Abstract:
Birth plans in the US have been historically used as a way for pregnant individuals to communicate their birthing preferences to healthcare providers (e.g. Bell et al., 2022). Research over the past three decades has demonstrated that the use of birth plans improves not just birth outcomes (e.g. Ahmadpour et al., 2002), but also a birthing individual’s sense of autonomy and self-efficacy (e.g. Davis-Floyd, 2001; Simkin, 2007). Only recently have researchers considered the use of a birth plan as an educational tool, utilizing it as an assignment to teach university students about evidence-based perinatal care (Soliday & Smith, 2017). This project builds on previous research, illustrating how to utilize the birth plan as a feminist pedagogical tool to educate students about birth justice within the context of (bio)medical discourse that constructs pregnancy and birth as disease and disordered. The use of a birth plan as a writing assignment for undergraduate students in a course designed for future healthcare professionals illustrates how it can be a tool to educate providers on how to center the embodied knowledge of pregnant individuals to facilitate improved birth outcomes and to foster equity among pregnant and birthing people: birth(ing) justice.
Introduction:
The United States spends more per birth than any other similarly industrialized nation in the world, yet maternal morbidity and mortality rates in the US are far worse than any other peer nation (World Health Organization, 2023). The (bio)medicalization of birth explains both the high monetary cost and the high maternal death rates associated with childbirth in the US via the routine overuse of medical interventions (often without medical indication) as is characteristic of obstetrical practice (Rutherford & Wood, 2022). In stark contrast to recent calls to action to decrease US maternal death rates from the American College of Obstetricians and Gynecologists, the American College of Nurse-Midwives, WHO, the National Institutes of Health, and the Centers for Disease Control (CDC), maternal death rates have risen substantially among all US women in recent years. In 2023, The National Center for Health Statistics reported that the US maternal mortality rate (the number of maternal deaths per 100,000 live births) had increased from a rate of 17.1 in 2018 to 20.1 in 2019 to 23.8 in 2020, and to 32.9 in 2021 (the last year there are data available). Maternal death rates are highest among Black, Indigenous, and Latina women. Black women’s maternal mortality rates in 2021, for example, were an alarming 69.9 (the number of maternal deaths per 100,000 live births) compared to Latina women (28.0) and white women (26.6) (Hoyert, 2023). The National Council of Urban Indian Health uses CDC data to report that American Indian (AI) and Alaskan Native (AN) women die at alarming rates from pregnancy-related deaths with maternal mortality rates in 2021 at 118.7 for AI and AN women. These racial/ethnic differences in maternal death rates are due to institutional forms of racism and provider bias (e.g. Bonaparte & Oparah, 2024; Gittens-William et al., 2024; Vedam et al, 2019) including physicians’ refusal to listen to Black women’s pain as an indication of a post-partum complication (Taylor, 2020). Moreover, when women of color are discriminated against by providers and the medical system, newborns are also impacted because of the interconnectedness of maternal and neonatal health. For example, Black infants are more than two times as likely to die than white babies during the first year of life (Greenwood et al., 2020) because of structural racism (Wallace et al., 2017). Montalmant & Ettinger (2024) discuss the impact of structural racism and resultant racial disparities in maternal mortality in the US at length, including suggested interventions focused on provider and institutional level bias training to improve cultural competency and respectful relationships with patients. Such interventions to disrupt the manifestations of structural racism are critical because, as the CDC boldly stated in September 2024, more than 80% of pregnancy-related deaths in the US are preventable: “A death is preventable if there was at least some chance it could have been avoided with reasonable changes to patient, family, provider, facility, system, and/or community factors” (np).
Maternal and infant death rates, and associated racial disparities, are expected to worsen in the near future amidst the current political landscape in the US. Proposed cuts to Medicaid will drastically impact both maternal and neonatal health given that 42% of all pregnancy-related healthcare is covered by this program. In some Southern US states, almost 60% of births are funded by Medicaid; eradicating this coverage will contribute to existing barriers that prevent access to prenatal, childbirth, and postpartum care, all of which are predictive of maternal and neonatal health outcomes. Women of color and their babies will undoubtedly suffer the most from Medicaid cuts with both maternal and infant mortality rates expected to rise as a result (Ranji et al., 2025). Moreover, the reversal of Roe vs. Wade in 2022 via the Dobbs decision eradicated privacy protections and bodily autonomy for pregnant individuals. The loss of a federal protection of privacy has important implications beyond the scope of abortion care, including the criminalization of pregnancy outcomes, and limited (or no) decision making among pregnant and birthing people with regards to their perinatal care including options for interventions, birthing location and attendants, and postpartum care (Kavattur et al., 2023). Researchers predict legal and institutional limits to bodily autonomy among pregnant and birthing people will result in future increases in maternal death, particularly among Black women and individuals in states with total abortion bans, as is typical in the US South (Kheyfets et al, 2023; Steveson et al., 2022).
In this context, with increasing restrictions on an individual’s ability to access the full range of reproductive healthcare, birth plans may be one tool to advocate for birth justice. In this paper, I suggest that the use of a birth plan as an educational and advocacy tool is one way to improve equity in pregnant and birthing people’s healthcare in the US healthcare system. Focused on educating future healthcare professionals on how to develop their own birth plan, the assignment described in this paper teaches college students in a ‘real life’ way how barriers to bodily autonomy among pregnant people is a form of birth injustice, suggesting that a birth plan can be used intentionally to facilitate birth justice through pregnant individual’s autonomous and collaborative decision-making in perinatal care. First, this chapter discusses birth justice as part of reproductive justice, to situate pregnant and birthing individuals’ need for bodily autonomy within an intersectional, human rights framework to understand discrepancies in maternal health outcomes. Next, I review the use, function and effectiveness of birth plans among US women[1]. Finally, I explain how I implemented the birth plan assignment in my undergraduate college course for future healthcare providers to teach undergraduate students about birth justice. A goal of the birth plan assignment is to illustrate how structural and institutional forms of bias impact individuals’ access to and experience of decision making in their perinatal health care.
Birth Justice
Birth justice is one aspect of reproductive justice (RJ), an intersectional theoretical framework and social-political movement (e.g. Price, 2010; Ross & Solinger, 2017). Developed in 1994 by a group of Black women, the “Women of African Descent for Reproductive Justice”, RJ focuses on how interlocking institutional forms of racism, sexism, classism, ableism, transphobia, and heterosexism curtail reproductive freedom. The three core principles of RJ are: the right to have a child, the right to not have a child, and the right to parent children in safe and healthy environments (Ross & SisterSong, 2007). Bodily autonomy and an individual’s ability to control the material conditions of their lives are central to RJ including access to: comprehensive sex education, a full spectrum of reproductive health care options, affordable housing, clean air and water, nutritious food, equitably funded schools and childcare options, living-wage jobs, paid family leave, and protection from interpersonal and institutional violence. In this way, reproductive justice is an expansive, holistic approach to ensure equity among all individuals across the span of their reproductive lives. Despite the broad conceptualization of RJ, it was not intentionally applied to pregnancy and childbirth until 2010, when the Advocates for Pregnant Women (NAPW) called for RJ advocates and organizations to extend reproductive justice to specifically include birth justice. A relatively newly articulated concept and field of study, birth justice contextualizes an individual’s ability to control their reproductive destiny within the material conditions of their lives (Oparah & Bonaparte 2016). Moreover, birth justice includes not just the right to give birth and parent with dignity, but also the right to autonomy and self-determination during pregnancy, childbirth, and during the postpartum period (Ross & Solinger, 2017). In this way, birth justice includes a pregnant individual’s access to: respectful and dignified care from a provider who is committed to their individualized care, out of hospital births and midwifery care, vaginal birth after cesarean (VBAC), their preferred method of pain management, postpartum and newborn care that aligns with their values and preferences, the ability to make autonomous decisions about prenatal care, the autonomy to refuse unnecessary medical interventions, and freedom from medical violence and coercive practices, including forced sterilization. The need for birth justice is evidenced by exorbitantly high rates of maternal death among US Black and Indigenous women due to the routine (and often coercive) overuse of obstetrical interventions (like C-sections, labor induction and augmentation) as form of provider bias that results in racial disparities in maternal and neonatal death. Birth justice is the conception of a standard of equitable, respectful, and accessible perinatal care for all pregnant and birthing people grounded in bodily autonomy and sovereignty. Organizations like Black Mamas Matter and the birth of Black Maternal Health Week are examples of birth justice in action (Oparah et al., 2018).
Birth Plans & Birth Justice
The birth plan as a communication tool between pregnant and birthing women and their healthcare providers was developed by Simkin & Reinke in 1980 for the International Childbirth Education Association to resist the increasing medicalization of childbirth in the US (Bell et al., 2002). Since the inception of birth plans, research over the past four decades has demonstrated that their use improves not just birth outcomes for birthing people and newborns (Ahmadpour et al., 2002; Bell et al., 2022; Ghahremani et al, 2023; Shareef et al, 2024), but also a birthing individual’s sense of autonomy and self-efficacy (Aliem et al., 2020; Davis-Floyd, 2001;Simkin, 2007). Individuals who use a birth plan experience fewer medical interventions, including induction, labor augmentation, and C-section (Afshar et al., 2018; Ghahremani et al, 2023; Vu & Herness, 2021). Moreover, birth outcomes for both birthing people and neonates are improved with the use of a birth plan, including fewer maternal postpartum complications like postpartum depression (Kuo, et al., 2010), improved Apgar scores for newborns, a reduced incidence of neonatal resuscitation, and higher rates of breastfeeding (Ghahremani et al, 2023; Lopez-Gimeno et al, 2021). The use of a birth plan is likely a protective measure against the overuse of unwanted medical interventions that are associated with an increased risk of maternal morbidity and associated risks to the neonate.
While the birth plan was initially developed as a communication tool for pregnant women to express their childbirth preferences to their providers, the use of birth plans has evolved with the continued increasing medicalization of pregnancy and childbirth in the US; increasingly the birth plan is a tool for self-empowerment and an educational practice for pregnant people (Bell et al, 2022). Researchers have found that the very process of developing a birth plan is an important step in a pregnant individual’s decision-making about their own birthing preferences as they sort through their own values, expectations, fears, and questions about childbirth (Ghahremani et al., 2023). Ideally, the development of a birth plan is predicated by a pregnant person’s own education about the various options available to them in childbirth, including how to manage pain, preferences around interventions, support people they want present, bonding and memory-making immediately after birth, and postpartum care including breastfeeding. The very process of reading, considering, and communicating about their birthing options (with friends, family, partners, and providers) is an act of embodiment and enactment of bodily autonomy (Shareef et al, 2024). The process of preparing a birth plan can transform a pregnant person from a patient who passively receives care (as is common in the US obstetric landscape) to an autonomous, self-actualized future birthing person who has a clear sense of their values and priorities because they have made decisions that support their own embodied knowledge from an informed position. From this place of self-awareness and agency, the birth plan can be used to scaffold a conversation before labor begins with healthcare providers, partners, and others about expectations, fears, and decision-making during childbirth (Bell et al, 2022; Shareef et al, 2024). In this way, the birth plan is not just a written communication tool, but a form of self-advocacy for a pregnant person to speak from during conversations with a healthcare provider. Shareef and colleagues (2024) describe four objectives of birth plans, “The first aim is to enhance education before childbirth … making [pregnant people] feel more confident and prepared for unexpected decisions during childbirth when time is limited. The second … is to assist women and their partners in developing informed preferences based on … educational information … regarding medical interventions like labor inductions or epidurals. … The third objective is to foster effective communication… with healthcare providers during pregnancy, ensuring that the providers are aware of the woman’s values and can anticipate any unrealistic expectations. The fourth aim … is to empower women to exert greater autonomy during childbirth” (pp. 2-3). Bell et al. (2022) found that the process of writing a birth plan is just as important as the final written document. The researchers found that a self-prepared birth plan that is created from a template, or checklist, and that is presented to the provider at the start of labor (but never discussed prenatally) is not in the true spirit of a birth plan (but may be called one) because the dialogue with the care provider is absent. Similarly, a provider-controlled birth plan, one that is generated from a template or pre-formatted list of ‘wishes’ that the provider supplies the ‘patient’ with, also evades the original intention of the birth plan to provide education, shared decision making out of discussion, and autonomy to the pregnant person. Medeiros & colleagues (2019) note that birth plans designed by providers or hospitals do not provide the full spectrum of laboring/birthing options to women, including only their preferred birthing options which prevents a pregnant person from learning about and being able to choose from the full range of childbirth care. Finally, the process of developing a birth plan that is aligned with their original intention is a birth plan that is shared with the care provider in advance to facilitate conversation about what options a pregnant person has to establish reasonable expectations about labor and delivery.
Although research supports the use of birth plans to facilitate communication, education, and self-advocacy, and women report an increased sense of control, better birth satisfaction postpartum, and there are better maternal and neonatal clinical outcomes with birth plans, providers may be reluctant to adopt their use (Bell et al., 2022). In fact, some health professionals have responded defensively to women’s attempted use of a birth plan (Whitford et al., 2014) perhaps because the birth plan challenges the provider’s autonomy and unilateral decision-making power (Hidalgo-Lopezosa et al., 2013). In fact, some providers justify avoiding the use of birth plans because women report disappointment when their birthing preferences are not respected, resulting in lower birth satisfaction (Ghahremani et al, 2023). While previous research has framed this as a failing of birth plans (Medeiros et al., 2019), perhaps it is more accurate to name this as a provider’s unwillingness or inability to engage in a conversation with the pregnant person about the feasibility of their plan. Shareef and colleagues (2024) found that providers’ negative attitudes towards birth plans were a barrier to their utilization as a shared decision-making tool among women, their partners, and healthcare providers. In contrast, other providers interviewed in Shareef’s study stated that the birth plan is a useful tool to establish realistic expectations with the pregnant person (and/or their partner), to initiate discussions of medical risks and to share relevant information, and to enroll partners in support of the pregnant person. Moreover, providers lauded the use of the birth plan as a tool to coordinate patient-centered care with various providers, for example when one provider transfers care to another, the birth plan can help coordinate care preferences. Partners who were interviewed in this same study reported that the birth plan as a conversational tool helped them learn how to advocate for their partner. Shareef et al. (2024) ultimately conclude that the successful use of birth plans is rooted in women’s internal empowerment gleaned from the process of developing a birth plan in consultation and in conversation with their health care provider (and partner, if applicable). The efficacy of birth plans depends on providers’ ability to provide external empowerment to pregnant women with a commitment to ensuring: “… a deep respect for women’s autonomous choices, integrating them seamlessly with the realities of medical practice” (Shareef et al., 2024, p. 15).
Gittens-Williams and colleagues (2024) advocate for the use of a birth plan with particular attention to birth inequity as a tool to address social determinants of health that are associated with poor care provision. When equity is an intended outcome for use of a birth plan, respectful and dignified forms of care, like equitable pain management and reciprocity in communication during shared decision making, is necessarily included. Using the socioecological model as a framework for birth equity, the researchers suggest that a birth plan can enroll family and more community-based forms of care postpartum to increase the likelihood that postpartum complications are not missed or ignored by healthcare providers, as is too common for Black women especially.
Birth(ing) Justice: The Birth Plan Assignment
It is only recently that researchers have considered the use of a birth plan as an educational tool for university students to learn about evidence-based perinatal care. Soliday & Smith (2017) used a birth plan lesson among undergraduate students in a general education social sciences course to examine the impact of using a birth plan as a teaching tool. Students completed several readings on a variety of topics related to pregnancy, childbirth, and postpartum care in preparation for a fifty-minute class lecture on the same topics. Next, students completed a preformatted worksheet with required specifics in their birth plan, including provider, birth location, preferences regarding interventions (like fetal monitoring, episiotomy), support people present, and postpartum preferences like breastfeeding and bonding. The researchers found that students overwhelmingly opted for birth preferences that reflect a physiological approach to birth and that students birth plans rejected birthing options associated with the medical model. In fact, compared to the general population, students preferred physiological birth significantly more. In their qualitative responses, students reported how much the birth plan lesson and assignment changed their knowledge and attitudes of evidence-based perinatal care. Most students reported that their learning in the class resulted in drastic changes in their preferences for a future birth, with them interested in avoiding routine medical interventions. This study illustrates the impact the birth plan can have as an educational tool.
As such, I wondered how I could use a birth plan assignment to teach students about birth justice, particularly because students in my courses are future health care providers and practitioners. I developed and implemented a birth plan assignment in my undergraduate 400-level reproductive justice class in which a majority of the students have a declared interest in a future career in healthcare. My goals for the assignment were to have students understand birth justice within the context of RJ, particularly regarding how reduced access to a full spectrum of perinatal care access in the medical model of birth limits an individuals’ bodily autonomy. Because providers are often resistance to birth plans, I hoped that as future health care providers, the process of developing a birth plan would put students in a patient/client position so that their learning was relevant and embodied for them. My teaching values are grounded in the belief that education can be transformative, that knowledge is empowering, and that to be effective, learning must be contextualized in the material conditions of one’s own life (Wood, 2022). Based on the expectation that teaching and learning have social justice implications, especially for marginalized individuals – for whom education can be life-changing, I identify as a practitioner of feminist pedagogy. At its core, feminist pedagogy is teaching and learning in intentional ways that seek to honor the intersectional dimensions of discrimination in individuals’ lives in order to overturn systems of oppression, like patriarchy, using a gendered-lens to disrupt discrepancies in power (hooks, 1994; Shrewsbury, 1997).
Based on the principles of feminist pedagogy, RJ, and the assignment goals, I structured the course such that birth justice was the last topic of the semester. Before the students learned about pregnancy and childbirth, we had already covered many other RJ topics including: the history of contraceptives in the US (including eugenics, population control, & forced procreation); the use and abuse of the bodies of women of color (the racist and patriarchal development of obstetrics and gynecology as a field of study, historical accounts of the lack of informed consent in forced sterilization); provider bias in the provision of reproductive health care (the coercive use of long acting reversible contraceptives, refusal to treat pain particularly among girls and women of color, rates of maternal death among marginalized birthing people); the criminalization of pregnancy and abortion through fetal rights; and the impact of abstinence-only education, cuts in Title X funding, parental rights initiatives, and a federal lack of privacy on individuals’ lack of the basic human right to control their own bodies, especially during pregnancy, post-Dobbs. As such, the topic of birth justice was situated within reproductive justice and the birth plan was just one part of students’ learning about pregnancy and childbirth.
I provided students with a very detailed set of instructions for the assignment, and we spent a full (75 minutes) class period in a birth plan writing workshop to help them think through the necessary questions to consider in the process of writing their plan. For example, because birth location and the availability of birth attendants are interdependent, I suggested that students begin their decision-making process by considering the pros and cons of the midwifery model and the medical model. Birthing laws are state-specific (notably, often following the tenets of abortion restrictions) so I also encouraged students to consider their geographical location as well as their own personal health histories (which they were never required to divulge).
After our in-class workshop, students completed the assignment on their own and were free to consult any resources they wanted including family members who have given birth (older sisters, mothers, and grandmothers), educational books and articles that I made available in our web-based learning platform, and any other supplemental information. My overview of the assignment to students on the course syllabus is as follows:
As we learn about childbirth, you’ll realize that choosing a birth experience means sorting through a lot of birth options, and that not all of these birthing options are equally available to everyone. For this assignment, you will imagine that you are writing a birth plan for your own childbirth (you’ll do this even if you are 100% sure that you never want to have biological children and/or that you aren’t able to do so). The point of the assignment is to have you consider different birthing options as if they were real decisions for you, so please do your best to use that perspective in working on the assignment. To prepare for this assignment consider what you’ve learned in our class readings and discussions about what interventions are routine, how each works, and your feelings about each one. Use all that you have learned about pregnancy and childbirth through our assigned class readings and birth plan workshop; you can consult any other sources (including friends and family) as well. Your assignment is to write your own birth plan – which outlines your desired birth scenario, including how you’d like to deal with pain, who will be with you in the room, where you’ll birth, and your preferences immediately after the birth (e.g. afterbirth, newborn care, breastfeeding). Your plan should be realistic and can only be one single-sided page (with a readable font size).
I used Ghahremani et al. (2023) recommendations for what components to include in a birth plan to provide students with different birthing options and scenarios to consider as they developed their birth plans, yet I also required that their birth plan was realistic (for example, that an epidural is not an option for a homebirth). Students were instructed that they were not permitted to use a preformatted birth plan or a checklist for the assignment so that students were positioned as agentic decision makers as they considered their perinatal care options. Preformatted or AI generated birth checklists do not require pregnant individuals to negotiate potential contradictions among birthing attendants, birthing location, institutional policies and financial implications of their care decisions, and research demonstrates that such preformatted checklists are not effective in practice (Medeiros et al., 2019).
Conclusions & Implications
When students submitted their birth plan assignment, I also requested that they submit a short response sharing their feedback about the assignment, including what they learned and if they thought the assignment was valuable for their future lives (especially if they are planning a future as a care provider); a qualitative analyses of these data will be shared in a future publication. Students also shared feedback during the in-class birth writing workshop, and without exception, students reported that this assignment was enjoyable and a helpful exercise that encouraged them to think critically and realistically about birthing options. As is the case with most US pregnant people (Declercq et al., 2013), most students developed a birth plan with preferences for a physiological birth.
Students’ in-class questions indicated their dismay and surprise about the limited options birthing people might actually have given the rhetoric of ‘choice’ around pregnancy. Similarly, students who have had in-person learning, for instance rotations in a medical facility, reported feeling ‘out of control’ and an associated sense of fear upon realizing that OB-attended hospital births may limit (prevent) an individual’s ability to make autonomous decisions about interventions, timing of labor/birth, and post-birth care (feeding, vaccinations, placental use) by virtue of hospital policy that disempowers individuals.
At the completion of this assignment, students really understood the dichotomy between the midwifery and biomedical models of care, and how even privileged birthing individuals may not be able to “have it all”. Students reported a real sense of how the material realities of pregnant individuals’ lives determine their ability to be autonomous and agentic in their perinatal care as determined by medicine as an institution, various forms of discrimination and oppression, geographical legal regulations, and financial determinants. Many students discussed the assignment with family members who had previously given birth, and these conversations gave them additional practical information about how to navigate the complexities of self-advocacy in the (bio)medical model of birth or, some students gained the courage to operate outside of the medical model of birth if it might be possible for them.
Importantly, students who are future health care professionals experienced the limited decision-making available to pregnant and birthing individuals as birth injustice. To date, research on birth plans as an educational tool have focused on patients’ education, yet a key prerequisite to a birth plan’s efficacy is a provider’s compliance with it. In this way, the birth plan can be utilized as an educational tool for the provider to learn about the pregnant person’s (medical) needs, preferences, and individual circumstances that may impact labor, delivery, and the post-partum period.
The framing of a birth plan as an educational resource about the pregnant person for others, a partner, family, and provider, posits a pregnant person’s lived experiences and embodied self-knowledge as epistemologically central to childbirth. As such, a pregnant person’s birth plan educates others about their care needs from a position of agency, autonomy, and positions them as experts on their own bodies. Centering the needs of pregnant and birthing people is especially important when an individual has experienced (sexual) trauma and pain associated with birth has the potential to be psychologically triggering. In this way, birth plans may be preventative against obstetric violence, associated birth trauma and the re-traumatization of birthing individuals who have previously experienced violence.
Regardless of trauma history, birth justice requires that birthing people are the experts of their own bodies, experience, and care. The use of the birth plan as an educational tool for the provider enables rich dialogue between the provider, pregnant person (and support people/partner, if applicable) before childbirth so that shared decision making can occur before labor begins when the pregnant person is more able to self-advocate, and if necessary and possible, can make alternate arrangements for a provider if an agreement for birth preferences cannot be made. Additionally, the birth plan can model the use of respectful and preferred language to the healthcare providers (Gittens-Williams et al., 2024).
Future research on the use of the birth plan as an educational tool among future healthcare providers will elaborate on students’ experiences of the assignment. Implications of using the birth plan as an educational tool geared towards providers (or future providers) positions the birthing person as the expert/teacher and the provider as a learner/facilitator, rather than as the person in charge. The nonhierarchical, respectful, and dignified care of pregnant and birthing people, as facilitated by a birth plan, is one way to initiate birth(ing) justice. Indeed, such care is demanded by pregnant people themselves and international stakeholders in maternal health including WHO (Baumont et al., 2023).
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[1] Researchers who study the use of birth plans in the US use the term ‘woman’ or ‘women’ to describe pregnant people. In this article, I use researchers’ terminology when I’m describing their work or methodology, and I use birthing or pregnant people at other times to represent the wide range of gender identities that pregnant individuals use. More research on the use of birth plans in minoritized populations, especially in gender nonconforming and trans women is needed to understand how a birth plan might function as a source of empowerment and as a communication tool to resist heterosexism and transphobia in medical settings.
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