Birth Plan or Birth Demands?

Emma Svanberg

This was a blog I wrote for Rebecca Schiller, CEO of Birthrights and author of Your No-Guilt Pregnancy Plan.

"Something that comes up a lot in the antenatal work that I do is the language around birth plans. Women often question the idea of a birth ‘plan’, instead feeling that they should remain flexible and go with the flow- go into birth with low expectations so they won’t be disappointed. On the flip side, many women who have had difficult or traumatic births feel understandably angry that the plans they had carefully formulated went out of the window, and often express a sense that they were ‘set up to fail’ as they hadn’t been aware of potential negative outcomes. Both lead us to question the usefulness of birth planning, and even whether it could be harmful.

The temptation is to say that birth planning is a bit pointless. Why plan something that is unlikely to go your way? So then we soften our requests. We refer to them as birth ‘preferences’ instead of plans, we ensure that the language on the plan remains flexible and polite instead of appearing demanding, and we go into birth believing that our plans are nothing more than a fairytale.

But actually I believe that birth planning is an essential component of pregnancy and antenatal care. As birthing women, it gives us the opportunity to do our research, to talk to people and find out about others’ experiences, to hear about different outcomes and consider what we might choose in different eventualities. As birth partners, it gives us the chance to hear about how we can best support the birthing woman and ensure that specific anxieties or concerns are aired before the birth. As healthcare professionals, it is a quick and easy way to hear what is important to the families we are working with, and a starting point for discussion.

The two main criticisms of birth planning are the potential to raise expectations, and the potential for conflict with healthcare professionals.

Creating False Hope

Let’s take expectations first. We know that going into birth with positive expectations also increases your likelihood of a satisfactory experience. So why are we dissuaded from making plans, and finding out information with which to create those expectations?

Birth is a deeply personal journey, and the positive and negative consequences of birth are felt throughout a family and for many years. Women enter their motherhood journey feeling either empowered or shaken to the core. Birth matters. In any other circumstance in our lives that had the power to change our future - from a wedding, to a job interview, to a house move – we would spend many hours planning and doing our research (even knowing that these too are circumstances during which things may happen outside of our control). So, why do we feel discouraged from doing the same over the birth of a child?

Partly, this is because we’ve all heard the negative stories of birth itself, and the understaffed and overstressed maternity services of the NHS (that is, where they still exist). But this doesn’t mean we need to chuck the birth plan out with the bathwater. It just means we need to include that situation in our planning. If you’re not likely to have a midwife you know during your birth, perhaps you’d like to think about an additional birth partner or a doula? If you know the services near you are struggling, can you have a conversation with your midwife about how you can still get what you need from them? If you are one of a queue of women waiting to see a stressed-out midwife, might there be an opportunity to speak again on the phone if you have questions left unanswered?

What is A Useful Plan?

The type of birth plan we’re talking about matters too. Many birth plans only cover an ideal scenario. This can reflect the belief that, if we don’t enter into birth positively, the anxiety raised by negative thoughts could interfere with oxytocin and make it more likely we’ll have a difficult birth. But let’s think about that for a moment. What raises anxiety in your day-to-day life? If you were going to a new place and felt nervous about how you would get there, would you ignore your worry and set off on your journey without a map? Or would you do a bit of research, think about the different ways of arriving and plan your journey? Would you perhaps, also get advice from people who make that journey often or who have made the journey before?

When we go into any new situation, or a situation full of uncertainty, we have a choice. We can deny, or we can plan. Denial actually raises anxiety for many people – those fears are still lurking in the back of your mind, festering and growing ready to jump out when your contractions start. Pulling them out and looking at them is what makes them less frightening. I often advise women and their birth partners to think through not only an ideal Plan A but also Plan B, C and D – including a worst case scenario allowing all of your fears to be aired. It means that, even if everything goes completely off piste, a birthing woman can still feel she has exercised choice and control over what is happening to her, and those around her know what she needs from them in order to offer the best support they can.

Setting Women up to Fail?

There’s often a worry that planning for a birth which then doesn’t happen can led to such disappointment that this may leave a woman feeling depressed or traumatised. But it isn’t disappointment that leads to mental health problems – it isn’t even a difficult birth. More usually, it’s feeling out of control or treated with a lack of compassion that can leave a woman and her partner feeling negatively affected by birth.

Of course, there’s also the dilemma of how to plan - you don’t know what it is you don’t know. Your maternity notes will have a section to offer guidance on the kind of topics you can start to think about, and there are lots of example birth plans online. Milli Hill’s book ‘The Positive Birth Book’ has a very comprehensive section on birth planning including icons you can use to create a visual birth plan (to ensure the key elements of your plan are easy to see).

Stepping on Toes

And what about the potential to cause conflict with healthcare professionals? They’re the experts aren’t they? Shouldn’t we defer to their knowledge?

When we see birth as predominantly a medical intervention (which it can be, but more usually it is not), then the expert opinion of midwives and obstetricians becomes paramount.

There may be times during birth when expertise is needed, but in an uncomplicated delivery, often the most expert of midwives will disappear into the background and allow you to listen to your own instincts. In many ways, our caution over birth planning – essentially making it clear what we want – is reminiscent of deferential attitudes towards medics that are dying out. We still consider this when writing birth plans, making sure that our language is polite and unchallenging. Of course we don’t want to challenge those who are tasked to care for us during birth, but equally we don’t need to feel that we have to be careful about their feelings being hurt. In my eyes, birth should be collaboration between all of the parties involved. In this way, there is a trust that a birthing woman will do what is best for her and her baby…and that a healthcare professional will also do what is best for the woman and her baby (or babies).

Birth planning then can be a crucial part of pregnancy, helping you think about your hopes and fear and providing a starting point for collaboration with those around you.

Making Birth Better

There’s something nagging at the back of my mind as I’m writing though, which is that I’m talking about an ideal scenario myself. Because of course we’re planning these births in circumstances that are far from ideal, and these will impact on the choices we can make and how able healthcare professionals are to work with us.

So here’s the plan I’d like to see for every woman – and these aren’t preferences, these are demands:

Please stop speaking about pregnant women and new mothers as if we are all the same person and want the same things

Please consider my active consent for interventions and also any lack of intervention you are considering. I would like to be fully informed of all aspects of my care

On that note, please make sure I have access to all of the information available about different birth choices and outcomes. Please talk to me about risks and benefits of different interventions. It’s ok to tell me stuff that might seem a bit frightening, if it will help me feel informed about the options available to me.

If I am choosing something that you disagree with, please take the time to find out why I am making that choice before outlining your position.

I would be grateful if you would use positive language – tell me how well I am doing, and avoid words like ‘just’, ‘fail’ and any mention of me potentially harming my baby. Trust that I have my baby’s best interests at heart

Please provide me a midwife who I can get to know and who will get to know me, and a maternity team who work well together because they are well supported themselves.

Please fully support the NHS, with fully staffed teams who have proper breaks, actually get to eat and go to the toilet when they need to, adequate rest, access to help when they need it and are treated with respect by the service they work within

Please offer appropriate long-term funding to those working on the Better Births initiatives, so they can actually see it through

I would like to be treated with compassion and respect at all stages of my pregnancy and birth journey (and beyond)

I would be grateful if you could trust my body, and encourage me to trust my body. This includes believing me when I say I feel that something is wrong, or that something unexpected is happening.

Unless I request otherwise, I would like the environment in which I give birth to be dark, soothing and quiet. If I choose to give birth on a labour ward, please help me do what we can to make this an oxytocin-inducing environment. If I have a C-section, please let me know about options for gentle C-sections.

Please look after me once I’ve given birth. I will need all of your support, and care. Please support me in bonding with my baby. Let me know about services I might need in the future, even if I don’t need them now. Ask me if I need help, ask me how I feel about my birth and most of all, keep asking me if I’m really ok."

Dr Emma Svanberg (aka The Mumologist) is a perinatal clinical psychologist working in London. As well as meeting people for therapy, she also runs supportive groups in her local area for parents and provides birth preparation courses combining hypnobirthing and psychology. She runs a number of campaigns on social media to raise awareness of parental mental health. She is currently involved in the Make Birth Better network exploring ways to improve birth. She has two small children and needs more sleep. You can email her here, or find her on Instagram (@mumologist), Facebook (/themumologist) and Twitter (@mumologist).

© Make Birth Better CIC 2019

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