A Midwife Breaks Down the Truth About Birth Plans

When I first saw this letter from the Weill Cornell OB/GYN team — I was appalled, enraged, but in no way surprised. While Weill Cornell has come out with a response and a “new” letter, the one they had given patients for years was a poorly written list of demands requiring a full submission to any and all levels of obstetric violence and a complete handing-over of a pregnant person’s autonomy and rights. Yes, even in 2022. 

It’s a brief, albeit complete, snapshot into the reason why we have the worst maternal morbidity and mortality rates of any global north country in the world and why those rates (remember though, “rates” are actual people dying during childbirth) are getting worse not better. 

A lot of people in the birth community have come out in support of birth plans — singing their praises and encouraging pregnant people to keep making them, even though there’s a huge disconnect in what’s actually going to happen in the hospital and what people are hoping for. We aren’t seeing these systems level-up to the preferences of pregnant people, and, honestly, no birth plan is going to change that. 

The truth is, I’m ambivalent about birth plans and here’s why: 

1. They put the onus of responsibility of this dangerous, racist, patriarchal and hierarchical healthcare system on the birthing person. People have to make a list (a birth plan) of how they want to be respected, which means the default is that the system does not respect people, their bodies or their choices. The basic expectations often listed on a birth plan — delayed cord clamping, immediate skin-to-skin, gentle cesarean birth if necessary, informed consent for all procedures and pelvic exams — should be standard of care, but they’re not, which is why people feel compelled to request these rights. Which leads me to…

2. The trauma and feeling of failure that I have witnessed someone process after their birth, and the grief I have held space for because someone put something in their birth plan that didn’t come to pass at the hospital. This level of personal and moral “failure” that a birthing person may hold can be immense and completely undercut the absolute magic of their birth (as I stand a midwife-witness). And the worst part about it all? The system makes it seem like this failure is the birthing person’s fault — that their expectations were too high. We already criticize, judge, ostracize women and pregnant folks enough, can’t we just let them be in the sacred presence of their birth without having a predetermined list of what it means for them to be successful? 

3. I appreciate not all care providers are created equally — our training, practices and belief of what birth is (i.e., a normal physiological process versus a disease or pathology) are vastly different. And for those who need a birth plan because they have toxic, patriarchal and violent “care” providers (as demonstrated in this letter), oftentimes these birth plans don’t open the door to conversation with someone who was trained to think they’re playing god, are of the mentality “provider knows best”, and were put into the birthing world to “save” people from themselves. A birth plan often acts as a false sense of safety and communication between the pregnant person and provider and, honestly, sometimes is like a scarlet letter causing more ridicule, scorn and fodder at the nurse's station: “Hahaha! Look here! It says ‘birth in hands and knees.’ What is she, an animal?!” or “She wants to use intermittent monitoring?! I’m not wasting my time on that.” (These are real quotes.)

I find so many times that the hopes and requests on someone’s birth plan stem from fear because hospitals in the United States aren’t actually safe places for people to give birth. 

For the thousands of people going to Weill Cornell hospital being told “don’t walk, run” to a different place, the sad truth is there aren’t many places for them to go where they will be safe, seen, heard, respected and treated as the badass birther they are. I don’t have an answer to this issue and I agree with the sentiment behind “run”, but we are likely sending them into the hands of people who will still hurt them. (Deep sigh.)

So, yeah, to me birth plans are mostly a symptom of a toxic and diseased system. I love the idea of pregnant people coming in with their questions, their hopes and quite literally, their dreams (pregnant people are so close to the veil, they can come in with some next-level otherworld vivid dreams!) and holding space for meaningful discussion. This is one of the most transformative experiences in a person and family’s life! We shouldn’t need birth plans to remind care providers and hospitals that people want and deserve respect and empowerment at baseline for their care. 

We hear a lot “birth is unpredictable and high risk” as a reason not to make a birth plan, too, and I don’t entirely disagree with that. Yes, birth is unpredictable…a very small percentage of the time (I’m talking 2-5%), and we as birth work providers know how to manage these situations medically and by communicating what is happening in a respectful way. Sometimes this means a birth preference needs to change, but oftentimes, it doesn’t. The fact that anyone would ever use the unpredictability of birth as a reason not to make a birth plan speaks more to their lack of medical acumen and poor communication skills than it does to the birthing person’s “inflexibility” and “irresponsibility”.

Furthermore, many of the reasons why birth is labeled as “high-risk” are concocted for control in a system that is an inherently risk-averse environment. In other words, a healthcare system built on making money off of people’s illnesses and need for acute care can’t tolerate the overwhelming safety and mystery of birth — it doesn’t give them money, power or control so it can’t be true. 

So, where do we go from here? 

If we want to get serious about women and pregnant people having full rights and autonomy over their bodies and their choices, we have to keep doing this: talking about the ways people are getting violated in plain sight. Birth plans were never the actual issue. What we are really about is how women and pregnant people are valued, respected, and free in our society. And we have to keep talking about it until more and more people wake up to the fact that their lives and their right to choose how to live them are being violated by these patriarchal systems. 

But, my suggestion? Still write those birth plans because they are an act of agency and protest! They stand as a reminder that you know you deserve better than what the system has to offer.  

Have conversations and requests and questions that push care providers out of their comfort zone. Go to childbirth classes that teach you how to move, how to dance and feel joy during labor (run from birth classes that only teach you how to be a good patient). Do research on your providers. Ask what their cesarean birth rates are, if they support VBACs, if they work with midwives or doulas, and IBCLCs. Be in community with other people who were empowered by their birth and be present for someone who was traumatized and is having a hard time transitioning to parenthood because of it. 

It is my hope though, we will one day collectively say “no more” to disrespect as standard of care and that our hopes and preferences for how we give birth will in fact be heard and respected. We can birth that change into being together.