Birth plan backlash

There’s been a lot of talk lately about physicians responding to their ‘patients’ birth plans by providing a copy of their own written birth plans of what they will or will not do, allow, accommodate, or condone during a woman’s labor and birth. The Feminist Breeder and Stand and Deliver have written recently about the hullabaloo, as have  The Unnecesarean and Crunchy Domestic Goddess. The following is an excerpt from an OB birth plan that was given to a pregnant nursing student during one of her prenatal visits. Just for fun I bolded the parts I thought were the most outlandish and offensive, or simply untrue.

DR. ________ “BIRTH PLAN”

Dear Patient:

As your obstetrician, it is my goal and responsibility to ensure your safety and your baby’s safety during your pregnancy, delivery, and the postpartum period… The following information should clarify my position and is meant to address some commonly asked questions…

* I do not accept birth plans. Many birth plans conflict with approved modern obstetrical techniques and guidelines…. Please note that I do not accept the Bradley Birth Plan.

* IV access during labor is mandatory.

* Continuous monitoring of your baby’s heart rate during the active phase (usually when your cervix is dilated 4cm) is mandatory. This may be done using external belts or if not adequate, by using internal monitors at my discretion… Labor positions that hinder my ability to continuously monitor your baby’s heart rate are not allowed.

* Rupture of membranes may become helpful or necessary during your labor. The decision as whether and when to perform this procedure is made at my discretion.

* I perform all vaginal deliveries on a standard labor and delivery bed. Your legs will be positioned in the standard delivery stirrups. This is the most comfortable position for you. It als

o provides maximum space in your pelvis, minimizing the risk of trauma to you and your baby during delivery.

* I will clamp the umbilical cord shortly after I deliver your baby. Delaying this procedure is not beneficial and can potentially be harmful to your baby.

* I recommend delivering your baby at around 39-40 weeks of pregnancy. This may happen through spontaneous onset of labor or by inducing labor. Contrary to many outdated beliefs, inducing labor, when done appropriately and at the right time, is safe, and does not increase the amount of pain or the risk of complications or the need for a c-section.

* Compared to the national average, I have a very low c-section rate… The decision as to whether and when to perform this procedure is made at my discretion and it is not negotiable, especially when done for fetal concerns.

Whatever happened to ‘patient rights,’ you might be wondering? We still have them. Women birthing in the hospital may pass by the  “Patient’s Rights and Responsibilities” document posted in the hallway, which they are sure to absorb between contractions on their way to their labor room.  And in case you weren’t sure, the American Medical Association does in fact publicly acknowledge patient rights as well. Locating an ACOG  public declaration of patient’s rights was much more challenging, hence no link, but I will keep looking.

Doctors are legally required to provide care to patients with whom they have an established, preexisting relationship. During labor and birth, you have the legal right to evaluate proposed procedures and treatments before they are done to you. You have the right to refuse a procedure or treatment. The trouble begins when your care provider perceives your wishes as a threat to their comfort level, your safety, or the safety of your baby; you have the right to push your baby out in a hands and knees position, but your doctor is worried s/he won’t be able to ‘deliver’ the baby safely (or comfortably) that way.

This kaleidoscope of ethical, legal, and clinical considerations comes up for all care providers at some time or another — and to be fair it’s enough to make a hospital provider’s head spin. How many double-binds can a doctor or midwife be in simultaneously, and with multiple laboring women? ACOG even published a guide to ethical decision-making for OB/GYNs to better navigate these circumstances in a professional, legal, and moral manner. Unfortunately in cases where ‘competing interests’ exist between birthing women, care provider, and hospital, women’s autonomy is often sacrificed in favor of provider protocols and liability concerns: I can’t deliver the baby on the birth stool because it is too far from the warmer, or the bed, or I’ll have to get on the floor…

Where does that leave women who want or need to give birth in the hospital? Should they just accept a labor and birth challenged by competing interests?  No. There is a massive, beautiful, inspired, smart, powerful childbirth movement in full force. Women of all ages, races and political persuasions are reclaiming their authority and demanding humane, dignified, safe, family-centered care.

On an individual level this reclaiming involves being clear about our role in the ‘doctor-patient’ dynamic.  When a woman initiates prenatal care with a physician or midwife she is, in essence, hiring that person or practice to provide her maternity care.  Not all women have a choice in care providers, but women residing in areas with a multitude of care providers, including family practice doctors, nurse-midwives and out-of-hospital midwives are exercising their freedom of choice by choosing to enter into a relationship with a care provider who practices within a certain model of care. In the US, most hospital-based providers practice in accordance with the medical model of maternity care whose ideology and protocols evolved to serve the beliefs, understanding, knowledge base, and values of physicians and hospitals.

Enter the ‘You Will and You Won’t’ lists of the physician birth plans. Finally some transparency! A few lucky women are being told, before their labor and birth, precisely what their provider’s standard protocols are. No more trying to call your provider’s bluff! This transparency affords women the freedom to move beyond the ‘unknowing victim’ role and into a position of  awareness, autonomy, and ownership. I think all physicians and midwives alike should offer these birth plans to their clients — they are the perfect tool for transforming the status quo in maternity care! This is exactly where we need to be to usher in the next wave of birth change.


15 thoughts on “Birth plan backlash

  1. Oh my gosh, if my OB (wait, I don’t have one! he he) gave me that “birth plan” I would RUN! There were so many factual, statistical errors (not just opinions or preferences) in that little note that I literally started laughing out loud many times.

    Thank you for the great info!

  2. P.S.

    Many women think that just because the doctor/nurse/hospital says it’s “mandatory” means that they no longer have any power or say, when in reality it’s not the “law” just procedure. When my first was born in a hospital I pretty much went against every “policy” they had, even when they told me that it wasn’t allowed, or it was mandatory. I signed every “against doctors orders” waiver they had because I wouldn’t vaccinate, and I wanted to go home right away. The mother is in charge of her baby, and we have so many more rights, and so much more power then they lead you to believe. 🙂

    • Right. The “law,” in the vast majority of instances, comes down on the side of the “patient” in the form of patient rights. I wrote about this in my Birth Plan post recently. Birthing women are in such a vulnerable place and the physician-woman power dynamic enables the perception that policies and procedures are somehow written in stone. They often feel like they are written in stone when one attempts to challenge them, but many women do, like you. It’s not easy, and there is often backlash — we’ve all heard the “dead baby” threats, and the threat of bringing in child protective services. Birth Change NOW!

  3. this is so ridiculous! i can’t even believe it. my doctor is encouraging me to write a birth plan, and is excited i’m taking a bradley method class. i wish all women could be lucky enough to have doctors (or midwives!!!) like him.

    • I too wish all women had care providers who served them with dignity and respect, and who honored their autonomy and instinct in birth. Glad you are happy with your care! Sadly, too many women know firsthand how docs will pay lip service to birth plans, and even encourage their patients to have one — ostensibly to honor their autonomy — but knowing that their comfort level and/or protocols will preclude much of the patient’s wishes from being honored.

  4. It’s sad that birth has become so fear based. It’s also sad that when women who have hospital births do try to stand up for their rights as patients, doctors’ egos come into play. And some of the threats you mentioned have come to fruition. There have been instances of women getting their babies taken away because the doctors called social services, saying that the woman endangered her child because she didn’t agree to have a c-section(when her baby was doing fine). That is just sad. Now, even if you don’t have a fear of birth going in, you have to fear what your OB might do when you choose to be an autonomous patient… I hope to have all of my children at home, with midwives. Keep up the good work!

    • I know, that hideous CPS threat has played out all over the country in various birth and postpartum situations. The provider-patient power differential can be truly catastrophic to normal birth.

  5. Holy shit, I cannot believe a doctor, who is supposed to abide by the Hippocratic Oath to do no harm, would actually LIE to all of his patients like this. There are so many lies in this birth plan, it’s unbelievable that someone could type it up, print it out, and give it to a pregnant woman with a straight face. Except maybe a misogynistic arrogant power-tripping asshole who may as well have written it like this:

    Birth Plan
    You do exactly what I say when I say it. My demands are non-negotiable. You have no rights. Now obey and perform like a good little lady.
    God of your pregnancy and birth

    I pity the women who don’t know enough (or are unable) to run away from practices like this. These doctors are dangerous.

  6. well goodness. at least this doctor is being honest in his/her straightforward list of rules for the patient. at least one would know what is she getting. but the disgusting part is (in addition to the complete bulldozing of a patient’s rights and autonomy) all the lies. this person cannot possibly be a good doctor if they believe and practice this way. induction always fine safe and dandy? please. actually the really disgusting part is that many women will continue care, even when presented with this document.

  7. I love your point! It’s too true that women spend a lot of time trying to figure out a practitioner’s model of care really is, versus what they will pay lip-service to.

    Is there a reason that doctors don’t keep their own statistics about births? Hospitals do, but doctors don’t or they don’t give them out. I feel like that’s another good way to find out what the reality is.

    • Some docs will supply selected stats if asked. I am not aware of any requirements of physicians to maintain stats and I do not know what percentage do. Interesting topic!

  8. This makes me so sick…. and sad. Sad because most women have never been told that they deserve better!!!!

  9. Pingback: Smith Birth Plan « Amy Elizabeth

  10. “There is a massive, beautiful, inspired, smart, powerful childbirth movement in full force.”

    Please. Wake up people. The answer to this is legislation. I have been through it. When you tell your physician (don’t call the “doctors”) that you disagree with something as simple as putting a pacifier into a baby’s mouth you can be shutdown and have to deal with Child Protektive [sic] Services making your life difficult. You won’t lose your baby over a reasonable objection to the hospital but you will have the hospital’s will imposed and the inconvenience of dealing with CPS and possibly the police.

    Here’s how a dispute in the delivery room or post partem works at any hospital:

    1. You tell them no.
    2. They tell you that they will either not give you that lovely epidural (comply or hurt pig dog!) or that they will do it anyway because its “medically necessary”. (Doctors are Gods in Amerika)
    3. You then can dispute with the hospital board or with a social worker which will take a week or two. By then the issue is passed and the hospital’s will has been imposed anyway.

    Here’s what you can NOT do:
    * take your baby out of the hospital without him/her being discharged
    * refuse any medical treatment to the baby the hospital, nurses, or doctors want to do

    Wake up people, you have no rights in hospitals. If you want to have freedom, you have to have your kid at home (which is illegal in some states too).

    • I agree, hospitals do operate on a system of coercion and compliance, and birth is no exception. You do have rights, but they are often virtually invisible. Refusing standard protocols can land you in a pot of hot water. It makes things harder for the staff, you are then perceived as “difficult” or worse…Sometimes thoughtful, honest, gentle dialogue can go a long way to getting what you want. Sometimes not. Fortunately there is an alternative for most women — homebirth. And homebirth is legal everywhere, it is the practice of midwifery by non-nurse-midwives that is still illegal in some states.

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