Controversy in Birth Series: Birth Plans Lead to the NICU


Controversy in Birth

As much as pregnancy and birth can be a magical and powerful entry into parenthood, there is also a lot of controversy around how people navigate their experience and make their own decisions. 

It can be difficult for parents or perinatal professionals to weed out the facts over myths when it comes to controversial birth topics, so we have created The Controversy in Birth Series to touch on the Top Controversies that are in the Birth world to provide some clarity on the topics. 

First up on the docket is the idea that Birth Plans lead someone to the NICU.


As birth workers we are all about #InformedChoice and believe that having open and honest communication about birthing options is something that every pregnant person should have access to. One of the ways that patients are opening the lines of communication with their birth team is by creating birth plans. This is typically a written document outlining the preferences that a birther has for during labour and the immediate postpartum. However research has found that not everyone feels that birth plans are helpful, especially Health Care Providers (HCP). 

Let’s take a look at why some HCP feel negatively about birth plans.

Disruption of the status quo over who is in charge during a birth

We can never know how the experiences of a HCP has influenced their patient care; the traumas they may have experienced or losses that have happened in their careers. These experiences no doubt consciously or subconsciously influence the recommendations they provide to their patients. So it makes sense that one of the strongest areas of opposition in regards to birth plans comes into account when the birth plan is outside of the usual practice of a hospital or health-care provider. It is a disruption to the status quo and can be interpreted as a form of disrespect or mistrust in their HCP. 

When patients have differing views or wishes than what the HCP feels is the best choice some HCP experience their birth plan as a threat to their authority.  The stress of this threat can lead to patients being treated poorly, such as being the focus of jokes, hostility and condescension. Which significantly impacts the patient’s experience. 

The myth that birth plans lead to the NICU

Research has found that up to 66.5% of HCP do not recommend using a birth plan and 31% believe they are predictors of negative obstetrical outcomes, such as having your baby go to the NICU. Studies suggest that HCP believe that birth plans create tension between them and their patients. They believe that patients with birth plans are less flexible or open to adjusting the plans as birth progresses. 

In addition to the belief that birth plans are predictors of negative outcomes, there is also concern that patients will experience less satisfaction from their birth. The word ‘plan’ gives the impression that things are within our control, and some HCP think that by having a plan means that they will be dissatisfied if that plan does not come to fruition. 

Something got lost in translation

What seems to be a misunderstanding, hence what has led to this controversy, is that birth plans are not about telling health care providers how to do their jobs, rather it is about opening the discussion for the birth to have a PATIENT led experience. Some people have started opting for the term birth preference, as it implied more room for change and nuance. It opens the doors to be able to have conversations about what the patient is feeling or desiring and why. 

Why Birth Plans (or preferences) are important

On the surface, a birth plan seems like a simple list of preferences a patient has, but in reality it is so much more than that. Birth plans encourage birthers to do research, become informed and make choices that are best for them and their babies. They provide the opportunity for patients to make truly informed decisions. The creation of a birth plan is just as, if not more important than the plan itself. The process of creating a plan allows for the possibility of evidence-based care through self-advocacy, rather than the harmful default of practice-based care that currently exists within the hospitals and birth centres. 

Results of creating a birth plan include improved patient care outcomes, improved satisfaction and higher engagement in the birthing process. Research has shown that 93% of women participating in creating a birth plan improved their understanding of the process of labour, and 92% were better able to express their wishes.

66% of study participants said that creating a birth plan was beneficial, and those that did not find it beneficial cited the main disadvantage was that health-care providers did not read them, were indifferent or did not follow the plan. 

Birth plans as a means of survival 

The United States is one of only two countries that has had their maternal mortality rates increase in the past 22 years (the other country is the Dominican Republic). So much of the birth experience is outside of a person’s control, so becoming informed and knowledgeable about options is not just a good idea, for some it is a means of survival. 

The cascade of intervention is not serving birthers, and becoming educated on their options gives them autonomy to make decisions that best serve them as an individual, rather than what is ‘typically’ done. What is currently happening in our reproductive health care system is not working, and creating a birth plan and understanding options is a way that individuals are taking control back in their own hands. 

If a HCP is looking for complacency and submission from their patients, then it makes sense that they would feel a birth plan is threatening. But for HCP who genuinely want their patients to have informed choice and bodily autonomy, birth plans help to build trust and confidence. When a HCP takes the time to read and really understand what their patient wishes, the patient’s confidence in their provider goes up. 

Birth plans are not the enemy, and the patients are aware of how their HCP feel about their birth plan which significantly impacts how they feel about their HCP and their birth experience.

So where do we go from here? 

Shifting attitudes towards birth plans by HCP could be incredibly impactful for their patients. If we could drop the idea that birth plans are rigid and need to be adhered to, and rather embrace that birth plans are the way birthers are expressing their needs and wants in a desperate attempt to make their HCP understand them. 

HCPs want their patients to trust and respect them. Patients want their HCP to understand what is important to them. It seems like a very clear line that birth plans have the capacity to accomplish both desires from the HCP and the patient. 

Let’s shift the belief about birth plans to be embraced by everyone on the birth team, and put the patient back in the centre of their care.

What you can do as a birth worker

Previous history and the World Health Organization (even the UN) state that birthers needs should be met as a basic human right. They have published their own status on what is evidence based support for each birthing person. 

Check out this lengthy PDF with all the details. (Heck print it out and put it in your birth bag) If you as a birth worker have clients experiencing this in their spaces you can speak up and support them to have their wishes respected. In any other position we would do whatever we can to support a persons wishes for their body and family.

We should be bolstering their confidence and intuition, trusting they know what is best for them and their baby. By doing so we can help them enter into parenthood comfortable and confident in their own abilities.


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