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Birth Plans in the UK
Birth Plans were first proposed by the Association of Radical Midwives who called it a Letter to the Midwife (1), in which they suggested that the woman set out what she wanted or did not want.
During the 1970s and 1980s the majority of women were admitted to hospital for the delivery of their babies and they were expected to comply with hospital policies. It was not uncommon for women to be given treatment they did not want and the Letter to the Midwife was an early attempt to ensure that the midwife, whom the mother would have been unlikely to have seen before, would understand what the woman wanted. The language was forthright, and the following are some examples:
‘I do not want and do not consent to the following:
- Shaving my pubic hair.
- An enema unless I have constipation
- A routine episiotomy
- Any drugs given to me or my baby without adequate discussion and my expressed permission in each instance.
- Any mechanical fetal monitoring.
I also request the following:
- I would like very much to help deliver my baby onto my stomach.
- For the cord to be cut after it has stopped pulsation (the list continues)
Sometime later Sheila Kitzinger expanded upon this and called it a Birth Plan. They became popular and while the Letter to the Midwife made it quite clear what the woman wanted, or did not want, later birth plans were very supplicatory:
'If possible ... 'Unless it is absolutely necessary I would prefer'. Such statements are dis-empowering as the staff would decide that ‘it was not possible' or that what they intended doing was ‘absolutely necessary'.
Despite the majority of birth plans being couched in gentle, and sometimes pleading, terms they were still viewed with hostility by many staff:
‘Some patients no longer accept advice - they insist on dictating their own treatment - no other discipline in medicine has this problem. Neurosurgeons do not have to contend with the Good Neurosurgery Guide' (2)
It was not long, however, before the hospitals started producing their own birth plans in which they set out the choices that they would consider reasonable and, of course, the choices were determined by the staff, not the woman.
‘We have been inundated with ladies with birth plans, and we have pre-empted this by presenting them with our birth plan, which tells them what we intend to do. Then we have discussed the various procedures and the reasons why. If they wished to then modify them they may, provided it is reasonable. This seems to have worked well and we have had no complaints'. P Bowen-Simpkins FRCOG, Swansea.
An example of a hospital devised birth plan was published in a professional journal with the claim that its use ‘has improved relationships with the staff and has made the midwife's role more rewarding' (3).
Examination of the choices that were devised (between local women and the medical staff) were a classic example of how ill-informed women can be persuaded to accept medical advice. The women were asked to tick three boxes: would like, no strong views and wish to avoid.
Amongst a long list of very spurious choices the form allowed them to choose between: A partial shave (at a time when the research evidence showed that pubic shaving was of no benefit); an enema (ditto); the presence of a partner/relative/friend; and wearing their own nightdress. Nothing too threatening to medical practice. 33% said that they would like a partial shave, as at that time many women erroneously believed that pubic shaving prevented infection. The majority, in almost every section, ticked that they had no strong views. Hardly surprising, because women at that time were very poorly informed. Having a ‘no strong views' panel ensured that the staff would be free to do as they pleased.
The section on labour dealt with routine interventions: continuous electronic fetal monitoring, ‘correcting a slow labour by rupture of the membranes; ‘correcting a slow labour by an intravenous infusion'; episiotomy. Once again, the majority expressed ‘no strong views'. There was no information on offer as to why a ‘slow labour' would need ‘correcting', let alone any information about the adverse effects these interventions can cause. What this form did was give the women the illusion of choice when they had no information on which to make any kind of judgement.
In 1998, a study was published asking if birth plans adversely affect the outcome of labour and the researchers found that those women admitted to their hospital with a birth plan had more interventions ‘The study has shown that women with birth plans have a significantly greater chance of needing forceps delivery - compared with women without birth plans. - The risk of most other forms of intervention was, also, found to be increased, but the change was not significant. The higher prevalence of forceps delivery may reflect an unintentional lack of support from irritated attendants' (4).
In AIMS' experience birth plans can be a useful tool if the woman knows her midwife, as it gives her the opportunity to discuss her intentions, hopes and wishes with someone who will be with her during the labour, and it provides useful documentary evidence of what the woman intended to do should there be cause for complaint. Our impression from the many calls we get from all over the UK, that women are now even more likely to be treated brusquely and not have their wishes met as they are often attended by someone they have never met and, because of the shortage of staff, who are clearly under great pressure. We feel, in all honesty, we have to warn women that making a birth plan may act against them, yet we do not want to give up the principle that maternity units are designed for women, not vice versa. We cannot send them into potential conflict at the most vulnerable time in their lives without warning them. This is yet another illustration of the continuous dilemma of fighting for better maternity care.
Beverley A Lawrence Beech
Hon Chair, Association for Improvements in the Maternity Services
August 2007
References:
- Anon (1980). Letter to the Midwife, AIMS Quarterly Newsletter, Spring 1980.
- Kitzinger S (1999). Birth Plans: how are they being used?, Br J Midwifery, May 1999, Vol 7, No 5., p300-303.
- Jackson P (1986). The Huddersfield Birth Plan, Maternal and Child Health, Jan 1986, p14, 16-17.
- Jones MH et al (1998). Do birth plans adversely affect the outcome of labour? British Journal of Midwifery, January 1998, Vol 6, No 1, p38-41.
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