 It is my very great pleasure to introduce Irene Gonzalez Perez who is a midwife in Tenerife, Tenerife where the sun shines. Lucky person. Anyway, she completed her midwifery training in London and is now a doctoral student and this presentation is based on her doctoral studies, birth plans and women having choices as a new concept in Spain. Okay so I'm going to hand over to you Irene and I'm going to find out where that interference with sound is coming from so can you now see, can you now see the, yes fabulous okay I'll also mute myself so it's just you. Thank you Linda. You're welcome. Hello good morning everyone or after an evening I don't know where what she's come from but welcome and happy day of the midwives. I just wanted to say that English is not my first language so apologies in advance and please feel free to ask if you don't get anything or just to interrupt and use these little text chat rooms on the left so we can have a smooth presentation. I have to say this is part of my PhD so literature from this presentation comes from Spain and in the UK and even I think I've got something from New Zealand and Australia about before with Sarah I would like to see what are you expecting from this session so I've got a few questions from you. What would you like to hear today? Have you worked with birth plans before? What's your opinion on birth plans or do you find them useful? Yeah thank you Linda. We're pleased to have Linda today she's one of the promoters of the birth plans which is and feel very lucky to work with her today especially with that they've got unconventional choices issues at FGM. Thank you Mikayla. Very useful essential, I like the word essential yes. Laura Richard says the birth plans are an opportunity for research for women to research I also think that's very true. Let's move on and to start with I think we need to define what a birth plan is so for the UK the health system the NHS the national health system they define a birth plan as a record of what really likely happens during your labour and after the birth and then I've got this Spanish definition from the Ministry of Health where they say that a birth plan is a document in which a pregnant woman expresses her preferences, needs, desires and expectations about the process of birth. A birth plan is also a legal document in most of the countries and it actually comes in form and they show that it is a lot and unique. I would also like to clarify that birth plans are dynamic documents that means that they might change and they might vary as the labour process because labour is not static and births are dynamic as well. Having said that, those are the most common choices and preferences that we find in most of the birth plans so this one is from the NHS again from the UK. Those are the choices that they get to half the women so they can choose a place of birth like a delivery, birth centres or a home birth who's going to be with her so who's going to be her best partner if she's going to go for any pain relief options, medical, pharmacological or known pharmacological pain relief and so on. In, I've got an example, can you see, I hope they say I shouldn't be using pictures but I find that this one is very intense off. These persons or these couple consider lots of choices from early stage of labour like induction, staying at home as long as possible and they even consider also newborn procedures or preferences if things are created from normality. You can see the C-section issue here. I'm just reading Linda here on the chat and she asked to give my baby her first breathe because I've loved the smell of a newborn baby. That's true. Well let's move on and before we get to the main body of this presentation I would like to go through the history of the birth plan. There we go. We cannot understand the history of the birth plan without three main processes within the 20th century. These are medicalisation, institutionalisation and industrialisation. So the move to hospital moving the birth to hospital settings was major shift in the philosophy of care, not only to women who experience the pathologisation of childbirth but also to the midwife. They became to work under doctors or obstetricians control and shifted towards obstetric nurses. That means they some of them even lost skills, midwifery skills that they have while the independent midwives have in and work in at home settings and assist in home birth. The paternalism emerged and the authoritative knowledge of the obstetrician in some country we still even have some paternalism as our model of care in which health professionals are still the ones who make the decisions and women, pregnant women, follow their instructions we can say like that. Then the culture and the social society tend to be with the institution even the midwife rather than being with the woman and they started to conceive the women's body as a machine and the baby as a product. Luckily the World Health Organization and some family groups emerged and fought for women's rights. So in the 70s the society for the support of home deliveries and also the WHO and also the why everyone aliens in 1999 started to fight for these rights that women lost with all these medicalization process. Especially last year the WHO recommended birth plans also to support women's decision and to get birth experiences especially positive birth experiences that they were forgotten within all these processes because they really were focused on having healthy physical and normal deliveries but they forgot the psychology mental side and the dimension of birth. According to Osmore and Grady women's autonomy and decision making are essential women tend to get. We also know that those women who have been involved in decision making have better outcomes and better experiences. Writing a birth plan provides also a greater degree of autonomy and control to the women's therefore promotes decision making during pregnancy labor and the postpartum period. But we cannot understand the birth plans we set some key words from the literature and from guidelines from autonomy not only for women but also for midwives. So women have to be able to make choices to be free to decide and opt for what they think is convenient for her and baby. On the other side for midwives they should be able to work as independent professionals with physiological birth and also to be accountable to make their own decisions. In terms of women choices they need to be able to opt and to choose for what they think is best for them within their family their culture and their beliefs. Also women's rights as an individual as a pregnant woman and as a person especially when it comes to equal rights and gender equality and discrimination against women. But we will discuss women's rights indeed later on we've got light on that. There's also a processes which is not only hard for women but also for professionals and some systems some healthcare systems have found that professionals should have that tool to support the decision making progress. Holistic care also called woman's centre of care, family focused care and in fact it's a model of care who takes into account the women as a whole. This means she, her family, her community, her beliefs etc. And we mentioned that with all this medicalization process the importance of mental health was not considered. So the first two models of care partnership model and via psychosocial model encourage the importance of considering mental health and the emotional and psychological dimension of birth while looking after and why caring for women in labour. And also it's important to say that psychological dimension cannot be easily separated from the physical dimension of labour. We can see that even the, sorry, this is the Spanish name of the WHO and they also recognise that being involved in decision to reprint and see it have positive birth experiences and better psychological outcomes. And also I would like to highlight that culture makes an impact on possession of childbirth. We mentioned the holistic care and the partnership care in which we need to consider a woman as a whole and as her beliefs, her culture, her family and to every single woman possession is different, is subjective. Like for example a good birth experience could be as a section because this woman was in foreign and she got to be the centre of her labour while for another woman, a woman who had Aboriginal birth without epidural. This could be the worst experience ever for her because she requested an epidural that she didn't go. So that is not a good experience for her. That means that every single birth experience is unique, subjective and the definition and the perception that every woman has about a birth might change. I would like to say there is a new term for these that they have been using lately in the UK in the United Kingdom and it's called the optimal birth which defines which optimal differs from one woman to another one. In the next slide we've got the load and it's only a bit of international low okay because I didn't want to go through Spain or the UK or anything just to both be international. If you see with the human rights and then I like the CDAW, the Committee of the Elimination of Discrimination Against Women on 1979 and the European Convention on Human Rights. Also we've got ethical principles which are closely related to legal aspects when you're looking after someone and these are the four main points which should support our practice every single day and our daily basics. Here we go. Some articles which are really linked to birth plans. So the right of being care, the right of having not discrimination against women, prohibition of discrimination as the European Convention on Human Rights says and now let's focus on our main topic. So the good of the birth plans. The first one is that by acquiring new knowledge the women, the birth planning power empowers women. It also educates the women about all the options and some women say that they feel more secure when completing their birth plans. The birth plans include the pregnant women, the decision making progress and it is a recent record of her preferences, choices and needs like in case of anything happens. There are more good sides of the birth plans. It helps with the communication between the health professionals and the women and it structures the discussion between them especially. It's also a document of agreement between the choices and the women's preferences and it also shows women's preferences with the person who are compliant in case that person who is with her during labor has the desire for her. For some women the birth plans reduce the stress especially when women make unconventional choices which tend to fright health professionals. However, there are some less good things of the birth plans and one of them is that there is agreement about the benefits of the birth plans. They are still controversial whether they should be used or not. Especially when it comes to perinatal outcomes but we need more investigation on these more studies because is it not clear if birth plans have been followed or I mean if the health professionals who are looking after those women in labor and who presented a birth plan if those professionals also snap and follow her birth plans or not. In terms of birth plan document they are only based on physiological birth. That means the women are no don't dare and sorry about complications or things that can deviate from nobility during labor. So complications like forceps and in that section I know discussed with those women and sometimes they get a false expectation about labor. There's also a conflict with the term planned. Some people say that you cannot plan your birth ahead. Births are dynamic, births are unpredictable and we should think of including a term like woman preferences or birth preferences instead of birth plan. And the last bit here says that some as we they designed a birth plan and they made these pro forma birth plans they are now institutionally sized. So we're telling women we're going to go for a women's centre of care. Our main issues can you feel unique? Your birth is the your your choices are personal and your birth plan should be personalised but then we're giving them a pro forma. Some of them don't even add their own choices to these pro forma birth plans because I need to say I have to say even if you get a piece of paper and you write there your birth plan this is legal, this is okay. You can write up Berlin and you don't have to use the pro forma birth plans which are given by the health retorts or by the health systems. And the last bit of the less good there we go is that do we really know if women's expectations are always respected? And even some women say they are not offered they haven't been offered choices while they are in labour. Also as we mentioned before these sense of failure that they might experience when they do not achieve the expectations because they think only about the physiological birth and they didn't consider that things might change, things might deviate from normality and we cannot predict that unfortunately. There are also some women who designed their birth plans as interpartial care guidelines which is really unfair because they should have those options for granted. I mean the evidence base or that choices that they ask for are the ones that the guidelines recommend but in some hospitals are not still offered. Let's say for low-risk women not having a line, a cannula, and these women have to ask for them not to have a line when they are in labour. Healthcare professionals are not familiar in some cases with birth plans or sometimes the model of care that they've been promoting within that healthcare system cannot include a birth plan. Let's say if we've got a paternalism system it's going to be very hard to adopt a birth plan and the women's choices within that paternalism system. So it's going to be the conflict between women and curcumin will arise especially because professionals tend to be reluctant to the use of a birth plan. Healthcare professionals also tend to forget the birth plans when emergencies emerge during labour and a forced level of control is sometimes promoted. As we say do we offer choices or sometimes do we ask health professionals to limit those choices? So we give them 100% and we need to think about this as well. And in conclusion before we finish I think that this is the I hope you all can see this picture I think where I found that this is the best aim of the birth plan is the process of becoming educated. Education empowers you, knowledge empowers you. So getting to know your options and your choices make you have a better experience. But also I've got another quad. This is just in case you couldn't see the picture. This is the same one. I've got this one. That the real achievement of the birth plan would be its disappearance so that we don't have to use a birth plan to communicate between midwives and women because when there is a good mutual beneficial relationship among those two you already know that women's preferences. Thank you everyone. That is fabulous Irene. Thank you so much. Any questions so far? Thank you all. Well there's been a lot of comments. I'll let you read the chat box now. I wasn't being rotten when I said don't get distracted because we do make comments as well as ask questions. So if you want to scroll back up a bit and see if there's anything you have to respond to. There's a good point there about birth plans being useful for women with special needs such as female genital mutilation. Yeah. There is a point in here when I say that some of the performer birth plans tends to institutionally size women's labour and say at the end of the day we treat everyone in the same way. When you have special need you cannot be treated and especially when you've got FGM which is such an issue when it's so much sensitive and special needs. So I think that especially when those different or unconventional issues are there women should be encouraged to have birth plans and as midwives as anti-natal midwives you need to tell them why don't you write and why don't you complete your birth plan. I totally agree Irene. Yeah I did. Gives the woman a voice. That was me sorry. Women should have the voice. Actually if you have a good midwife communicating well with the women in a continuity of care away so that they become partners in this process from pregnancy then there wouldn't really be a need for a birth plan. Yeah I don't know how familiar are you with continuity of care. Sorry it's just not the same. Have you heard about continuity of care everyone there please. Because I know that in New Zealand, Australia and some countries are familiar but like here in Spain we didn't have any clue about that and they've been promoting this continuity of care recently in the UK and other countries. So the same midwife or the same team, small team of midwives look after one pregnant woman and as a result this midwife gets to be looking after her during pregnancy, labour and postpartum period and if she can't, if this midwife can't another member of her team would go but as they are small groups the woman usually has made them all during pregnancy. So relationships, choices, preferences and needs are already in place because they've been getting to know each other for 40 weeks or during pregnancy sorry and at the end they are together during labour as well so these encourage mutual and partnership model of care in which the birth plan shouldn't be needed. We have had continuity in care for a long time in the UK but it's kind of gone away and come back again and it's something we'd like to strive to but the same as Michaela has said it's an issue when we're short of midwives or midwives are not used to working to that pattern of care so there's a little bit of resistance but there's so much evidence supports good outcomes for women who are cared for by a midwife that they know. They are promoting this lately so much in the UK that I think it all came back after this birth plan study back in 2011 or 2014 so the research is the evidence is very robust so the experiences, sorry women's birth experiences on prenatal outcomes is all much better when you have had continuity of care. So birth plans are useful if there's no continuity of care that's what I think is being said here. When there is no continuity of care then you need to get to know the woman you're looking after in labour and you need to discuss the birth plan with her which we usually forget when we meet someone we need to go through her notes and we need to ask her what does she want what is she expecting, what are her needs and something as simple as do you want to pay your little RTI. It's a matter of communication it's fundamental and essential we don't have we cannot ignore communication even when we have a birth plan so see you need to ask her and even if she doesn't complete a birth plan you still need to have that conversation you still need to talk to her and get to know her needs and preferences. Yes it's all about communication really isn't it? Yeah a cornerstone on midwifery care. So in Spain you told me the other day that women getting choice and consequently birth plans is a fairly new thing is that right? Yeah sorry the birth plan was written in 2010 so only nine years and not only is hard for women but for health professionals like midwives of traditions and so on because we are not used to these model of care and we need to remember to give them choices to strength communication is a new system actually. So who who's in charge of child birth in Spain is it the midwives or is it the obstetricians? The obstetrician we've got limited autonomy here unfortunately. Sorry I missed that what was that say that again? It's still the obstetrician we're not independent midwives at all so we still offer obstetrician and midwife care we don't have independent midwives at all. It's not necessary to have independent midwives it's good to have a partnership between the obstetrician and the midwife. Especially for I mean for low-risk women for example we don't get to have the autonomy to look after them by ourselves. Okay so the medical the obstetricians then will probably interrupt this whole process that you're trying to encourage here of giving women choice and communication because they are notoriously not good at communication. It's tricky for all of us as I say if you haven't worked with choices if you haven't been on that system even as a midwife we have to learn and we we have to be told what should do and what is best at the end of the day for midwives sorry for women for outcomes and babies outcomes. So are the women themselves used to having choice are they dealing with the option of having choice? Not really. So it's a new it's a new concept for them as well that they need to. Yeah for sure. I think the role of the incident on midwives is quite crucial. Just not only teaching or educating women on labor but on the rights and on the options allow the autonomy and the choices that they can make during labor. Just a bit of theory of legal theory. Let's say let's put that and let's use the word legal. Yes have you seen this comment about a woman who made a birth plan for her partner to express what she wanted from him as being pragmatic that man appreciated a lot because it was concrete. I can see that perspective actually although you'd think that again that they could talk because talking and communicating ought to come to the same conclusion really particularly between a man and his wife or wife and her husband or partner rather. Yeah this is also another tricker thing. As a woman in labor you need to have there someone who will be able to support you and encourage you and coach you and some people are not ready for that. So sometimes you need to make sure who do you take with you to the labor ward because for some partners or even for your sister or your mother they are not they they can't do that and we all need to know our friends or our relative limitations and take care of someone who can't support us and that someone that we don't have to look after because we have enough with ourselves in labor and looking after ourselves and baby. Yes Selena said men often don't know what to do and it's fun it's not fun to feel powerless and our men do men do the men attend the births in Spain? Yes yes they do. Have they always done that or is that recent as well? I think it's quite a reason not us reason are the birth plan but yeah we haven't been like that forever. I'll need to have they anywhere else really. Yeah it is a quite fancy and new tide. It's all a very fascinating conversation really. I took a healthy woman at 35 and a half weeks who wanted a water birth. She had an awesome water birth but getting her getting to help her celebrate it was a systematic challenge. What do you mean it was a systematic challenge Irene? No idea. Oh is that Irene going to try and speak? Would you like to speak Irene? Irene Chain Calvarski that is. Yeah that takes a great midfire. No one is speaking so I'm going to start. Okay begin the scene. I'm afraid your reception is really poor Irene. Do you want to write it in the chat box? I'll write it for you no problem. Or whoever that was that was speaking just then. Well have we got any more questions because we're coming up towards the end of the session? Any more comments? I think Irene's point that what was that one in that previous slide? You said that you said that the real achievement as a birth plan would be it's disappearing. I think that is spot on what we would like to see. And certainly birth plans in the UK now are less common because women do now know often that they've got choice and there's a lot more discussion and communication and explaining done correctly during pregnancy. Yeah you're lucky you've been through that already like we are all in the transition and we need our tools to support the practices. Yes we're all at very different positions across the world. Yes. But that's that's the usefulness of something like this conference where the all of everybody is able to come together and discuss these points because for some people in some parts of the world having a safe environment in which to enable the women give birth is a higher priority than giving them choice even though choice should be given there are other there are other priorities out there it's very difficult for everybody but we're all moving on so that's fabulous. Yes I like the title too Celine. Okay so I think we should wrap this up now so I'm going to just go through the last few slides for everybody if that's okay. So without the any question a bit oh now Irene were you going to say something else? No really we finish. Oh okay okay.