Many women will approach birth with a complex set of hopes and concerns. These will reflect many influences including their previous experiences, the stories they have been told (Weston 2001) and their personality (Saisto et al 2001a). In some instances, the anticipation of the unknown generates fear of childbirth (Wijma et al 1998) as highlighted in Chapter 6. The evidence is not clear regarding the most appropriate intervention to help women overcome this fear. In a study by Ryding et al (2003) it was found that women who had consulted specially trained midwives because of fear of childbirth during pregnancy reported a more frightening experience of birth than women in the comparison group. Saisto et al (2001b) randomly allocated women who had presented with fear of vaginal birth to either a combination of cognitive therapy and written information (intensive therapy) or to information only (conventional therapy). They found that women in the intensive therapy group had shorter labours and that birth-related anxiety was reduced. There was no difference, however, between the two groups in the incidence of postnatal depression.

How women anticipate birth has significant sequelae for their experiences. In a large prospective study exploring women’s expectations and experiences of childbirth (Green et al 2003) it was reported that women in 2000 were significantly more worried antenatally about the thought of pain in labour, than women in 1987. This increase was particularly marked for primigravid women with 26% choosing the option ‘very worried’ compared with only 9% in 1987. Women in 2000 were also significantly more likely to accept obstetric intervention than their counterparts in 1987 (Green & Baston 2007). Midwives need to help women regain their faith in their ability to birth their babies without assistance. Further research is required to explore the most appropriate ways to enhance women’s confidence and to facilitate and promote unassisted birth.

Women who have high expectations have better psychological outcomes than women who have low expectations (Slade et al 1993, Green et al 1998). Women should be encouraged to develop confidence in their abilities to cope with the challenge of labour, and this should be one of the aims of preparation for childbirth classes. The provision of information about the choices available, such as pain relief, will enable women to be actively involved in decisions about their care. Involvement in decision-making is an important contributor to a positive birth experience, enhancing a woman’s sense of control of the situation (Gibbens & Thomson 2001).

In a national survey of women’s experience of maternity care conducted by the National Perinatology Epidemiology Unit (NPEU) (Redshaw et al 2006), 89% of first time mothers who responded said that they had been offered antenatal classes as part of their NHS care compared with 59% of women who had already had a baby. However, not all pregnant women who are offered classes take up the invitation; 33% of primigravid women and 80% of multgravid women did not attend. This may be for a range of reasons, including classes being full, not being held at convenient times or places, or not perceived as useful. Further subgroup analysis revealed that black and minority ethnic women were less likely to be offered classes, less likely to attend and less likely to attend with their partner than white women born in the United Kingdom.

The timing of local, community-based daytime classes may preclude many birth partners from attending classes with their pregnant partners. Provision should therefore be made in the evening or at weekends for those who want to attend. However, attendance at classes is not always reflected in a more positive experience of birth for fathers. In a study that aimed to explore if fathers’ attendance at childbirth preparation classes influenced their experience of the birth (Greenhalgh et al 2000), it was reported that, for some fathers, attendance at classes was linked with a less positive appraisal of the childbirth experience. However, where men have been prepared as ‘productive’ participants in the labour process their involvement can have a positive impact on their partner’s birth experience (Diemer 1997). It is important that all birth partners are involved and acknowledged for the support they provide. There is a need to provide childbirth preparation for men based on their expectations and individual perspective (Hallgren et al 1999). A report by the Fatherhood Institute (2008) highlights the lack of provision for the preparation of men for their role during childbirth. It calls for ‘Relevant and securely funded NHS antenatal education that is appropriate to the needs of modern families and inclusive of fathers’ (p. 8).

Depending on local provision, women should be encouraged to attend classes that best meet their individual needs. Classes for women who have already had a baby, for women expecting a multiple birth or for teenagers, are some examples of classes that cater for women’s specific needs rather than the ‘one class fits all’ approach. The National Institute for Health and Clinical Excellence advises that women should be offered participant-led antenatal classes and breastfeeding workshops (NICE 2008).

Women can also make physical preparations for the birth. These may include attending activities designed especially for pregnant women, such as aquanatal and relaxation sessions. Preparations can also be made for an active labour by becoming familiar with and practising strategies to cope with contractions using non-pharmacological means. Women should be informed of the potential benefits of the strategies available, to ensure they have realistic expectations of their effectiveness (Spiby et al 2003). Fletcher (2003) outlines the National Childbirth Trust’s campaign ‘Don’t take it lying down’, designed to encourage women to remain upright and mobile in labour. She argues that midwives can influence the positions that women adopt during labour by the way they either react to or facilitate the creation of an environ­-ment conducive to active birth. Women can be made to feel that the delivery room is theirs to adapt to their own needs or, alternatively, be made to feel that their requests or suggestions are too difficult to accommodate. The NPEU survey (Redshaw et al 2006) reported that 88.5% of all women who had a vaginal birth, did so on a bed, 6.1% on the floor and 4% in water. Multiparous women were more likely to give birth on the bed (15%) compared with primiparous women (7%).

Student midwives can play a significant role in helping women feel that their hopes and aspirations for the birth will be acknowledged and upheld wherever possible. The fresh knowledge and enthusiasm that the student midwife brings to clinical practice can contribute to the introduction of alternative ways of working, under the close supervision of experienced midwives.

Government policy advocates that women should be able to make choices about their place of birth and use of pain relief, and that they should be given sufficient information in an accessible way, to help them make informed decisions (Department of Health 2007). Preparation for childbirth classes can be a valuable resource for women when it comes to making choices about what happens to them during labour. However, not all women are able or want to attend. Some women formalize their decisions before labour by completing a birth plan. This is a written outline of a woman’s wishes for her birth. It may cover issues such as what kind of pain relief she would prefer, whether or not she wants to have electronic fetal monitoring and what position she would like to give birth in.

The use of birth plans has escalated in recent years and forms part of the National Maternity Records. There are many other alternative versions and examples available to women who have access to the internet. Some take the form of written lists created by the woman indicating the conditions in which certain interventions will be acceptable and when they will not. Others include a general philosophy of parents’ hopes and aspirations for the circumstances in which their baby will be born. Many units use their own particular format to facilitate the birth planning process, often including a tick-box list with some room for specific comments. Although they have the advantage of providing structure to a discussion, they may not reflect the interests of the woman or encourage her to think about what she really wants (Nolan 2001). Kaufman (2008) describes how birth plans can take different forms, such as mind maps and decision trees, to help the woman explore how she feels about the birth. The popularity of birth plans has fluctuated, and they are sometimes seen as a hindrance by professionals rather than a tool to enhance woman-centred care. Simkin (2007) argues that birth plans do have a place in contemporary maternity care; that women still want to be heard and there are practitioners who use them respectfully to enhance the woman’s sense of control.

Completion of a birth plan provides a useful opportunity for the woman to discuss the available options for the management of her care (Kaufman 2008), whether at home or in hospital. Their use may help to enhance communication between all members of the multi-professional team (Enkin et al 2000). Some Trusts have specific policies and targets in relation to the completion of this aspect of the maternity notes, whereas other units do not formally dedicate either time or documentation to this activity. Where the birth plan forms part of routine care, this provides dedicated time for the midwife and woman to spend time together where the focus of the interaction is not abdominal palpation or blood pressure measurement. However, in reality, it may be combined with an antenatal examination.

In ideal circumstances, the midwife would visit the woman at home to discuss the birth plan. One of the main advantages of undertaking this activity in the woman’s home is that she is more likely to feel relaxed and able to ask questions in an environment in which she has control. Meeting the woman on her own ground also provides the midwife with much valuable information about the circumstances in which the woman lives and in which she will care for her new baby.