Prevalence, characteristics, and satisfaction of women with a birth plan in The Netherlands

The contribution of birth plans to shared decision-making from the perspectives of women, their partners and their healthcare providers

BACKGROUND

The birth plan is a document expressing a pregnant woman's childbirth preferences, enabling communication of expectations and facilitating discussions among women, their partners, and healthcare providers for key birthing decisions. There has been limited research on the role of birth plans in shared decision-making (SDM). Our study aims to explore how the use of birth plans can contribute to SDM from women's, partners, and healthcare providers' perspectives.

METHODS

We conducted in-depth interviews with women, their partners, and their healthcare providers. We used a thematic analysis to identify themes and subthemes. Furthermore, we created a grounded theory about the role of birth plans as a tool in SDM.

RESULTS

Three main themes were created: ''Creating a birth plan", ''Getting all on board" and ''Birth plans in the daily practice of decision-making". Most women, partners, and healthcare providers agreed that birth plans can facilitate communication and SDM. Women and their partners viewed the birth plan as a tool to prepare for birth. Most healthcare providers mentioned the birth plan as a tool to get to know the women, their partners, and their preferences. Barriers are the attitude of healthcare providers toward birth plans, such as their evident resistance to the birth plan itself or to certain preferences. Another barrier is the assumption women and their partners may have that these plans can accurately predict the childbirth experience, enhancing the chance of a disappointing, negative experience. Some healthcare providers view birth plans as barriers to SDM.

CONCLUSION

The use of a birth plan seems to promote women's, partners', and healthcare providers' involvement in the birth process, and seems suitable to facilitate SDM. Further research is required to explore strategies for overcoming barriers, including healthcare providers' attitudes toward birth plans and the expectations of women and their partners regarding their role.

Impact of shared decision-making on women's childbirth preferences: A cluster randomised controlled trial

BACKGROUND

Midwives provide counselling for birth plans (BPs) to women during prenatal care; however, the impact of individualised BP counselling interventions based on shared decision-making (SDM) regarding women's preferences is unknown.

METHODS

This randomised cluster trial included four primary healthcare units. Midwives provided BP counselling based on SDM to women in the intervention group (IG) during prenatal care along with a handout about evidence-based recommendations. Women in the control group (CG) received standard BP counselling from midwives. The main outcome was preference changes concerning BPs.

RESULTS

A total of 461 (95.5 %) pregnant women received BP counselling (IG, n = 247; CG, n = 214). Women in the IG changed their BP preferences for 13 items compared with those in the CG. These items were: using an unique space during birth (81.1 % vs 51.6 %; p < 0.001), option for light graduation (63 % vs 44.7 %; p < 0.001), listening to music (57.3 % vs 43.6 %; p = 0.006), drinking fluids during labour (84.6 % vs 93.6 %; p = 0.005), continuous monitoring (59 % vs 37.8 %; p < 0.001); desire for natural childbirth (36.6 % vs 25 %; p = 0.014), epidural analgesia (55.1 % vs 43.6 %; p = 0.023); breathing techniques (65.2 % vs 50.5 %; p = 0.003), massage (74.9 % vs 55.3 %; p < 0.001); birthing ball use (81.9 % vs 56.9 %; p < 0.001), spontaneous pushing (49.3 % vs 28.7 %; p < 0.001), choosing birth position (69.6 % vs 41.5 %) and delayed umbilical cord clamping (67.8 % vs 44.1 %; p = 0.001).

CONCLUSION

SDM counselling, together with a handout about evidence-based recommendations on childbirth and newborn care, produced more changes in women's preferences expressed in the BP than standard counselling.

On-demand mobile hypertension training for primary health care workers in Nigeria: a pilot study

BACKGROUND

Only one out of every ten Nigerian adults with hypertension has their blood pressure controlled. Health worker training is essential to improve hypertension diagnosis and treatment. In-person training has limitations that mobile, on-demand training might address. This pilot study evaluated a self-paced, case-based, mobile-optimized online training to diagnose and manage hypertension for Nigerian health workers.

METHODS

Twelve hypertension training modules were developed, based on World Health Organization and Nigerian guidelines. After review by local academic and government partners, the course was piloted by Nigerian health workers at government-owned primary health centers. Primary care physician, nurse, and community health worker participants completed the course on their own smartphones. Before and after the course, hypertension knowledge was evaluated with multiple-choice questions. Learners provided feedback by responding to questions on a Likert scale.

RESULTS

Out of 748 users who sampled the course, 574 enrolled, of whom 431 (75%) completed the course. The average pre-test score of completers was 65.4%, which increased to 78.2% on the post-test (P < 0.001, paired t-test). Health workers who were not part of existing hypertension control programs had lower pre-test scores and larger score gains. Most participants (96.1%) agreed that the training was applicable to their work, and nearly all (99.8%) agreed that they enjoyed the training.

CONCLUSIONS

An on-demand mobile digital hypertension training increases knowledge of hypertension management among Nigerian health workers. If offered at scale, such courses can be a tool to build health workforce capacity through initial and refresher training on current clinical guidelines in hypertension and other chronic diseases in Nigeria as well as other countries.

What are antenatal maternity care needs of women who conceived through fertility treatment?: a mixed methods systematic review

BACKGROUND

Existing research indicates that pregnant women who conceived through fertility treatment might experience more stress and anxiety compared to women who conceived spontaneously. Therefore, these women might have additional antenatal care needs.

METHODS

A search for both quantitative and qualitative studies was performed in PubMed, PsycINFO, CINAHL and MEDLINE through May 2021, guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist. 21 articles met the inclusion criteria. After methodological quality appraisal using the Mixed Methods Appraising Tool, 15 studies were included in the review.

RESULTS

Analysis of the studies identified behavioral, relational/social, emotional, and cognitive needs and women's preference about maternity care. Women who conceived through fertility treatment reported lower social and physical functioning scores and elevated levels of anxiety and depression compared to women who conceived spontaneously. They reported difficulties adjusting to pregnancy and experienced a care gap between discharge from the fertility clinic and going to local maternity care services for their first consultation, and a care gap postpartum.

CONCLUSIONS

Women who conceived through fertility treatment have additional antenatal care needs. We recommend to offer these women more frequent check-ins, and to pay attention to the impact of their infertility and treatment on their pregnancy.

Preferences for labor and childbirth, expressed orally or as a written birth plan: Prevalence and determinants from a nationwide population-based study

BACKGROUND

Shared decision-making is an important component of a patient-centered healthcare system. We assessed the prevalence of parturients with preferences for their labor and childbirth, expressed verbally in the birthing room or as a written birth plan, and studied maternal, obstetric, and organizational factors associated with their expression.

METHODS

Data came from the 2016 National Perinatal Survey, a cross-sectional nationwide population-based survey conducted in France. Preferences for labor and childbirth were studied in three categories: expressed verbally, in writing (birth plan), or unexpressed or nonexistent. Analyses used multinomial multilevel logistic regression.

RESULTS

The analysis included 11,633 parturients: 3.7% had written a birth plan, 17.3% expressed their preferences verbally, and 79.0% either did not have or did not express any preferences. Compared with the latter group, written or verbal preferences were both significantly associated with prenatal care by independent midwives (respectively, adjusted odds ratio (aOR) 2.19; 95% confidence interval (CI), [1.59-3.03], and aOR 1.43; 95% CI [1.19-1.71]) and with attendance at childbirth education classes (respectively, aOR 4.99; 95% CI [3.49-7.15], and aOR 2.27; 95% CI [1.98-2.62]). As years in traditional schooling increased, so did its association with preferences. Conversely, parturients from African countries were significantly less likely than French mothers to express preferences. A written birth plan was also associated with characteristics of maternity unit organization.

CONCLUSION

Only one in five parturients reported having expressed preferences for labor and childbirth to healthcare professionals in the birthing room. This expression of preferences was associated with maternal characteristics and the organization of care.

Maternal-infant outcomes of birth planning: A review study

The birth and delivery plan is the center of clinical communication between the pregnant woman and the midwife, which is in the scope of health care services and is designed and provided to specialists with the participation of the woman and her husband during pregnancy. This document reflects the preferences, expectations, and fears of pregnant women regarding the birth process. This study was conducted with the aim of determining the maternal and neonatal outcomes of the birth plan: a review study. In this review study, Persian databases Magiran, SID, and English databases Pubmed, Scopus, SID Elsevier, Web of Sciences, and Google Scholar search engine using English keywords including Maternal outcome, neonatal outcome, birth schedule, delivery plan, birth plan, and their Persian equivalents were searched from 2000 to 2022. Numerous studies were selected and analyzed in a quantitative and qualitative manner that was related to the purpose of the present study in terms of content. Among 948 articles, 13 of the most relevant ones were selected and analyzed for this study. The results of the review of the studies showed that the birth plan has an effect on women's empowerment, satisfaction with childbirth, positive experience of childbirth, cesarean section rate, epidural use rate, episiotomy rate, Apgar, and umbilical cord pH of the newborn. The maternal and neonatal consequences of the birth plan prevail over its negative consequences, and the use of the birth plan can increase women's empowerment, satisfaction with childbirth, positive experience of childbirth, and reduce the rate of cesarean section and negative maternal-neonatal consequences.

Alternate Birth Strategies

Community birth is defined as birth that occurs outside the hospital setting. Birthing in a birth center can be safe for certain patient populations. Home birth can also be safe in well-selected patient with a well-established transfer infrastructure should an emergency occur. Unfortunately, many areas of the United States and the world do not have this infrastructure, limiting access to safe community birth. Immersion during labor has been associated with decreased need for epidural and pain medication. Delivery should not occur in water due to concerns for infection and cord avulsion. Umbilical cord non-severance (also called lotus birth) and placentophagy should be counseled against due to well-documented risks without clear benefit. Birth plans and options should be regularly discussed during pregnancy visits.

Birth plans: definitions, content, effects, and best practices

The first written guide for birth plans was introduced in 1980 as a means for birthing people to document their choices in the child birthing experience. The birth plan offers an opportunity for the patient and the provider to discuss the birthing process and determine how to safely accommodate patient preferences. Patient satisfaction with birthing plans is variable and may depend on how many requests they have, how many of their plans are accomplished, route of delivery, and whether complications arise during or after delivery. Unmet expectations may lead to posttraumatic stress disorder, but following a birth plan may also be protective against it. Birthing people who use a birth plan may be less likely to use epidural anesthesia, have early amniotomy, or use oxytocin. The first stage of labor may be longer when a birth plan is used; however, there does not seem to be a decrease in the length of the second stage of labor among patients with a birth plan. Some providers believe that a disadvantage of birth plans is disappointment when birth plans are not able to be followed, and others consider that birth plans interfere with professional autonomy.

The application of a continuous partnership-based birth plan in China: A randomized controlled trial

BACKGROUND

The cesarean section rate is as high as 36.7% in China, much higher than the average cesarean section rate of 27% in Asia. With the implementation of the two-children and three-children policy, the primipara with cesarean will also face the choice of repeated or even multiple cesareans, which will increase the risk of maternal perinatal mortality and serious fetal pulmonary morbidity. To reduce the cesarean section rate, a series of midwifery service measures such as the birth plan have been taken in China and it has played a certain role in improving the birth outcome and maternal birth experience. However, the areas carrying out birth plan are often economically developed with advanced medical conditions. the application effect of birth plan in economically underdeveloped areas with limited medical conditions in China is unknown.

OBJECTIVE

To evaluate the effects of a continuous partnership-based birth plan on local women's birth outcomes and experience in Haikou which is an economically underdeveloped city in China.

DESIGN

A randomized controlled trial study design was used.

PARTICIPANTS

90 primiparous women who received pregnancy service from the obstetrics clinic of one of tertiary hospitals in Haikou city, Hainan Province between July 2020 and December 2020 and planned to give birth in this hospital were recruited.

METHODS

After eligibility was determined, consents obtained and baseline surveys completed, 90 participants were randomly allocated to study groups with concealed opaque envelopes by a blinded research assistant and each group were 45 participants. Participants in control group received routine obstetric health service and nursing care, while participants in the experimental group received the continuous partnership service of midwives on the basis of routine care. At the same time, the birth plan was formulated and implemented, and the relevant indicators were recorded and analyzed during and after birth, including cesarean section rate, non-medical indication cesarean section rate, oxytocin use rate, perineal lateral resection rate and anxiety degree.

RESULTS

The cesarean rate in the experiment and control groups were 20.45% and 57.14%, of which the non-medical indication cesarean rate in the experiment and control groups were 22.22% and 50.00%, respectively, whereby the difference of cesarean rate and nonmedically indicated cesarean section rate between the groups was statistically significant (χ² = 12.231, p < 0.001;χ² = 9.101, p = 0.003). Besides, the differences in anxiety degree, neonatal NICU transfer rate and satisfaction of birth between the two groups were statistically significant (p < 0.05). While there was no significant difference in oxytocin use rate, perineal lateral resection rate, neonatal 1-min and 5-min Alzheimer's score between the two groups (P > 0.05).

CONCLUSION

The birth plan based on continuous partnership can reduce medical intervention, improve birth outcomes, reduce anxiety and optimize maternal birth experience of women, which is worthy of promotion in economically underdeveloped areas of China.

Effectiveness of birth plan counselling based on shared decision making: A cluster randomized controlled trial (APLANT)

Background

A birth plan (BP) is a written document in which the pregnant woman explains her wishes and expectations about childbirth to the health professionals and aims to facilitate her decision-making. Midwives’ support to women during the development of the BP is essential, but it’s unknown if shared decision making (SDM) is effective in birth plan counselling. We hypothesized that women who receive counselling based on SDM during their pregnancy are more likely to present their BP to the hospital, more satisfied with the childbirth experience, and have better obstetric outcomes than women who receive standard counselling. We also aimed to identify if women who presented BP to the hospital have better obstetric outcomes and more satisfied with the childbirth experience.

Methods

This was a randomised cluster trial involving four Primary Care Units. Midwives provided BP counselling based on SDM to the women in the intervention group (IG) during their pregnancy, along with a leaflet with evidence-based recommendations. Women in the control group (CG) only received the standard birth plan counselling from midwives. The primary outcomes were birth plan presentation to the hospital, obstetrics outcomes and satisfaction with childbirth experience. The Mackey Satisfaction with Childbirth Scale (MCSRS) was used to measure childbirth satisfaction.

Results

A total of 461 (95.5%) pregnant women received BP counselling (IG n = 214 and CG n = 247). Fewer women in the intervention group presented their BP to the hospital compared to those in the control group (57.8% vs 75.1%; p <0.001). Mean satisfaction with childbirth experience was high in the IG as well as the CG: 150.2 (SD:22.6) vs. 153.4 (SD:21.8); p = 0.224). The information received about childbirth during pregnancy was high in both groups (95.1% vs 94.8%; p = 1.0). Fewer women in the IG used analgesia epidural compared to those in the CG (84.7% vs 91.7%; p = 0.034); women who combined non-pharmacological and pharmacological methods for pain relief were more in number in the IG (48.9% vs 29.5%; p = 0.001) and women who began breastfeeding in the delivery room were more in number in the IG (83.9% vs 66.3%; p = 0.001). Women who presented their BP had a greater probability of using combined non-pharmacological and pharmacological methods for pain relief aOR = 2.06 (95% CI: 1.30–4.30) and early skin-to-skin contact aOR = 2.08 (95% CI: 1.07–4.04).

Conclusion

This counselling intervention was not effective to increase the presentation of the BP to the hospital and women’s satisfaction with childbirth; however, it was related to a lower usage of analgesia epidural, a higher combination of pharmacological and non-pharmacological methods for pain relief and the initiation of breastfeeding in the delivery room. Presenting the BP to the hospital increased the likelihood of using pharmacological and non-pharmacological methods for pain relief, and early skin-to-skin contact.

Women's view on shared decision making and autonomy in childbirth: cohort study of Belgian women

Background

Health care providers have an important role to share evidence based information and empower patients to make informed choices. Previous studies indicate that shared decision making in pregnancy and childbirth may have an important impact on a woman’s birth experience. In Flemish social media, a large number of women expressed their concern about their birth experience, where they felt loss of control and limited possibilities to make their own choices. The aim of this study is to explore autonomy and shared decision making in the Flemish population.

Methods

This is a cross-sectional, non-interventional study to explore the birth experience of Flemish women. A self-assembled questionnaire was used to collect data, including the Pregnancy and Childbirth Questionnaire (PCQ), the Labor Agentry Scale (LAS), the Mothers Autonomy Decision Making Scale (MADM), the 9-item Shared Decision Making Questionnaire (SDM–Q9) and four questions on preparation for childbirth. Women who gave birth two to 12 months ago were recruited by means of social media in the Flemish area (Northern part of Belgium).

Linear mixed-effect modelling with backwards variable selection was applied to examine relations with autonomy in decision making.

Results

In total, 1029 mothers participated in this study of which 617 filled out the survey completely. In general, mothers experienced moderate autonomy in decision-making, both with an obstetrician and with a midwife with an average on the MADM score of respectively 18.5 (± 7.2) and 29.4 (±10.4) out of 42. The linear mixed-effects model showed a relationship between autonomy in decision-making (MADM) for the type of healthcare provider (p < 0.001), the level of self-control during labour and birth (LAS) (p = 0.003), the level of perceived quality of care (PCQ) (p < 0.001), having epidural analgesia during childbirth (p = 0.026) and feeling to have received sufficient information about the normal course of childbirth (p < 0.001).

Conclusions

Childbearing women in Flanders experience moderate levels of autonomy in decision- making with their health care providers, where lower autonomy was observed for obstetricians compared to midwives. Future research should focus more on why differences occur between obstetrics and midwives in terms of autonomy and shared decision-making as perceived by the mother.

Immersive virtual reality on childbirth experience for women: a randomized controlled trial

OBJECTIVE

To evaluate the effectiveness of immersive virtual reality (VR) on patient satisfaction as a distractive tool and pain relief among laboring women.

METHODS

This was a randomized, controlled clinical trial with 42 laboring women allocated to VR intervention and control groups. Among women in the VR group, patient satisfaction with the use of VR was assessed by a Virtual Reality Satisfaction Survey, measured by a Visual Analog Scale (VAS) score and evaluated by questioning them about whether they would choose VR in future labor. As a primary outcome, patient satisfaction scores regarding the overall childbirth experience were compared between women in the two groups. A secondary outcome was pain assessed by a visual pain rating scale in the early and active phases of labor in women in both groups. Psychometric information was also collected from participants in each group using the Beck Anxiety Inventory and Beck Depression Inventory.

RESULTS

We observed a high level of patient satisfaction with the use of immersive VR during labor. The VAS revealed a mean satisfaction score of 87.7 ± 12.9 out of a maximum of 100. Twenty out of 21 (95%) women in the VR group stated that they would like to use VR again in future labor. VR improved pain scores in early labor and contributed positively to the overall childbirth experience. The mean pain score pre-VR was 2.6 ± 1.2 compared to 2.0 ± 1.3 post-VR (p < 0.01). Anxiety and depression scores were similar in participants in the intervention and control groups (p = 0.103 and p = 0.13, respectively).

CONCLUSION

Immersive VR application during labor was associated with higher patient satisfaction based on our study findings. VR also improved participants' pain scores in early labor before epidural administration. Immersive VR may find a place as an adjunct in labor and delivery units to improve lengthy labor experiences for women. Studies with larger groups of participants are needed to confirm these observations.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT05032456.

Development of a simple and effective online training for health workers: results from a pilot in Nigeria

Background

Health workers (HWs) in Africa face challenges accessing and learning from existing online training opportunities. To address these challenges, we developed a modular, self-paced, mobile-ready and work-relevant online course covering foundational infection prevention and control (IPC) concepts. Here, we evaluate the first pilot of this course, conducted with HWs in Nigeria.

Methods

We used a learner-centered design and prototyping process to create a new approach to delivering online training for HWs. The resulting course comprised 10 self-paced modules optimized for use on mobile devices. Modules presented IPC vignettes in which learning was driven by short assessment questions with feedback. Learners were recruited by distributing a link to the training through Nigeria-based email lists, WhatsApp groups and similar networks of HWs, managers and allied professionals. The course was open to learners for 8 weeks. We tracked question responses and time on task with platform analytics and assessed learning gains with pre- and post-testing. Significance was evaluated with the Wilcoxon signed-rank test, and effect size was calculated using Cohen’s d.

Results

Three hundred seventy-two learners, with roles across the health system, enrolled in the training; 59% completed all 10 modules and earned a certificate. Baseline knowledge of foundational IPC concepts was low, as measured by pre-test scores (29%). Post-test scores were significantly higher at 54% (effect size 1.22, 95% confidence interval 1.00-1.44). Learning gains were significant both among learners with low pre-test scores and among those who scored higher on the pre-test. We used the Net Promoter Score (NPS), a common user experience metric, to evaluate the training. The NPS was + 62, which is slightly higher than published scores of other self-paced online learning experiences.

Conclusions

High completion rates, significant learning gains and positive feedback indicate that self-paced, mobile-ready training that emphasizes short, low-stakes assessment questions can be an effective, scalable way to train HWs who choose to enroll. Low pre-test scores suggest that there are gaps in IPC knowledge among this learner population.

The Birth Plan Experience—A Pilot Qualitative Study in Southern Spain

Background: Healthcare systems advocate for quality care and humanized relations in routine birth care, and have therefore created the Birth Plan, a document available to pregnant women to state their preferences in relation to the birth process. Methods: This qualitative research with a phenomenological design was carried out to record the experiences of women who presented a Birth Plan. Sample selection was carried out using non-probabilistic, intentional and convenience sampling, selecting seven participants who were willing to participate and share their experiences. Results: After analyzing the content of the interviews, four categories emerged: “respecting the woman’s wishes: humanizing the birth process”, “information and primary Care”, “expectations regarding the care received” and “results of using the birth plan”, with their corresponding subcategories. Conclusion: Women consider it beneficial to present a Birth Plan, because it informs them about the process and gives them the opportunity to have a better experience, which takes into account their preferences for making the delivery less instrumental. In addition, they state the importance of having trained professionals involved, and call for more attention to be paid to the birth process in general.

Birth plan presentation to hospitals and its relation to obstetric outcomes and selected pain relief methods during childbirth

Background

The information on birth plan (BP) usage in Spanish hospitals is scant.

Aim

To identify the percentage of pregnant women presenting a BP at five hospitals in Spain, the reasons why some women failed to do so and how BP presentation relates to obstetric outcomes and selected pain relief methods.

Methods

In this descriptive, multi-centre study, data were retrospectively collected. During the postpartum visits at primary healthcare centres in various health districts in Barcelona (Catalonia, Spain), a data collection sheet about obstetric outcomes and analgesia was administered to 432 mothers who had completed a BP during their pregnancies. The main outcome was the rate of BP presentation to the hospital. The sociodemographic and obstetric characteristics and pain relief measures were compared to identify any differences between mothers who presented a BP and those who did not.

Results

A total of 422 (99.7%) women were studied; 51.2% of women (95% confidence interval (CI): 46.4–55.9) had presented a BP. The main reason for not presenting a BP was because the hospital midwives did not request them (61.2%). No differences were observed in BP presentation according to age, the country of origin, education, employment or hospital. Mothers who presented a BP were more likely to start breastfeeding in the birthing room (82.4% vs. 73.3%; p = 0.024). Epidural analgesia was the most common method used for pain relief (88.9%), and women who presented a BP attempted to use concomitant non-pharmacological methods more often (50.5% vs. 38.8%; p = 0.012).

Conclusion

Almost half of the mothers failed to present a BP, usually because midwives did not request it.