e-Health Services to Support the Perinatal Decision-making Process:
An Analysis of Digital Solutions to Create Birth Plans
Carla V. Leite
a
and Ana Margarida Almeida
b
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).
a
https://orcid.org/0000-0001-5803-2775
b
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
Copyright
c
2022 by SCITEPRESS Science and Technology Publications, Lda. All rights reserved
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;
(c) labor and/or birth plan creation features; (d) in
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
NU TB SK MN
Total by
Category
Introduction
1
1
2
0
4
Consent and
Information
0
1
1
0
2
Particular
Requirements
1
1
1
0
3
Freedom
1
2 2
1
6
Ambience and
Equipmen
t
1
2
2
1
6
People
1
2 2
1
6
Type of Birth
1
2
1
2
6
Early
interventions
0
2
2
1
5
Fetal
monitoring
1
2
1
1
5
Pain
management
2
2
1
1
6
Medication
0
2 2
1
5
Late
interventions
0
2
1
1
4
Umbilical
cord and
Placenta
0
1
1
1
3
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
r
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
HEALTHINF 2022 - 15th International Conference on Health Informatics
410
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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