Birth as Battle - Plans are Useless but Planning is Indispensable

On birth information, support and planning - countering a culture of normalized trauma and contempt by encouraging informed consent and empowered decision making

“In preparing for battle I have always found that plans are useless but planning is indispensable”

Dwight D. Eisenhower

A letter signed by three New York City doctors recently made its rounds on the internet. This letter, distributed to women in their OBGYN practices for as long as eight years, exemplifies the disdain that many medical professionals have for women informing themselves and showing up as active and empowered participants in their own births. The target of the letter was women who document their preferences for their births in a style that is commonly called a "birth plan". They wrote that “birth plans can be a detriment to our relationship”, that they feel that “the use of birth plans too frequently sets up unrealistic expectations and conditions for potential conflict.”

Since going viral, Weill Cornell has issued an apology, stating that the letter was “erroneously placed in an information packet to patients” and has removed the letter permanently. But an obstetric culture that allowed a “dated, insensitive letter” that is counter to a “culture to put patients at the center of their care” to circulate for years is worthy of some thoughtful consideration.

When it comes down to it, the reality of birth is complicated and overwhelming and presents a challenge to everyone involved. When it’s game time, things move quickly and pressure on parents to make decisions by medical professionals can be a bit ‘gun to your head’.

During birth, you don’t have time to educate yourself about the range of options available to you. If you haven’t already planned for how you would make a particular decision in advance of birth, you likely won’t have the opportunity to during, and the decision will be made for you. These doctors know that.

Moreover, in my estimation and experience, most women are going into the pregnancy and birthing experience blind. Yet doing so is like arriving to take the Bar Exam without studying all summer (I’m a lawyer 😊) or running a marathon without going through rigorous training in advance of the race.

It’s jarring because it is true even with respect to highly intelligent, educated women, who are otherwise adept at seeking out and absorbing information and knowledge on a myriad of topics. A universal experience such as birth and motherhood should not be as shrouded in mystery and uncertainty as it is.

So what does a birth plan really represent that frustrates these doctors and creates an impediment to their practice of “modern obstetrics”? Wouldn’t a woman’s baseline understanding of her options and preferences make for easier and more productive communication with doctors during and prior to her birth? How can a birth plan present such a conflict that it would compromise instead of strengthen the relationship between doctor and patient? Typically, mutual understanding and communication creates alignment, not discord between individuals.

To understand the medical hostility to birth plans, and to architect a new status quo that benefits all parties to the birthing experience, we need to first survey the current state of birthing in the US.

Giving birth in the United States today

From our first cultural experiences with birth, it’s made out to be barely controlled horror. And when so much of our sexual education is directed at preventing pregnancy, it’s no shock that when we are finally ready to become mothers, we have little to no knowledge about what pregnancy and birth are like in reality— and many of our imaginations have been tainted and tormented by the often gory, excruciating, and traumatic depictions of birth in pop culture.

Unfortunately, reality often looks closer to these nightmarish depictions than it needs to. This is largely because women are not equipped with the information they need to be empowered through the birthing process. This is a problem that is exacerbated by the culture of contempt for informed consent that has developed among medical professionals, and which is exemplified by the authors of this letter.

During birth, it is commonplace for medical professionals to treat everything with the urgency of life or death, to use terminology that no layperson has ever heard, and to act dismissive or impatient when someone asks questions instead of immediately deferring to them.

Data shows that this culture is not resulting in better outcomes for women. The United States has the highest maternal mortality rate among developed countries and 45% of women leave the delivery room reporting their birth experience as traumatic (with quality of provider interaction being key to the subjective experience of trauma).

These statistics are unacceptable, and advocating against birth preparation and planning is certainly not likely to resolve them. Many women come into their births with birth plans in a conscious and intentional effort to prepare themselves to encounter this system and to protect themselves from becoming these statistics.

How planning makes birth better for everyone

I am a birth doula, a non-medical professional who acts as a patient advocate and support person throughout the entire pregnancy and birthing process. As a doula, I strongly believe that a woman will birth best where she feels safest, and the conditions under which a particular woman feels safest will be as varied and diverse as each individual woman.

The physiological and hormonal processes central to successful birth are supported by the achievement of this foundational sense of safety. Birth plans can play a critical role in cultivating this sense.

When I co-develop birth plans with clients, we are not married to a specific outcome or series of interventions. We discuss every possible intervention on the menu for birth in whatever setting she’ll be birthing (e.g. hospital or at home). As we discuss the options on the menu, we talk about the various possibilities that may arise due to unexpected circumstances during the birth.

In many ways, birth is like a choose your own adventure story—but it’s happening in real time. Throughout your birth experience, you and your team will be called to make a multitude of decisions that will impact your overall experience.

Discussing ahead of time all of the decisions that may need to be made is psychologically beneficial to maintaining an overall sense of safety, peace, and security in what is necessarily an unpredictable environment.

You cannot go into birth expecting to be able to control every element of it (birth plans aren’t structured that way either). However, you can go into birth understanding every iteration of what may or may not happen to your body and your baby during the experience. You can help yourself to feel prepared to make any decision that arises during your birth by making a birth plan, and discussing the range of all possible options with a trusted birth professional in advance of your birth.

And birth plans do more than provide opportunity to explore and determine preferred delivery tactics—they establish a shared language for effective communication.

Birth plans are communication channels—keep them open

A birth plan is a strategy for organizing your understanding of the complicated process of birth and structuring communication in regard to it. When doctors say they will not engage with women on their birth plans, they are essentially refusing to participate in a strategy for ordered communication that can be incredibly beneficial to parents in making sense of an overwhelming and technically complex experience.

Not only do you have the right to informed consent— full authority over what happens to your body— you also have the right to be communicated with by medical professionals in the method that you choose and which is most helpful to your informed decision making— be that with reference to your birth plan, or otherwise.

Absent a clear and documented medical emergency, there is no reason why your providers would not be able to communicate with you about your predetermined birth plan and any necessary deviations from it.

To claim otherwise is indicative of a deeply disturbing level of laziness, a preference for convenience and expediency over hard work— a cultural trend that can be observed across many sectors of modern society— but certainly not one that should be tolerated in the practice of medicine, and most especially during the sacred experience of birth.

This is a salient point in a medical context in which professionals are badly incentivized: to choose interventions that maximize profits, to increase efficiency, and to limit their legal liability in ways that are not necessarily aligned with a patient’s best interests or the requirements for safe and successful birth.

Changing preferences in light of changed circumstances

Birth is hard work. Not every challenge in birth is an emergency worthy of overriding your predetermined preferences— though you may notice during birth in the presence of new information that your preferences change.

This is normal and should be applauded, as changing opinions and preferences in light of new information is a healthy indication of sound decision-making capability.

Flexibility certainly has a place in cultivating psychological openness that can be helpful in minimizing trauma in connection with a non-preferred birth experience. But your openness and flexibility in birth should only be tested with good reason.

Convenience of hospital staff and unwillingness of medical professionals to familiarize themselves with an individual patient and such patient’s preferences, is NOT good reason. Hospital staff who refuse to communicate with you as requested, ignore your preferences, or override your informed consent/refusal are showing you EXACTLY who they are.

Ultimately, an apology for the letter is a start. But the attitude of these doctors is not unique in the culture of modern obstetrics—it’s just rare that it becomes the center of an internet scandal.

Source: Instagram @Tranquilitybyhehe

Greater systemic and cultural change in the birth space is desperately needed. In the meantime:

Birth is a battle in which not everyone in the room is fighting with the same set of incentives. Arm yourself with information and comrades who will fight for your interests and preferences. Go into the trenches with people you trust. And don’t go into battle unarmed.

Make birth plans. Stick to them if you can, and appreciate that they help to prepare you to make educated changes to your plans in light of new information. Birth is a major accomplishment and one for which you will be better off for having prepared.