SUSAN OLMSTEAD: As an obstetrician, tell me about how you feel about birth plans.
DR YALDA AFSHAR: I really support a woman’s decision to prepare for pregnancy, for childbirth, and to experience them in a way that she feels empowered. And if that includes writing a physical birth plan, then so be it. I’ll support that decision. e cohort of women who have birth plans is actually increasing in Labor and Delivery (L&D) throughout the country. We have to be cognizant of that. As I’ll discuss a bit later, the term “birth plan” is pretty restrictive. I’m trying to use “birth preference” more because we know that birth really can’t be planned. So these are preferences that can be shared.
MS OLMSTEAD: That’s a very good point. Do you encourage patients to write out their birth preferences or do you wait for them to bring up the topic?
DR AFSHAR: I don’t bring up the topic of a birth plan, per se, but I bring up birth choices. I love to have that discussion prenatally, antenatally, before a woman presents in active labor. That’s really what I think the whole point of a birth preference document should be. It should kind of heighten the therapeutic alliance between the mom and the provider. And it should be a little bit of back and forth, some shared decision-making.
I don’t encourage my patients to write down their preferences, but if they do, I support that. I steer them towards more evidence-based decision-making in creating a birth plan. In the United States, birth plans aren’t the norm on L and D whereas in other countries and areas, such as the UK and Scotland, they’re part of the national maternity record and a standard of care.
MS OLMSTEAD: I didn’t realize that. In other countries, is there a national form that’s used universally?
DR AFSHAR: Yes. There is a universal, standardized birth-preparedness document.
MS OLMSTEAD: What about patients who write up a birth plan and have unrealistic expectations? How do you help steer them toward more realistic expectations of birth?
DR AFSHAR: That’s actually a big issue in this era of shared decision-making. We know that women who have a higher number of birth plan requests are less satisfied with their birth experience. The fewer things that are fulfilled from their birth document, the more unsatisfied they are. I think what’s important is that if someone lists something that’s unrealistic and not part of the standard of care, we discuss it.
This is an issue with a lot of birth plans that are found on the Internet. Many of them include outdated procedures like prophylactic enemas and routine episiotomies. The American College of Obstetricians and Gynecologists has had a stance against both of those procedures for a while now. We need to focus birth preferences on things that are a little more tangible, real, and in touch with day-to-day L & D.
I use the topic of birth preparedness to tell my patients that I come to work every single day saying, “How can I make the life of moms in labor better? How can I ensure a safe pregnancy outcome for the mom and the baby?” And I think that spelling that out helps establish a little more trust. A birth document can be a tool to foster that.
MS OLMSTEAD: I’m sure that helps patients feel a lot more conâ dent and comfortable. If you were to develop the ideal plan, one that you would hope a patient might come to you with, what would it include?
DR AFSHAR: We’ve actually started developing such a tool. The ideal plan, for me, would be a decision-making tool that says, “The evidence shows this about xyz. What is your preference about that?” or “The evidence shows that a vaginal delivery is associated with better outcomes for xyz.” Then a patient would choose. The focus is on evidence-based practice recommendations in labor, birth, and for the newborn. Ideally, it should be 1 page and very simple.