Practices suggested in social media for birth plans

Rev Bras Enferm. 2020;73(5): e20180847 http://dx.doi.org/10.1590/0034-7167-2018-0847 7 of ABSTRACT Objective: To describe and analyze the practices suggested in social media for the elaboration of Birth Plans, available on Blogs/Sites and not included in the WHO recommendations. Method: Qualitative, exploratory, descriptive study with thematic analysis. A total of 41 e-mail addresses were selected for analysis among the 200 web addresses previously identified between March and July 2016. Three web addresses were in Portugal and the others in Brazil. Results: 48 practices not included in the recommendations of the World Health Organization (WHO) were identified. Conclusion: Blogs/Websites, as means of transmission, circulation and production of knowledge, enable the horizontal expression of values, encourage women to plan the events considered important for their deliveries and put childbirth decisions on the hands of women, which has caused controversy in the discourse of humanization of childbirth. Descriptors: Humanizing Delivery; Obstetric Nursing; Evidence-Based Nursing; Health Education; Social Media.


INTRODUCTION
Every birth is a unique process in women's lives and each event brings different meanings. Predicting a growing trend of interventions, the WHO has encouraged countries to reassess the technologies used in childbirth and has drawn up a list of practices (1) that has encouraged women to choose the type of birth they want (2) .
Expectations of pregnant women regarding the type of delivery have been related to how the information on the subject is made available and how easily they can access this information.
The Birth Plan is a favorable strategy for sharing and discussing good quality information during prenatal care (2)(3) . It is also the first practice listed according to level of evidence in the set of activities classified by the WHO (1) in 1996. In 2018, the WHO (4) classified practices for intrapartum care according to the stages of labor.
If in 1996 it was recommended that the Birth Plan should be designed as "a personal plan determining where and by whom birth will be attended, made with the woman during pregnancy and made known to her husband/partner and, if applicable, to the family" (1:3) , in 2018 it is described as a document that must be individualized "according to the woman's needs and preferences". Therefore, the Birth Plan should be elaborated by the pregnant woman, based on information provided by the professionals who provide prenatal care according to the best available evidence (2)(3)(4) .
The publication of the WHO Plan of Birth Recommendations (1) occurred at the time of the emergence of the World Wide Web -WWW. The web (or internet) provides a large volume of information that can quickly and globally put women in touch with their interests and needs (5) . Social media generates new political perspectives shared between individuals, in civil society and in the local and municipal governments, and also offers possibilities to understand the challenges of building democratic citizenship in contemporary times (6) . Blogs/Websites, as social environments, are important in Health Education regarding childbirth and, therefore, are relevant for user and professional autonomy.
The importance of the Birth Plan may be related to the prevention of obstetric violence, which is defined as acts performed by health professionals to the female body during reproductive processes characterized by overuse of interventions, unnecessary medication, pathologization of the normal physiological processes of birth, and negligence (7) . The Birth Plan is focused on respecting women's choices regarding their own childbirth and on the right to dignified, respectful care, without any kind of violence (1,4) .
The evidence used in the elaboration of a Birth Plan is constantly updated according to new studies, which currently indicate that practices can be less interventionist, more respectful and dignified, and still maintain or improve perinatal outcomes (3) . The elaboration of a Birth Plan must be based on new attitudes and perspectives regarding dominant practices: changing a practice means that one has had the opportunity to rethink and has the strength to make changes occur.
Believing that Blogs/Sites are places of transmission, circulation and production of knowledge that give voice to women, the following guiding questions were elaborated: Do Blogs/Websites suggest practices different from those recommended by WHO for Birth Plans? What are the practices suggested?

OBJECTIVE
To describe and analyze the practices suggested in social media for the elaboration of Birth Plans, available on Blogs/Sites and not included in the WHO recommendations (1,4) .

Ethical aspects
The description of the analysis and discussion respected ethical aspects related to the authorship of the texts studied and the checklist of the Consolidated Criteria for Reporting Qualitative Studies (COREQ). As the data analyzed had a public and unrestricted character, the project that originated this study was not submitted to the Research Ethics Committee, as it is not included in the CEP-CONEP specifications.

Study design, setting, data sources
This is a qualitative, exploratory, descriptive study (8) . The Google website was chosen to search for analysis material, as it is considered "the largest source of visitors for the vast majority of Blogs" (5) . It is the first page of results and it receives the highest number of visits (9) on the web.
The data sources were Blogs/Websites that contained suggestions for Birth Plans.

Inclusion and exclusion criteria, data organization and period
The terms WHO, PDF and SUS were chosen to go along with "Birth Plan" when searching for publications of interest for the study. A total of 200 web addresses were selected on March 31, 2016. Between April and July, 41 web addresses were identified, 26 blogs and 15 websites, three in Portugal and the others in Brazil. The determination of these 41 web addresses occurred by crossing information, which showed that 56 addresses were repeated and 103 did not have suggestions for Birth Plans or this information could not be accessed. The information found in the Birth Plan suggestions was typed in an Excel spreadsheet that contained the names of the 41 Blogs/ Websites in its rows. All practices identified were categorized into columns and then compared with those described in the WHO recommendations (1,4) .

Analysis of data
The initial analysis occurred between August and December 2016, when the practices identified were compared with those recommended by WHO up to this year. For the elaboration of this article, the analysis was reviewed according to recommendations published in 2018 (4) , which showed that the categories described in the initial analysis of this study were already aligned with the current recommendations (4) . Therefore, the criteria for classifying the practices in this study were the periods during or before hospitalization, during labor, during delivery, in postpartum or in case of c-section. An electronic file of the material selected for analysis was constructed in the Excel program, using the program's "filter" feature, which showed 48 practices different from the recommendations published in 1996 (1) and in 2018 (4) . During data analysis, Cultural Studies methods were applied, meaning that methodological choices were made in a practical and reflective manner, according to the demands posed by the research problem, which does not represent lack of scientific rigor (10) . The analysis of the material published by WHO in comparison with the empirical material produced in cyberspace, enhanced both sources, without one excluding the other. Immersion into cyberculture produced in a cyberspace showed ways of producing practices that go beyond those described by WHO, releasing specific, important and necessary practices and knowledge, described by internet users, into the space of science and society.

RESULTS
Forty-one Birth Plans were analyzed, from which 48 practices not included in the WHO recommendations emerged (1,4) , as shown in Chart 2.

DISCUSSION
For better understanding and analysis, the practices suggested in the Blogs/Websites were categorized according to labor stage and the updated WHO classification (4) into five categories.

Suggested practices before and during hospitalization for delivery
The suggestions for this period refer mainly to the preservation of individuality and of sensory function. Regarding the use of personal objects, the suggestions included not removing contact lenses or glasses, hearing aids and dental prostheses, as it would restrict sight and hearing, or compromise the self-image of parturients. Another suggestion was the permission to wear personal clothing and to use alternative methods of pain relief and childbirth comfort, such as body-support ropes, birthing ball, seed bags, swimming pool, and yoga mats. All of these practices are recommended in the National Guidelines on Care in Normal Birth (11) . It is known that some institutions routinely deprive parturients of these objects and practices, justifying this attitude by claiming increased risk of infections or loss of objects. Current scientific evidence does not associate infections to the use of the personal objects (11) . Also, in services with organized work processes, the loss of the user's belongings is minimal or does not occur.
The Blogs/Sites emphasize that care should be individualized; therefore, women should be called by their names, and practices such as asking pregnant women to "spread their legs" (12) without knowing their names, and professionals not identifying themselves  when examining women should be avoided. The Brazilian Civil Code (13) emphasizes that a person's name is a right, since it is what characterizes them in their family and in society. In addition, bonding and empathy practices reduce the possibility of violence, facilitate care and improve care outcomes (11) . Regarding the place of choice for delivery, WHO recommends that "women should give birth in a place where they feel safe" and that spontaneous labor should be awaited (1) .

Suggested practices for use during labor
Massages, stimulation of practices such as walking, vertical positions, relaxing breathing, analgesia through electrical stimulation, promotion of and assistance in hot baths and cryotherapy contribute to the physical and emotional well-being of the pregnant woman (14) . The presence of a doula reduces c-sections, labor time, use of oxytocin, and the need for anesthesia and forceps (11) .
Pleasant sounds, absence of noises other than childbirth and/or silence facilitate the concentration of women and mobilizes archaic brain structures that help these processes to occur physiologically (15) . In this sense, music promotes the release of endorphins that make uterine contractions more bearable (16) .
Regarding the time to go to the place chosen for delivery, Blogs/ Websites alert that rush to get to the hospital opens space for a "cascade of interventions" (1) . Therefore, waiting for active labor at home can prevent unnecessary practices and iatrogenesis.
Another suggestion is including in the Birth Plan the moment for communicating hospitalization and birth to family and friends, as some situations may cause embarrassment and anxiety, as described by a user of Blog/Website vila mamífera2/dadada (Chart 1): "I don't want to cause anxiety if I have long labor, but I also don't want to exclude them from the process".

Suggested practices for use during childbirth: expulsion and placental stages
Dimmed lights during delivery can promote comfort and make the environment welcoming and more similar to the mother's womb (15) .
Fathers cutting the umbilical cord is a practice that symbolizes the "beginning" of a shared responsibility for the child's development (17) . It offers no risks and may occur before or after placental expulsion (11) . The collection of umbilical cord blood for freezing depends on strict criteria, which must be clarified beforehand. The Ministry of Health and the coordination of the Brasilcord Network are opposed to the use of private cord blood banks, highlighting the lack of public benefit and the "misleading way that private cord blood banks advertising has been done. International agencies recommend no public investments in private cord blood banks" (18) . Some women include seeing the placenta in their Birth Plans, and others request to take the placenta home to use it in cultural practices, causing discomfiture in maternity wards. Article 19 of the Human Rights Code advocates "freedom of opinion and expression, which includes the right to not to be disturbed" (19) . Therefore, in this situation, the placenta can be delivered to the woman upon request.
There is controversy over who will capture images of the birth. Filming or photographing is a good way of remembering this moment, as long as it does not disturb the mother's concentration or prevent the father from participating in the process. For some, the decision of capturing images must be made by the birth attendant, and may "be carried out by the companion or an authorized professional, upon agreement of the physician" (20) . However, we question: is it up to the birth attendant to decide whether to capture images of people who want to document part of their lives?
Seeing the birth of a child through a mirror and the possibility of touching the baby's head when crowning were suggestions to encourage women to perceive their body and their baby's movement. It is a practice with no risks and no financial costs (21) , which depends only on the sensitivity of the team It is a moment of orientation about what each push represents for the progression of the baby in the birth canal and about the modifications of the perineum. Therefore, it promotes the participation of women in the birth process. Arm and leg restraints and the use of stirrups are common practices when the lithotomy position is adopted. The research Nascer no Brasil showed that the lithotomy position is used in 91.7% of births in the country (22) . Containment practices are not encouraged or recommended, as they limit movement and skin-to-skin contact, and require woman to work against gravity during the expulsion stage (11) . Skin-to-skin contact should begin immediately after birth and continue during the "golden hour, " as it soothes the baby and mother, helps the cardiorespiratory stability of the newborn, reduces crying and stress, keeps the baby warm, favors early breastfeeding and helps the formation of the microbiome (23) .
Restricting the number of people in delivery rooms provides privacy and improves outcomes of this period (11) . The inclusion of academic students in care actions qualifies teaching and care (24) , while teaching them to respect women's individuality. The presence of trusted childbirth attendants is related to the choice for public or private institutions.
Perineal laceration suture prevents postpartum hemorrhage when the tear is deep or extensive, and it should be performed under anesthesia. Most perineal lacerations are superficial and do not need suture (11) Genital antisepsis during childbirth causes discomfort and is not associated with better outcomes. Therefore, as it does not improve infection rates, it should not be routinely performed (11,19) .

Suggested practices for the postpartum period
Current recommendations advise against the use of milk formulas, water and pacifiers, recommending exclusive breastfeeding until the sixth month of life. Breast milk contains all the nutrients and antibodies necessary for the baby (23) and should be offered on demand. Currently, there are only few women that admit they do not want to breastfeed. Some procedures should be delayed (23) or not performed in the first hour of life. Thus, practices such as early cord clamping, anthropometric assessment, vaccine administration, Credé's prophylaxis, vital signs check, aspiration of the airways and gastric aspiration and lavage should be postponed. The recommendation of no bath in the first hours of life is based on the best available evidence (25) . This should not be considered carelessness; it should be seen as an important care measure.
The presence of friends and family can bring comfort, safety and feeling of prestige and support from acquaintances (21) , even in practices such as bathing or changing the baby.
Joint accommodation is a practice recommended by the WHO so that mother and baby are not separated, as they must be together in the same room 24 hours a day (4) . Therefore, it is necessary to identify when the postpartum woman needs help to care for the newborn or when she needs rest. The nursery prevents interaction and bonding of the baby with the mother and family (17) , and hinders the promotion of care practices and health education; therefore, it is not recommended.
The suggestion of including early hospital discharge in the Birth Plan is corroborated by the WHO (4) , which recommends specialized obstetric care for at least 24 hours after an uncomplicated vaginal delivery in which mother and newborn are healthy.
In Brazil, the vaccination calendar indicates the vaccines and ages in which children should be compulsorily vaccinated (26) .

Suggested practices for use before a C-Section
Hand restrains are routinely used during C-sections to facilitate handling of equipment by anesthetists and surgeons. Since it prevents the mother from holding and breastfeeding the baby in the first hour of life and impedes skin-to-skin contact (25) , hand restraints are contrary to WHO recommendations (4) .
Use of mirrors and lowering curtains were the subject of professional advice on "the right of patients to dismiss hospital protocols, [because they would] cause sensitive difficulties in care, which may lead to risk of infections and other nuisances for the service provided" (27) . However, monitoring birth through a mirror or by lowering curtains are more active modes of participation of women, and are not associated with increased infections (11) .
Skin-to-skin contact between mother and newborn during Csection suture is not included in the WHO recommendations (1,4) . However, skin-to-skin contact is a practice that should be stimulated and facilitated at any type of birth (24,27) .
When the woman has previously decided to have a C-section, it is important that she goes into labor. Spontaneous onset of labor decreases the chances of prematurity, increases oxytocin levels and aids in breast milk ejection (23) .
In the Brazilian Guidelines for Cesarean Operation (28) , there are no recommendations for partial shaving or any other type of hair removal.
The suggestion of including the choice of women-friendly doctors, anesthetists and hospitals (29) in Birth Plans does not guarantee that this choice will be respected.
Sedation can lead to pregnancy amnesia and disrupt the interaction between mother and baby. Therefore, non-pharmacological pain relief strategies and methods may be associated or used exclusively, according to pain assessment after a C-section (30) .

Limitations of the study
This study had no limitations for data collection or analysis.

Contributions to the area of health
The practices and desires of women for the birth of their children, described in Birth Plans presented in Blogs/Websites and different from WHO recommendations, can broaden discussions that go in the same direction as health care models that promote critical thinking of current practices, making delivery and birth even more personalized.

FINAL CONSIDERATIONS
This research highlights the existence of an information network that encourages women to plan the events considered important for the birth of their children. Blogs/Websites, as means of transmission, circulation and production of knowledge, enable the horizontal expression of values and put childbirth decisions on the hands of women, which has caused controversy in the discourse of humanization of childbirth.
Blogs/WebSites have added 48 suggestions different from the recommendations of the WHO. These suggestions may not be included in a list of WHO recommendations as described, as they do not specifically refer to the mechanisms of childbirth. However, the publication of the latest recommendations opens up a wide range of possibilities for the inclusion of women's desires in Birth Plans, dignifying the moment, enabling professional and peer support, ensuring informed choice, preventing abuse, and giving new meanings to childbirth.