Use and influence of Delivery and Birth Plans in the humanizing delivery process

OBJECTIVES: get to know, analyze and describe the current situation of the Delivery and Birth Plans in our context, comparing the delivery and birth process between women who presented a Delivery and Birth Plan and those who did not. METHOD: quantitative and cross-sectional, observational, descriptive and comparative cohort study, carried out over two years. All women who gave birth during the study period were selected, including 9303 women in the study. RESULTS: 132 Delivery and Birth Plans were presented during the first year of study and 108 during the second. Among the variables analyzed, a significant difference was found in "skin to skin contact", "choice of dilation and delivery posture", "use of enema", "intake of foods or fluids", "eutocic deliveries", "late clamping of the umbilical cord" and "perineal shaving". CONCLUSIONS: the Delivery and Birth Plans positively influence the delivery process and its outcome. Health policies are needed to increase the number of Delivery and Birth Plans in our hospitals.


Introduction
The delivery is a normal and natural process, a vulnerable period for women's health, in which the environment and the health activities exert great influence. In the mid 20 th century, the delivery process was institutionalized, changing from the home-based to the hospital-based deliveries. By considering the delivery as a hospital-based process, certain routine and protocoled practices were included, such as episiotomy, shaving, enemas, induction of birth, without any endorsement of their routine use by means of scientific evidence. The delivery was included in the health care model of disease (1) , considering women as ill persons in need of medical care (2) . In view of this situation, in 1985, as a result of WHO's birth recommendations, a process started to standardize the delivery, in which the states were encouraged to reconsider the technology applied to birth, acknowledging that each woman should choose the type of delivery she wants, thus contributing to return the women's protagonist role (3) .
In Spain, in the 1990's, professional and women's groups start to consider that delivery care is excessively interventionist (4) In 1996, WHO in Geneva (5) published the guide "Normal birth care: a practical guide", giving rise to different documents in defense of normal birth (4,6-7) . That is the start of women's empowerment, which is demonstrated most clearly in the Delivery and Birth Plan.
The concept of Delivery and Birth Plan was coined by Sheila Kitzinger in the United States in 1980 (8) . The Anglo-Saxon countries echoed this new document and started to use it to require delivery with as little medical intervention as possible. The importance of the Delivery and Birth Plans derives from the respect for the Bioethical Principle of Autonomy, thus enhancing women's control over the delivery process and contributing to a positive effect on their satisfaction (9) , serving as an important tool to prepare for birth (10)(11) and reducing the women's "fears" thanks to the information and communication they offer (10)(11)(12)(13)(14)(15), ; constituting a reflection process for the women (12,16) .
The pregnant women have always felt the need to plan and inform their families and health professionals about what is important to them, so as to be able to feel safe and support during the birth process (16) .
In addition, it should not be forgotten that pregnancy and delivery are the preliminary steps of motherhood, representing the start of the acquisition of the maternal role. Ramona T. Mercer, the author of the theory "Becoming a Mother", defends that the acquisition of the maternal role is a process that demands psychological, social and physical action from the woman (17) , in which she should be aware of her role as the mother of a creature who needs her care and who depends on her. The woman's decision will affect her creature since pregnancy, which is why she should make the decisions after long periods The following exclusion criteria were considered: ─ Women with a programmed c-section.
─ Women who gave birth after less than 37 weeks of pregnancy.
─ Women whose fetus died before birth. To collect the data, the "Delivery room record" registered in the software Selene was used (Computer program used in Hospitals of the Spanish Health System).
The following research variables were adopted:    (Table 1). The distribution of the sample according to the weeks of pregnancy is shown in Table 2. As observed, the largest percentage of the sample is concentrated in week 40, with 32.4% (34.1% and 28.78%). In the comparison of the delivery process and its outcome among the women with a Delivery and Birth Plan, the analysis of the contingency table revealed significant differences for seven variables (p≤0.005, expected frequency ≥5 and residual adjustment ≥2).
Regarding "skin to skin contact", the total percentage was 27.4%, against 60.41% for the deliveries with a Delivery and Birth Plan. Concerning the "choice of the dilation and birth position", 48.1% against 62.5%.
After a logistic regression analysis, it was determined that the three most influential variables were "skin to skin contact" (OR=4.26), "election of dilation and delivery period" (OR=1.8) and "perineal shaving" (OR=1.6).

Discussion
In contact contributes to a better adaptation to the physiological changes in the mother and infant (19) .
Similarly  (20) and NICE includes it as a recommended practice in one of its guidelines (21) .
Concerning the "choice of the dilation and delivery posture", the EAPN (6) and the Ministry of Health defend that, during the expulsion period of the birth process, the woman should choose the position she finds most comfortable, which influences the safety and satisfaction dimensions; in addition, this practice has been endorsed in a Cochrane review (22) . In the present study, satisfactory and significant results were found, as the choice of the position increased by 14 (23) .
One important piece of information obtained in this study is that the rate of "eutocic births" increases from 73.8% to 81.66% (p=0.018) in the group of women who presented their Delivery and Birth Plan. This fact influences the safety and effectiveness dimensions (6) .
Concerning the "intrapartum c-sections", no significant drop has been observed, similar to the data obtained in other studies in the same context (24) , although studies developed in other countries have found significant differences for this variable (25) .
As regards unexpected data obtained in our study, the women's demand for "enemas" and "perineal shaving" surprisingly increases by 3.6% (6.8 vs. 10.4; p=0.027) and 4.6% (12 vs. 16.6; p=0.023), respectively, among the women who presented a Delivery and Birth Plan.
These two practices are no longer used routinely, but do not involve any harm for the woman or fetus. They only involve the woman's comfort and shame. These data may be due to the fact that the women who presented a Delivery and Birth Plan know their ability to choose and prefer to use these practices for the sake of comfort and to avoid embarrassing situations, such as bowel movements while giving birth.
The study limitations include the lack of completion of forms, which were eliminated to minimize possible bias, as well as the absence of some interesting parameters from the "Delivery room register", which would have broadened the perspective in this study, such as the participation in birth preparation classes, length of dilation and parameters of fetal wellbeing.

Conclusion
It should be highlighted that the Delivery and Birth Plan is positively related with increased "skin to skin contact", "late clamping of the umbilical cord" and the rate of "eutocic births", practices that directly and indirectly reduce the health spending on hospitalization rates of women and infants. In addition, the women's autonomy is strengthened by the "choice of the dilation and delivery position", the "intake of foods or fluids" and even through the use of "enemas" and the "perineal study context. In addition, health policies need to be created for the dissemination of these documents and the use of the Delivery and Birth Plans needs to be enhanced among the pregnant women in the community studied. In that sense, the Primary Health Care midwife is the competent professional to accompany the women during the elaboration of this document.