Senior Lecturer, Department of Health and Social Care, Glasgow Caledonian University, UK

Hollins Martin, C. J. (2008). Birth planning for midwives and mothers. British Journal of Midwifery.16 (9):583-587.

Caroline J. Hollins Martin PhD, MPhil, BSc, PGCE, ADM, RM, RGN

Senior Lecturer, Department of Health and Social Care, Glasgow Caledonian University, UK

Address for correspondence: Caroline Hollins Martin, Senior Lecturer, Department of Health and Social Care, Floor 2, Goven Mbeki Building, Glasgow Caledonian University; E-mail:

Birth planning for midwives and mothers

Abstract

If women are to be empowered to make choices for childbirth, it is important that midwives explore and discuss their wishes and feelings about the delivery options available. Providing practical and sensible information should facilitate women with constructing a more accurate picture from which realistic hopes, fears and expectations can be formulated about impending labour. To facilitate midwives with this process, a flexible framework for a “birth plan” has been proposed. This easy to complete template can be used to assist childbearing women with assimilating their ambitions and desires regarding labour. Birth planning is important, since studies that compare women’s expectations of childbirth with actual experience present contrasting accounts, with disappointment, guilt and failure compared with delight, pride and success. Since experiences differ, it is recommended that midwives audit birth satisfaction against women’s birth plans. Results would inform auditors of whether there is satisfaction with a woman’s birth experience and the quality of care that she perceived she received. Women’s articulated wishes about birth would facilitate understanding of why satisfaction/dissatisfaction occurs.

Word count = including abstract and references

Key Words: birth plan, intranatal, education, preparation, audit, evaluation, birth

satisfaction

Key Points

(1)Providing practical and sensible information should empower

childbearing women to make informed and realistic choices about birth.

(2)Birth planning facilitates women with assimilating ambitions in relation to impending labour.

(3)Audits of birth satisfaction are important, since scores inform maternity care professionals about the quality of care women perceive they recieve.

Birth planning for midwives and mothers

Over recent years childbearing women have requested more choice and control in relation to the process of giving birth (DoH, 1993, 2004; Gibbins and Thomson, 2001; RCOG, 2007). Concepts of control and confidence are firmly associated with birth satisfaction (Goodman et al., 2004; Knapp, 1996), with women who feel in control during labour reporting raised levels of satisfaction and emotional health at 6 weeks postpartum (Green et al., 2003). Womenwho feel in control during labour are also more likely to express long-term satisfaction with their birth experience when asked years later (Simkin, 1991). Kitzinger (1992) describes the perceptions of some women who 50 years later are still trying to deal with memories of dreadful childbirth over which they had minimal control. In order for midwives to optimise women’s experiences, they require to explore and discover their feelings and wishes in relation to giving birth (Gibbens and Thomson, 2001). Thorough preparation enhances sense of confidence (Handfield and Bell, 1995), since realistic expectations are promoted and expectantly filled. Participating in decision-making is a vital component of birth satisfaction, with the concept linked to feeling in control of emotions (Berg et al., 1996; Gibbins and Thomson, 2001). Preparation also has an effect on duration of labour (Niven, 1994), with postpartum adjustment determined by perceptions of confidence and control in the prenatal period (Beeb et al., 2007; Sieber et al., 2007; Soet et al., 2003).

For the midwife, consumer and researcher, birth satisfaction includes treating women with respect, listening to their aspirations, considering their comfort and providing the particular kinds of pain relief they request. Every woman constructs expectations of childbirth, with variation among individuals in appreciating these concepts (Gibbens and Thomson, 2001).

Good antenatal education is an important part of preparing women for childbirth, since knowledge exerts influence upon women’s confidence and ability to cope (Sinclair, 1999) and effects perceptions of their birth experience (Gibbins and Thomson, 2001). One of the aims of parenthood education is to enhance women’s self-efficacy in relation to giving birth (Handfield and Bell, 1995). Self-efficacy is described by Bandura (1982) as an individual’s estimate of their own ability to succeed in reaching a goal. Bandura’s self-efficacy theory centres around gaining information about a person’s predicted performance and how this effects their perceived ability to cope. Of chief interest to midwives, is that high self-efficacy beliefs concerning ability to cope during labour have been found to reduce levels of pain experienced (Larsen et al., 2001; Stockman & Altmaier, 2001). This has important implications for midwives, since women who anticipate poor self-performance can have birth preparation tailored towards reducing specified areas of anxiety and providing individualised support.

Ninety-five percent of midwives support the concept of choice provision, which involves encouraging women to play an integral role in decision-making (Hollins Martin and Bull, 2006), consistent with what is directed in social policy documents (DoH, 1993; DoH, 2004). Encouraging articulation of preferences in a clear, precise and interpretable way should raise midwives awareness of the childbearing woman’s philosophy and ambitions for labour. This is important since Neuhaus et al. (2002) found many women expressing a perception of birth as a normal process that does not require hospital care. These women perceived that “home birth” would:

-provide them with more freedom of choice.

-cause them less anxiety than a hospital birth.

-accommodate more personal relationships with the midwife.

-result in less medical intervention.

It is interesting that discussions surrounded childbirth are conducted in such a polarised manner, with belief that one process is medicalised and the other naturalised (Neuhaus et al., 2002). Perhaps the best alternative to clinical obstetric care is not to have a homebirth, but rather an improvement of births in the hospital setting (Schmidt, 1997). Effective birth planning would be one contribution toards achieving this goal.

There are a variety of ways that midwives can prepare women for childbirth. Information may be presented in parenthood education classes, information packs, books, pamphlets, through use of audiovisual aids that are presented as documents or accessible “on line”. Education empowers women to formulate pictures of their hopes, fears and expectations about impending labour (Price, 1998), with a written “birth plan” one way of expressing choice (Price, 1998). A “birth plan” should not be a written prescription of orders that midwives must follow. Instead, it is a concrete copy of articulated ideas and expectations about how a woman would like her birth to proceed. To facilitate midwives with the process of birth planning, a flexible framework has been constructed. This easy to complete template is medium through which women can communicate their ambitions and desires about birth to the intranatal midwife.

The hitchhikers guide to “birth planning”

(1) Clearly define the purpose of a “birth plan”

A “birth plan” is a written account of how the woman would like her birth to proceed. Content ought to consist of the woman’s preferences about what she considers would make her birth a gratifying and satisfying experience. The following template has been designed to guide midwives through the process of birth planning with a childbearing women (see Table 1).

TABLE 1

(2) Provide information and evidence to underpin choice

During the process of writing a “birth plan”, it is critical that the information given is evidence-based (Reynolds & Trinder, 2000).It is unethical for the midwife to filter, censor or alter information solely to perpetuate hospital culture and protect themselves from fears associated with challenge from authority. All options should be disclosed, even when they are not available in the woman’s chosen place of birth, since litigation includes failure to provide accurate details about specific treatments that were or were not made available. Antenatal classes are one medium for transmitting important information. In such a forum, information may be given and followed up with discussion about thoughts, feelings and experiences in relation to the options presented (National Childbirth Trust, 1995). Contents of discussions might include:

(a) The advantages of normal birth in relation to:

- post-natal pain reduction (Tucker, 1996).

- quicker physical recovery (Johanson et al., 1993).

- improved opportunities for bonding (Odent, 1999).

- reduced cardiototcography and intervention (Patison and McCowen, 2005).

- amniotomy, which is contraindicated in a healthy term pregnancy (Fraser et al.,

1993).

(b) The pros and cons of different methods of pain relief.

(c) The benefits of mobility during labour.

(d) Advantages of adopting particular positions before and during labour (Al-Mufti

et al., 1996).

(e) The benefits of having a continuous support person present (Hodnet et al., 2003).

(f) The importance of providing partner choice about whether to attend birth or not.

(g) Preferred place of birth

(Studies of planned home births in developed countries have shown sickness and

death rates for mother and baby are equal to or better than hospital birth statistics

for women with uncomplicated pregnancies (Olsen, 1997).

(h) Physiological versus active management of third stage.

(i) Initiating feeding.

(j) Use of Vitamin K.

Table 2. provides a flexible framework for a “birth plan” that may be given to the childbearing woman to complete.

TABLE 2

The importance of evaluation

So why then, is the concept of birth satisfaction so important? This question can be answered in two words, “cost” and “quality” (Ware, 1994). Put simply, management of birth cannot be of high quality unless the person is satisfied with the care they have received (Mahon, 1996).

Studies that compare women’s expectations with actual experience of birth present contrasting accounts; one central discrepancy involves a disparity between pain anticipated and what is actually experienced (Hallgren et al., 1995), with this inconsistency influencing women’s perceptions and emotional outcomes post event. For instance, disappointment, guilt and failure may be contrasted with delight, pride and success (Quinne et al., 1993). Reduced capacity for coping during labour (Shearer, 1995) and high anxiety (Heaman et al., 1992) are also central predictors of a negative birth experience (Larsen et al., 2001; Shearer, 1995; Stockman & Altmaier, 2001). Accordingly, identifying anxiety provoking features is imperative if midwives are to instil confidence in women’s ability to cope during childbirth.

For these reasons, women’s expectations and experiences of childbirth become important and should be evaluated. Scores will inform about whether or not there is satisfaction with the quality of care perceived to have been received. Findings would assist with advancement of care provision on several counts; (1) Identifying facets of disappointment that may be remedied. (2) Advancing research, e.g., correlating scores with other psychometric measures, i.e., self-efficacy, anxiety, depression, locus of control. (3) Evaluating models or systems of care as a stand alone instrument or as a screening test prior to in depth qualitative work.

Conclusion

It has been proposed that quality “birth planning” become elemental practice for midwives in the UK. First and foremost, self-assessed profiles of desires about childbirth will provide deeper insights into women’s wants from their birth experience. From these expressions, midwives may come closer to meeting the needs and wishes of childbearing women, in accordance with requests of social policy documents (DoH, 1993; DoH, 2004). It is important to stress that many of the problems that occur during labour are unavoidable, especially when the process is complicated with fetal distress, maternal suffering, failure to progress, obstructed labour, malposition and so forth. Nonetheless, occurrence of such complications does not negate responsibility towards attempting to provide a fulfilling experience and appropriate, effective and holistic care to childbearing women. It is therefore recommended that practice development midwives use valid and reliable psychometric tools to assess women’s satisfaction with their birth experience.

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Table 1.The midwives guide to “birth planning”

______

Questions to ask the childbearing woman Points for discussion

______

1. Where would you like to give birth? - options available

- advantages and disadvantage of having, e.g.,

(a) homebirth

(b) hospital birth

(c) waterbirth etc.

2. What kind of birth would you like? - differences between natural, augmented and

induced labour.

- advantages and disadvantages of adopting

different positions during the second stage of

labour.

- differences between active and physiological third

stage.

- the purpose of episiotomy, instrumental delivery

& caesarian section.

3. What would you like the environment to be like? - homeliness, e.g., music, lighting, bed, beanbags

- freedom to move, walk, change positions

- own or hospital clothes?

- degree of privacy desired.

- who is to cut the cord?

- the place of taking photographs.

4. Do you want to be mobile during labour?- advantages and disadvantages of ambulating

during first stage of labour.

- interventions and their consequences, e.g.,

(a) cardiotocography

(b) epidural

(c) intravenous infusion

5. Do you want/not want pain relief?- the benefits of endorphins as natural pain

relief and their role in promoting bonding.