Evaluation of the birth plan implementation: a parallel convergent mixed study

Abstract

Abstract Introduction: Pregnancy, childbirth and motherhood are among the most significant events in women’s lives. Mother’s instruction and active participation in decision-making process of childbirth plays an essential role in mother’s physical fitness as well as psycho-social preparedness. A birth plan can be a productive and key tool to have a natural and physiological childbirth. The implementation of a birth plan is common in developed countries, but it is rather new in developing ones. So far, no investigation on birth plan intervention has been conducted. Therefore, the research team decided to assess the implementation of birth plan on childbirth experience and maternal, neonatal health outcomes through two stages: Quantitative (randomized controlled clinical trial) and qualitative (content analysis). Methods: The present study uses a mixed-method with a parallel convergence approach, including both qualitative and quantitative phases. The quantitative phase was a randomized controlled clinical trial, Which was performed on 106 pregnant women, 32–36 weeks of pregnancy who referred to the Midwifery Clinic of Taleghani Medical Research and Training Hospital. Socio-demographic and obstetrics characteristics questionnaire, the Delivery Fear Scale (DFS) of Wijma (version A), and the Edinburgh Postnatal Depression Scale (EPDS) were were completed for eligible participants. Participants randomly assigned to the two groups of birth plan and control using a randomized block method. The mother requested birth plan was implemented by the researcher after admitting them to the delivery ward, Routine hospital care was provided to members of the control group. During and after the delivery, the questionnaire of delivery information, neonatal information, and Delivery Fear Scale (DFS) was completed. Also, a partogram was completed for all participants by the researcher. The participants in both groups followed up until 4-6 weeks post-delivery, whereby the instruments of Childbirth Experience Questionnaire (CEQ2.0), Support and Control in Birth (CEQ2.0), Edinburgh’s Postpartum Depression Scale, and PTSD Symptom Scale 1 (PSS-I) was completed 4–6 weeks postpartum by the researcher through an interview. Independent t-test, ANOVA and chi-square tests were used to analyze the data. In the qualitative phase to explain the experiences of childbirth using the birth plan. In-depth individual interviews were used for data collection. The sampling was of a purposeful type. The data analysis was performed through content analysis with a conventional approach. Results: The mean (SD) CEQ score of the participants in the birth plan group 3.2 (SD: 0.2) was significantly higher than that of those in the control group 2.1 (SD: 0.2) (MD= 1.0; 95% CI: 1.1 to 0.9; P˂0.001). The independent t-test results indicated no significant difference between the birth plan 222.0 (SD: 57.0) and control 207.7 (SD: 53.4) groups in terms of the mean (SD) duration of the active phase of labor (P=0.223). Also, the mean (SD) Support and Control in Birth (SCIB) score of the participants in the birth plan group was significantly higher than that of those in the control group (P˂0.001). The mean (SD) DFS score (during labor) (P=0.015), EPDS scores (P˂0.001) and PTSD score (P˂0.001) of the participants in the birth plan group was significantly lower than those in the control group. The frequency of emergency C-sections of the participants in the birth plan group was significantly lower than those in the control group (P=0.007). No significant difference was found between the birth plan and control groups in duration of the second phase of labor (P=0.903), third phase of labor (P=0.386), admission of a newborn in NICU (P=1.000), neonatal Apgar score in the first minute (P=0.048) and fifth minute (P=0.731). The analysis of the related qualitative data of women’s experiences led to developing eight main categories including: satisfaction, perceived safety, an increased level of pain tolerance, preparation for childbirth, active participation in decision-making process, strengthening self-confidence and self-management, support and unfulfilled expectations.

Conclusion: The results of present study indicated that making a birth plan leads to an improvement in women’s experiences, an increase in her support and childbirth control, a reduction in tokophobia, symptoms of depression and post-traumatic stress disorder (PTSD), and an increase in the degree of vaginal childbirth. Given a high record of negative experiences and related factors, the policy makers and planners are recommended to implement birth plan to improve positive experiences of childbirth and increase women’s active participation.