Design and Health World Health Design
 













Birthing Unit Design: Researching New Principles

Calming colour and lighting in the birthing pool room
The Birthing Unit Design Guideline developed at the Sydney’s University of Technology creates a design tool that will help to optimise the birthing experience for both mothers and midwives.

As part of an effort to modernise existing birthing facilities, many maternity units throughout Australia are currently being rebuilt or refurbished. However, in the state of New South Wales (NSW), a critical appraisal of the recently updated Department of Health Guidelines for Maternity Services revealed that they had failed to take into account a number of new developments in the area of ‘caring/healing’ architecture1,2.

These new insights, and the set of holistic design principles that stem from them, need to be considered in order to be able to optimise healing environments in care settings, especially in maternity.

Methodology
To look at the impact of birthing unit design, our research team conducted an extensive examination of the existing literature, and gathered further insights from surveys of birthing women, and in-depth interviews with midwives in clinical practice and architects in health facility practice.

Using this information, the investigating team then prepared a set of principles for the creation of optimal birth spaces that are less stressful for women and more conducive to normal birth. These principles were enumerated and described in detail in a Birthing Unit Design Guideline.

From this guideline an audit tool, called the Birthing Unit Design Spatial Evaluation Tool (BuDSET), was developed. The next step in the methodology is to conduct a validation process, using the BuDSET instrument, at six selected sites for each of six birth units within the South East Sydney and Illawarra Area Health Service (SESIAHS) of New South Wales. SESIAHS provides birthing services in a range of primary to tertiary maternity units in rural and urban settings.

These units, therefore, provided the team with a range of sites, including newer, older, smaller and larger units, to enable comparison of context and setting and also to determine a baseline of compliance with the BuD principles.

A calm environment at Aryshire Maternity Unit at Crosshouse Hospital, designed by Keppie Design
Birthing context
Over the past 50 years, the design of birthing units in developed countries has focused on providing places for women to give birth in hospital environments, fully equipped with technology in order to ensure that births are safe. However, both doctors and midwives have raised concerns that medicalised hospital environments may have, in fact, contributed to the increasing rate of interventions – and in particular, caesarean sections – and the additional risks that these interventions bring2,3.

The campaign to promote ‘normal birth’ conducted in 2005 by the UK’s Royal College of Midwives refl ects how the tide is turning against the continued acceptance of technical intervention4. Concerns were raised about the consequences on the health of the mother – the potential for infections, deep venous clots, longer recovery, reduced physical and emotional health – as well as the impact on children born to mothers who had had previous caesarean deliveries, including stillbirths, congenital malformation, central nervous system injury and other risk factors3,5.

But even if interventions are being used to help ensure good outcomes, hospitals need to realise that most women do not need to give birth in physical spaces that are the equivalent of an intensive care unit.

The ability to lie back, kneel or move into other positions in the birthing pool all assist during labou

r
Learning from home births
In 2004 there were only 589 homebirths reported in Australia, representing 0.2% of the 257,205 births that took place that year. There were 5,079 births in midwife-managed birth centres6 . Despite the small numbers – which may not take some unreported births into account – it has been through the home birthing movement that change has come.

Particularly in the UK, Europe and Australia, an understanding of what women choose to do when unencumbered by a medicalised environment has become more evident7.

Comparing the behaviour of labouring women in hospital with those who give birth at home reveals that homebirth midwives have developed a profound understanding of the important elements in non-medicalised birthing8,9. At the turn of the 20th century, during the move away from birthing at home, three critical elements were lost9:
• the opportunity to undergo labour in a familiar environment
• the close and trusting personal relationship between the woman and midwife and the continuous support that was provided by this person
• the belief in childbirth as a natural physiological event.

The ‘environment’ is more than physical space or location – it also takes up an emotional space in the hearts and minds of women who are undergoing labour and giving birth. This environment has a powerful influence on both the woman and the midwife. Women who are asking for home-like environments and continuity of care with a designated midwife, as well as more choice and involvement in decision-making, are unconsciously looking for the elements that have been lost from the home birthing environment9,10.

Studies of women giving birth at home show that women respond in dynamic and disinhibited ways in response to the feeling of the baby pressing on their cervix or moving through the pelvis. Women were quiet and noisy, clothed or naked, restless or still, paced the room, rocked back and forth, sat in chairs, lay on the bed, squatted in the  toilet, stood under the shower, lay in the bath, leaned over the mantelpiece, window sill or partner and chose many different locations within their homes in which to give birth10.

This was not the experience found in hospital births. In hospital, midwives and birthing women found themselves constrained not only by the lack of privacy and the lack of accessible bathroom and en-suite facilities, but also by the only piece of furniture in the room: the high, narrow, metal bed with plastic under-sheet and ever-ready stirrups. The bed, taking up the majority of space and seeming to suggest the birth should only be on the bed, has become a major theme in the changes needed to correct the architecture of birthing spaces.

Is birthing design important?
Italian architect Bianca Lepori10, an international specialist in birthing unit design, has raised concerns through her publications and conference appearances about poor total environments for birthing in hospitals. Especially having an impact is her recognition that poor physical environments are a major contributor to the creation of a pathological rather than a physiological place for birthing.

Lepori constrasts the positive spirit of the home birth to hospital environments, which, she believes, cause women to unconsciously accept the technologically expedient pathway laid down by the hospital birthing process.

In doing this, women have disconnected themselves from the natural pathway of being present and actively participating in the birth. Lepori says that, although technology is essential for safe birth, we have forgotten the ‘soul’ of the places we build – and we need to bring the battle between the technical and the emotional into balance. She uses the idea of the integration between the left and right hemispheres of the brain coming together in ‘Mindbodyspirit Architecture’, creating an optimally correct place for birthing to occur.

Only recently has the general public started to become aware that the spaces we build, and the environments enclosed by these spaces, have a signifi cant impact on our health. Populist books by authors like Christopher Day (Places of the Soul, 200411) and Alain de Botton (The Architecture of Happiness, 200612) have extended this idea to wider audiences.

But the building itself is not the only element in the whole human environment. By concentrating on the building itself and not on the kind of place it creates, we have failed to grasp the psychosocial impact of our buildings.

De Botton12 argues: “The significance of architecture is premised on the notion that we are, for better or worse, different people in different places – and on the conviction that it is architecture’s task to render vivid to us who we might ideally be.”

In other words, the places in which we undertake specific tasks will affect us in profound ways and we need to understand who we are and in what ways the environment created by our buildings is supportive of what we wish to do.

The corollary to this is that in understanding people’s behaviour when they occupy spaces, we begin to understand how to design them better. Christopher Day11 notes: “All activities demand different states of being. If we are in the wrong state for the job, we feel stressed. Our environment can provide the soul mood appropriate to the situation.”

Stress reduction is a critical element in supportive or salutogenic (health-giving) space design. And the relationship between stress and the physical environment has been well established in studies over the past 10 to 15 years13.

Getting women’s views
A significant piece of research conducted by the National Childbirth Trust (NCT) in the UK in March 200314 provides convincing evidence that not only do women believe the place in which they give birth is important for a successful birth, but they are also clear about what they need in that space.

The NCT surveyed 2,000 women who had given birth between the years 2000 and 2003. The results showed that:
• Ninety percent of women felt that the physical surroundings can affect how easy or difficult it is to give birth
• Many women did not have access to facilities felt to be essential during labour
• Most women felt a clean room with ensuite, comfortable furniture for themselves and their companion and the ability to move around were highly important
• Women wanted control of heat, light and, especially, who came into the room
• Women did not want to change rooms to give birth or to use a birth pool
• Women giving birth in a hospital were less likely to have helpful facilities available than those who gave birth at home or in midwife-led birthing centres
• Women with good facilities were more likely to have a natural birth, while women who had an emergency caesarean were less likely to have had access to good facilities.

The birthing pool should be sufficiently deep and provide comfortable access for birthing partners and midwives

Privacy was an essential element that came through in many ways, including the ability not to be overheard, to control those who entered into the room and to not be able to hear other women labouring or birthing.

Most women felt the hospital bed was not important as an adjustable device for different positions in labour or in birth – many suggested it be moved out of the way.

The items that were considered important included: a birthing pool (although those with no experience of this were ambivalent), beanbags, floor mats, pillows and comfortable furniture. The ability to have control of lights, so they could be adjusted to low brightness levels when needed, and quietness were important to help birthing.

Unhelpful elements were: the hospital atmosphere, small spaces that did not enable movement and walking around, an uncomfortable bed that was not adjustable, open doors, being heard, toilets outside the room, and rooms that were either too hot or cold with no temperature control.

Clearly the consistency across the NCT survey, and its correlation with other research, provides a high level of confidence that the results can be applied more generally.

Humans and their environment
In order to create the kinds of spaces women need for birthing in hospitals, we must understand what women do when allowed to birth naturally and to judge the quality of that space in achieving its salutogenic objectives.

Research into the quality of architectural space and usage has proven difficult when examining ‘scientific’ evidence15. Essentially, this is because studies carried out in normally occupied spaces are hard to control for confounding variables. As Day11 notes: “What is often dismissed as human subjectivity is the unconscious ability to synthesise many factors: however because it’s unconscious, many personal preferences get muddled in.”

When we come to designing better living and working environments it is with the unconscious response to space that we are concerned. As Day11 says: “Even if nobody looks at them, everybody responds to background visual impressions. We see this visual ‘mood’, can talk about it afterwards, remember it for years – but when asked to draw any of it, have hardly any idea how it actually looked!”

Particularly in health facility planning, we are anxious to ensure that the unconscious effects of built space provide positive human physiological responses – principally, stress reduction. Good spaces generate positive feelings or mood through the parasympathetic nervous system. By understanding what causes the negative effects of stress and anxiety, we are able to reduce the impact on people who are using our spaces.

A format for design guidelines
Christopher Alexander16, through his seminal work on design quality, showed that if we examine the whole space, and not just the elements of it, we can achieve a qualitative response that is considered pleasing, stimulating and ‘good’.

Birthing Unit Design Guidelines
In order to present the findings of this research we have chosen to use the Pattern Language format developed by Alexander. He provided a formula that identified a design problem (an observable problem requiring a solution), the underlying assumption about this problem (a testable hypothesis) and the solution (the suggested way of solving the problem). The formula produces a series of ‘patterns’ that can be linked into a design solution – these are recognised as universal objectives for the design.

Artwork helps to set the tone, providing a welcoming atmosphere for birthing mothers

The project team have developed a series of patterns as a guide to determining the benchmark for an ideal birthing unit. These patterns form the basis of the BuDSET audit tool. In the following section, we have used Alexander’s format to illustrate and describe the tendencies people have for use of spaces and it is that which drives the quality of the spaces needed in the birthing unit design.

The essential starting point for this Birthing Unit Design Guideline is giving birth at home. Evidence shows that, for women who are healthy and anticipate having a normal birth, giving birth at home is ideal17. However, we acknowledge that in many developed countries, the proportion of women who give birth at home is small.

Therefore, the birthing unit outlined in this document provides principles for the design of a health facility birth unit based on homebirth principles, listed in a sequence that reflects the progressive flow that a woman takes through the birth unit.

Access to the community
Labour and birth should happen as close to home as possible. Proximity to friends and support are essential for a healthy healing birthing experience and being a long way from home makes this diffi cult. Proximity to home can also be a spiritual thing. The familiarity of the birth space can reflect sufficient elements of home to reduce alienation and anxiety.

Outside access to the birthing unit
The entrance to the maternity unit must be easily identified. There should be a dedicated entry area in a general hospital facility to reduce anxiety and give confi dence for a safe arrival. Entry through the emergency department is inappropriate.

Welcoming arrival
Consideration must be given to how we find and then approach the birthing unit once inside the health building. Long corridors can be frightening and cause anxiety for first-time arrivals, especially those who are not sure how far it might be or if there is help nearby. This fear is exacerbated at night when the lights are low and no one is around.

Easy wayfinding
Double doors and airlocks that are not automatic can be difficult to manoeuvre and put roadblocks in the way of hurrying or anxious people. Airlock spaces, while necessary for security, can make labouring women claustrophobic and increase anxiety. The preference is for an easy route from the outside door to a birthing unit entrance that has glass doors where staff and support can be readily seen.

Birthing unit as home
A birthing unit should be like a home. It should be possible to become familiar with the unit very quickly. Small is beautiful, therefore larger birthing units should be developed in groups or clusters that have an individual feel. Access to an outside area is important, both for enabling a view to the outdoors as well as providing potential access to nature.

The arrival hall
The public arrival area should be a transition space. We need to be able to transfer emotionally from being an ‘outside person’ to an ‘inside person’. A space that enables this transition to take place is emotionally important. Staff should be accessible for support and direction, and the space should be as nonhospital-like as possible.

The family room
From the transition space, one should enter a welcoming shared space. This is where the family or support people, when not in the birth room can wait comfortably, occupied or asleep on a lounge. Women can share experiences and give each other support.

The mother’s room
The mother’s personal space for birthing should be immediately accessible from the public area. It should not be possible to get lost down corridors on the way. Corridors should be familiar and welcoming, hotel-like where room entries are highlighted in recessed openings, focused ceiling lights identify rooms and, if possible, external windows in the corridor enable orientation to the outside and the way ahead.

Privacy
The birthing woman should control the room. An alcove at the entry can provide a place to wash hands and a cupboard for supplies before entry to the unit. The woman can see who is entering and has control over her space. The room should have an atmosphere of cleanliness and order and contain feminine symbols of beauty, wholeness and harmony.

Home comforts
Many women complain that rooms are designed around clinical procedures and the simple things, which make the space
familiar and accessible, are missed14. There should, therefore, be a cupboard to provide adequate space for the woman’s belongings. This should be designed for easy access, and for quick unpacking and repacking as women are not there for long.

Birthing pools and large baths
In the NCT study14, the second most important feature of the labour room identified by the women as helping to facilitate their birth was access to a pool or large bath. Of those who felt this was an important element, two-fi fths had not had access to a pool during their last labour.

Midwives who use birthing pools say women prefer the bath not to be in the centre of a space but drawn over to one side of the room. The ability to lie in the water, hold on to a supporter, kneel, move about or sit up, all assist during labour and birth.

There should therefore be a tub bath in one corner of the room, preferably designed so that only one side of the bath faces the room and is not able to be approached from all sides – thereby not placing the occupant on display. The approach side of the bath should allow a support person or midwife to sit and assist or to remain for some time without discomfort. There also needs to be a wide edge on the wall side of the bath so the women can sit out of the bath or the partner can lean in (as shown above).

The bath must be deep enough for a woman to be on her hands and knees with her bottom submerged. Most commercial baths are not deep enough and mean that a woman must recline (lie on her back) to labour or give birth. A supine position has been shown to be counterproductive to the physiology of giving birth.

The bath must have a showerhead with a pulsing feature and the fi xed rail for the shower head must be nogged into the wall if plasterboard, so the woman by pulling up can use it for support. Keeping the bath water hot is an issue and consideration must be given to allowing higher levels of temperature or faster fl ow rates than the normal to quickly add hot water to the bath. Spa baths are not recommended due to cleaning and infection control issues.

Convenient ensuite/bathroom
In addition to the bath, which becomes more of a feature of the birth room, there should be a bathroom with toilet, hand basin and shower for normal ablution functions. The studies supported by the NCT survey indicate that ready access to an ensuite toilet enables women to remain relaxed and can open up their bodies without fear of soiling floor mats or the bed.

Material support for birthing
Women will use other features in the room at different times during labour and birth. Such items include a mantle piece for the woman to lean on. Women often feel more comfortable leaning on something while standing. The mantle piece should preferably be of wood so that the texture and the appearance are domestic and have a natural feeling. Where possible, there should be tiered soft-covered benches along a wall so that the woman can lie or sit on them.

These spaces are also important for the midwife or partner to rest on as well. The woman can sit on the floor and lean against the benches, or use them to stabilise herself while squatting. They need to be covered in soft material that can be easily cleaned. Material such as fl oor mattresses, bean bags, balls, pulling ropes and other supports for labour and birth should be available but kept out of the room and brought in as required.

Lighting sets the mood
Lighting is critically important. In the first instance, natural light should be available and used. Natural light supports the biorhythms of the body and knowing whether it is day or night is an important orientation. Light affects mood and stimulates people physiologically as well as psychologically.

Colour builds the spirit
Careful selection of colours is important to support mood, by either stimulating with brighter colours or providing restful
psychological responses with warm tones that are more subdued in colour. Small amounts of strong colour will provide stimulating vignettes but generally rooms must have less white and cream in exchange for stronger pastel colours. The birthing pool should be sufficiently deep and provide comfortable access for birthing partners and midwives.

Technical support
The need for medical gases and suction are fundamental to delivery, even though the focus of this guide is on low-risk uncomplicated births. Oxygen, suction and nitrous oxide should be stored behind cupboards and a service panel exposed by pulling open doors or dropping a table down. While women want the assurance of this technology, they don’t want to see it.

Managing the bed
The bed in the birthing suite is important and currently bed types vary dramatically between units. Some have typical inpatient beds incorporating electronic or manual adjustments while others have fixed home-style double beds.

An examination of beds leads to the following performance specification. The bed must not be the focus of the room. Too often the room has been sized with a bed in mind and little else. This means that mobility and a capacity to remain upright becomes limited. Recently, large double beds have been used in birthing suites and, while the intention is fine, this has meant even less room is available for anything other than a bed. It is preferable that the bed is pushed out of the way, for example behind the door, and the balance of the room left for multiple activities to suit the woman during labour and birth.

Most women do not use the bed when alternatives are offered. This is especially true if sufficient space is available and women are supported to remain off the bed. Some women will kneel or stand in front of the bed, some will squat using the side of the bed to hold onto, and many will give birth on their hands and knees on the floor leaning against the bed.

The bed needs to be low. It needs to move. It needs to be possible to lean against the bed when there is no other means to do so. If the woman has to use the bed, a birthing bar across the end of the bed can be used to lean against. The bed is a critical element in setting the expression and impression of the birthing room. If the bed ‘screams’ of technical clinical procedures then the whole birth experience will reflect this style of labour and birth.
 
Controlling sound
Soundproofing is required so that the room is quiet on the inside and women feel they can make noise during labour without being overheard. Soundproofing the room also means that women in the waiting room are not distracted or worried by the noise of women in labour.

Ancilliary spaces
Other rooms in the unit should include the supply room, a blanket warmer, clean linen supply and dirty linen hold, and a disposal room. The equipment store should be of a reasonable size. It needs to be located close to the birth room to reduce clutter and to allow flexibility in the use of different birthing support materials.

Biophilia: connecting to nature
An important element of health facility design is the connection with nature – to enable patients, family and the public to move easily out into gardens and courtyards. This is recognised as an important stress-reducing element. Considerable research by bioscientists in the past 30 years suggests that humans gain enormous psychological, physiological and certain health responses by engaging with living things.

Conclusion
The development of the patterns which led to the audit tool and the consequent review of built facilities will help provide documented evidence for use in the design of better birthing units. The literature supports the notion that physical environments provide both positive and negative effects on birthing outcomes. Women prefer quite specific types of places in which to give birth.

If we can ensure the essential elements of these designs are provided in every case, we will have reduced anxiety, increased support and might expect to see reductions in the ‘fear cascade’ that creates the demand for interventions that could have negative consequences for both mothers and babies.

Authors

Ian Forbes is adjunct professor and director of the Research Unit Group for Health Architecture and Planning at the University of Technology in Sydney, New South Wales. He is also a principal health planner and architect at GHD Architecture.



Maralyn Foureur, Nicky Leap and Caroline Homer (pictured left) are professors of midwifery in the Faculty of Nursing, Midwifery and Health at the University of Technology. Caroline Homer is also director of the Centre for Midwifery, Child and Family Health in the Faculty of Nursing, Midwifery and Health at the University of Technology.

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