Controlling the uncontrollable - paradoxes of birth plans, expectations and reality. A critical frame analysis

Birth plans are commonly promoted to enhance women's autonomy during childbirth, yet evidence of their effectiveness remains inconsistent. The aim of this study was to map and discursively analyse birth plan templates in Swedish public maternity care and online from a gender perspective, focusing on autonomy, decision-making and informed consent.

We collected birth plan templates from 21 healthcare regions and developed an online search strategy to identify web-based templates and instructions for writing a birth plan. In total, we analysed 64 documents using Critical Frame Analysis.

Our analysis revealed five frames with six related discursive struggles. Birth plans could improve care and birth experiences, while women's wishes were both encouraged and dismissed. Birthing women had capacity to express their wishes, yet significant expertise was implied. Birthing women had agency and decision-making power, but birth plans provided no guarantees for fulfilling women's wishes. Midwives and maternity care were accommodating and adaptable, yet midwives lacked time for birth plans and birth plans were sometimes framed as unnecessary. Finally, childbirth was portrayed as both possible to plan for and unpredictable and impossible to control.

Framings of birth plans navigated between accommodating women's preferences and the need for organisational efficiency. The coexistence of empowering frames and contradictory messages illustrates the ambiguity surrounding birth plans. The wide range and conflicting instructions may increase the gap between birth expectations and birth experiences. Heightened awareness of birth plans and how they relate to birthing women's autonomy is important for Swedish maternity care.