• Birth Plans: Who Are They for, Anyway?

    As the United Kingdom eagerly awaited the birth of the third royal baby, details swirled around outlets and social media about the Duchess of Cambridge, Kate Middleton’s birth plan, related security details, media address and special arrangements for hospital staff. For a member of the royal household, a birth plan is a practical necessity. But, for the rest of the world, the idea of a “birth plan” carries another meaning — an elaborate outline of obstetric preferences, usually in the spirit of delivering as naturally as possible, to facilitate “the most memorable, life-changing, joyful experience of a woman’s life.”

    Indeed, birth is beautiful, and miraculous. As neonatologists, my colleagues and I have the privilege of witnessing it every day. From extremely premature babies to those full term, to attend a delivery is to witness the wonders of life. And most birth plans are harmless — doulas, yoga balls, soothing music and candles, simple comforts to help women through the process of labor and delivery.

    But some birth plans are dubious for any benefit, and others are outright harmful to the baby, for whom birth plans are not necessarily written. Still, parents ask to carry it out, even for babies admitted to the neonatal intensive care unit for complications not anticipated beforehand.

    Popular components in birth plans are refusals to administer Vitamin K and Hepatitis B shots. Some parents refuse antibiotics due to moral or religious objections, or because some antibiotics contain animal products. Others refuse x-rays because of personal beliefs against radiation, or insist on skin-to-skin kangarooing with the newborn, even in cases of severe respiratory distress requiring oxygen support.

    A surprise setback places parents in an extremely difficult spot. It’s understandable for them to feel that due to a complication the birth of their dreams has been derailed. But nonetheless, inflexible adherence to birth plans sometimes become a threat to the baby’s health and serve to please only the parents — and that’s not what birth plans should be about.

    Birth plans have existed for decades, in response to the institutionalization of the childbirth in mid-20th century, with the transition from home- to hospital-based process. Certain practices — episiotomy, induction, shaving, enemas — became routinely implemented despite limited data, and eventually many were abandoned. Since then, with the recommendations of organizations like the WHO, there has been a growing movement towards ensuring safe childbirth that also meets the psychological and emotional needs of women, allowing them to have a sense of control — overdue but still impressive efforts, as no doubt the process can be emotionally as well as physically traumatic.

    Birth plans perhaps remain particularly popular no doubt in part due to recent surge in celebrities’ promotion of practices in the name of “lifestyles” — from vaginal steaming to eating placentas. Home births with known risk factors are increasing in number, despite contraindications from American College of Obstetricians and Gynecologists, such as vaginal birth after prior cesarean delivery, breech presentation, and multiple gestations.

    Obstetrical practices and outcomes have come a long way over the past century. Developments in the technique of instrumental delivery, antibiotics for puerperal fever, safe blood transfusion and improvements in obstetric anesthesia, have all led to dramatic decrease in maternal mortality rate.

    Public health efforts, too, have also saved lives by implementing vitamin K prophylaxis, an effective prevention for vitamin K deficiency bleeding, a bleeding disorder in early infancy that can result in neurologic deficits and death. Erythromycin eye drops or ointment is also state law in many states, to prevent neonatal conjunctivitis that can lead to blindness. Both are measures recommended by the CDC and the American Academy of Pediatrics.

    Of course, all women should feel empowered and knowledgeable in medical decision-making. For so long, women have been made to feel they are not in control of their own bodies; in childbirth, a woman should not be made to feel like a bystander, and writing a birth plan is a way to communicate her wishes. There is nothing wrong with being specific in preferences for maximal satisfaction, and if it results in a most positive experience for all involved, all the better — except when it comes at a cost to the baby.

    Birth plans are fine, even beneficial for maternal well-being most of the time, but no two births are alike. And when strict adherence to a birth plan leads to harm to the baby, allowances must be made to deviate from the plan in the moment.

    Yet, there is also much that we, as health care providers, can learn from truly listening to the wishes and individual needs of our patients. Physicians and patients often have different perceptions of birth plans. One study showed a large gap between health care professionals and women regarding outcomes of birth plans; 65% of medical personnel and 2.4% of patients reported that birth plans had overall worse obstetric outcomes than without. Physicians must make more effort to understand the concerns, mindset, and information sources of expectant mothers, help women feel a sense of bodily autonomy during pregnancy and birth, and then have open and frank conversations to help close such discrepancy.

    In an era when health-related information is more accessible than ever, parents may be overwhelmed and feel pressured to make the right choice out of a seemingly endless list of options. Birth plans are here to stay, and they should. In what may be a scary moment of a woman’s life, there should be a concerted effort to making her feel in control, and birth plans can do that.

    But as participants of childbirth, it must be recognized that the baby — not the parents — is front and center, the central character whose lead should be followed. It is for the baby’s well-being that, sometimes, birth plans might have to be put on hold, even veer off-course. Perhaps the true birth plan is one that involves building a doctor-patient culture that supports working together, one that honors patient autonomy and uses medical expertise to save lives, and gives newborns everything they need in their first moments of life.