I've been mulling this one over all week, trying to pinpoint what exactly makes me so uncomfortable about ACOG stating that they encourage women to write birth plans instead of having homebirths (there are actually MANY reasons I'm uncomfortable about it...see my letter to ACOG below.)
The natural childbirth movement has raised up the Birth Plan like a revolutionary torch to reform birth in America, when in reality, Birth Plans mean quite little to birth professionals all over the country. Every childbirth author from Kitzinger to Simkin will tell expectant mothers to write one. But in all honesty, the words "birth" and "plan" really shouldn't have ever gotten mixed up with each other. Anyone who has been around birth realizes that it rarely goes as planned. Don't get me wrong, I'm not upholding the rallying cry of the "birth is an emergency" movement and saying that things often change dramatically, rapidly and drastically for the worse, rather, merely that birth is the unfolding of a process, and there are myriad different twists and turns that process can take, much of it dependent on how much unfolding is permitted to happen. Expecting the unexpected is a large part of working with birth.
My issue with Birth Plans are this: it seems that too many women put off actually discussing (or evendeciding on) their desires for birth until the time comes to present their Birth Plan. They hope to avoid verbal confrontation or resistance by showing up with a piece of paper that outlines their wishes, assuming it will be easier for the care provider to just agree to what's in writing instead of having to ask difficult questions of someone in a perceived position of authority. I know that for me personally, this is exactly what I did. I had asked questions of my care provider throughtout pregnancy and up to that point been presented with what should have been unsatisfactory, vague answers. When said care provider saw my Birth Plan, the response was less than stellar. In fact it was dismissive and sarcastic, and what inspired me to change providers and birth location at 37 weeks.
The problem with Birth Plans is that in a lot of cases, they mean virtually nothing if hospital policy is in conflict with the requested care. Too many women are writing "I want the freedom to eat and drink during labor" and "No IV unless medically necessary" without actually finding out if their hospitals even permit these practices. It's important to note here that there is practically nothing you absolutely have to consent to in the hospital, but if it is their policy, they will do what they can to get you to comply. Do you really want a fight over every item on your Birth Plan? If you are against every single policy and practice at the hospital, perhaps you should reconsider giving birth there. Just as if you are asking a homebirth midwife to perform tasks beyond her normal scope of practice, perhaps home is not the appropriate location for your birth.
Another issue that is up for interpretation is "medically necessary". Most Birth Plans start out with a paragraph that states the birthing mother will deviate from this plan if the health of her baby is in jeopardy and thus medically necessary. The mere fact that women include this paragraph illuminates clearly just how little faith our culture has in birthing women. Where exactly are these women who are putting the health and lives of their babies at risk in order to stick to the Plan? It should be assumed that women will obviously do what needs to be done in the case of a true emergency. However, instead of writing "No episiotomy unless medically necessary" or "I prefer to go into labor and avoid an induction unless medically indicated" on a Birth Plan, simply asking your care provider in what instances they perform an episiotomy or an induction yields a better and more open response. Rather than telling them how to do their job, you give them an opportunity to tell you how they practice. And regardless of what is written on your Birth Plan, that is the kind of care you are going to receive too. You owe it to yourself, and to them, to find someone whose philosophy is aligned with yours, rather than trying to change and battle for the kind of care you want from someone who doesn't offer it. Asking a highly technological OB who is quick to perform Cesareans for a non-interventive birth is no different than going to a homebirth midwife and asking to have your water broken and be induced at 39 weeks with an automatic episiotomy culminating your birth experience.
It bears repeating from a different source. Diana Korte writes in The VBAC Companion that women need to find out how their care providers generally practice because "the care you receive will be similar to what your doctor does routinely with other pregnant women in her care." Again, rather than simply coming in with a list of preferences, ask how your provider prefers to practice. This is a much more effective, open, and honest form of dialogue. Beware of anyone who says they "never" do this or that. Even the best providers use interventions, no matter how rarely, in certain circumstances. It's wonderful if your provider will agree to use intermittent vs. continous electronic fetal monitoring, but you should find out in which instances your provider feels continuous monitoring is safer and more beneficial.
What worries me about ACOG's endorsement of Birth Plans is that they could be counting on women to be taking cozy comfort in having their wishes in writing but not necessarily ever questioning their doctors in person. I hate to sound like a conspiracy theorist, but considering how condescending and paternalistic the rest of ACOG's statement on homebirths was, I'm not sure it's so far-fetched. Much of what is commonly requested on a Birth Plan has very little to do with the doctor since it often occurs long before the doctor shows up to catch the baby. A Birth Plan is not legally binding in any way. Without these important discussions with your care provider, a Birth Plan has little more value than a letter to Santa. And perhaps ACOG is banking on that.
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