Repercussions of using the birth plan in the parturition process

Abstract

OBJECTIVE

To analyze the repercussions of using the Birth Plan in the parturition process from the national and international scientific production.

METHODS

Integrative literature review performed in the LILACS, PUBMED, CINAHL and SciELO, comprising 13 articles published in English, Spanish and Portuguese, in the period from 2008 through 2018.

RESULTS

The construction of the Birth Plan during prenatal influences positively the process of parturition and maternal-fetal outcomes. Unrealistic expectations can cause dissatisfaction with the experience of childbirth. Care providers play a central role in supporting its planning and fulfillment.

CONCLUSIONS

The analyzed publications justify the clinical implementation of the Birth Plan, once it represents an intensifying technology of humanized care and maternal satisfaction. There are still some challenges related to the use of this instrument concerning women’s adherence and professional support to improve the fulfillment of the Birth Plans.

Keywords:
Pregnancy; Planning; Parturition; Humanized delivery; Decision making; Review

Resumo

OBJETIVO

Analisar as repercussões da utilização do Plano de Parto no processo de parturição a partir da produção científica nacional e internacional.

MÉTODOS

Revisão integrativa da literatura realizada nas bases de dados LILACS, PUBMED, CINAHL e SciELO, compreendendo 13 artigos publicados nos idiomas inglês, espanhol e português, no período de 2008 a 2018.

RESULTADOS

A construção do Plano de Parto no pré-natal influencia positivamente o processo de parturição e os desfechos materno-fetais. Expectativas irrealistas podem causar insatisfação com a experiência de parto. Prestadores de cuidado desempenham papel central no apoio a realização do planejamento e no cumprimento deste.

CONCLUSÕES

As publicações analisadas justificam a implementação clínica do Plano de Parto por se configurar como tecnologia potencializadora de cuidados humanizados e satisfação materna. Persistem desafios relacionados à adesão das mulheres ao instrumento e apoio profissional para melhorar o cumprimento destes.

Palavras-chave:
Gravidez; Planejamento; Parto; Parto humanizado; Tomada de decisões; Revisão

Resumen

OBJETIVO

Analizar las repercusiones de la utilización del Plan de Parto en el proceso de parto a partir de la producción científica nacional e internacional.

MÉTODOS

Revisión integrador de la literatura realizada en las bases de datos LILACS, PUBMED, CINAHL y SciELO, compuesta de 13 artículos publicados en inglés, español y portugués, en el período de 2008 a 2018.

RESULTADOS

La construcción del Plan de Parto en el pre-natal influye positivamente en el proceso de parto y en los resultados materno-fetales. Las expectativas poco realistas pueden causar insatisfacción con la experiencia del parto. Los proveedores del cuidado tienen un papel central en la planificación y conformidad con el plan.

CONCLUSIONES

Las publicaciones analizadas justifican la aplicación clínica del Plan de Parto, debido a su configuración como tecnología que potencia el cuidado humanizado y la satisfacción materna. Persisten algunos problemas relacionados con el uso de este instrumento en relación a la adhesión de la mujer y el apoyo profesional para mejorar su cumplimiento.

Palabras-clave:
Embarazo; Planificación; Parto; Parto humanizado; Toma de decisiones; Revisión

Introduction

The care provided to women in the parturition process has undergone significant changes over the years. The delivery, initially done by traditional midwives in a familiar and intimate environment, became, after the second half of the 20th century, a hospital and surgical event. At that time, discoveries in the field of science and technology sought to control complications and possible conditions of maternal and fetal risk. Such advances were essential to the development of the medical knowledge, however, culminating in the establishment of medicalization of the female body¹.

This scenario gave rise to the technocratic model, currently predominant in modern Western medicine, especially in the care provision to delivery and childbirth. This paradigm was described by the American anthropologist Davis-Floyd as a focused medical care model, which conceives pregnancy as an illness and the childbirth as a critical moment of an unreliable machine that needs to be controlled quickly through often unnecessary professional interventions².

This hegemonic model contributed to women being expropriated from their knowledge, losing control and active participation in labor and delivery, which impaired the exercise of their autonomy and negatively impacted the childbirth experience. In this culture of “hospitalization” of the childbirth, the woman ceased to be the protagonist of this event and forgot that she is responsible for conducting this moment³.

In this context, in the late 1970s the Birth Plan was introduced by prenatal educators, with the purpose of facilitating the communication between pregnant women and health professionals, as well as encouraging informed decision-making about choices, risks and outcomes of labor⁴. Thus, since its creation, the Birth Plan has become increasingly popular in Western countries in defense of the autonomy of women during the childbirth⁵.

The Birth Plan is the first in a series of recommendations from the World Health Organization (WHO) called “Good Practices in the Care Provision During Delivery and Birth” and advocated since 1996 aiming to reorganize and humanize the obstetric care around the world⁶. It is a written document of legal nature, where the pregnant women express their preferences and expectations regarding the care they would like to receive during labor and delivery, considering their personal values, desires and needs, in order to avoid unwanted interventions^7-8.

It is recommended that the Birth Plan should be performed after the pregnant woman is informed about the physiology of labor and delivery; the possibility of making choices; the valuation of the normal delivery; the non-pharmacological methods for pain relief; the risks of unnecessary interventions such as cesarean surgery without clinical indication; among other information⁸. In addition to the preferences and expectations related to the obstetric management, the content to be registered may include support people who will be present at the time of labor and delivery; choices regarding water and food intake; body positions to be adopted; desired care of the newborn; medical interventions in the face of possible complications and cultural observations⁵.

After being built during the gestational period, preferably with the professional support of a primary care service, the Birth Plan must be presented to the maternity team that will provide care to the woman, enabling shared decisions among those involved in the parturition assistance⁸. Thus, in addition to providing greater control over childbirth events, this planning favors the communication between women and their caregivers, especially if they are unable to communicate effectively under certain circumstances⁹.

Thus, the Birth Plan offers obstetrical care providers important details about the choices of women, guides the care provided throughout the parturition process and allows the health professional to offer personalized and quality care for each woman, which provides bonding and favors labor. The process of professional-pregnant woman bonding and emotional support are effective measures that provide pain and labor tension relief, positively influencing the care provision³.

Based on the principle of Autonomy Bioethics, the Birth Plan increases women's control over the process of parturition, since it serves as an important tool in preparing for the childbirth; diminishing women's fear due to information and communication; besides promoting a process of reflection and decision-making by women. Therefore, it has been considered a strategic tool in the promotion of female empowerment and active participation during parturition, which contributes to improve satisfaction with the delivery experience⁷.

Although the benefits of using the Birth Plan seem to be universal, this instrument has been criticized for being considered rigid and unrealistic, which may adversely affect the obstetric outcomes and contribute to a negative experience⁵. A recent narrative review, which gathered international published research on the document, concluded that there is still a lack of consensus on its use. While little evidence suggests that writing a Birth Plan does not meet the intended goals, as it is associated with increased obstetric interventions and unfavorable outcomes for women, many health professionals are not convinced of this, suggesting contrary opinion¹⁰.

Thus, faced with conflicting findings of empirical research that explored the positive and negative results related to the use of the Birth Plans, this research was conducted from the following guiding question: What repercussions can the performance of a Birth Plan during the prenatal period have in labor, delivery and postpartum?

The study aimed to analyze the repercussions of the use of the Birth Plan in the process of parturition based on national and international scientific production. By exploring the advantages and disadvantages of using this tool, the present research aims at adding important information to the obstetric area, to be applied in the development of effective and useful technologies for women and their caregivers. The relevance of this research is to minimize the controversies surrounding the use of the Birth Plans, from the clarification about the influence of the use of this tool on the experience of childbirth in different obstetric contexts.

Method

This is an integrative review, developed based on material already elaborated, made up of scientific articles. This study was based on the theoretical framework of Whittemore and Knafl¹¹ and carefully followed the following steps: 1) selection of the research question; 2) definition of the characteristics of the primary surveys of the sample; 3) selection, in pairs, of the surveys that made up the sample; 4) analysis of the findings of the articles included in the review; 5) interpretation of the results; and 6) presentation of a critical synthesis of the findings.

Unpublished articles were defined as object of analysis, with scientific evidence from primary studies, with a quantitative or qualitative approach. The publications were selected in databases recognized in the scientific and academic field for gathering a wide national and/or international scientific literature: Latin American and Caribbean Literature in Health Sciences (LILACS), PUBMED, Cumulative Index to Nursing and Allied Health Literature (CINAHL) and Scientific Electronic Library Online (SciELO).

The operationalization of this study began with a consultation to the Descriptors in Health Sciences (DeCS) and to the Medical Subject Headings (MeSH), for knowledge of the most appropriate terms for the searches. Considering the inexistence of a descriptor registered in the DeCs that corresponds to the term “Birth Plan”, combinations of comprehensive descriptors such as “pregnancy”, “humanized delivery” and “decision-making” were performed in Portuguese and in English in several search exercises. In these, a large volume of texts was accessed, without the desired studies being apprehended, possibly due to the thematic specificity. Thus, it was necessary to opt for the use of keywords in Portuguese and in English, namely: “plano de parto”/ “birth plan”; “plano AND parto”; and “childbirth plan”.

The bibliographic survey was conducted through online searches, from January to March 2018, which resulted in the selection of 1,547 articles from different databases. Articles published between 2008 and 2018 in English, Portuguese and Spanish, which were electronically available in their entirety, and that after reading contemplated the object of study investigated were established as inclusion criteria. Studies of other modalities than the primary studies (editorial, reports of experiences, reflective studies, etc.) were excluded; as well as documents of government agencies, theses, dissertations and monographs; books and chapters of books; works presented at events; technical material; and journalistic articles, which totaled fourteen articles.

The publications were initially selected from the reading of the title and abstract, to later be read in full. Articles repeated in more than one database were included only once. After the initial survey based on the established selection criteria, an interpretative reading of the selected articles was performed, when those of interest and those without relevance to the study were selected according to the following synoptic char. The selected publications that were consistent with the proposed objective totaled fourteen articles, which were included in the final corpus of work analysis.

In this process, the subjects discussed in Chart 1 were identified.

Chart 1:
Final result of the articles selected for the analysis of the effects arising from the use of the Birth Plans

Database	No. of publications found	Number of publications excluded	Total of selected articles
LILACS	143	142	01
CINAHL	131	127	04
PUBMED	1,254	1,247	07
SCIELO	19	18	01
ALL DATABASES	1,547	1,534	13

• ^Source:
  Research data, 2018.

The extraction of the information of interest was carried out with the aid of an own instrument, which included the following items: general identification of the article (authors, country, year and publication period); objectives and methodological characteristics of the research; main findings, limitations and conclusions of the studies.

The analysis of the primary data of the included articles and their synthesis occurred in a descriptive way, starting from a synoptic chart that contemplated in detail information extracted from each study. The organization of the material made possible the classification by similarities and the thematic grouping of the evidences, which were analyzed and later discussed based on the humanization and birth reference frameworks.

Results

Chart 2 presents an overview of the empirical material (13 articles), with emphasis on the characterization, methodological aspects and results of the related articles.

Chart 2:
Characterization of the publications that composed the sample

Authorship	Title	Year of publication/Place	Type of study/Sample	Objective(s)	Repercussions in parturition
Mouta RJO, Silva TMA, Melo PTS, Lopes NS, Moreira VA(3)	Plano de Parto como estratégia de empoderamento feminino	2017 Brazil	Qualitative exploratory study 11 parturients	To analyze how the Birth Plan provided female empowerment during labor and delivery.	The construction of a Birth Plan provided the empowerment of women in the process of parturition, since all of them felt as protagonists of their childbirths, had the physiology of their bodies respected making the moment pleasurable, less painful and unforgettable.
Hidalgo-Lopezosa P, Hidalgo-Maestre M, Rodríguez-Borrego MA(12)	Birth plan compliance and its relation to maternal and neonatal outcomes	2017 Spain	Retrospective, cross-sectional, descriptive and analytical 178 clinical records	To know the degree of fulfillment of the proposals reflected in the Birth Plans and determine their influence on the main obstetric and neonatal outcomes.	As the compliance with the Birth Plan increases, the rate of cesarean section decreases and the results in the first minute Apgar test and umbilical cord pH improve.
Anderson CM, Monardo R, Soon R, Lum J, Tschann M, Kaneshiro B(13)	Patient Communication, Satisfaction, and Trust Before and After Use of a Standardized Birth Plan	2017 Hawaii	Intervention 81 women	To describe how a culturally and educationally diverse group of women evaluated communication, satisfaction, and confidence with the use of a birth plan.	The communication, confidence and satisfaction scores were high after delivery, although the increases were modest.
Afshar Y, Mei JY, Gregory KD, Kilpatrick SJ, Esakoff TF(14)	Birth plans -Impact on mode of delivery, obstetrical interventions, and birth experience satisfaction: A prospective cohort study	2017 California (EUA)	Prospective cohort study 300 women (143 with Birth Plan	To examine whether the presence of a Birth Plan was associated with the type of delivery, obstetric interventions and patient satisfaction.	Women with and without the Birth Plan had similar probabilities of cesarean delivery. Although they have fewer obstetric interventions (intravenous oxytocin, amniotomy and epidural), those who had a Birth Plan were less satisfied with their experience when compared to women with no plans.
Divall B, Spiby H, Nolan M, Slade P(15)	Plans, preferences or going with the flow: An online exploration of women's views and experiences of birth plans	2017 United Kingdom	Qualitative descriptive study Sample for convenience of unspecified size - women who have participated in parenting forums who have or have not used A Birth Plan	To explore women's views on Birth Plans and the experiences of their performance and use.	The benefits of the Birth Plans were: increased communication with health professionals; awareness of the options available and sense of control during parturition. However, many respondents believe that the idea of birth "planning" is problematic and are reluctant to perform one.
Mei JY, Afshar Y, Gregory KD, Kilpatrick SJ, Esakoff TF(9)	Birth Plans: What Matters for Birth Experience Satisfaction	2016 California (EUA)	Prospective cohort study 302 women	To categorize individual Birth Plans and determine if the meeting of requests is associated with the satisfaction with the birth experience.	Having a greater number of requests met was associated with a positive birth experience and sense of control. However, having a high number of requests was associated with a percentage reduction in the overall satisfaction with the birth experience.
Suárez-Cortés M, Armero-Barranco D, Canteras-Jordana M, Martínez-Roche ME(7)	Use and influence of Delivery and Birth Plans in the humanizing delivery process	2015 Spain	Quantitative, cross-sectional, observational, descriptive, comparative cohort study. 9,303 women	To know, analyze and describe the current situation of the Childbirth and Birth Plans in the context studied, comparing the process of childbirth and its completion among the women who presented and those who did not present a Birth Plan.	The study found a positive relationship between the use of the Birth Plan and the increase in skin-to-skin contact, late cord clamping and the rate of normal deliveries. In addition, it reinforced the women's autonomy.
Whitford HM1, Entwistle VA, van Teijlingen E, Aitchison PE, Davidson T, Humphrey T, Tucker JS(16)	Use of a birth plan within woman-held maternity records: a qualitative study with women and staff in northeast Scotland	2014 Scotland	Qualitative study 42 women 24 health professionals	To investigate the experiences of women and staff with a standard Birth Plan.	The perceived benefits included the opportunity to highlight preferences, improve communication, stimulate discussion, and cope with anxieties. However, not all women experienced these benefits or understood the purpose of the Birth Plan. Some were unaware of the tool or did not have the necessary support from the team to discuss or have confidence about their options.
Welsh Joanne V, Symon AG(17)	Unique and proforma birth plans: a qualitative exploration of midwives׳ experiences	2014 England	Qualitative study 9 midwives	To evaluate the midwives' view on the Birth Plan	The term “Birth Plan” has been considered inappropriate by some midwives for creating unrealistic expectations in women. In their view, the Plans are becoming 'standard' by routinely requesting the same things (childbirth without intervention), some midwives feel pressured by this document which causes irritation.
Aragon, M., Chhoa, E., Dayan, R., Kluftinger, A., Lohn, Z., & Buhler, K(5)	Perspectives of Expectant Women and Health Care Providers on Birth Plans	2013 Canada	Cross-sectional study 122 women and 110 health care providers and support people	To understand the perspectives of women, health care providers and support people use of Birth Plans.	All the women and their caregivers considered the Birth Plan a valuable communication and education tool. However, respondents noted that women may be disappointed or dissatisfied if a Birth Plan cannot be implemented.
Magoma M, Requejo J, Campbell O,Cousens S,Merialdi M,Filippi V(18)	The effectiveness of birth plans in increasing use of skilled care at delivery and postnatal care in rural Tanzania: a cluster randomised trial.	2013 East Africa	Randomized trial 905 women	To determine the efficacy of the Birth Plans in increasing the use of specialized care during childbirth and in the postnatal period among pregnant women in a rural district with low demand for health facilities for delivery but high acceptance of prenatal care.	The implementation of Birth Plans during pregnancy may increase the demand for qualified delivery and postpartum services without adversely affecting the satisfaction of women and providers.
Pennell A, Salo‐Coombs V, Herring A., SpielmanF, Fecho K(4)	Anesthesia and analgesia-related preferences and outcomes of women who have birth plans	2011 USA	Prospective cohort study 63 women	Describe the anesthesia preferences and results related to analgesia of women who used a Birth Plan.	Most women agreed that the birth plan improved their birth experiences, sense of control, and communication with health care providers, and it was an enlightening tool.
Kuo SC, Lin KC, Hsu CH, Yang CC, Chang MY, Tsao, CM, Lin LC(19)	Evaluation of the effects of a birth plan on Taiwanese women's childbirth experiences, control and expectations fulfilment: a randomised controlled trial	2010 Taiwan	A double-blind randomized controlled study 296 women	To evaluate the effects of Birth Plans on fulfilling women's delivery expectations, their control over the childbirth process and their overall experience.	The experimental group had a higher degree of positive experiences and greater control of childbirth than the control group.

• ^Source:
  Research data, 2018.

The study places were: The United States with three publications (21.4%), Spain and Africa with two publications (14.2%), Brazil, Hawaii, United Kingdom, Scotland, England, Canada and Taiwan with one study each (7.1%). The publications were distributed between 2010 and 2017, with 2017 standing out, when there were five published studies, which shows the emergence of the theme.

The scientific debate on the Birth Plan in Brazil is emergent, although the academy is giving it increasing importance. A reflection of this is found in the reduced number of published national articles on its use, especially in the context of the public health system. Internationally, scientific production is numerically more significant and increasing. Many of them analyze the use of the Birth Plan by different approaches (maternal-fetal outcomes, users, professionals and services perspectives), since this tool is incorporated in some foreign health services.

Regarding the design, the qualitative and cohort studies (28.5% each) and cross-sectional studies (21.4%) stood out. The analysis and interpretation of the data contained in the studies allowed the construction of three main evidences, namely:

Evidence 1: The construction of the Birth Plan during the prenatal care positively influences the delivery process and maternal-fetal outcomes.

All the analyzed publications presented benefits derived from the use of the Birth Plan. Because it is an educational tool that stimulates the discussion and the obtaining of information^5,15, its performance contributes to women's empowerment and promotes women's autonomy/protagonism during the parturition process^3,5,7. Informed about the options available, pregnant women can make choices about the position adopted during labor, food or liquid intake, and even refuse some procedures such as the use of enemas and perineal trichotomy, which generates safety and less anxiety^7,16.

The studies show that the Birth Plan favors a more natural/physiological delivery process and provides better obstetric and neonatal outcomes, such as a reduction in the cesarean rate, thus contributing to the increase in normal delivery rates^7,12. To the newborn it provided better Apgar scores and umbilical cord pH, increased skin-to-skin contact and timely clamping of the umbilical cord^7,12, in addition to a lower rate of neonatal hospitalizations in the ICU¹⁴.

Having the body physiology respected has made the experience of childbirth positive, pleasurable, less painful and unforgettable for women^3,13. Improved communication scores with the health team were identified^{4-5,12-13,15-16}, since the implementation of the Birth Plan stimulated the dialogue with their caregivers, enabled women to highlight their preferences and facilitated the coping of anxieties¹⁶, providing greater confidence, satisfaction and a sense of control during labor and delivery^{4,7,9,12-13,15-16,19}. In addition, the implementation of Birth Plans during pregnancy increases the demand for skilled services in childbirth and postpartum¹⁸.

Evidence 2: Unrealistic expectations can cause dissatisfaction with the delivery experience.

Satisfaction with childbirth is directly proportional to the degree of compliance with maternal expectations/choices¹², therefore, there is a greater tendency for women to feel disappointed, frustrated, and dissatisfied if the childbirth does not occur as described in the Birth Plan^5,9,14.

Although the majority of the studies indicate greater satisfaction with the parturitive experience among women who used the Birth Plan^{4,7,9,12-13,15-16,19}, a study showed that, despite providing fewer obstetric interventions, the use of this tool generated lower satisfaction compared to women without Birth Plans¹⁴.

To improve compliance, it is essential that women do not create unrealistic expectations about the Birth Plan, consider the possibilities from the organizational context of the service^9,13,16) and recognize the unforeseeable nature of childbirth so that they are open/flexible to the necessary changes in their preferences/choices if necessary^5,15.

Studies suggest that the denomination “Birth Plan” is improper, by encouraging in women the belief that birth can be “planned”, which may lead to unrealistic expectations^5,15-17. As alternatives, terminologies are suggested that emphasize the need for flexibility due to the dynamic nature of childbirth, such as “birth preferences”¹⁵ and “birth guide”, which refer to the idea of a roadmap to be used as a reference for discussion among women and health professionals in order to promote understanding of the procedures⁵.

Evidence 3: Caregivers play a key role in supporting and performing the Birth Plans.

International and national studies point to a lack of knowledge about the purpose and benefits of the Birth Plan by pregnant women^3,16) and even by professionals¹⁶, which reflects in the adhesion to this tool. Thus, women need to be actively encouraged and supported in carrying out a Birth Plan by their caregivers, which can provide better interaction between them, as it encourages useful discussions, allows women to communicate specific concerns, and enables the shared decisions¹⁶.

Carrying out a Birth Plan without professional support may seem challenging for women who do not have the confidence and knowledge to make choices, as in the case of primigravidae^15-16. However, professionals report that they do not always perceive the need to discuss options and assist women in carrying out this planning, in addition to claiming the lack of time to perform this task in the daily services¹⁶.

Regarding the professional support for the application/fulfillment of the Birth Plan, it is observed that women who did not have their planning considered in previous childbirth experiences do not feel motivated to repeat it in a subsequent gestation, mainly because they perceive themselves skeptical as regards the documents being read and followed by the team of professionals who care for them. Other reasons for pregnant women not carrying out the plan are related to the fact that they find it unnecessary, first because it is an unpredictable event, secondly because of the trust they have in health professionals, who, in their conception, are able to make important decisions when it is necessary¹⁶.

Regarding the opinions of professionals about the Birth Plan, these vary between those who support it and those who have a negative perception¹⁵, mainly by understanding it as a tool used to establish unrealistic expectations for an unpredictable process¹³. Some caregivers reported feeling uncomfortable with the pressure of being faced with this document¹⁷, which may negatively impact the clinical care. Some women report the non-recognition and respect of health professionals for their stated preferences in the Birth Plan¹⁵.

Discussion

Considering that the proposal for the humanization of childbirth is based on the tripod: restoration of the female protagonism; view of the childbirth as a human biopsychosocial cultural event; and linkage with evidence-based medicine²⁰⁾ the scientific productions analyzed in this study make it possible to show that the Birth Plan is a technology that enhances the humanized care of the woman and the newborn.

The positive effects of using the Birth Plan are in line with the guidelines recommended by the World Health Organization (WHO)²¹ and stimulated by the Ministry of Health²² to promote good practices in the care of delivery and childbirth, because they are consistent with current scientific evidence, and therefore, favor the improvement in the quality of maternal and child health care.

Presenting a Birth Plan does not only mean delivering a child with fewer interventions, but in addition to favorable clinical repercussions, this technology develops psycho-emotional issues, once they feel more prepared, women expressed confidence, autonomy and greater participation in the parturition process, which results in a positive impact on the labor experience¹².

Despite the beneficial effects of using the Birth Plan, there are resistance and challenges to be overcome in the use of this tool in different contexts. In general, the number of women who present it is still low, although there is evidence that it is slowly increasing in several countries¹². The lack of use of this instrument by women is mainly due to the lack of knowledge about the Birth Plan and its purpose, as well as the lack of professional support needed to understand the available options and express preferences^16,23.

It is important to emphasize the importance of the nurse professional in stimulating and supporting the use of the Birth Plans, since women attended by obstetrical nurses are more likely to use it when compared to those assisted by obstetricians^3-5.

Another challenge to be overcome is the failure to comply with the Birth Plans, which creates dissatisfaction among women. In places where the obstetric scenario is highly medicalized and interventional, it is often used for the protection against unnecessary interventions, to improve communication and have more control of the process^9,16. In this context, unrealistic expectations and unnecessary solicitations can lead to the frustration of women as well as creating situations of conflict with team professionals¹⁶.

Requests considered to be dispensable by professionals, such as “establishing good communication” or “not performing interventions unless they are necessary”, can generate negative reactions in the team, for implying that good care would not be provided unless it was explicitly requested in the Birth Plan¹⁶. Thus, it is observed that the greater the number of requests recorded in the document, the greater is the general dissatisfaction of women with the experience of childbirth⁹.

The reasons for the low level of performance of the Birth Plans are multiple, with two main highlights. First, the course of the labor process is uncertain; therefore, in the face of unforeseen events and unexpected complications, it may be necessary to disregard the requests. The second reason is related to the tension generated between the parturient and the professional, due to a supposed loss of autonomy of the latter. In the latter case, the Birth Plan acts as a barrier in the caregiver-pregnant interaction¹².

As a way to reduce this tension, it is mentioned the dialogue between the parties, the importance of prenatal education and some care in the construction of Birth Plans¹². When there is dialogue and flexible delivery planning during the prenatal care, it is observed that even when women's documented preferences are not fully met, they can express satisfaction with the use of plans, feelings of dominance, and participation in the process^5,9. In this sense, the dialogue on the options for labor and delivery can be considered more important than the Birth Plan itself¹⁴.

Regarding the preparation of more realistic Birth Plans, prenatal education should more openly address the different philosophies that surround care delivery in different contexts of childbirth, so that women are more conscious to choose the professional and delivery environment that best suits their beliefs and needs. In addition, it is necessary to reduce the potential of seemingly disappointing results when considering the pregnant woman's clinical condition (risk factors), in addition to the facilities and policies of the service, in order to avoid disappointment and increase the understanding that delivery cannot be planned meticulously¹⁷.

In this sense, a study indicates that the obstetrician nurses actively involved in delivery care are the ideal professionals to support the construction of a Birth Plan, mainly because they are clear of the real possibilities that can be offered to the pregnant women in the services^15,17. In addition, it is of the utmost importance that the document constructed by the woman in the gestational period be elaborated and/or shared with the health professional who will care for her at the time of delivery, since the success of a Birth Plan also depends on open communication and on the bond built between women and their caregivers¹⁶.

The Birth Plans can assume varied models, which differ mainly in the format, size and complexity^13,15-16, without a better structure or a “standard” model for all women¹⁵. In general, they can present themselves as a form, composed of structured questions, where the woman indicates the items she considers appropriate for her experience. Another possibility is to prepare it in the form of text, which allows the pregnant woman to freely talk about her preferences in a personalized way¹².

Standardized versions of Birth Plans found in some prenatal services may be a simple way to introduce women who are unfamiliar with this instrument. Compared with those found on the Internet, standardized Birth Plans can offer women labor and delivery options available in a specific maternity hospital service, avoiding unrealistic expectations in the pregnant woman¹³.

Similarly, rigidly formatted and prescriptive Birth Plans may present women with an illusion of choice, while restricting themselves to practices allowed in a given institution^16-17, which runs counter to a personalized approach to centered care needs and decisions of the woman¹⁵. In addition, very long documents and the inclusion of inaccurate or outdated information may decrease the likelihood that hospital staff will read them in the care planning^9,13. Thus, instead of operating as an effective communication tool, Birth Plans can become unintentional obstacles that generate friction between caregivers and parturients⁹, and/or maternal frustrations when the choices made are not met in their entirety.

As a way of recognizing the possibility of "planning" failures and unpredictability of the nature of childbirth, a flexible approach to Birth Plans is necessary¹⁵. Therefore, this instrument must be understood as something dynamic, so the pregnant woman will have the power to re-create the way she wants her delivery to occur during the parturition process and her caregiver will be responsible for managing those changes and sharing decisions³, especially when the interventions are initially undesirable, but necessary due to maternal and/or fetal safety.

In this direction, the Birth Plan was described as a “living document” and an “evolving document” suggesting that it should be changed as new information and changes in circumstances arise in the parturition process⁵. Thus, the greatest challenge of professionals is to support their construction with realistic and flexible birth preferences, to establish constructive dialogues that allow women to prepare for unexpected situations as well, in addition to ensure that this planning is followed as closely as possible within the evolutionary possibilities of labor¹⁵.

Final Considerations

The publications analyzed show that the creation of a Birth Plan during the prenatal period positively influences the parturition process and maternal-fetal outcomes, however, unrealistic expectations of the women may cause dissatisfaction with the experience. In this context, caregivers play a key role in supporting the preparation of Birth Plans consistent with the clinical condition of women and with the reality of the health service being used, as well as in fulfilling them during the parturition process.

Among the benefits of using the Birth Plan is the promotion of a more natural and physiological delivery process; better communication with health professionals; greater awareness of the processes involved in labor and delivery; greater sense of control, autonomy and protagonism; better obstetric and neonatal outcomes and a higher degree of maternal satisfaction.

Thus, it is possible to state that the Birth Plan is a technology that enhances humanized care for women and newborns and has contributed to the improvement of the quality of obstetric care, however, there are still some challenges related to the use of this instrument, such as: need for greater dissemination among professionals and stimulation of their use by pregnant women; routine inclusion in Primary Care services; support in the elaboration of these documents to increase the compliance rate, preferably by obstetric professionals who know the clinical conditions of pregnant women and the reality of obstetric health services; and finally, the elaboration of flexible plans, which consider the unpredictability of the childbirth, to improve its implementation and compliance, as well as maternal satisfaction.

In view of the above, the evidence found justifies the clinical implementation of the Birth Plans, however, the involvement and support of trained and sensitized professionals are essential in the preparation and implementation of this planning. More studies are necessary to understand how to narrow the disparities between the expectations described in maternal plans and the experiences, as well as to improve compliance and satisfaction with their use.

The limitations of the study refer to the inclusion of articles available only in English, Portuguese and Spanish, and the difficulty of access to some international publications because they are not available in full for free, which led to the non-inclusion of some studies on the subject.

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Publication Dates

• Publication in this collection
  06 June 2019
• Date of issue
  2019

History

• Received
  25 July 2018
• Accepted
  20 Nov 2018