). Practices that are often written in birth plans such as allowing women to move or walk during labor, providing emotional and physical support by a person of their choice, and pushing in a nonsupine position are based on scientific evidence (Lamaze International, 2007; Lothian, 2006). However, Declercq, Sakala, Corry, and Applebaum (2006) have reported that only a small number of women receive these forms of care. The opposite perspective holds that birth is inherently fraught with risk and danger. On the basis of that theoretical underpinning, in the United States, safety is assured through routine use of continuous fetal monitoring, intravenous lines, and restrictions on eating, drinking, and mobility (Lothian, 2006). Unfortunately, these interventions are not themselves evidence-based. In the case of continuous fetal monitoring, research has not shown benefit of electronic fetal monitoring over intermittent auscultation in low-risk mothers (Lyndon & Ali, 2009). In fact, research has shown that its use has increased the rate of cesarean and operative vaginal births without reducing neonatal morbidity or mortality (American College of Obstetricians and Gynecologists, 2009). Despite this, it is the standard practice in most hospitals, perhaps because of the fear of litigation. Lothian (2006) has written extensively on the topic of legal considerations trumping best evidence for practice. The purpose of this article is to present the existing evidence on perinatal outcomes in women with birth plans and to explore the phenomenon of divergent perceptions and implications for informed consent, patient autonomy, and birth satisfaction. Background History of the Birth Plan Beginning in the 1930s, when birth moved from home settings into hospitals, women began giving over control of their births to physicians and technology; some say that this led to a paternalistic environment for childbirth (Lothian, 2006). In response to what they perceived as an increasing emphasis on medical intervention, technology, and impersonal care, childbirth educators introduced the birth plan in the late 1970s; this was done in order to help women take back some control of the birthing process (Bailey, Crane, & Nugent, 2008; Wier, 2008). Birth plans are written documents that list women s preferences for their labor and birth (Grant et al., 2010; Kuo et al., 2009; Simkin, 2007). Some have likened the birth plan to a living will; both are healthcare directives that express our wishes about normal life events: birthing and dying (Philipsen & Haynes, 2005, p. 47). These documents can speak for us when we are most vulnerable (Yam, Grossman, Goldman, & Garcia, 2007). The birth plan was originally intended as a tool to educate and empower women, encourage shared decision making, facilitate communication about expectations, and develop trust between women and their caregivers (Pennell, Salo-Coombs, Herring, Spielman, & Fecho, 2011; Simkin, 2007). It is thought that by learning about the process of birth and exploring their values and desires, women s confidence in their ability to give birth September/October 2013 MCN 269

3 would be increased (Kaufman, 2007). The ultimate goal is to have a positive childbirth experience through a sense of increased control (Berg, Lundgren, & Lindmark, 2003). Research suggests that a sense of control is associated with a positive birth experience, regardless of the outcome (Berg et al., 2003; Carlton, Callister, & Stoneman, 2005). Most women who write birth plans want an unmedicated birth with few interventions (Deering, Heller, McGaha, Heaton, & Satin, 2006; Grant et al., 2010). Common elements of the birth plan include requests to ambulate during labor, drink fluids as desired, to receive the baby to the abdomen after birth, and to have support persons in attendance. They also often contain a list of things that the woman wishes to avoid, such as continuous fetal monitoring, episiotomies, pain medications, and epidurals (Anderson & Kilpatrick, 2012; Deering et al., 2006; Grant et al., 2010). Some women choose to birth at home because of their concern that they won t be able to have the birth they want in the hospital (Lothian, 2010). A study of these women by Lothian (2010) found that they invested much time in preparing for their births. By the time the baby was born, they felt confident in their ability to give birth naturally; Carlton et al. (2009) have shown that adequate investment in preparation for birth is key to having an unmedicated birth. Lamaze International (2007) has identified six evidence-based care practices that allow birth to unfold in a natural, physiological process. These six care practices are (1) labor begins on its own, (2) freedom of movement throughout labor, (3) continuous labor support, (4) no routine interventions, (5) spontaneous pushing in upright or gravity-neutral positions, and (6) no separation of mother and baby with unlimited opportunities for breastfeeding (Lamaze International, 2007, p. 12). According to Lothian (2007), it is important for women to fully understand these practices if they want a birth with less intervention. Unfortunately, prenatal education offered by hospitals is often a generic program that introduces women to the practices of the hospital and does not concentrate on empowering women to make informed decisions for their own birth (Carlton et al., 2005). Birth Plans and Perinatal Outcomes Cesarean Births While research on perinatal outcomes of women who write birth plans is limited, the available evidence suggests that there is not an increase in cesarean rate in these women. In their retrospective study of 67 patients with birth plans in a military tertiary care hospital, Deering et al. (2006) found that 75% of women had normal, spontaneous vaginal births, 6% experienced an operative vaginal birth, and 19% had cesarean births. It is not known what the standard cesarean rate for this hospital is. In a different study, Deering, Zaret, McGaha, and Satin (2007) compared the outcomes of women with birth plans to matched controls without birth plans. There were no statistically significant differences in cesarean rate (17% in the birth plan group versus 12% in the group without a birth plan). Hadar, Raban, Gal, Yogev, and Melamed (2012) conducted a retrospective study of the outcomes of women with self-prepared birth plans in Israel. They found that these women were less likely to undergo a cesarean birth when compared to women who did not prepare a birth plan (9.3% versus 19.5%). In their prospective cohort study of 63 women with birth plans at a large, university-based tertiary care hospital, Pennell et al. (2011) found an increased rate (28.6%) of cesarean birth in women who prepared birth plans compared with the overall rate at their institution. It is not known what the overall rate was, nor if there was a significant difference between the birth plan group s rate and the overall rate. Birth plans are common in developed countries, but they are a new concept in developing countries. Yam et al. (2007) introduced the birth plan to low-income women in a large hospital located in Ciudad Juarez, Mexico. In this setting, the cesarean rate rose significantly; private hospitals reported that 53% of women gave birth by cesarean. All nine of the study subjects had never heard of birth plans. Most reported that they were unaware that they had rights as a patient. The women completed the birth plan with the assistance of one of the practitioners. Following the intervention, four of the nine women (44%) reported having cesarean births. It is not known if these were primary or repeat cesareans. Honoring Requests Avoidance of episiotomies and epidurals is frequently listed in women s birth plans (Anderson & Kilpatrick, 2012; Deering et al., 2006; Grant et al., 2010). In the study by Deering et al. (2006), 24% of the women who specifically requested no episiotomy received this intervention. Fifty-two percent of the women who specifically requested no epidural received one. The authors conclude that the patients agreed to the intervention when their physicians counseled them that the physicians considered it a necessary intervention (Deering et al., 2006, p. 780). No interviews were conducted with the women, so this conclusion is questionable. Deering et al. (2007) reported that 83% of the women requested no episiotomy, but 25% had one anyway. Of the 58% who stated they did not want an epidural, 48% received one. The authors conclude that patients agreed to the interventions because their healthcare providers told them it was warranted. Again, no interviews with the patients were conducted to confirm this supposition. Hadar et al. (2012) reported that of 91.6% of women requesting no episiotomy, 34% received one. Of 46% of women requesting no epidural, 27% received one. The authors state that this is not due to the low compliance by medical staff or epidural unavailability, rather 270 volume 38 number 5 September/October 2013

4 because a change of heart by the women themselves (p. 2057). It is possible that routine hospital practices, such as continuous electronic fetal monitoring and intravenous lines that restrict women s movement, may lead to slower labors, increased discomfort, and exhaustion, which may cause women to change their preferences about pain management (Carlton et al., 2005). Pennell et al. (2011) found that of women requesting no epidural, 54.5% received one. Eight out of nine women in the study by Yam et al. (2007) did not have a preference about episiotomy, and three (33%) of them received one. Despite the fact that many birth plan requests were not honored, women reported satisfaction with preparing a birth plan (Pennell et al., 2011; Yam et al., 2007). Childbirth Satisfaction Childbirth satisfaction represents a sense of feeling good about one s birth. It is thought to result from having a sense of participation and control, having expectations met, and feeling empowered, confident, and supported (Benoit, Westfall, Treloar, Phillips, & Jansson, 2007; Kuo et al., 2010; Lothian, 2006). Despite this widely held belief, two studies have shown that having a pain-free labor and birth did not improve a woman s satisfaction with her birth (Carlton et al., 2005; Lothian, 2006). Several studies have reported on childbirth satisfaction in women who write birth plans. Kuo et al. (2010) conducted a study in seven Taiwanese hospitals where birth plans are rarely used. This large, randomized, single-blind controlled trial utilized a checklist-style birth plan. Participants in the experimental group were asked to choose which options they would like. After completing the birth plan, participants discussed it with their obstetrician and both signed the document. The results showed a significant difference in childbirth satisfaction, sense of control, and level of fulfillment of expectations in the experimental group, which reported a much better experience overall (Kuo et al., 2010). Helk, Spilling, and Smeby (2008) found that the creation of a birth plan helped to ameliorate a disabling fear of childbirth. Women stated that it was helpful to think about and write down their preferences, and know that their needs would be attended to. Of the participants who wrote birth plans, 86% found them to have a positive effect. Lundgren, Berg, and Lindmark (2003) reported that, although the birth plan was not effective in improving women s birth experience in the overall group, there were beneficial effects for some subgroups regarding fear, pain, and concern for the baby. Conversely, Berg et al. (2003) found that in women with complicated pregnancies and/or births, the creation of a birth plan increased fear, anxiety, and decreased overall satisfaction with the birth experience. They concluded that because a birth plan can increase a woman s awareness of possible occurrences, it should not be used with women at high risk. Benoit et al. (2007) were interested in the contextual experience of women suffering from Declercq et al. (2006) reported that, although women recognized their right to informed consent and informed refusal, 73% of women who had episiotomies were not given a choice in this decision. postpartum depression. Their mixed-methods longitudinal study found that satisfaction with the birth experience was closely linked with postpartum depression. Women who felt in control of their birth plans and had continuous support from a midwife when things didn t go as planned were very satisfied with their birth experiences and experienced less postpartum depression. This is important because of the potential long-term impact on the mother child relationship (Declercq et al., 2007; Kuo et al., 2010; Lothian, 2006). Ethical Implications The question being addressed today, as in the past, remains: Should women have a right to directly express their concerns and preferences and have them heeded by their clinical caregivers? (Simkin, 2007, p. 50). This question goes to the heart of informed consent and patient autonomy, two values that are regarded highly in medical ethics, and considered a fundamental obligation of caregivers (American College of Obstetricians and Gynecologists [ACOG], 2005; Carlton et al., 2005; Wier, 2008). These concepts recognize that patients inherently know what s best for them and that medicine is not infallible (ACOG, 2005). Today, there still exists an environment of paternalism in obstetrics (Wier, 2008) where many women are provided limited choices (Lothian, 2010). Women reported that they felt poorly informed about interventions such as induction and cesarean (Declercq et al., 2006). Those who work with laboring patients know that often, routine practices will occur unless women refuse them (Philipsen & Haynes, 2005). Declercq et al. (2006) reported that, although women recognized their right to informed consent and informed refusal, 73% of women who had episiotomies were not given a choice in this decision. Research shows that women consistently expressed a desire for information to exercise their autonomy (Carlton et al., 2005; Fleming et al., 2011; Helk et al., 2008; Lothian, 2010; Yam et al., 2007). The birth plan is one tool that can be September/October 2013 MCN 271

5 utilized in the informed consent process. It can open up the dialogue so that any conflict in expectations can be resolved and women can make informed choices (Bailey et al., 2008; Grant et al., 2010; Kuo et al., 2010; Lothian, 2006; Wier, 2008). Conclusion As Grant et al. (2010) discovered, while there is no scientific evidence to support the hypothesis that patients with birth plans have worse outcomes, their research demonstrates that caregivers believe that they do. This is important because it may influence the way they care for the patient during labor. If providers suspect that a patient with a birth plan will be more likely to have a cesarean section, it may lead them to this intervention sooner than it would for a patient without a birth plan (Grant et al., 2010, p. 34). Divergent perceptions and priorities may lead to conflict between caregivers and patients. Patients may feel unsupported because nurses and doctors may focus more on technology rather than face-to-face patient care (Fleming et al., 2011). Nurses and doctors may become frustrated because patients come into the hospital with a list of expectations, but have not prepared emotionally or physically for their birth (Carlton et al., 2009). Some say that the birth plan is not necessary. Instead, labor and birth units should provide evidence-based care, and women should choose healthcare providers who share their philosophy about giving birth (Capitulo, Perez, & Lepsch, 2005). Herein rests the dilemma there is a lack of evidence-based practices (Hotelling, 2007), and there is a lack of communication between patient and caregiver. If a birth plan is to be an effective tool, it must be more than a checklist of options. Instead, it should be a thoughtful reflection of a woman s understanding of the physiology of birth, and what she will need to feel safe and supported during her labor (Lothian, 2006). It must be used to initiate a dialogue between the patient and her healthcare provider early in pregnancy. This process can enhance understanding, flexibility, and the patient healthcare provider relationship. Perinatal nurses are in a pivotal position to influence birth satisfaction through the use of birth plans. Prenatally, childbirth educators and antepartum nurses should educate women about labor and birth, what they will need to feel confident and safe, and the risks and benefits of interventions (Carlton et al., 2005; Lothian, 2006). These nurses should also provide appropriate resources and encourage women to communicate with their healthcare providers early and frequently about their preferences for labor and birth (Lothian, 2006; Simkin, 2007). Supporting women s preferences during labor has been shown to increase satisfaction with birth (Carlton et al., 2005). Open communication about the birth plan and the woman s preferences should begin on Nursing Clinical Implications 1) Dissemination of research shows the birth outcomes and childbirth satisfaction in women with birth plans. 2) Evidence-based education for nurses should include how to support an unmedicated laboring woman. 3) Nurses that teach childbirth preparation classes should include evidence-based practices, information about decision-making, informed consent, and informed refusal. 4) Women should explore their values to determine what they need to feel safe and confident in their ability to give birth. 5) Birthing facilities should become more transparent about policies so that women can make informed decisions about where to birth. 6) The antenatal nurse should provide information and resources to the patient and encourage women to communicate with their healthcare providers early and frequently about their preferences for labor and birth. 7) The dialogue about birth preferences should be initiated by the healthcare provider early in pregnancy and continue throughout pregnancy. 8) Open communication between the nurse and the patient about a woman s birth plan should begin upon admission and continue throughout labor and birth. 9) During labor, nurses should actively involve women in the decision-making process by giving information and offering choices. 10) Perinatal nurses should educate themselves about the evidence-based practices that promote physiologic birth. 11) Informed healthcare providers should step forward to speak out about inconsistencies and superstitions surrounding women with birth plans. 12) Policies should be enacted on a local, state, and national level that support women s rights, the ethical treatment of pregnant women, and protection for caregivers that act in a manner that shows a fundamental respect for the autonomy of their patients. admission, and continue throughout labor. When things don t go as planned, giving information and offering choices actively involves the woman in the decision making process (Anderson & Kilpatrick, 2012). 272 volume 38 number 5 September/October 2013

6 Finally, nurses need to educate themselves about the evidence-based care practices that promote physiological birth and develop skills in supporting a woman through an unmedicated birth. Perhaps in doing so, we can dispel the myths that surround the birth plan and help to create satisfying birth experiences for women. Shelley White-Corey is an Assistant Professor, Texas A&M Health Science Center, College of Nursing, Bryan, TX. She can be reached via at White- Corey@tamhsc.edu. The author declares no conflict of interest. DOI: /NMC.0b013e31829a399d References American College of Obstetricians and Gynecologists, Committee on Ethics. (2005). Maternal decision making, ethics, and the law. ACOG committee opinion number 321. Obstetrics & Gynecology, 106(5 part 1), American College of Obstetricians and Gynecologists. (2009). Intrapartum fetal heart rate monitoring: nomenclature, interpretation, and general management principles. ACOG practice bulletin number 106. 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A., Goldman, L. A., & Garcia, S. G. (2007). Introducing birth plans in Mexico: An exploratory study in a hospital serving low-income Mexicans. Birth, 34(1), assets.babycenter.com/ims/content/birthplan_ pdf.pdf ONLINE For 25 additional continuing nursing education articles on obstetric topics, go to nursingcenter.com/ce. September/October 2013 MCN 273