What obstetricians really think about birth plans

Having been a GP obstetrician for 15 years, I found this SMH Polly Dunning piece titled, The ‘birth plan’ is a shortcut to disappointment, time to ditch it quite intriguing. Especially as I’ve been evaluating my own philosophy on, and approach to, birth plans recently.

In my early days of obstetrics, I confess I would cringe a little when a patient handed me their birth plan. I also admit to having used the line, “My objective is to deliver you a healthy baby and a healthy you.”

This line was what I called ‘expectation management’ back then. It was intended to let the patient know that, “Yes, it would be nice if everything went according to this plan, but it probably won’t, and at the end of the day my one job is to ensure you and your baby make it through the birth alive.”

Years of clinical training ensured that the only outcome I cared about back then was the clinical one. A subsequent stint as a medical administrator taught me a great deal about the importance of perception and expectations.

That role saw me managing the complaints my hospital received. Many of these complaints came from patients (or relatives) in which the clinical outcome was excellent. In trying to better understand how an excellent clinical outcome could deliver a bad experience, I met with the patients. And in almost all situations, their issues centred around expectations not being met, lack of communication and the feeling their opinion was not valued.

For a woman to create a birth plan for herself, she must first undertake research and become more informed about the process. Since educated patients ask more questions, more conversations ensue. These conversations allow for greater development of trust between the patient and their healthcare provider which facilitates better communication. Which in turn ensures the experience being delivered is as good as the clinical care.

Yet, resistance to birth planning continues to prevail within the medical fraternity. This resistance is supported by the belief that birth planning sets the patient up to fail. Some obstetricians also view birth planning as something that undermines their ability to best manage a given birth and deliver a good outcome.

When I co-founded One for Women this year, a key driver of the clinic was to provide the continuity of care mentioned in Dunning’s piece as something all women should have access to, but currently, only 8 to 10 per cent do.

Given our focus, we’re highly aware of the impact a poor birth experience can have on a woman’s mental health. This then impacts their capacity to enjoy the experience of motherhood, especially in the crucial three months following birth (what we call the fourth trimester). That’s why, as part of our clinic’s policies, we decided to actively involve the patient in the creation of birth plans.

Which brings me to what particularly caught my eye in Dunning’s article. She mentions the approach of researcher, doula and birth cartographer Catherine Bell:

To assist women in making informed decisions, Bell has developed “birth maps” as an alternative to birth plans. The map’s “if this, then that” approach puts women back in the driver’s seat of their own birth experience and medical care.

“Decisions are pre-made for various scenarios, with consultation with the care providers and communicated to all the key players … It’s a multi-pathed map offering alternate routes.”

After reading and considering the above, I decided to change our clinic’s approach to one of creating birth maps instead of birth plans because it’s now very clear how the word ‘plan’ lends itself to the idea of ‘failure’ (when said plan cannot be executed).

Meanwhile, the word ‘map’ means we can agree there is a destination we’re all heading towards, and we can plot out a few routes to get to that destination. But it’s also possible that once we’re on our way along our preferred route, a completely unexpected change in direction or detour might be required. And that’s ok.

As Dunning notes:

A sense of control and agency can really count when it comes to how we experience the birth process. Research shows whether we have a positive or negative recollection of our birth experience is often about whether we feel like we are making the decisions.

I’m intrigued to see whether this simple change in terminology will assist us in helping our patients feel like they’re in the driver’s seat when they’re giving birth, and if any changes are made to the route, they’re fully informed as to why.

I hope it helps us deliver a birth experience that transitions them smoothly into that crucial fourth trimester and ensures that when they look back on their early days of motherhood, they can do so with a smile.

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