unique and proforma birth plans: a qualitative exploration of midwives׳ experiences

Unique and proforma birth plans: A qualitative explorationof midwives' experiences

Joanne V. Welsh, RM, BA (Hons), MSc (Staff Midwife)a, Andrew G. Symon, RM, MA (Hons),CTHE, PhD (Senior Lecturer)b,n

a Addenbrooke's Hospital, Hills Road, Cambridge CB2 0QQ, UKb Mother and Infant Research Unit, School of Nursing & Midwifery, University of Dundee, 11 Airlie Place, Dundee DD1 4HJ, UK

a r t i c l e i n f o

Article history:Received 16 October 2013Received in revised form30 January 2014Accepted 2 March 2014

Keywords:Birth planMidwife-led unitObstetric unitChoiceExpectations

a b s t r a c t

Background: birth plans detailing a woman's preferences for intrapartum care are a common feature inBritish maternity units, and are a means of encouraging the implementation of choice. Proforma versionsmay be incorporated routinely in antenatal case notes, or the woman may devise her own unique birthplan. Although women's views of birth plans have been explored, the views of midwives have not to datebeen evaluated. The growth of midwife-led units in the UK has highlighted different philosophies of care,some of which can be reflected in the different types of birth plan. Given the increasingly diverse natureof UK midwifery workplaces we set out to explore and compare the experience of midwives working inmidwife-led and obstetric-led settings in relation to unique and proforma birth plans.Method: qualitative study using focus groups of midwives in a midwife-led unit (MLU; n¼5) andobstetric-led unit (OLU; n¼4) in the East of England. We used an interpretative phenomenologicalanalytical approach.Findings: three main themes arose from the data. Firstly, the term ‘birth plan’ can be misleading, and wascriticised for encouraging the belief that birth can be ‘planned’. In addition, midwives claimed that‘unique’ birth plans, especially those influenced by some consumer advocacy groups, are becomingstandardised in their rejection of policies and procedures and requests for intervention-free birth.Secondly, birth plans were a source of irritation for midwives in both groups, although the cause of theirritation differed between groups. Finally, it was found that midwives in both groups felt that birth plansput pressure on them, although again, the source of the pressure, and therefore the way in whichmidwives reacted to this pressure, differed between groups.Conclusions: the term ‘birth plan’ can be misleading and create false expectations. If ‘unique’ birth plansare becoming ‘standardised’ in the sense that they routinely request the same things, they are littledifferent to proforma birth plans. Some midwives perceive pressure both from women and the widermultidisciplinary team as a result of birth plans, a perception that causes some irritation.

Introduction

Birth plans detailing a woman's preferences for her intrapar-tum experience (Lothian, 2006) were introduced in the UnitedKingdom [UK] in the 1970s as a response to the increasingmedicalisation of labour (Kitzinger, 1999). They provide womenwith a platform to explore and articulate their preferences for thebirth experience to those caring for them (Kitzinger, 1999; Lothian,2006). In the context of a health care system that promotes serviceuser choice, this may be seen as a significant achievement. Women

may present in labour with an individually researched and writtenbirth plan, a proforma birth plan that is a feature of their maternitynotes, or no birth plan at all.

Given the current drive to promote choice and the need forpractice to be evidence-based, it is surprising to find that the mostrecent empirical evidence in the UK-based literature is Whitfordand Hillan's (1998) questionnaire survey of 107 women, and Joneset al.'s (1998) six-month audit of outcomes for 1172 women, 42 ofwhom had used a birth plan. The international literature doesprovide more recent examples of empirical studies from the USA(Deering et al., 2007; Grant et al., 2010; Pennell et al., 2011),Australia (Brown and Lumley, 1998; Peart, 2004), Sweden (Berg etal., 2003; Lundgren et al., 2003), Mexico (Yam et al., 2007), Taiwan(Kuo et al., 2010), Israel (Hadar et al., 2012) and Canada (Aragonet al., 2013). Given the wide geographical and cultural spread of

Contents lists available at ScienceDirect

journal homepage: www.elsevier.com/midw

Midwifery

n Corresponding author. Tel.: +44 01382 388534.E-mail addresses: jovwelsh@gmail.com (J.V. Welsh),

a.g.symon@dundee.ac.uk (A.G. Symon).

Please cite this article as: Welsh, J.V., Symon, A.G., Unique and proforma birth plans: A qualitative exploration of midwives' experiences.Midwifery (2014), http://dx.doi.org/10.1016/j.midw.2014.03.004i

Midwifery ∎ (∎∎∎∎) ∎∎∎–∎∎∎

the countries cited here, it is unsurprising that these studies haveproduced some conflicting results. Particular care must be takenwhen drawing comparisons between different cultural and clinicalsettings, not least because many of these reflect maternity carewithin a largely obstetric model. Some opinion-based pieces dooffer insights into this issue but these cannot off-set the lack ofrecent and relevant empirical evidence for the UK context.

The birth plan is thought to enhance communication betweenwoman and care provider, and can therefore be used as a platformfrom which women can explore and articulate their preferencesfor the birth experience (Too, 1996b; Brown and Lumley, 1998;Perez, 2005; Pennell et al., 2011). However, in both the UK and USAit has been claimed that the birth plan has been institutionalised(Price, 1998; Kitzinger, 1999; Nolan, 2001; Lothian, 2000, 2006;Simkin, 2007). This refers to its incorporation into the maternitynotes, with the corresponding use of terminology that steerswomen to make certain choices (Kitzinger, 1999; Peart, 2004;Kaufmann, 2007): women are presented with the illusion ofchoice, birth plan options being restricted to established commonpractices. That hospital policies can constrain a midwife's ability totailor care has also been noted in the UK (Too, 1996a, 1996b; Price,1998; Robinson, 1999; Nolan, 2001). Similarly, in the USA Lothian(2000, 2006) reports that practitioners can become institutiona-lised within their workplace, which restricts their flexibility inaccommodating birth plan requests. Others have noted that birthplans can create tensions between women and their care provi-ders, which may in turn provoke negative attitudes from careproviders and ultimately impact upon clinical care (Too, 1996b;Kitzinger, 1999; Robinson, 1999; Simkin, 2007).

In the UK maternity care provision has changed over recentyears. Redshaw et al. (2011) note a significant growth in England inmidwife-led units (MLUs) which offer antenatal, intrapartum andpostnatal care. MLUs are contrasted with obstetric-led units(OLUs) in the UK, in which midwives are still the lead caregiversat most births: the term ‘obstetric-led’ refers to the fact thatobstetric and other medical facilities are available on site, unlike ina midwife-led unit. Although the pattern of service provision isdynamic and complex, there is some evidence that the ‘philosophyof care’ varies between these types of unit (Coyle et al., 2001a,2001b; Lavender and Chapple, 2004). Broadly speaking, midwivesin MLUs are in a better position to provide continuity of care and amore woman-focussed approach. As we explain below, one way inwhich this difference sometimes manifests itself is in terms of thetype of birth plan that is typically seen.

Given the centrality of choice in the rhetoric around contem-porary maternity care, and given the growth of MLUs in the UKwhich aim to operationalise that choice, it is perhaps surprisingthat birth plans have received less attention in recent years. Theinternational literature, although more recent and enlightening insome respects, inevitably reflects the prevalent model (oftenobstetrician-led) in the relevant country, and while the views ofwomen are at least accorded some prominence in these studies, itis noticeable overall that the midwife's view has been largelyignored. As she has a key role in discussing and trying to effect thewishes of the labouring woman in the UK, this represents a gap inthe evidence base. Sandall et al.'s (2013) recently re-issuedCochrane review has focussed attention on midwife-led care – auseful reminder that different models of care exist. Mead (2003)has identified the tendency of midwives working within thesedifferent models to adopt the ethos of their working environment,resulting in significantly different approaches to care, a pointechoed by Lavender and Chapple (2004). It is evident that differentworking environments in maternity care have evolved within theUK. One example from local experience is that women attendingthe MLU often proffer individually-written birth plans, although‘proforma’ birth plans are a feature of the handheld notes given to

all women. While a small minority of women attending thecorresponding OLU within the same NHS Trust also write indivi-dual birth plans, most complete the ‘proforma’ version. Broadlyspeaking, then, the different types of birth plan can be said toequate to the different unit types. While the proforma's pre-defined sections are intended to focus the discussion around birthpreferences, there is concern that in practice they may bedeterministic, thereby restricting real choice. Thus we have twoissues: a lack of overall evidence concerning UK midwives'experiences of dealing with birth plans, and a growing divergenceof practice with regard to birth plans. We therefore set out toexplore midwives' experiences of birth plans. As a secondaryconsideration, we used the workplace (in this case an MLU andthe corresponding OLU within the same NHS Trust) as a backdropagainst which to compare the experiences of midwives in twodifferent environments. The proforma birth plan was taken from apage in the local unit's handheld maternity notes. It listed ‘Ques-tions you might like to think about’ (e.g. coping with pain, fetalmonitoring, and after the birth) and had blank boxes for thewomen to fill in their responses. The unique birth plan was a freetext document that demonstrated how women take a blank canvasand write out their birth preferences without being steered bycertain questions.

Methods

Interpretative Phenomenological Analysis (IPA) – based onphenomenology and concerned with the exploration of an indivi-dual's lived experience (Smith, 2004) – was chosen as thetheoretical framework on which to base this research. IPA recog-nises the dynamic process of research, paying attention to the roleplayed by the researcher in interpreting participants' perspectives(Smith, 1996, 2004; Biggerstaff and Thompson, 2008; Smith andOsborn, 2008).

Focus groups were chosen as a means of data collection.Although some note that focus groups are not the traditionalmeans of data collection in phenomenological research, we sup-port Bradbury-Jones et al.'s (2009) conclusions that this can in factbe justified in an interpretive study providing the researchersacknowledge the implications of this approach. With the firstauthor (JW) being a member of one of the groups under review, acompletely detached (‘bracketed’) approach is rather implausible.Indeed, the scope for searching for interpretations within thegroup context is likely to be enhanced. Reflexivity in this processwas attempted, with the first author consciously refraining frominterjecting in the focus groups until absolutely necessary.

All available midwives working in the MLU (n¼9) and OLU(n¼50) in question were sent emails explaining the nature of theresearch, and asked to contact the researcher should they wish toparticipate. From this potential sample six MLU and five OLUmidwives agreed to participate. In the event one midwife fromeach group was unable to attend on the day, so the two focusgroups consisted of five midwives from the MLU (MW1– MW5)and four from the OLU (MW6–MW9). Within each focus group themidwives were considered to form a homogeneous entity, sharingas they did a common workplace. As we note above, withinmaternity care this has been found to engender a shared philoso-phy of care (cf. Mead, 2003; Lavender and Chapple, 2004).

The first author (JW) facilitated and observed both of the focusgroups. An additional note taker was present for the MLU focusgroup, but due to unforeseen circumstances could not attend theOLU focus group. The MLU focus group took place in the emptypostnatal bay of the MLU (there were no women on the MLU at thetime) and the OLU group took place in an office. Both lastedapproximately one hour. Discussion aids (a proforma and a unique

J.V. Welsh, A.G. Symon / Midwifery ∎ (∎∎∎∎) ∎∎∎–∎∎∎2

birth plan, both based on local examples) were circulated at thebeginning of the session to stimulate discussion. A list of promptsand questions based on existing literature was also used (e.g.‘What feelings are provoked when you see this birth plan?’ ‘In yourexperience do you think women presenting with birth plans tendto achieve their desired experiences?’ Discussions were audiorecorded with the prior written consent of all participants. Thesewere then transcribed verbatim and analysed independently byboth authors using thematic analysis. This involved the identifica-tion of preliminary themes, identifying connections between thesethemes, clustering related themes together, and the generation ofsuper-ordinate and sub-ordinate themes. Consultation betweenthe two authors confirmed the final analysis of themes. Once datahad been analysed for each group, cross group analysis allowed forconvergent and divergent themes to be identified.

The relevant University Research Ethics Committee (UREC11055) and the participating NHS Trust's research departmentapproved the research.

Findings

The principal aim was to explore midwives' experiences ofbirth plans, with a secondary aim of comparing the experiencesfrom two different settings. Three main themes arose from thedata, revealing areas of similarity and difference between the twogroups. Firstly, the term ‘birth plan’ was felt to be misleading inboth groups, and not particularly useful in the role of preparingwomen for childbirth. In particular, the use of the word ‘plan’ wasbelieved to lead women to develop unrealistic expectations abouttheir forthcoming experience. Furthermore, although womenapparently believe their own birth plans are unique, midwivesoften disagreed, indicating that they are just as regimented asproforma birth plans. Secondly, birth plans were a source ofirritation for midwives in both groups, although the cause of theirritation differed between groups. Finally, midwives in bothgroups felt that birth plans created pressure for them.

The term ‘birth plan’

Some birth plan terminology was deemed to be a hindrance. Inparticular, using the word ‘plan’ was deemed to contribute towomen's unrealistic expectations regarding labour:

A plan suggests you can plan it, so that's what's [pause], you can'tplan it. You can't totally plan labour can you? (MW6 [OLU])

Midwives from the OLU recognised that it was not just the term‘birth plan’ that made some women appear inflexible in theirexpectations. Indeed, they identified the National Childbirth Trust(NCT) as a cause of the rigidity associated with the term ‘birthplan’, going so far as to say that the NCT encouraged women torefuse intervention:

…so they go to the NCT, and they get ‘don't let them do this,don't let them do that’… (MW9 [OLU])

Both groups identified that expectations documented in thebirth plans sometimes ignore clinical realities. Interestingly, whilstMLU midwives mainly discussed this in terms of their concernsthat women did not know how they would cope with labour, OLUmidwives focussed more on women not understanding that theyare necessarily not in control of their labour. The term ‘birth plan’therefore gives a false sense of control:

…when it's their first time, they don't know how they're gonnacope with labour… (MW5 [MLU])

…but what they don't appreciate is that really, they're not incontrol of what happens at all. If it's gonna happen, it will happen,regardless of what they've got written down. (MW7 [OLU])

Consequently, both groups of midwives were concerned thatunrealistic expectations held by women that they can plan theirbirth, increases the chance of women feeling disappointed whentheir expectations are not met. This phenomenon was noted withparticular reference to the ‘unique’ birth plan:

…with the (unique) birth plan particularly, if anything unto-ward does come, does happen, she doesn't get the birthexperience that she wants, how is she going to cope with thatpostnatally? (MW7 [OLU])

The belief that womenmight be disappointed when a birth did notgo according to plan was more firmly held among the OLU midwives.Furthermore, they commented critically on the NCT as a factor con-tributing to women's disappointment if labour did not go as planned:

And you can tell the ladies that had been to NCT classes.Because they were very regimented and they make women feelbad about having epidurals and things like that…(MW8 [OLU])

Reference to the NCT being regimented suggests that ‘unique’birth plans are effectively just another type of standardisedproforma birth plan. Indeed, midwives in the MLU group notedthat they frequently saw replicated ‘unique’ birth plans:

…they've all been from the same class, they've known eachother, and they've all had pretty much the same birth plan.(MW2 [MLU])

When addressing the issue of helping women make moreeffective, realistic birth plans, that help to avoid disappointment,and increase awareness that birth cannot be meticulously planned,midwives in both groups commented on the need for a midwife tobe more actively involved:

I think the main thing for me with birth plans is having them(women) speak to somebody, preferably a midwife, to gothrough their birth plan with them, to highlight, you know,what is realistic… (MW8 [OLU])

Consequently, although midwives in both groups found theterm ‘birth plan’ to be misleading, they each commented that bothproforma and unique birth plans were useful tools to aid commu-nication between midwives and women, and therefore help toraise awareness that the birth plan needs to be fluid:

And like the proforma one, it's kind of a good discussion toolisn't it? (MW1 [MLU])I would say that the unique one there probably, you wouldprobably have a lot of discussion with them… (MW5 [MLU])

Given that midwives in both groups felt that women misunder-stood the role of the birth plan, it is perhaps not surprising thatthis research also found that birth plans sometimes act as a sourceof irritation for midwives.

Birth plans as a source of irritation

Midwives in both groups expressed feelings of irritation if a birthplan hinted that a midwife may not act in the woman's best interests.In particular, midwives in both groups commented on the request inthe unique birth plan, ‘At the point of delivery I do not want to be cutas I would prefer to tear naturally.’ They claimed that womenmisunderstand the role and intentions of the midwife:

That makes me think that this woman thinks that that's what wedo. That we cut people when there's no indication. (MW2 [MLU])

J.V. Welsh, A.G. Symon / Midwifery ∎ (∎∎∎∎) ∎∎∎–∎∎∎ 3

Midwives in both groups commented how they found suchrequests annoying:

…that's one thing that gets your back up, like, ‘without myconsent’, or if, ‘unless necessary’. It's, yeah, we'd never doanything that wasn't necessary to get a baby out. Well, Iwouldn't. (MW3 [MLU])

Whilst midwives from both groups expressed irritation andsome defensiveness towards birth plans, these experiences andexpressions differed between groups. In particular midwives fromthe MLU felt defensive when women didn't trust their professionalexperience and skills, or apparently thought they would actinconsiderately:

…they seem to think that we're kind of idiots….you knowexpecting us to just blurt things out and you know, kind of offerthem things that they don't want. (MW1 [MLU])The ones that's yeah, really, really, really detailed, and reallyfeel like they're attacking you and your skills as a midwife.(MW3 [MLU])

By contrast, it appeared that OLU midwives' feelings of irrita-tion arose from women's apparently inaccurate and overly opti-mistic expectations for labour, and their ability to control it:

It's that somebody with this sort of (unique) birth plan wouldcome in with that attitude anyway. And almost write, ‘this iswhat I'm going to do’. (MW9 [OLU])

Additionally, midwives in both groups suggested that certainconsumer advocacy groups often present midwives in a negativelight, and this influences women's birth plan requests. Conse-quently, midwives in both groups talked of experiences wherethey felt women mistrusted them to support their birth plans, andfurther, talked of women using birth plans as a means of protect-ing themselves from unnecessary procedures:

But the way it's (unique birth plan) worded is as if we would tryto push something on her. (MW2 [MLU])And sometimes they can be quite defensive towards youbecause they think you're not going to follow it… (MW8 [OLU])

A further source of irritation for OLU midwives was the viewthat women are inflexible with regard to the best interests of theinfant. In particular, they talked of situations where women, andthose with unique birth plans in particular, were seen to put theirexperience of labour above their infant's well-being, although theOLU midwives used anecdotes concerning women who had sig-nificant pregnancy complications to reinforce this point:

…because she wanted ‘her’ experience, and whenever youspoke to her, that was all it was about, was her experience.And it was the first time she ever stopped to think, actually,there's a baby in there that's not worried about her experience,it just wants to be helped to be born. (MW8 [OLU])

By contrast, whilst recognising that women seek to have asatisfying birth experience, midwives from the MLU felt thatwomen did not pursue their experiences to the detriment of theirunborn baby:

Especially if it's changing things because of a kind of specificreason, like you've got thick meconium or if you've gotdecelerations….they do seem to generally accept that the babycomes first. (MW1 [MLU])

MW6 attempted to explain the perceived selfishness highlightedby OLU midwives, by noting that based on their experiences, women

and midwives have very different perspectives of what to expect inlabour:

But is that because as professionals we see adverse outcomes?… the statistics on babies dying and mums dying, is pretty,is fortunately in our country very low, so they're notactually, they're going in thinking ‘How do I want to birth?’…(MW6 [OLU])

However, in their experience, both groups of midwives foundthe proforma birth plan to be more flexible than the unique birthplan, thus provoking less irritation:

…it's (unique) not very flexible. Then the other birth plan's(proforma) a bit more flexible. (MW1 [MLU])

Midwives in the OLU group identified that actively involvingthe midwife in antenatal education about childbirth would con-tribute to more realistic planning from women, and thereforereduce feelings of irritation experienced by midwives:

I wish that community midwives could spend more time withwomen to say to them ‘we only do this IF there's a medicalneed to do it.’ (MW8 [OLU])

Birth plans as a source of pressure

Unique birth plans were felt by both MLU and OLU midwives tocreate certain pressures to provide appropriate care. Midwivesfrom the MLU spoke of feeling pressure to facilitate women'sdesired birth expectations:

I think when you see one like this (unique birth plan), there'sexpectations on us isn't there really? To help them achieve that.In a way that's quite scary and daunting. (MW5 [MLU])

In spite of this pressure, midwives were also able to feel a senseof achievement and satisfaction when they were able to assist awoman in achieving her ideal birth. One midwife demonstratedthis satisfaction by saying that she was able to look at a woman'sbirth plan following labour and tick off what had been successfullyachieved:

It does feel good afterwards. Tick, tick, tick. (MW3 [MLU])

Conversely, the OLU midwives felt pressure from obstetric staffto get women to change their birth plans to conform to hospitalpolicies:

And that's the thing. You actually become obstructive to thedoctors because you are advocating for that woman, and thenthat can put you in more of a difficult situation. (MW8 [OLU])

Indeed, midwives in both groups showed some feelings ofbeing constrained by institutional requirements:

They need to realise that you've got to, you know, do someassessment. (MW1 [MLU])And you know, you do have to disturb them, ‘cos we have ourrules and regulations for listening in, and doing blood pressuresand all those sorts of things. (MW8 [OLU])

Additionally, midwives in the MLU felt that unrealistic expecta-tions created a certain pressure. In such situations midwives didnot want women to feel disappointed that labour was not as theyhad expected:

But what's quite challenging is when somebody's got a big longbirth plan, no pain relief, no intervention, and then they comein in latent phase, convinced that they're in active labour…because then having to say, either ‘You're not in labour and

you're going home’, or ‘You're saying you want pain relief, soyou're breaking your birth plan…. (MW3 [MLU])

Pressures placed on midwives in different settings came fromdifferent sources, and for the MLU midwives, feeling able to beflexible in caring for women with specific requests helped themachieve desired outcomes:

I think it's easier if you know what they want in the first place,just to work a little bit harder to give them that. If you don'treally know what they want, you can't really give them theexperience they might want. (MW4 [MLU])

For these midwives, birth plans seem to contribute to midwivesand women working towards shared goals, although this is notalways straightforward. By contrast, the OLU midwives did notseem to feel they were able to be so flexible, being constrained by‘rules and regulations’, which are in part determined byobstetric staff.

Discussion

The term ‘birth plan’

This study appears to be the first to identify that some mid-wives feel the term ‘birth plan’ is a misnomer. In particular,midwives from both groups felt that the term ‘plan’ gave womena false expectation that they will have control over their labour,and can plan exactly what will happen.

Our secondary consideration of comparing the two groupsrevealed some intriguing differences in experience, with MLUmidwives commenting that they frequently encounter replicated‘unique’ birth plans. However, as ‘unique’ birth plans are moreoften found in the MLU, it is perhaps not surprising that the OLUmidwives had less opportunity to make this observation. Price(1998), Kitzinger (1999), Nolan (2001) and Simkin (2007) havecommented that proforma birth plans are ‘institutionalised’: whileclaiming to promote women's active participation in birth plan-ning, their standardised approach actually removes choice. Thecurrent study appears to be the first to identify that ‘unique’ birthplans may be similarly ‘institutionalised’.

In relation to this, it is interesting to note that both groups ofmidwives identified the NCT, seen as an ardent promoter ofintervention-free labour, as a dominant external organisation insculpting and standardising women's birth plan requests. How-ever, midwives negatively stereotyped the NCT, noting that itsinfluence apparently encouraged women to rebel against inter-ventions in labour. Davies and Iredale (2006) also found thatmidwives believe consumer groups which provide antenataleducation raise unrealistic expectations. Aragon et al. (2013) notethat such expectations can lead to feelings of disappointmentwhen things do not turn out as hoped.

It is perhaps not surprising then that OLU midwives felt theorganisations that influence birth plan requests are a contributingfactor in women's feelings of disappointment when expectationsare not met. This supports Lundgren et al. (2003) who found thatwomen with birth plans were more likely to have disappointingexperiences due to unrealistic expectations. Moreover, Goodmanet al. (2004) and Hauck et al. (2007) found that women who hadtheir childbirth expectations met were more satisfied with thetotal childbirth experience and themselves than their counterpartswhose expectations were not met. These findings echo O'hare andFallon (2011) who found that women were left feeling inadequate,disempowered and lacking a sense of achievement when theirexpectations were not met.

Birth plans as a source of irritation

Given that MLU midwives saw women using birth plans as adefensive tool, it is perhaps not surprising that midwives in bothgroups alluded to birth plans creating tension between womenand their midwives, and causing irritation among midwives (cf.Too, 1996b; Kitzinger, 1999; Robinson, 1999; Simkin, 2007).

Whilst this study found that midwives from both groupsassociated unique birth plans with irritation, the experiences andcauses of irritation differed between the groups. MLU midwiveswere irritated when they felt women did not respect their skillsand experience and when they were perceived by women to actinconsiderately. For the OLU midwives, feelings of irritation werecaused by women's perceived lack of flexibility and understandingthat clinical interventions may be necessary – a finding echoed byPrice (1998), Nolan (2001), and Lothian (2006). Equally, OLUmidwives appeared offended that women wished to challengetheir control (cf. Perez, 2005). Indeed, Too (1996b) and Wier(2008) commented on midwives' reluctance to surrender theircontrol over labour. The current study supports Blix-Lindström etal.'s (2008) and Lindberg et al.'s (2005) research which concludedthat midwives find it difficult to surrender to women their controlas an ‘expert.’

There was agreement between groups that irritation arosewhen women specifically requested that interventions were notperformed unless necessary. Kaufmann (2007) observed that theserequests often arose where women consulted internet-basedtemplate birth plans. In this research, it was the experience ofMLU midwives that women made such requests based on whatthey had been taught locally in NCT classes. Larsson (2009)suggests that women view the internet as reliable, and do notfeel the need to discuss information sourced in this way with theirmidwife. If the same applies to information learned via NCTclasses, then women may continue to make requests that willcause irritation.

Both groups of midwives identified that the unpredictablenature of childbirth warrants the need for flexibility in birth plans(cf. Too, 1996a; Price, 1998; Kaufmann, 2007). Indeed, it was theexperience of MLU midwives in this research that women wouldact flexibly if the safety of their infant was compromised, a findingsupported by Berg et al. (2003) and Peart (2004).

Whilst midwives in both groups highlighted this need forflexibility, both groups had experienced situations where theunique birth plan was inflexible, to the extent that women seemedto place a higher value on their personal experience of labour thanon their infant's safety. In particular, OLU midwives repeatedlyreferred to women's lack of understanding regarding interventionon the grounds of safety. However, all of their anecdotes con-cerned extreme cases, focusing on women who already hadsignificant complicating pregnancy factors that may well haverequired some form of intervention. In the focus groups, midwiveswere able to pick and choose the anecdotes and stories theywished to illustrate their experiences of birth plans. Such story-telling allows the storyteller to reinforce their point by recon-structing their version of events (Hill Bailey and Tilley, 2002). In thisresearch, the sharing of extreme cases, where women had refusedintervention, heightened the sense of maternal inflexibility.

Furthermore, the experiences and perceptions of the OLUmidwives that women can be inflexible to their infant's needsmay be coloured by the clinical realities of their working environ-ment. Consequently, when women make choices at odds with OLUphilosophy, they are deemed to be inflexible and even selfish(Davis, 2003). It is not surprising however that women do makesuch choices: Leap and Edwards (2006) note that women's viewsregarding safety are often broader than those held by midwives.The question must be raised therefore about whose safety is being

considered when OLU midwives view women's rejection of theiradvice for intervention as being inflexible. In particular, HollinsMartin and Bull (2006) found that midwives were fearful oflitigation in situations where they had supported women indecision making, and found that the best way to avoid this wasto follow hospital protocol. Equally, Kitzinger et al. (2006) com-mented that midwives feel the need to intervene to produceevidence that they have taken preventative action rather thandoing nothing at all.

Birth plans as a source of pressure

When caring for women with birth plans both MLU and OLUmidwives had experienced pressure to provide appropriate care.MLU midwives felt pressure to fulfil women's expectations forlabour, and in line with Too's (1996b) findings, this pressure wasgreatest when providing care for women with detailed birth plansand high expectations.

By contrast, OLU midwives experienced pressure because theyhad to mediate between the woman and obstetric staff. Suchfeelings, which in turn influence midwives' decision making skills,are imposed by hierarchical constructs found in the obstetric-ledsetting (Kirkham, 1996; Hunter, 2003; Russell, 2007). Stapletonet al. (2002) go so far as to suggest that such hierarchicalconstraints leave midwives trying to balance conflicting loyalties,often resulting in the implementation of obstetric-led policies andprotocols, and a processing mentality that ensures women actcompliantly with obstetric preferences. This finding of pressure onthe OLU midwives from obstetric staff supports Davies and Iredale(2006) who found that birth centre midwives felt less pressure fromobstetric staff to fit in, as they are able to act more autonomouslythan their OLU counterparts.

This raises a further interesting issue surrounding woman-centredcare. In particular, the question must be raised about how midwivesfacilitate woman-centred care in the presence of hospital guidelines,and policies and protocols that apply general rules to individualwomen (Magill-Cuerden, 2005; Edwards and Murphy-Lawless,2006). Indeed, such policies and procedures were identified in theliterature review as barriers to the implementation of birth planrequests (Too, 1996b; Price, 1998; Nolan, 2001; Lothian, 2000, 2006).Furthermore, the notion that hospital policies and protocols under-mine midwifery autonomy is not new (Lavender and Chapple, 2004;Hollins Martin and Bull, 2006). It is well documented that thehospital setting creates a ‘with institution’ approach to care(Hunter, 2004) that holds values of standardisation, predictabilityand efficiency (Walsh, 2006), which are at odds with woman-centredcare. It is clear that women themselves are aware of these differencesin care provision, with hospital care being associated with achievingthe requirements of the institution rather than being flexible andpersonal (Coyle et al., 2001a), whilst women view birth centrephilosophy as enabling the birth process to happen free of inter-ference (Coyle et al., 2001b).

Edwards and Murphy-Lawless (2006) note that women areexpected to make responsible choices, which are themselvesmapped out by medicine and based on managing risk. Conse-quently, holistic care is overlooked as little consideration is paid toa woman's physical and emotional well-being. However, policiesand protocols act merely as guidance: implementing themwithoutassessing the individual situation is an inappropriate and ques-tionable practice that can detract from a woman's experience(Symon, 2006). Furthermore, policies and protocols are based onthe results of population surveys, and may not be transferrable tothe individual (Greenhalgh, 2002). Indeed the NMC Code (NMC,2008) reinforces the point that midwives should treat women asindividuals. Midwives have an obligation to question obstetricpractices interfering with woman-centred care.

Limitations

This study has several limitations. It is geographically limited toone relatively affluent area of England, and as the first author (JW)has worked at the MLU in question for some years, it is possiblethat this influenced both recruitment and the focus group discussionitself. Conducting research in one's own place of work can lead toparticipants offering socially desirable answers (Litosseliti, 2003; Rees,2011). It is also feasible, given the politics of local maternity serviceprovision, that the OLU midwives viewed JW (an MLU midwife) asa rival. We concede that the response rate from the OLU was low.Self-selection bias may have been particularly pronounced. To reducethe potential for researcher bias in the analysis phase the secondauthor (AS) independently analysed the transcripts.

Due to last minute commitment changes, the OLU focus groupran without a note taker. Whilst the presence of a note takerduring focus group discussions is often recommended, it is notdeemed to be essential (Wilkinson et al., 2004; Holloway andWheeler, 2010). Consequently, the OLU discussion can still beviewed as a focus group discussion, but the integrity and compar-ability of data gained from this group may be questionable giventhat its facilitation differed to the MLU group.

Whilst stimulus materials are useful at drawing out discussionswhich allow comparisons between groups to be made (Barbour,2007), the materials used here – being locally based – may not betypical of birth plans seen elsewhere, thus limiting transferabilityof results.

Conclusion

Despite these limitations, several interesting issues have beenraised that support existing evidence. This research has also providedtwo further insights: firstly, the term ‘birth plan’ has been consideredby some midwives to be inappropriate, contributing to the develop-ment of women's unrealistic expectations, and in particular thenotion that a labour can be ‘planned’. We suggest that the term‘birth preferences’ may be a more helpful term. Secondly, ‘unique’birth plans, especially those influenced by some consumer advocacygroups, appear to be becoming standardised in their refutation ofpolicies and procedures and requests for intervention-free birth.

Although the scale of our study means our conclusions aretentative, we found that the good intentions surrounding theintroduction of birth plans have been somewhat undermined bythe problems they have created. These included raising barriersbetween women and midwives due to feelings of irritation,although distinct approaches may be needed to tackle this as thenature of the irritation varied between units. Barriers were alsoraised between midwives and the wider multidisciplinary team asmidwives try to act as women's advocates. As Robinson (1999)suggests, perhaps success will come when women believe thatthose caring for them will act in their best interests, thus renderingthe birth plan obsolete. This belief can only come about if womenunderstand not only the process of birth, but also how theseprocesses may deviate from normal and require intervention.

Antenatal education should address more openly the differ-ences in philosophy surrounding care provision in differentintrapartum settings so that women are more aware of how suchinterventions may be initiated in different settings. Women maythereby be more likely to choose a birthing environment mostsuited to their beliefs. As a result, birth plan use can be more effective,reducing the potential for apparent disappointing outcomes.

Conflict of interest

The authors state that they have no conflict of interest.

References

Aragon, M., Chhoa, E., Dayan, R., Kluftinger, A., Lohn, Z., Buhler, K, 2013. Perspec-tives of expectant women and health care providers on birth plans. J. Obstet.Gynaecol. Can. 35, 979–985.

Barbour, R., 2007. Doing Focus Groups. Sage Publications, LondonBerg, M., Lundgren, I., Lindmark, G., 2003. Childbirth experience in women at high

risk: is it improved by use of a birth plan? J. Perinat. Education 12, 1–15.Biggerstaff, D., Thompson, A.R., 2008. Interpretative phenomenological analysis

(IPA): a qualitative methodology of choice in healthcare research. Qual. Res.Psychol. 5, 173–183.

Blix-Lindström, S., Johansson, E., Christensson, K., 2008. Midwives' navigation andperceived power during decision-making related to augmentation of labour.Midwifery 24, 190–198.

Bradbury-Jones, C., Sambrook, S., Irvine, F., 2009. The phenomenological focusgroup: an oxymoron? J. Adv. Nurs. 65, 663–671.

Brown, S.J., Lumley, J., 1998. Communication and decision-making in labour: dobirth plans make a difference? Health Expect. 1, 106–116.

Coyle, K., Hauck, Y., Percival, P., Kristjanson, L., 2001a. Ongoing relationships with apersonal focus: mothers' perceptions of birth centre versus hospital care.Midwifery 17, 171–181.

Coyle, K., Hauck, Y., Percival, P., Kristjanson, L., 2001b. Normality and collaboration:mothers' perceptions of birth centre versus hospital care. Midwifery 17,182–193.

Davies, J., Iredale, R., 2006. An exploration of midwives' perceptions about theirrole. MIDIRS 16, 455–460.

Davis, D., 2003. Spoilt for choice: consuming maternity care. Br. J. Midwifery 11,574–578.

Deering, S.H., Zaret, J., McGaha, K., Satin, A.J., 2007. Patients presenting with birthplans. A case–control study of delivery outcomes. J. Reprod. Med. 52, 884–887.

Edwards, N., Murphy-Lawless, J., 2006. The instability of risk: women's perspectiveson risk and safety in birth. In: Symon, A. (Ed.), Risk and Choice in MaternityCare. An International Perspective, 2006. Churchill Livingstone, Edinburgh,pp. 35–49.

Goodman, P., Mackay, M.C., Tavakoli, A.S., 2004. Factors related to childbirthsatisfaction. J. Adv. Nurs. 46, 212–219.

Grant, R., Sueda, A., Kaneshiro, B., 2010. Expert opinion vs. patient perception ofobstetrical outcomes in laboring women with birth plans. J. Reprod. Med. 55,31–35.

Greenhalgh, T., 2002. Intuition and evidence – uneasy bedfellows? Br. J. GeneralPract. 52, 395–400.

Hadar, E., Raban, O., Gal, B., Yogev, Y., Melamed, N., 2012. Obstetrical outcome inwomen with self-prepared birth plan. J. Matern. Fetal Neonatal Med. 25,2055–2057.

Hauck, Y., Fenwick, J., Downie, J., Butt, J., 2007. The influence of childbirthexpectations on Western Australian women's perceptions of their birthexperience. Midwifery 23, 235–247.

Hill Bailey, P., Tilley, S., 2002. Storytelling and the interpretation of meaning inqualitative research. J. Adv. Nurs. 38, 574–583.

Hollins Martin, C.J., Bull, P., 2006. What features of the maternity unit promoteobedient behaviour from midwives? Clin. Eff. Nurs. 9, e221–e231.

Holloway, I., Wheeler, S., 2010. Qualitative Research in Nursing and Healthcare, 3rdedn. Wiley-Blackwell, Oxford

Hunter, M., 2003. Autonomy, clinical freedom and responsibility. In: Kirkham, M.(Ed.), Birth Centres. A Social Model for Maternity Care, 2003. Books forMidwives, London, pp. 239–248.

Hunter, B., 2004. Conflicting ideologies as a source of emotion work in midwifery.Midwifery 20, 261–272.

Jones, M.H., Barik, S., Mangune, H.H., et al., 1998. Do birth plans adversely affect theoutcome of labour? Br. J. Midwifery 6, 38–41.

Kaufmann, T., 2007. Evolution of the birth plan. J. Perinat. Education 16, 47–52.Kirkham, M., 1996. Professionalization past and present: with women or with the

powers that be?. In: Kroll, D. (Ed.), Midwifery Care for the Future. Meeting theChallenge, 1996. Bailliere Tindall, London, pp. 164–201.

Kitzinger, S., 1999. Birth plans: how are they being used? Br. J. Midwifery 7,300–303.

Kitzinger, S., Green, J.M., Chalmers, B., et al., 2006. Why do women go along withthis stuff? Birth 33, 154–158.

Kuo, S., Lin, K., Hsu, C., et al., 2010. Evaluation of the effects of a birth plan onTaiwanese women's childbirth experiences, control and expectations fulfil-ment: a randomised controlled trial. Int. J. Nurs. Stud. 47, 806–814.

Larsson, M., 2009. A descriptive study of the use of the Internet by women seekingpregnancy-related information. Midwifery 25, 14–20.

Lavender, T., Chapple, J., 2004. An exploration of midwives' views on the currentsystem of maternity care in England. Midwifery 20, 324–334.

Leap, N., Edwards, N., 2006. The politics of involving women in decision making.2nd edn. In: Page, L.A., McCandlish, R. (Eds.), The New Midwifery. Science andSensitivity in Practice, 2006. Churchill Livingstone, Philadelphia, pp. 97–123.

Lindberg, I., Christensson, K., Ohrling, K., 2005. Midwives' experience of organiza-tional and professional change. Midwifery 21, 355–364.

Litosseliti, L., 2003. Using Focus Groups in Research. Continuum, LondonLothian, J.A., 2000. The birth plan revisited. J. Perinat. Education 9, viii–xi.Lothian, J., 2006. Birth plans: the good, the bad, and the future. JOGNN 35, 295–303.Lundgren, I., Berg, M., Lindmark, G., 2003. Is the childbirth experience improved by

a birth plan? J. Midwifery Women's Health 48, 322–328.Magill-Cuerden, J., 2005. How do maternity services provide individualised care?

Br. J. Midwifery 13, 480.Mead, M., 2003. Intrapartum care of women suitable for midwifery-led care –

midwives' perception of their own and their colleagues' practice. Evid. BasedMidwifery 1, 4–11.

Nolan, M., 2001. Birth plans a relic of the past or still a useful tool? Pract. Midwife 4,38–39.

Nursing and Midwifery Council, 2008. The code: Standards of Conduct, Perfor-mance and Ethics for Nurses and Midwives. NMC, London

O'hare, J., Fallon, A., 2011. Women's experience of control in labour and childbirth.Br. J. Midwifery 19, 164–169.

Peart, K., 2004. Birth Planning – is it beneficial to pregnant women? Aust. J.Midwifery 17, 27–29.

Pennell, A., Salo-Coombs, V., Herring, A., et al., 2011. Anesthesia and analgesia-related preferences and outcomes of womenwho have birth plans. J. MidwiferyWomen's Health 56, 376–381.

Perez, P.G., 2005. Birth plans: are they really necessary? Am. J. Matern. Child Nurs.30, 288–289.

Price, S., 1998. Birth plans and their impact on midwifery care. MIDIRS 8, 189–191.Redshaw, M., Rowe, R., Schroeder, L., et al., 2011. Mapping maternity care: the

configuration of maternity care in England. Birthplace in England researchprogramme. Report No. Final Report Part 3 08/1604/140. HMSO, Southampton,UK

Rees, C., 2011. Introduction to Research for Midwives, 3rd edn. Churchill Living-stone, Edinburgh

Robinson, J., 1999. The birth plan game. Br. J. Midwifery 7, 642.Russell, K.E., 2007. Mad, bad or different? Midwives and normal birth in obstetric

led units. Br. J. Midwifery 15, 128–131.Sandall, J., Soltani, J., Gate, S., Shennan, A., Devane, D., 2013. Midwife-led continuity

models versus other models of care for childbearing women. CochraneDatabase Syst. Rev. (Art. No.: CD004667)

Simkin, P., 2007. Birth plans: after 25 years, women still want to be heard. Birth 34,49–51.

Smith, J.A., 1996. Beyond the divide between cognition and discourse: usinginterpretative phenomenological analysis in health psychology. Psychol. Health11, 261–271.

Smith, J.A., 2004. Reflecting on the development of interpretative phenomenolo-gical analysis and its contribution to qualitative research in psychology. Qual.Res. Psychol. 1, 39–54.

Smith, J.A., Osborn, M., 2008. Interpretative phenomenological analysis. In: Smith, J.A.(Ed.), Qualitative Psychology, 2008. Sage Publications, London, pp. 53–80.

Stapleton, H., Kirkham, M., Thomas, G., Curtis, P., 2002. Midwives in the middle:balance and vulnerability. Br. J. Midwifery 10, 607–611.

Symon, A., 2006. The risk-choice paradox. In: Symon, A. (Ed.), Risk and Choice inMaternity Care. An International Perspective, 2006. Churchill Livingstone,London, pp. 1–11.

Too, S., 1996a. Do birthplans empower women? A study of their views. Nurs. Stand.10, 33–37.

Too, S., 1996b. Do birthplans empower women? A study of midwives' views. Nurs.Stand. 10, 44–48.

Walsh, D., 2006. Subverting the assembly-line: childbirth in a free-standing birthcentre. Soc. Sci. Med. 62, 1330–1340.

Whitford, H.M., Hillan, E.M., 1998. Women's perceptions of birth plans. Midwifery14, 248–253.

Wier, J., 2008. Informed consent and the birth plan. Pract. Midwife 11, 17–18.Wilkinson, S., Joffe, H., Yardley, L., 2004. Qualitative data collection: interviews and

focus groups. In: Marks, D.F., Yardley, L. (Eds.), Research Methods for Clinicaland Health Psychology, 2004. Sage, London, pp. 39–55.

Yam, E.A., Grossman, A.A., Goldman, L.A., Garcia, S.G., 2007. Introducing birth plansin Mexico: an exploratory study in a hospital serving low-income Mexicans.Birth 34, 42–48.

unique and proforma birth plans: a qualitative exploration of midwives׳ experiences

Documents

rechnung-schreiben.de · web viewproforma-rechnung...

proforma arab

positioning proforma

women's perceptions of birth centre care: a qualitative

the official newsletter of proforma | ... · proforma...

validity of recalled v. recorded birth weight: a...

evaluacion proforma

proforma ocs

birth fathers of children adopted after care proceedings...

proforma rechnung / proforma invoice

pt ciputra development tbk dan entitas anaknya/ and its...

proforma sinco

final proforma

proforma credentials

proforma presupuestaria

proforma rechnung / proforma invoice...

att proforma

noc proforma

ma si dice ‘proforma’ o ‘la proforma’?

proforma finallllll