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The Intervention Birth Plan Review

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Reproductive health services emphasis their resources on reducing perinatal mortality rate and have less attention to the quality of care and the experiences of the women (1). In the European countries, some efforts have been done to change this kind of care towards women-center care and it is suggested that the patient’s satisfaction and their experiences can be considered as a quality index (2). Childbirth experience is defined as “individual life event, incorporating interrelated subjective psychological and physiological processes, influenced by social, environmental, organizational and policy contexts”.

Studies in the obstetrics field have rarely evaluated the mother’s experience as an outcome (3). While, assessing mothers’ experience help care providers to better understand their needs and expectations to perform needs-based interventions in order to improve the mothers’ satisfaction (4, 5). Negative women’s experiences of childbirth can affect post-traumatic stress disorder (PTSD) (6), post-partum depression (7) and decision to have the next pregnancy as well as the type of childbirth (8).

Description of the intervention Birth plan was firstly introduced in 1980 in response to the increasing trend toward the medicalization of childbirth (9, 10). Birth plan approach emphasizes on the relationship between the pregnant women and health care providers, respects women right to be involved in decision making and would lead to feel more control over her labor and delivery process (11). Birth plan is a written document by a pregnant woman during the antepartum period, which describes her physical and emotional preferences about labor and childbirth process and she present to provider at the time of labor.

Two formats have been provided for the birth plan. In the first format, there is a list of choices that the pregnant woman can have during labor and childbirth (music playing, support person, walking, take a shower, massage, breathing techniques, epidural, episiotomy, breastfeeding, …). The second format includes some open-ended questions in which the pregnant woman can describe her preferences during labor and childbirth (12, 13).

Mother participation in obstetric decision-making increases satisfaction with the labor and childbirth experience.

In the medical-based care, the pregnant woman’s feelings and desires are often ignored, and she is not involved in the process of decision-making related to her care (14). The positive relationship between a pregnant mother and her health care provider and her involvement in the decision-making process could lead to feeling of satisfaction regarding the childbirth .Women who are involved in their care process usually will have a better childbirth experiences due to having the sense of more control compared to inactive women in decision-making. Therefore, as much as the ability of woman to control her own care increases, her satisfaction rate would increase as well (15-17). In a qualitative study, women were more satisfied with their childbirth experiences; despite the fact that in some women, their delivery had not gone as planned (13).

Despite the importance of women’s childbirth experiences and its effect on short and long-term outcomes after delivery, we found no systematic review article that evaluates the effect of birth plan on childbirth experiences. The aim of this study was to assess whether a birth plan approach compared with standard or routine approach in nulliparous women affects the childbirth experiences.


Data Source and Identification of Studies

Our search strategy involved the use of a valid filter to identify RCTs by PubMed’s MeSH terms. The search terms included “birth plan”, “birth plans”, “childbirth plan”, “childbirth experience”, “childbirth experiences” and “satisfaction”.

This systematic review was performed by searching several databases including the english data base (Cochrane Library, PubMed, Web of Science, MEDLINE, Embase, CINAHL, Scopus, Google Scholar) and Persian data base (SID, Magiran, Iran med and Barakat). The researchers also searched for references in reviewed clinical trial articles in which birth plan was compared with standard care.

Inclusion Criteria

The randomized and quasi-randomized controlled trials published in English and Persian with respect to the language of publication that had compared the birth plan approach with routine or standard approach without a time limit were included. The trials were only included in the study that had measured the childbirth experiences as an outcome. The unrelated studies such as duplicate articles, systematic review, case-control and cohort papers as well as letters to the editor were among the exclusion criteria.

The PICO defined for this review article included: Participant (The singleton pregnant women with gestational age of 32 weeks or beyond and age of 18 years or older without obstetric complications), intervention (implementation of birth plan), comparison group (routine or standard care) and outcome (childbirth experience or satisfaction). The study exclusion criteria included lack of the comparison group and measurement of the childbirth experiences qualitatively.

Assessment of risk of bias in included studies

Two authors independently (SGH؛ JN( determined the risk of bias for studies (Figure 1) through the criteria set out in the Handbook of Cochrane (18). Any disagreements were resolved through discussion and, if necessary, through consultation with a third person (MM).

Random Sequence Generation (Checking for Possible Selection Bias)

The method used to create allocation sequence was assessed as low, high or unclear risk of bias. In case of using unpredictable randomization process, such as computer-based random numbers or tables of random numbers, the risk of bias was reported low. In case of using a non-randomized allocation method such as date of birth, odd and even numbers and file numbers for allocation sequence, the risk of bias was reported high.

Allocation Concealment (Checking for Possible Selection Bias)

Trials were assessed as low risk if they used central allocation method, sealed opaque envelopes or phone allocating method for allocation concealment. Trials were assessed as high risk if random allocation was open.

Blinding of Participants and Personnel (Checking for Possible Performance Bias)

The trials were reported with low risk of bias in which both researcher and participant were blinded.

Blinding of Outcome Assessment (Checking for Possible Detection Bias)

The outcome assessment method was assessed independently for each outcome. The strategy used for blinding of outcome were assessed as low, high or unclear risk of bias. The trials were reported with a low risk of bias in which the outcome assessors were blinded.

Incomplete Outcome Data (Checking for Possible Attrition Bias)

The strategy used for incomplete outcomes was assessed as low, high or unclear risk of bias. The trials were reported with low risk of bias that had no lost data or there was a relevant balance between the groups. Exclusion, loss and the number of participants recruited in every step of the analysis were assessed in comparison with the total number of samples. Also, the exclusion or loss reasons and methods for balancing missing data, if described in included studies, were reported.

Selective Reporting (Checking for Reporting Bias)

The trials were reported with a low risk of bias in which all of predetermined outcomes have been reported. The trials were reported with high risk of bias if all predetermined outcomes were not reported or there was a primary outcome in the trial that had not been predetermined.

Data Extraction and Analysis

Data analysis was performed using RevMan-version 5.3 software. The data from only two studies were combined using meta-analysis. One of the studies excluded from the meta-analysis as it had not measured the childbirth experiences quantitatively.


Study selection

By searching the databases, 598 published articles were found, of which, 548 and 47 articles were excluded by review of the titles and the abstracts, respectively. Afshar et al. (19) study was excluded as it had been just presented in abstract form at the conference, and its full text was not available. Lundgren et al. study was excluded by review of the text as it had measured outcome qualitatively. Finally, two trials that had measured the impact of birth plan on childbirth experiences, were included in this systematic review.

Study characteristics

Kuo et al. study (2010) (11) was conducted on 330 primiparous women with at least 32 weeks gestation who received prenatal care from one of seven Taiwanese medical center. Following written informed consent, eligible women were allocated to either birth plan or control group using block randomization. The nurse gave some explanations about birth plan to the women in the intervention group. In the next stage, each of the participants had discussion with the obstetricians about the birth plan. Each woman in the intervention group wrote her own birth plan. Woman’s birth plan was placed together with her health handbook. When woman entered the labor ward, gave her birth plan to the nurse. According to the written plan of each woman, the nurse provided care. Control group received standard care. Finally, one day after delivery, the childbirth experiences were measured.

Farahat et al. study (2015) (20) was conducted on 260 primiparous women in Egypt. When the primiparous women visited the clinic at 36 to 42 weeks gestation to get prenatal care, researcher provided some explanations about purpose of the research. Following written informed consent, eligible women were assigned to either birth plan or control group using odd and even numbers. The intervention group were asked to write their birth plan. According to the written plan of each woman, the nurse and physician provided care. Control group received routine care.

Risk of bias in the included studies

The risk of bias for each of the included studies were described based on Consort checklist in the table. In Kuo et al.’s study (11) an appropriate method such as the block randomization method had been used for allocation sequence; however, adequate descriptions had not been provided for allocation concealment. Regarding the blinding process, only the “single blind” phrase had been mentioned, and there was no information that who has been blinded in the study. It seems that Kuo et al’s study is at risk of incomplete outcome bias due to sample attrition.

It seems that Farahat et al.’s study (20) was at risk of selection bias, since a predictable method i.e. odd and even numbers approach had been used for allocation the samples into the groups and allocation concealment had not been used. It also seems that study of Farahat et al. was at risk of performance bias because blinding process was not clear.

Results of studies

The results of Kuo et al.’s study (11) showed that the mean score of childbirth experiences in the intervention group (93.8 (SD = 10.1)) was significantly higher than the control group (90.5 (SD = 12.5)) (P=0.01).

The results of Farahat et al.’s study (20) showed that the mean score of childbirth experiences in the intervention group (1.8 (SD = 0.3)) was significantly higher than the control group (1.3 (SD = 0.4))) P<0.001(.

Synthesis of results

The information on birth experiences of the two papers were collected. The data were combined using RevMan software. Due to high heterogeneity of the studies (I2 = 97%), the Random Effect was reported instead of Fixed Effect. Also, the tools used in these studies were different; thus, the standard mean difference was reported instead of the mean difference (18). In Kuo et al. study (11), childbirth experiences questionnaire developed by Marut and Mercer was used. The questionnaire includes 29 questions with a Likert scale (scores from 1 to 5). Total scores range is from 29 to 145 and higher scores indicate higher levels of satisfaction with the childbirth experience. In Farahat et al study (20), a validated questionnaire by Mackey was used. It consists 40 questions and questions from 37 to 40 measure birth experience. The total score 12 and higher indicate positive experiences.

The results of the meta-analysis based on Random Effect showed that the birth plan has no statistically significant effect on the birth experiences among nulliparous women (mean difference: 0.85; 95% CI:-0.25 to 1.95; P=0.130; I2=97%) ( Figure 2). However, the results of the meta-analysis based on Fixed Effect showed that the birth plan has statistically significant effect on the birth experiences among nulliparous women (mean difference: 0.75; 95% CI: 0.58 to 0.93; P<0.00001; I2=97%) ( Figure 3).

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