Ladies: Lose the Birth Plan. Make a Birth Map instead.

#soulsearchinginsuburbia #midwifery #birthcartography #informedbirth #positivebirth #birthtrauma #informedchoice #informedbirthpreparation #maternitycare #maternitycareinaustralia #itstime #birthtime

I attended Catherine’s “Birth Cartography” workshop last week. Yes, birth cartography. Sounds interesting doesn’t it? It is. I am in my third year of working rostered shifts as a midwife across the birthing suite and the pre and postnatal ward at a large, tertiary public hospital. It is physically and emotionally demanding work that I have been struggling with on many levels.

Attending this workshop was a deep breath of fresh air, not just because of the training but also because of the company. To sit amongst this group of inspiring women was illuminating. Midwives stretching themselves beyond the standard, expected, mainstream career path; positive birth advocates like Jodie Miller, who recently published her very personal memoir about maternity activism “What does it feel Like Being Born?”. I can’t wait to read it. Women like Catherine Bell– woman, mother, doula, ABA breastfeeding counsellor and educator (with a Masters degree in Science to boot)- bravely pioneering a brand new species of ‘birth plan’ for the maternity world:

The Birth Map: Boldly going where no birth plan has gone before.

As a midwife and as a woman who has given birth twice without a map, or too much of a plan, I love it. It is what has been missing as a tool for women to better understand not only the physiological birthing process but also the models of maternity care available to them in Australia, and to what extent those models can support said physiological birthing process. Not all maternity models are created equal, and not all models are highly visible. Most women do not know there are 11 different models of maternity care in Australia, even though not all are available in all areas at all times, to all women. But there certainly is more to consider than “Shall I go public or private?”.

In my (public) place of work, Birth Plans often get a bad rap. How often have we heard that birth plans “go out the window”? They can do- often by the women themselves! In large tertiary hospitals where most women are induced and true spontaneous birth pathways with zero intervention are almost as rare as unicorns, there is no place for many of the style of birth plans that are presented. Why is that, when RANZCOG makes the following statement:

“It is important that women and their families are allowed enough time to consider their choices and to make decisions after reflecting upon the information they have received. They should be encouraged to seek additional information and advice as they require, and allowed to make a considered decision. Women who have been fully informed regarding a recommended course of action, and the potential consequences of not pursuing such management, should have their decisions respected.”

(p. 9, 2017, Ranzcog Maternity Care in Australia)

Far too often, maternity care providers are not convinced women have been fully informed or understand and accept the potential negative consequences, and as a result, we fear liability and litigation. Perhaps we are so wary in our mainstream model of care because we know it’s unlikely our system has been able to provide those opportunities for genuinely considered decision-making. Good birth plans should be all about informed choices (more often presented, wrongly, as informed consent- they are not the same things). You can’t have the former without the latter. So many times, I’ve heard fellow midwives and doctors dismiss a birth plan, saying, “These are the women who will be first to come back and sue.” This should not be the way. It shouldn’t feel like Us v. Them. It shouldn’t feel so fraught. Our own professional registration should not feel so threatened at every turn. But some days, it really does.

Why? Because women may have copied and pasted icons from the internet, followed someone else’s plan that sounded lovely, or, most often, their Plan only considers one pathway, the preferred pathway, and doesn’t cater for the unexpected. The contingencies. So often, there is little to no research or understanding behind the Plan, and as a result, there is no strength of conviction behind the ‘wishes’ or ‘intentions’ listed. Because of this, once in the throes of the reality of their labour, it becomes just as easy for these women to “throw the birth plan out the window” themselves. As far as the partners/support people are concerned, they often find themselves feeling just as unprepared, just as lost, just as overwhelmed and confused. This is not the optimal start to parenthood, and not what anyone wants.

We need to do better for our women.

Catherine Bell has developed the Birth Map as an alternative to these rigid, straight line, often uninformed plans to provide women, and their support people, with the resources they need to ask the right questions at the right times of the right people, and to investigate and plan for contingencies. Catherine argues that simply providing women with information is not enough for them to be able to make informed choices. We need to give them the questions.

The Birth Map, assuming nothing and preparing for anything, encourages consideration of the fast birth pathway as well as the expected and the contingency pathways. In Catherine’s words, “birth might not be predictable- but it is preparable” (Bell, 2020, p. 43). Sure, there is an expected birth pathway you are hoping for, or need to follow (e.g. spontaneous vaginal birth with no intervention or a planned Caesarean section due to placenta praevia, where the placenta covers the cervix, precluding vaginal birth), accompanied by a set of expectations and choices around that pathway informed by the reality of the maternity model of care you opt for, whether that be by choice or by obligation.

There are also contingency plans: if this, then that.

Induction of labour is ‘offered’ to you at 40 weeks? What are the questions you need to ask of your care providers? Why are they recommending this intervention? What are the considerations you need to take into account, and what will be your threshold for saying yes? The Birth Map also helps women understand the language around ‘risk’ and highlights the importance of using the right word at the right time. Consider the difference between the words danger, risk, chance and opportunity. For example, a woman may be told her risk of stillbirth doubles if she doesn’t consent to an induction of labour at a certain gestation. Often that statement alone is enough to send couples into panic mode and blindly comply, fear in their hearts. Whatever is safest for the baby, they say. Did they stop and ask what the statistic being referenced actually is? Did they ask what research this is based upon? The quality of that evidence? Did they take the time to think it through and make an informed decision? If it was a 0.4% chance of stillbirth, which then doubles to a 0.8% chance, perhaps those are odds she’s willing to bet on, when considered in the overall context of her particular circumstances.

No one ever talks about the 99.2% chance all will be fine.

Reminding women of the BRAIN acronym (benefits, risks, alternatives, instinct, and doing nothing) is critical to helping her and her partner navigate every decision point in her childbearing journey. Every time ‘informed consent’ is sought, where a yes is assumed and compliance is expected, women need to use their BRAIN. As Catherine writes so well:

“You have the right, and responsibility, to decide” (Bell, 2020, p. 14).

Women, please. Embrace your power. Express your power. Don’t keep it hidden. This is your birth, your way. Knowledge and understanding must replace ignorance and fear, leading you to make decisions based on truly informed choices, no matter what.

This is what we all- women, their partners, and caregivers- need.

And we need it yesterday.  

 Bell, C. (2020). The Birth Map. bellabirth.org.

RANZCOG (2017). Maternity Care in Australia: a framework for a healthy new generation of Australians. https://ranzcog.edu.au/RANZCOG_SITE/media/RANZCOG-MEDIA/About/Maternity-Care-in-Australia-Web.pdf