I first heard of a birth plan in the summer of 2016 at a hypnobirthing class I took while I was pregnant. My daughter’s father and I dutifully attended the eight-week birth education course at a local hospital. There, we were part of a circle of first-time parents who, like us, had questions about everything from the best positions for labor to what an epidural does. When it came time to talk about birth plans, we were given templates and told that this was our chance to tell our obstetricians and other hospital staff what we did or didn’t want. Don’t want an episiotomy (the less and less common surgical cut to the perineum that’s sometimes used to help get the baby out)? Write it in your birth plan. Hoping to have your mom in the room with you? Write it in your birth plan. You can see where I’m going with this.
I welcomed the opportunity to plan for my ideal birth, but I knew early on that I’d have only so much say in the process. At 10 weeks, my obstetrician had detected large fibroids blocking my birth canal, so I knew I was going to need a C-section. Still, I had requests. I wrote down that I wanted to be conscious during the surgery, and, assuming we were both healthy enough to cuddle, I wanted immediate skin-to-skin contact with the baby.
My delivery and postpartum period went pretty much as planned, which isn’t the case for so many other black pregnant and birthing people. Far too many of us face complications that can cost us our lives, resulting in a maternal mortality rate that is three to four times higher in black women than it is in white women. The majority of these deaths—60 percent, according to the Centers for Disease Control and Prevention—are preventable.
SELF’s series on black maternal mortality has explored what large-scale health care and policy strategies various experts believe are necessary to address this problem. But what, if anything, can we do to improve our chances of surviving and thriving during pregnancy, birth, and the postpartum period? Are there things we can learn about the health care system and our rights within it so that we’re better prepared for interactions with institutions and clinicians? Is there any way the birth plan, a tool first documented in 1980 to help people have more informed and fulfilling childbirth experiences, can help address our black maternal health crisis?
Asking if we can plan our way toward health and safety doesn’t excuse health care institutions and providers from listening to black families and acknowledging the ways their own beliefs and behaviors contribute to black women’s deaths during pregnancy, childbirth, and postpartum. But while the systems we birth in figure out how to keep us alive and well, experts in maternal health say we can try to take matters into our own hands as much as possible.
Before we dive in, two notes. First, a lot of these recommendations are predicated on various medical realities of being black and pregnant or postpartum in the United States of America, which you can read more about in the rest of our black maternal mortality series. Second, we’d be remiss not to mention that the ability to follow many of these recommendations depends in large part on having different types of privilege, like access to money, transportation, and health insurance. The suggestions below won’t be an option for many black pregnant and postpartum people in our country, which is a shameful reality that needs to change.
With all of that in mind, here are the tips experts suggest for black pregnant people worried about surviving pregnancy, childbirth, and the postpartum period.
Learn about what is and isn’t normal during pregnancy, delivery, and postpartum.
“People don’t generally learn about their health in school or anywhere else. Trying to go from zero health literacy to everything you need to know about pregnancy is a big lift. Part of the point of a prenatal visit is for us to talk with you about what you should be expecting, from, ‘You might see some spotting—here’s how much is normal and what to do,’ all the way to, ‘These are the signs of labor.’ But I actually suggest seeking out group prenatal care if possible. When you’re just with me, I’m only talking to you for 15 or 20 minutes. In a group, you have a cohort of people who are doing the same thing, so you can have a more robust conversation. Instead of me giving you some directives and maybe a sheet of paper with some signs and symptoms, it becomes a bigger conversation, which I think is better for absorbing the information.” —Joia Crear-Perry, M.D., fellow of the American College of Obstetricians and Gynecologists, founder and president of the National Birth Equity Collaborative
Interview potential providers if you can.
“Don’t expect that the gynecologist you’ve been seeing for annual care is automatically going to be who you want there when you give birth. In our practice, people will come for consultations with the midwives and ask us questions about our practice to see if it’s a good fit. I very rarely have anyone who’s not a well-to-do white woman do a visit like that. They know that they have options and are going to use their power to explore those options. Black families should be interviewing people, too. Say, ‘I’d like to come in for a pregnancy consultation.’” —Anayah Sangodele-Ayoka, certified nurse-midwife, M.S.N., MS.Ed., clinical faculty at The George Washington University Medical Faculty Associates and co-founder of Black Breastfeeding Week
“Have specific questions to ask the provider, like, ‘Do you know what preeclampsia is? What’s too much bleeding, in your opinion? How would you handle it? Are you comfortable working with black people? Are you culturally competent? What does that mean to you? What’s the policy around cultural competency here?’” —direct-entry midwife, certified doula trainer, and doula educator Shafia M. Monroe, M.P.H.
“One of the things I’m hearing more from my circle of black female friends who are pregnant or recently have given birth is that they’re having these conversations with their providers. They say, ‘What do you know about the black maternal mortality rate? What are you going to do to make sure that I don’t die during childbirth?’” —Rachel Hardeman, Ph.D., professor at the University of Minnesota School of Public Health
Get yourself a doula if you can.
“I’ve always been a big advocate of doulas. The best doulas are the ones who are good judges and who will also stay in communication with the physician when needed. The communication is the big piece.” —Yolanda Lawson, M.D., fellow of the American College of Obstetricians and Gynecologists, board-certified ob/gyn at MadeWell OB/GYN in Dallas and associate attending at Baylor University Medical Center
“Doulas are an incredibly important part of the care team. We know that doulas have the potential to improve outcomes, particularly for birthing people who are low-income or from communities of color. Having the doula in on the development of a birth plan and knowing it backward and forward is critical to its success. In the thick of it, it’s the doula who’s going to be able to refer back to that birth plan and say, ‘Here’s our shared goal. How does what you’re recommending fit into that? And if it doesn’t, why?’” —Hardeman
Find a care team that is culturally competent and understands your unique needs and concerns as a black pregnant person.
“You want someone who has an understanding of what it means to be black and to be a woman or a pregnant person in America, intergenerational trauma, the history and the context of people of color in the medical system, sexual trauma and PTSD, and all of the other things that black women, women of color, and pregnant people are often thinking about. They should also be very transparent about the things that they don’t know. Regardless of your socioeconomic bracket, you bring your lived experiences of being black into birthing. You want someone who has a full and complete understanding of what that means.” —Chanel L. Porchia-Albert, certified doula, certified postpartum doula, certified lactation consultant, and founder and CEO of Ancient Song Doula Services in Brooklyn, NY
Visit a few different practices to find the best fit.
“There is publicly available hospital data around the rate of cesarean births, so access that. You can also ask about it while on a tour or call labor and delivery, ask what those rates are, and ask what that rate looks like for the race or ethnicity with which you identify. You can also ask what strategies they are actively implementing around the drivers of the disparate rate of cesarean births and what they’re doing to modify their care in the context of the fear that black mothers and birthing people have.” —Karen A. Scott, M.D., M.P.H., hospitalist and professor at University of California, San Francisco and sexual, reproductive, and perinatal epidemiologist rooted in reproductive justice
Ask who will actually be delivering your baby on the day of.
“One thing people may not understand about the way health care works is the difference between types of practices, like an academic facility versus a private practice. I work in an academic facility. I train medical students, physician assistant students, and midwifery students. The attending physicians are very often not the ones who do birth. It’s going to be residents, who you almost never meet in prenatal care. People may be surprised by that when they come in during labor and they’re like, ‘But I’ve been seeing Dr. Such and Such.’ It is important to ask that from the beginning: ‘Who’s going to be at my birth? Is it going to be you or a student?’” —Sangodele-Ayoka
Create a birth plan that includes your main preferences and goals.
“There’s got to be a human piece. Do you have a doula? Is your partner going to be available? Is it your mom? Is it your sister? I would say, ‘In the best-case scenario, these people are going to do this. In the worst-case scenario, these people are going to do this.’ For every block of time, I would be very clear in terms of what you would hope to be doing, whether it’s in a birthing tub, whether it’s walking around, whether it’s dancing. Then there’s an interventions piece. Spell out what interventions are acceptable under what circumstances. Do you want an IV? Do you want fluids? Do you want an epidural? I have seen tables in birth plans where people have really laid it out, like, ‘Let’s say my membranes have been ruptured for eight hours, and people are starting to become concerned about my infection risk and the baby’s lung capacity. I would like to try this, this, and this before moving to induction.’” —Monica R. McLemore, Ph.D., M.P.H., R.N., nursing professor at the University of California, San Francisco
“In this era of fragmented health care, I would encourage folks to think beyond just, ‘I don’t want an IV.’ What birth experience do you want? What are the traditions you want to continue? What does birth mean to you? It’s helpful to define that on your birth plan. ‘This birth is a symbol of this…’ People don’t know what birth means to most communities, but particularly to a community where the narratives and norms of humanity have been so contorted and degraded and devalued. Is this birth a sign of liberation or resistance? Is it a renewal of a vow? If there is something traumatic or something triumphant about the experience of pregnancy, I need the birth plan to frame the interaction. I want to know the humanity of your birth as opposed to just the mechanics and management. If I can understand the meaning there, it can shape how I approach my communications, interactions, counseling, and decision-making.” —Dr. Scott
Understand that you might not get everything on your birth plan.
“In our organization, we call them ‘birth preferences’ because babies in utero can’t read. They don’t know or care what your plan is. It’s really about being thoughtful and intentional around your preferences and maintaining a sense of openness and flexibility. Your birth is your first introduction to parenting because kids are not always going to do what you tell them or want them to do.” —board-certified ob/gyn Amanda P. Williams, M.D., M.P.H., fellow of the American College of Obstetricians and Gynecologists, director of maternity services at Kaiser Permanente Oakland Medical Center in California
“We don’t use birth plans at Ancient Song. We call them ‘birth goals.’ A lot of times, when individuals are working with something considered to be a ‘plan,’ they think they’re somehow a failure if those things don’t happen that way. In reframing, it’s giving the person the power and control to say, ‘I understand that birth is something that is very fluid. Within that fluidity, I may not get everything that I want on this particular document, and that’s okay.’” —Porchia-Albert
“I see birth plans as no different from an advance directive at the end of life. While you are as clear-minded as possible, you write out the ideal circumstances under which you would like your birth to happen and what you’re willing to accept or tolerate if things don’t go as planned. Things can come up during pregnancy that will change your birth plan, like if you want a home birth but you’re developing a clinical condition that needs closer monitoring.” —McLemore
Consider turning your birth plan into a letter to your doctor.
“You can think big. Not just ‘I want to give birth in a squatting position,’ but, ‘I don’t want to have pregestational diabetes or to be anemic.’ ‘I want our economic situation to be okay.’ ‘I want it to be a thundershower when I birth. I want it to be a full moon. I want to feel relaxed. I want to hear music.’ Then you can turn that into a letter to your doctor, which is an idea I saw in the book The Doula Guide. ‘Dear Dr. Mary, Thank you for working with me and my partner. We’re so happy you’re going to help us reach our dreams around birth…” At the end, we say, ‘Thank you for listening to my wishes.’ We include a lot of appreciation because we don’t want providers to put up walls.” —Monroe
“The most successful birth preferences are the ones that are personal and short. Something more personal would be, ‘My birth team includes my partner, my sister, and my doula. My mother is not traditionally helpful, so please help me encourage her to make her visits brief.’ Or, ‘The person who can best speak for me is my partner if I’m unable to speak for myself.’ Or, ‘I have a history of sexual trauma from when I was a teenager. It is very important to always tell me first before you do an intimate examination.’ Also, don’t be afraid to do an introduction that pulls out the reality of what it’s like to be a black woman birthing in America. ‘Hi. My name is Amanda. Thank you for being here on the day of my birth. I’m aware that black women have three to four times the rate of death and an increased risk for many complications. I don’t want to be a statistic. I have lived in this body for the past however many years. Please listen to me. My birth team of love and support includes these people. These are the elements of this birth that matter the most to me.’ I think making a preamble that grounds the experience and says who you are and who your important people are is of great value.” —Dr. Williams
Discuss your birth plan with your support people.
“Birth should be a community event. We live in a society that sometimes tells us that it’s just you, and that’s what makes a lot of pregnant people feel isolated. It’s about not just educating the pregnant person but also educating the support people. If everyone on the team understands what you want for yourself and your child, then it makes it a lot easier if you have to advocate for yourself.” —Porchia-Albert
Discuss it with your providers, too.
“Start having that discussion about your birth plan from day one. In my research on Roots Community Birth Center, which is a freestanding birth center here in Minnesota, I realized that’s exactly what they do. It’s a midwifery-based model of care that is African American-owned and culturally-centered. In that first prenatal visit, they ask things like, ‘What are your resources? What do you value? Who’s your support system?’ Those conversations continue and build on each other throughout the nine months of pregnancy, allowing that birth plan to fall into place.” —Hardeman
“Ask, ‘How do you feel about birth plans? How do you feel about doulas and family in the room?’ Some practices are very explicit about not working with birth supporters, and they don’t want to hear your ideas about birth. You want to know that before you get too far gone.” —Sangodele-Ayoka
“When you present in labor and delivery, a birth supporter like your doula should make sure the labor and delivery nurse on that shift gets a copy of your birth plan and that there’s a quick conversation: ‘Here’s our shared goal. Here’s our shared vision. I know that things may take a turn or go differently, but here’s what we’re working toward.’ Discuss that beforehand. Every time there’s a shift change, that person should become part of your team.” —Hardeman
Prepare for possible pushback from providers, then seek care elsewhere if you can.
“When black people make a birth plan, it automatically seems confrontational to the system. The power dynamic changes. Know that when you make it. People and systems are not accustomed to black folks asking for things, having requests, having advocates, and having other things that they consider to be for folks who are privileged.” —Dr. Crear-Perry
“We as clinicians are often not trained to say, ‘It’s a real gift to be able to be at this person’s birth.’ We’re trained to think about it as, ‘This is our occupation.’ Then we get confused when families feel like they’ve been mistreated. It is a philosophical difference around how we see the birthing environment, what the space is for, and whose it really is. That throws a wrench into an entire system when, all of a sudden, we want an empowered birthing person slash community of individuals who want some say in what that experience is like.” —McLemore
During Labor and Delivery
Know that you can and should speak up if something seems wrong.
“I don’t want to put the burden on our patients to feel like they have to somehow battle for their safety in our health care systems. At the same time, if you feel like you’re not being listened to, it could be effective to say something along the lines of, ‘I know this might be something that you see commonly, but this really scares me. For me, this feels really different.’ Something like that would make me pause.” —Neel Shah, M.D., Master of Public Policy, fellow of the American College of Obstetricians and Gynecologists, ob/gyn at Beth Israel Deaconess Medical Center in Boston, director of the Delivery Decisions Initiative at Ariadne Labs, professor at Harvard Medical School, and founder of March for Moms
“Tell your provider, ‘I need you to really hear me right now because I’m worried.’ If they’re standing up, ask them to sit down and to look directly at you instead of looking at their computer if they have one in the room. Let them know that this is new, this is different, and you’re worried, so please help you or tell you what tests they can do to alleviate your concerns. Doctors are so often pulled in a million directions that they will go to their default and see traditional patterns as opposed to listening. The easy answer might not actually be the right answer, but realizing that takes engagement and asking questions.” —Dr. Williams
“If necessary, it’s okay to say, ‘Is there someone else I can talk to?’ The hierarchy of medicine and medical care makes people feel like perhaps they can’t ask for what they want. If you want a different provider, that’s okay, and you should be able to ask for that. There’s unfortunately not a script that’s been tested that we can say we know works. That’s why it’s so important that those support people are around, the doula or whoever else you decide to have in the room.” —Hardeman
During the Postpartum Period
Lean on your family and friends.
“Really think about who your team is going to be, whether that’s given family or chosen family. Start building that village of folks who are going to drop off a casserole or keep you company. Be ready to say, ‘I have a baby on me, could you please bring me a glass of water or fold the laundry?’ It’s really hard to be alone with a newborn. If there’s not another grown-up there, you might say, ‘I’m feeling short of breath, but I’m just going to suck it up.’ Have those additional people around so that if you don’t feel right, you can call your doctor and go in and get evaluated. Chest pain, difficulty breathing, suicidal thoughts—those are some warning signs that are important to know about.’” —Alison Stuebe, M.D., MS.c., associate professor in the department of obstetrics and gynecology at the University of North Carolina School of Medicine
“The postpartum period is a time to really be vocal and speak up with the people who are going to be present about how you want to be taken care of. Your doula’s not going to stay there. The nurse is only going to check in every so often. You want to make sure somebody is there to support you in the ways that you need around basics, like helping you get to the shower, making sure that you’re eating foods that you feel comfortable with, and supporting you in voicing when something is wrong.” —Sangodele-Ayoka
Find local groups of other black parents who can understand the hard stuff.
“It’s so important to have culturally appropriate breastfeeding groups. Black folks have to delve into a whole ‘nother set of issues when breastfeeding. In Café au Lait, a breastfeeding support group for New Orleans families of color, we talk about going home and dealing with your mother who didn’t breastfeed and she’s trying to give this baby Carnation milk and rice cereal. We create your breastfeeding support. We feel that it is super important to have someone that looks like us show us.” —Nikki Greenaway, also known as Nurse Nikki, board-certified family nurse practitioner and internationally board-certified lactation consultant, co-founder of the New Orleans Breastfeeding Center
Prioritize your postpartum checkups.
“Not enough of our mamas go back for their postpartum checkups, and it’s even less if they gave their baby up for adoption, had a stillborn, or are homeless. We have this mass amount of people who are not getting postpartum care. This is your time to heal. Pregnancy is nine, ten months. Birth is one to two days. But being postpartum is really the rest of your life. The way you care for yourself and the help that you get could dictate how healthy you are for the rest of your life.” —Greenaway
Even the best birth plan can only do so much.
Over and over again, the experts I spoke to emphasized that while planning and research are important for black pregnant people and their families, our maternal health crisis won’t be solved until there’s meaningful change in our pregnancy and birthing systems.
Throughout my own pregnancy, I had private insurance through the Affordable Care Act. I saw the same doctor at each of my prenatal visits, and he also performed my C-section. I was not rushed through appointments, and I used that time to express my fears and concerns. We were able to build a rapport with our care providers. We were able to build trust. Not enough of us have this experience.
In an effort to research the disrespect and abuse that can happen in maternity care, along with her colleagues, Shanon McNab, M.P.H., M.I.A., a consultant with the Averting Maternal Death and Disability program at Columbia University’s Mailman School of Public Health held 16 focus groups for women of color who had given birth in New York City hospitals. They also held focus groups for community-based doulas and conducted dozens of interviews with clinicians and hospital staff.
“What we found was this deep sense of mistrust on both sides,” McNab tells SELF. “[A lot of women talked about] deeply [mistrusting] the medical institution and not really having a reason to trust why this provider is telling me that I don’t know my body or that I need this intervention. On the other hand, the clinicians are saying, ‘I know nothing about this woman. I don’t know how many prenatal visits she went to. I maybe don’t have all of her records. I have no reason to trust what she’s saying when my clinical instinct is telling me something different.’”
In a sense, we’re at an impasse—one that’s killing pregnant and postpartum people across the country. The practical advice above about how to care for ourselves and each other during pregnancy, birth, and postpartum is critical to our wellbeing. But so, too, is fixing a broken health care system that treats people differently based on markers such as race, class, and insurance status.
“We [at Ancient Song] are very transparent in a know-your-rights framework of what you have the right to as a patient and as a parent,” says Porchia-Albert. “But if those institutions are not willing to make accommodations and changes to the ways in which they deliver care to black and brown people, it’s not going to matter.”
Quotes have been edited and condensed for clarity.
This story is part of an ongoing series on Black Maternal Mortality. You can find the rest of the series here.