In defense of birth plans.

Lately, I have encountered, both in personal interaction and in online media, confusion and hostility regarding the notion of preparing a "birth plan." I really liked making a birth plan and was glad I had one, so I feel compelled to write about what a birth plan is in the first place and why it's worth writing one.

A birth plan is a document that a pregnant woman writes, in conjunction with her partner and relevant care providers, that explains her preferences for how she would like to approach her birth experience. It should be concise because there isn't always a lot of time for your nurses and doctor to sit down and, ya know, read a dissertation on what you want to do during your labor. A birth plan should include the kinds of things you would like to do to help facilitate a more comfortable and easy labor, to the extent possible. If you would like to have the freedom to move around, sit in a birthing tub, try nipple stimulation, etc., those are the kinds of things you can put on your birth plan. If you want the epidural, put that down, too. The idea is to give your care providers an idea of the range of things you would like to try (again, to the extent possible). There are a wide array of non-pharmaceutical, less-invasive strategies that can help ease long and/or difficult labors, which carry lower risks than many of the medical interventions nurses and doctors are trained to employ. Writing down non-medical interventions helps your care team know if you'd like to try things they don't typically think to offer, but that you can try with the help of a partner or doula.

Here's what a birth plan isn't (or shouldn't be): it isn't a list of demands or expectations for every thing you are going to do throughout the process, and in what order. When people scoff at the idea of a birth plan because "you can't plan birth," they aren't understanding the idea or reasoning behind birth plans. Obviously, you can't plan your birth. Nobody says you can. (In fact, it's funny to hear this being said by people who appear to have no problem with planned inductions. Not funny, haha, but funny ironic.) No, a birth plan is not a chronology of events, forecasting the process and outcome of your birth. If you are operating under that assumption, then you are potentially setting yourself up for disappointment. The idea is not to plan out your birth; it is to provide information about what kinds of techniques you would like to try during labor and delivery. Maybe the term is misleading and we need a new one. Suggestions, anyone?

Now to the other important part: Why does it matter?

In the late 19th and early 20th centuries there began a major shift in how women gave birth in the United States. Before this period, almost all births were attended at home with midwives; beginning in this period, more and more women began to have (male) doctors attend their births, and then started to have their babies in hospitals (more driving for you, less driving for him). Medicalizing pregnancy and childbirth has brought both significant risks and benefits in the intervening years. There is much we mothers can be grateful for when complications arise (drug-induced respite, life-saving surgeries...). However, there have been- and continue to be- dark chapters to this story. The twilight sleep is one infamous and obvious historical example.

The twentieth century also saw great strides in another, related area: medical ethics. As a result, there are established patient protections, like respect for personal autonomy and the right to give informed consent. Medical patients are to be informed about their conditions and their treatment options, which includes information regarding risks and benefits. The applicability of these basic ethical safeguards has not, however, been clearly established when it comes to pregnant women in labor and there continues to be debate as to the rights of women in labor, particularly when respecting their autonomy may seem to conflict with the welfare of the newborn. I didn't realize it needed to be said in this day in age, but in March of this year, an NIH expert stated "In obstetrical decision making, women retain their rights of bodily integrity, just as people do in all other situations." Evidently, this is not obvious to a lot of obstetricians and hospital administrators.

Historically, and today, women in labor have not been fully granted the ability to determine, in any way, the kind of births they have desired. We have been involuntarily laid on our backs, hooked up to machines and IVs, shaved, been given episiotomies, and told when we could push. We have been made to feel that birth is happening to us and that the doctors are the only ones who know what is happening and what to do. These things have been done ostensibly to help us and yet the United States has a miserable rate of c-sections and maternal deaths. We are not just "there." More often than not, our bodies can tell us what we need and we have the right to make it known whether or not we want to be cut here or there, or in what position we can best push the baby out, when our own bodies give us the cue. No, you can't plan out your birth, but you can put forth a piece of paper that says, "No thank you," if someone comes up to you with a fetal monitor and tells you to lie down.

Moreover, as indicated above, there are a lot of things women can do to ease labor and delivery that doctors are not taught in medical school (and are therefore not researched, not seen as effective, and not used). This is changing in some parts of the country, but it highlights the need to educate ourselves, because there is no guarantee that your docs or nurses are going to suggest, or be able to help you with, "alternative" (non-medical) strategies (i.e.- making out with your husband, massage, position changes). Having these on your birth plan alerts your care providers that you'd like to try things other than, or in addition to, medical interventions like Pitocin.

The fact that "you can't plan it out" is a primary reason why you write it down- you don't know if you are going to be in the best position to speak your mind, to argue or consent, because most of us get to a point somewhere along the line where talking isn't so much what we feel like doing. Sure, hopefully your husband or partner can speak on your behalf, but what if he or she can't? It's nice for the nurses to have something to post on your door for all to see, right? (That being said, hopefully you have also already discussed your preferences with your health care provider, so it's not going to be a big shocker when he or she gets there). Consider it to be like an advanced directive, but for birth. Maybe we should change the term to "birth directive."

Here's another reason to write a birth plan. It gets you to do your homework. Part of being informed should include informing yourself. Talk with other moms, doulas, midwives, doctors, nurses, anyone you can and gather up all of the information you can so you know what your options are, what suits you, and what sounds like a bad idea. This is your birth, so it's for you to decide. Read up on c-section practices, what kinds of drugs are available, alternative pain management techniques etc. to figure out what things you would like to try, even if you are "planning" an unmedicated birth. It never hurts to know all your options, as long as you are fully informed about the risks and benefits of those options. Almost nobody plans on a c-section (though it happens), but they are common and it's important to know what to expect, so read up on that too and see what you can work out with your medical team if you want to be able to see the baby right away, have her stay in the recovery room, etc. Plus, if you come in with a concise, well-researched birth plan that shows you have been reading about nipple stimulation, pain management options, etc., it is more likely that you will be treated as a competent decision-maker worthy of respect, and not a crazy lady who needs to be strapped down and told what to do.