e-Health Services to Support the Perinatal Decision-making Process:

An Analysis of Digital Solutions to Create Birth Plans

Carla V. Leite

and Ana Margarida Almeida

Digital Media and Interaction Research Centre (DigiMedia), Department of Communication and Art,

University of Aveiro, Aveiro, Portugal

Keywords: Digital Solutions, Online Services, Healthcare Planning, e-Health, Pregnancy, Perinatal, Labour and Birth.

Abstract: This research aims to provide an overview of the existent digital solutions for birth plans’ creation, intending

to contribute for the advance of e-health services focused on the perinatal decision-making process. Primary

data was found through a web search procedure. Better ranked options complying with the following criteria

were included: (a) available online and for free; (b) pregnant people as the target audience; (c) labor and/or

birth plan creation features; (d) in English. Four online services were found, and a two part study was

conducted: a) a non-exhaustive benchmarking-like analysis of webpages where the digital solutions to create

birth plans were provided, according to six dimensions; b) followed by a content analysis of the digital

solutions, resulting in 13 categories emerging, that were scored according to their occurrence and

completeness. “Consent and Information” category had the lowest score, what is considered critical for the

full purpose of a birth plan creation; while, “Freedom”, “Ambience and Equipment”, “People”, “Type of

birth” and “Pain management” categories achieved the highest scores. Two solutions were considered

particularly incomplete. Results show three solutions based on checklists, and one on visual icons. All

solutions were based on a delivery approach, not including interactive or audiovisual components.

1 INTRODUCTION

The process of information analysis, making a

decision and implementing it, known as informed

decision-making is one of the most complex

mechanisms of human thought (Zakerihamidi et al.,

2915). It requires the development of critical and

reflective thinking, in order to understand reality, to

avoid prejudice, and to achieve historical and social

emancipation (Machado et al., 2007).

Informed health decisions can be better supported

when individuals can communicat and share their

views with experts who understand the scientific

evidence, and can present risks, benefits and

alternatives (Stirling et al., 2017).

How the individuals are exposed to information

may have considerable repercussions in how they

balance risks and benefits (Slovic et al., 2005).

Besides, access to data does not mean its

appropriation and full understanding, as well as the

ability to self-diagnose (Lundberg, 1989).

https://orcid.org/0000-0001-5803-2775

https://orcid.org/0000-0002-7349-457X

Avant-guard healthcare services are changing

care model to be more person-centred (Mezzich et al.,

2016) counting with preventive care to minimize

clinical interventions (Jansen et al., 2013),

prioritizing the parturient satisfaction on quality of

care reforms and health-care delivery (Galle et al.,

2015), following the World Health Organization

(WHO) health system responsiveness framework

(Mirzoev & Kane, 2017).

Studies show that pregnant women who

participate actively in the decisions: feel more

satisfied; have a more positive perception about the

birth; tend to be more prepared; feel more in control;

have a greater participation in the process, which

contribute to reducing anxiety and stress during the

process (Figueiredo et al., 2012; Lozoff et al., 1988;

Hidalgo-Lopezosa et al., 2017).

Birth Plans gained expression as communication

tools during the 80’s, when WHO classified them as

a top category of recommended practices, advocating

safety reasons (WHO, 2006). however no

Leite, C. and Almeida, A.

e-Health Services to Support the Perinatal Decision-making Process: An Analysis of Digital Solutions to Create Birth Plans.

DOI: 10.5220/0010814600003123

In Proceedings of the 15th International Joint Conference on Biomedical Engineering Systems and Technologies (BIOSTEC 2022) - Volume 5: HEALTHINF, pages 405-412

ISBN: 978-989-758-552-4; ISSN: 2184-4305

405

standardized form was made available. Despite

several renowned institutions all over the world

endorsing childbirth literacy and the preparation of a

birth plan (AAP & ACOG, 2012), there is a well-

documented negative perception and controversy

related to birth plans among the labor and delivery

teams (Afshar et al., 2017), that can be due to the fact

that not every detail can be predicted during labor

(Whitford et al., 2014). More accurately described as

a decision aid for birth preferences, this document is

meant to enhance expectant parents involvement, and

to support their decisions regarding labor and birth

(Lothian, 2007), since for its creation it is required the

discussion of options and clarification of perceptions,

beliefs, fears and motivations, therefore triggering

meaningful communication between expectant

parents and healthcare workers, and ultimately

resulting in awareness and knowledge (Goldberg,

2009).

Despite several studies showing that there is an

opportunity to reach expectant parents through digital

technology (Shiffler et al., 2017); and the fact that the

Internet is being widely used across the globe as an

educational tool to gather pregnancy-related

information (Bjelke et al., 2016; Sinclair et al., 2018);

digital health technologies to support expectant

parents specifically the perinatal period (the time

during labor and birth) were reported as one of their

major unmet needs, that could be significantly

improved (Robinson et al., 2018).

In order to understand how the Internet is

supporting the birth plan’s creation, an exploratory

analysis of the webpages providing a digital solution

to generate birth plans was conducted, plus a content

analysis to reveal the covered topics. Results are

expected to provide an overview of the current

existent solutions, and to highlight how complete are

they, when compared to each other, aiming to

contribute to better understand if a care model is

being clearly followed.

2 METHODS

Digital solutions were collected using a web search

procedure, and the solutions included are the ones

that better ranked while searching for the following

queries: “birth plan generator”, “create birth plan”

and “birth preferences”; and, considered as a

contribution for this study according to the

following selection criteria: (a) available online and

for free; (b) expectant parents as the target audience;

English language. Redundancies were eliminated,

so the ones found to be similar were not included in

this list. Data was gathered between February and

May of 2020. The content out of the scope of this

study was not analyzed, and consequently excluded,

namely regarding infant care and non-immediate

postpartum.

The analysis of the webpages of the online

services consisted on a non-exhaustive

benchmarking-like search (figures 2 to 5), following

a set of dimensions (figure 1). This part of the

analysis intends to make explicit the context where

the digital solutions to create birth plans can be

found, the technology needed and some user

behaviors expected, to be possible to interact with it.

Figure 1: Dimensions for analysing webpages providing

digital solutions to support the birth plan creation (authors’

proposal).

The second part of the study was focused solely

on the Plan dimension of the digital solution: in order

to explore the material, following a content analysis

approach (Bardin, 2008), the raw data was organized

and clustered to make it possible to highlight their

characteristics. Categories and related sub-categories

that raised from the analysis are listed on Table 1,

being mutually exclusive, homogeneous, relevant,

productive, objective and reliable (Bardin, 2008;

Esteves, 2006). The set of sub-categories emerged

from a single plan, or from the combination of two or

more plans.

The existence of each Category was addressed,

and a score was assigned according to their

completeness (Coutinho, 2011). Since a binary

analysis was not possible, three different

classifications were defined: a) Complete (2 points);

b) Incomplete (1 point); c) Highly incomplete or Not

mentioned (0 point).

The score allowed a total calculated as an

overview for each plan (26 as maximum points), and

at the same time, to analyze each category among the

four plans (8 as maximum points).

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406

Table 1: Categories and Sub-categories for the plans’

analysis (authors’ proposal).

Categories Sub-categories

Introduction

Headline; Identification; Clinical

History; Location.

Consent and

Information

Update; Informed of options;

Professional’s decision.

Particular

requirements

First language; Accessibility; Religion;

To bring something; To record or to

photograph.

Freedom

To move; To eat and drink; To breath;

To vocalise; To push; To change

position; What to wear; Others.

Ambience and

Equipment

Light; Mirror or Low screen; Silence or

Music; Equipment; Privacy.

People

Companion or Partner; Support;

Students; Healthcare provider; Others.

Type of birth Water; Vaginal; C-section; VBAC.

Early

Interventions

Trichotomy (shaving); Enema (clyster);

Perfusion (IV/saline lock); Cervical

exams; Rupture or Stripping

membranes; Urinary catheterisation;

Alternative methods.

Foetal monitoring Cardiotocography; Doppler; Others.

Pain Management Anesthesia; Analgesia; Water; Others.

Medication Induction or Augmentation; Others.

Late and Post

interventions

Perineal relaxation; Forceps or Vacuum;

Episiotomy; Perineal suture.

Umbilical cord

and Placenta

Clamp or Cut; Blood or Stem cells;

Discharge; Observation; End.

3 RESULTS

Four online services, with a digital solution each,

were found. One solution was from a publicly-funded

healthcare system, and three from private companies:



National Health Service from the United

Kingdom (NHS UK) (presented on section

3.1) - https://www.nhs.uk/conditions/pregnan

cy-and-baby/how-to-make-birth-plan;



The Bump - https://www.thebump.com/a/

tool-birth-plan (presented on section 3.2);



She Knows - http://pregnancyandbaby.com/

calendars/articles/937331/birth-plan-creator

(presented on section 3.3);



Mama Natural - https://www.mamanatural.

com/visual-birth-plan/ (presented on section

3.4);

3.1 NHS UK Solution (NU)

The first analyzed solution was the NHS UK -

National Health Service from United Kingdom. It

consists of a single document available for download

on the official website (figure 2). The usage and

importance of creating a birth plan is explained on

this specific webpage. Along with this introductory

text, some link suggestions to other pages of the same

website are recommended, enabling the user to

explore related content.

The plan is available through public link

download (no need to be registered), not being

necessary to prove UK citizenship. The access was

made from outside UK and allowed the visualization

of a sets of checklists by topic, some including also a

text box for comments. Each topic starts with a quick

introduction to each topic, clarifying more technical

terms. It counts with nine pages related to labor and

birth, plus three regarding pediatric care. It includes a

paragraph in each section to advice the best practice,

to clarify some clinical terms, and sometimes to

present alternatives. However, some questions do not

require a clear consent or refusal, and the women only

states if the topic was or not discussed with the

midwife/doctor, there is a textbox under each of those

questions that opens the space for comments that can

be used, for example, to state preferences, thoughts

and/or concerns. The legal recognition of this

document is not clear, since there are no signatures or

personal details addressed, besides the pregnant

women’s name.

Figure 2: Results from NHS UK solution analysis.

e-Health Services to Support the Perinatal Decision-making Process: An Analysis of Digital Solutions to Create Birth Plans

407

3.2 The Bump Solution (TB)

Second solution analyzed was The Bump, with a web

page dedicated to the birth plan topic; despite this

fact, it does not provide any explanation or suggest

links to be consulted regarding the plan topics, only

stating briefly the beneficial usage of a birth plan

(figure 3).

It is not possible to edit electronically the

document provided for download through a link, even

with proper software to edit forms, since it is

supposed to be printed and filled out by hand. It is

presented as a birth plan template of six pages, with

the header making it clear its purpose. The only

textboxes presented are to be filled with identification

on the top of the document. The following topics are

grouped by background-color, following even/odd

contrast colors (light teal and salmon). It is mostly

arranged in a double column grid of answers using

checkboxes, counting with options in favor, against

and not sure about each mentioned topic.

The website announces a mobile application

focused on pregnancy and parenting, which includes

a similar checklist as a feature. However, it was not

Figure 3: (left and top): Results from The Bump solution

analysis.

possible to analyze it in depth, since I’s availability is

limited to certain regions. On the other hand, the

output from the mobile application is announced to be

an email sent to the midwife/medical doctor.

The Bump plan does not include any text boxes for

comments or notes; it only works as a checklist of

preferences. It doesn’t include any option of refusal;

it states avoidance instead. Besides having clear

spaces to identify all the parts involved, no other

details are required, so the legal recognition of this

document is not clear. This birth plan includes the

possibility of check some clinical details that are

relevant for the birth, and the women can clearly state

the type of birth preferred.

3.3 She Knows Solution (SK)

The third analyzed solution consists in an online form

available on the She Knows website (figure 4). The

webpage, where the form can be filled and generated,

includes some notes about the usage of a birth plan,

stating the upside of creating two birth plans: one for

the support team and another for the health providers.

To create the birth, expectant parents need to pick

the sentences that describe their preferences. This

means that several options are presented, and they

need to check the ones that apply. Then they need to

press a button in bottom that will submit the form,

what triggers a new tab to open with a web page filled

with the inserted data.

The document generated needs to be saved or

printed, and it cannot be edited later on. Visually, this

solution is not as appealing as the others analyzed in

this study, but it is simple and clear. In addition, the

sentences that were not checked in the form cannot be

read in the final document, so it only contains

information that the expectant parents find useful.

As a help system for filling the form of the plan,

there are some text instructions available. It is

possible to customize font, title, greetings and a pre-

filled introduction. This form includes sentences to be

checked as agreed. It is divided by sections that can

be displayed or hidden in the final document. Some

sections include links as suggestions to other web

pages related to that specific topic. All sections

include text boxes for notes that can be filled in. In

some questions, the user can define which is the

priority option to be considered, and which other

options should be considered after that one.

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Figure 4: Results from She Knows solution analysis.

3.4 Mama Natural Solution (MN)

The forth solution analyzed was Mama Natural that

consists of a document made available in a webpage

for free download (figure 5), and the web page is

focused on clarifying the usage and importance of a

birth plan. It does not contain information explaining

the topics, but it suggests some links to other pages of

the website.

The document is presented in a visual format,

showing 20 icons, each with a simple key on the

bottom of each. It can be inferred that pink icons are

refusals (e.g.: “no medication”, “no episiotomy”),

while the blue ones are requests and information of

preferences. However, since the key is a brief

explanation of the icon, it is not clear if it is an

expectant parent preference or a definite refusal. This

might be intended just to trigger discussion, since it is

described in the web page that one of the goals of

using this visual birth plan is to avoid conflicts

between the expectant mother and the health care

providers.

To customize the plan, expectant parents need to

download a Word document, and use proper software

for text edition. This template works by an exclusion

process, which means the users can delete the icons

which they do not agree with and keep the others.

According to captions, this plan seems to assume that

there is a set of procedures that will be done unless

they state otherwise.

There are two areas: during labor and after

delivery, organized by 5 columns of icons, which

makes the plan really compact, up to two pages. The

icons are clear and with a coherent design. Aesthetics

seem to play an important role for readability, and it

is the only plan taking advantage of semiotics from

all four analyzed. However, few information is

provided, also it is not clear the relation between

competing alternatives (e.g.: “donating cord blood”

and “delayed cord clamping”).

Figure 5: Results from Mama Natural solution analysis.

In order to understand which topics are covered

by the plan of each digital solution, a content analysis

was conducted, focusing on the presence and

completeness of each one of the 13 categories that

emerged. A sum-up of the obtained results is

presented on Table 2.

4 DISCUSSION AND

CONCLUSIONS

All the analyzed solutions assumed a document-

delivery approach, with three of them requiring a

specific software for text edition, and only one being

an online generator. Three of the solutions listed

options in a checkboxes format, and in some cases

also displayed text boxes for the user to add some

details; while one of the solutions opted by a

semiotics approach, by providing symbols that could

be deleted or kept, according to the user’s preference.

By collecting this data was possible to understand

the context and format of the birth plans generators,

and by carrying a content analysis it was possible to

e-Health Services to Support the Perinatal Decision-making Process: An Analysis of Digital Solutions to Create Birth Plans

409

Table 2: Content Analysis results by Category and by

Solution.

Category

Introduction

Consent and

Information

Particular

Requirements

Freedom

2 2

Ambience and

Equipmen

People

2 2

Type of Birth

Early

interventions

Fetal

monitoring

Pain

management

Medication

2 2

Late

interventions

Umbilical

cord and

Placenta

Total by

Solution

9 22 19 11

Complete - scored 2 points: considered fully or close to

fully complete, when the majority of sub-categories were

covered.

e.g.: “Fetal Monitoring” found on The Bump Plan: I’d

like fetal monitoring to be: a) Continuous Intermittent

Internal; b) External; c) Performed only by Doppler; d)

Performed only if the baby is in distress.

Incomplete - scored 1 point: considered when some (at

least one, but not the majority) of sub-categories were

covered;

e.g.: “Freedom” Category found on Mama Natural Plan:

Free Movement; Food and Drink for mama.

Highly incomplete or Not mentioned - scored 0 points:

considered when none of the sub-categories were covered, or

when not presented as an option, but rather a statement of

being a topic under discussion, and no option intended for

consent/refusal listed.

e.g.: “Late Interventions” Category found on NHS Plan: I

have/have not discussed with my midwife or doctor why an

episiotomy might be necessary; I (would like/wouldn’t

like/not sure yet whether I would like/do not mind if) my

partner or companion(s) to be with me if I have a forceps or

vacuum delive

y).

point out the categories included in each birth plan,

and how complete are they in comparison to each

other. It is noticeable that the birth plans covered a

wide set of topics, that were summed-up into 13

categories. However, the results reveal a massive

difference between two groups: a) NHS UK and

Mama Natural plans lack completeness in the

majority of the Categories; they do not cover five and

three of the categories, respectively; and both have

only one category considered as Complete; while b)

The Bump and She Knows plans mention all

categories; have higher numbers on completeness,

with 9 and 6 fully or close to fully complete approach,

respectively. These results may suggest that different

care models are being followed, with the The Bump

and She Knows plans being more person-centered by

providing a high number of options to be addressed

as decisions.

When analyzing from the category’s perspective,

it is noticeable that “Freedom”, “Ambience and

Equipment”, “People”, “Type of birth” and “Pain

management” achieved 6 points each, being therefore

the most complete categories among all plans.

“Consent and Information” was the less addressed

category among the plans obtaining 2pts. This result

seems critical considering the purpose of a birth plan,

and relevance of them for the human right standards

to information and to informed-decision as a patient

(WHO, 2019). By including options regarding

“Update”, “Informed decisions” and “Professional’s

decision”, sub-categories related how the expectant

parents want to deal with information, previous to and

during labor and birth, the plans could help pregnant

people and companions to manage their expectations

more appropriately when requesting or facing the

need for care (DGS, 2015).

Possibly, those options

were assumed as a right or a common procedure by

the organizations/companies who created the plans.

However, listing the options is considered a careful

and safe position to make the provider aware of the

need to request consent during each interaction,

informing the pregnant person and companions what

to expect along the process, and the options to deal

with, since presenting them and enabling the

participation in the decisions may have a positive

influence in the pregnant person’s satisfaction

(Lothian et al., 2007). It could also be relevant to

approach this category from both healthcare

professional and expectant parents’ views: the

pregnant person and companions may have different

expectations regarding when updates coming from

healthcare professionals should happen, according to

a certain frequency or upon specific stages; it could

include options regarding how the expectant parents

would inform their new/final decisions, or even

change any decision according to the process at the

moment.

Instead of following a mandatory protocol that

requires the healthcare professional to obtain the

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patient signature to accept a procedure upon

admission, there are essential components during

information exchange and involvement to assure

comprehension, adequacy of information and

freedom of choice (Goldberg, 2009; Ford et al.,

2003). Several studies show the importance of

training healthcare professionals in this domain,

being also fundamental to train expectant parents so

they can make informed-decisions regarding labor

and birth (Hindley & Thomson, 2005). It is crucial to

recognize expectant parents' individual autonomy,

which characterized by auto-determination, skills to

set goals, personal values, freedom to choose and

plan, and to proceed accordingly (Espanha, 2009).

The informed-decision making process is one of

the most complex mechanisms of human thought,

since it requires the development of critical and

reflective thinking (Machado et al., 2007). Creating

opportunities to put the patient in the center of the

decision process can help to foster the compliance

with the established expectant parents rights. They

have already been incorporated in different national

and international regulations (e.g.: English common

law, Napoleonic Code, US Constitution and Bill of

Rights, Helsinki Declaration) and are highly endorsed

by global organizations (e.g.: World Health

Organisation, Médecins sans Frontieres and Amnesty

International) (Krogstad et al., 2010).

This study provided an overview of the current

existent solutions, and classified how complete are

they in comparison to each other. However, the

results were not crossed with scientific evidence-

based data, it could be interesting in a near future to

establish how they comply with current healthcare

guidelines by WHO (2018) - which were within the

scope of our previsously published work (Leite &

Almeida, 2021).

The analyzed solutions range from a long scroll

on a webpage, to a nine pages’ document. However,

if the solutions were truly interactive generator tools,

dynamic features could be included to facilitate the

display of so that amount of categories, along with the

following proposals: a) to have a system for locking

the mutually exclusive options of the same question;

b) to have a system for sorting the options of the same

question according to preference; c) to include a

visualization of dependencies in relation to other past

and future options to be chosen; d) include full and

relevant information to support expectant parents

while marking the options (not as external referrals);

e) to clarify which options will be available according

to possible occurrence of events.

Future work on this topic could also be conducted

in order: to understand the optimal extension of the

information to be provided, to avoid cognitive burden

and maximize reading comprehension (Zisman-Ilani

et al., 2017); to define which options (categories and

sub-categories) should be included in a birth plan; and

to assess the knowledge built and awareness gained

through the usage of such digital solution.

ACKNOWLEDGEMENTS

The authors would like to thank: HEALTHINF 2022

organisation; the anonymous reviewers for the most

helpful comments; University of Aveiro, and António

Moreira in particular. CVL would like to

acknowledge the funding from the Portuguese

National Funding Agency for Science, Research and

Technology (FCT - Fundação para a Ciência e a

Tecnologia) and the European Union, through the

European Social Fund (Programa Operacional

Regional Centro) for the Doctoral Programme in

Technology Enhanced Learning and Societal

Challenges (PD/00173/2013), through the doctoral

grant PD/BD/143077/2018.

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