Rise Of The Birth Plans - Mayo Center for Innovation - Healthcare Design and Transformation

The Rise of the Birth Plan: A Design Opportunity for Patients and Hospitals

Post Written by Guest Blogger Stephanie Habif

As I prepare for the birth of my second child, I feel incredibly grateful that I have access to hospital practitioners who honor and respect my birth plan. To be able to talk with my maternity care team about the experience my partner and I want to have while birthing our baby is special. Very special. But it shouldn’t be. It should be standard.

“The perception among many providers is that parents with a birth plan are unreasonable and high maintenance. When in reality, if you sit down and look at birth plans, they are tools about current, evidence-based practices and the ethical and legal obligations providers already have to uphold to their patients” said Cristen Pascucci, Vice President of ImprovingBirth.org.

The Rise of the Birth Plan

The birth plan was envisioned as a tool to help expectant parents prepare for the physical and emotional aspects of the birth process, plan ahead for how they want various situations handled outside of the emotions of the moment, and provide a vehicle for communicating with each other, their care providers, and other hospital staff prior to birth. Here in the United States, we have seen a surge of birth plans over the last decade. Why? “The rise of the birth plan has to do with people wanting specific services and understanding that those services may be outside of the typical U.S. standard of care,” said Pascucci. “Women are more informed and more empowered. There is greater awareness around how the U.S. hospital birth system works, and our nation does not have great track record.”

Let’s look at the numbers:

  • Over the last 50 years, the national cesarean delivery rate has increased seven-fold. It peaked in 2009 at 32.9% and had dropped slightly, to 32.2%, in 2014. Approximately one mother in three now gives birth by cesarean section (Source: Childhood Connection)
  • 42% of first time mothers experience artificial induction of labor, which doubles the risk for a cesarean section. Induction is often performed unecessarily (Source: American Journal of Obstetrics & Gynecology)
  • Cesarean deliveries are the most common operating-room procedure performed in the United States. The rate of this procedure varies drastically among hospitals across the country, ranging from 7% of all births at the hospital with the lowest rate of caesarean deliveries to 70% at the hospital with the highest rate (Source: The New York Times)
  • U.S. women are more likely to die during childbirth than women in any other developed country. The United States ranks highest in developed countries maternal death rate (Source: Time)
  • The U.S. ranks 25th in infant mortality and related factors among developed countries (Source: CDC)

“Research shows that some of the most common practices in U.S. hospitals are contrary to what scientific evidence shows is best - and most women experience care that actually increases the chances that they or their babies will be injured or develop complications” said Pascucci.

Why is this our landscape? According to ImprovingBirth.org:

  • Tradition: healthcare, and especially maternity care, is slow to change. Some common practices today – such as separating newborns from their mothers at birth, having women push on their backs, putting labor on strict timelines – stem from protocols and beliefs from the 1940s and 1950s that have long been debunked by science.
  • Profit and liability concerns: Policies and protocols that try to make birth efficient and predictable often conflict with women giving birth. For example, controlling the speed of labor with medication can be an appealing option for care providers whose time is limited, but it can be much more painful for women and can cause complications like fetal distress and hyper stimulation of the uterus. Almost half of women in the U.S. receive medications to speed up their labor.
  • Differences in provider practice styles: when there is such great variation in standard of care, women may not know what they are going to get.

When you look at the wide variety in standard of maternity care practices and the outcome numbers, no wonder expectant parents want to use a birth plan. “Most expectant parents understand that giving birth is unpredictable, so the birth plan offers a little more predictability,” said Pascucci. “Birth plans really are careplans. If it were a birth plan, it would read ‘I’m going to dialate at 1cm per hour and have contractions every 3 minutes……’”

In reality, a birth plan is a communication tool to get involved in your care. It is an outline on a piece of paper that the patient designs and uses to talk with the care team.

A Birth Plan Gone Awry

Caroline Malatesta had a birth plan in preparation for her fourth baby. Halfway through her pregnancy, she switched hospitals because where she had delivered her previous three babies would not honor her birth plan. She responded instead to a hospital marketing campaign at a different place that promised to honor any “personalized birth plan.” It turns out she experienced what has become known as the “bait-and-switch” in maternity care. That is a hospital promising to honor the patient at the center of the experience but in truth, practicing trickle down care.

Caroline’s doctor signed off on her birth plan, and when she arrived at the hospital in labor, the nurse claimed no knowledge of her birth plan. Because Caroline’s doctor was not on call that day, the nurse pursued maternity care that went against her plan and left Caroline with a permanent nerve injury. She is now suing the hospital and its parent company, Tenet Health (currently under separate criminal investigation by the Department of Justice for alleged obstetrics-based fraud).

The Birth Plan Design Opportunity

“Research shows that when practitioners are open to and honor birth plans, rates of positive birth outcomes are higher; whereas when practitioners reveal negative attitudes or perceptions around birth plans, more negative birth outcomes happen” said Pascucci.

Women are asking for better and more personalized care in the form of birth plans. Unfortunately, there is no standardization of care around the application of birth plans. The American Congress of Obstetricians and Gynecologists [ACOG] has invited several councils and organizations that represent birth in the U.S. to their annual meeting this Spring to discuss birth plans. Why now? Americans are not happy about the maternity care system.

Hospitals should care because birth plans may have a direct impact on patient satisfaction scores. We are now in a time when hospital bottom lines depend on patient experience, and most research outlines communication and emathy from nurses and doctors as the most important determinants of patient satisfaction. According to a recent study published at the NIH, preoperative communication and attentiveness on the day of an operation were the most important determinants of overall surgeon rating. Hopsitals with high cesarean section rates should especially bear this in mind.

When I was pregnant the first time, I learned how to design my birth plan by asking friends who were already parents. I brought my plan to one of my care visits to talk it over with my provider. And I checked in with the hospital registrar to confirm that my birth plan was on file so that no matter who received me the day I labored would know about my birth plan. I also put my partner and doula in charge of advocating for my plan on the day. However, I am a health care design professional. For everyone else who is not, there is enormous opportunity to educate and empower expectant parents & hospitals on how to design and benefit from a birth plan.