Birth Sets

Birth Sets

By Esme Dowle

FEBRUARY 21, 2023 ‘Disobedient Categories’ with Edwina Attlee.

BARC0134 History and Theory of Architecture.

1

Birth Sets Abstract: In an age of rapid technological development, labour and birth has become increasingly more medically advanced and interventionalist with a greater separation from the home. Alongside this, there is an increasing understanding of how mental wellbeing can affect physiological state and yet a consideration of the emotional and psychological wellbeing is often excluded. This piece examines how institutional space can affect the experience of the birth set and explores alternative environments as inspiration for the future of medicalised and non-medicalised birth space design.

First, the existing design guidelines (such as salutogenesis) will be described and used to assess the current approach to hospital maternity rooms. Then a comparison will be made between the textural palette of hospital and home birth sets and how these features affect the sense of privacy and access. Finally, layout, orientation and the resulting relationships will be analyzed to better understand the impact space can have on mental wellbeing and behaviour.

A series of interviews have been conducted to gather stories of labour and birth and descriptions of their associated settings. These statements will be used as supportive evidence and used to empathize with the childbirth process. Within my role as an architecture student, I also assisted with a birth space workshop which provided some visual representations of idealized birth spaces.

The collages created by the midwifery students of the workshop will also be used as primary evidence. Overall, the sensory experience of contemporary birth space will be investigated with hope that the potential use of birth space design principles in other architectural realms could inspire more sensitive architecture.

2

Contents Introduction………………………………………………………………………………………….…. page 4 Chapter 1: How does medicalised space affect the progress of labour and what design principles exist to guide the future of birth set design?

• • • •

Salutogenic Design ……………………………………………………………………………………. page 6 Hospital Typology .…………………………………………………………………………………….. page 7 The Active Birth Set …………………………………………………………………………………… page 12 Lighting as a Stimulant ………………………………………………………………………………. page 13

Chapter 2: Texture and Boundaries • • • •

Tactility and Access of Oxytocin ……………………………………………….……………….. page 15 Texturally Dispersed Birth Suite ………………………………………….……………………… page 17 Grounding …………………………………………………………………………………………………. page 20 Phenomenology ………………………………………………………………………………………… page 21

Chapter 3: Layout, Orientation and Relationships • • •

Margherita Birth Centre……………………………………………………………………………. page 23 An Informal ‘Introductory Lounge’……………………………………………………………. page 25 Minokovska’s Birth Set …………………………………………………………………………….. page 28

Conclusion ……………………………………………………………………………………………… page 32 Glossary ………………………………………………………………………………….………………. page 34 Image References …………………………………………………………………………………. page 25 Bibliography …………………………………………………………………………………………... page 36 Appendix …………………………………………………………………………………………..……. page 39 3

Introduction Until the 1930s, childbirth in the UK happened predominantly at home in the presence of the pregnant woman’s family with support from the invited midwives. 1 During and after the second world war, a societal push towards development and production transferred the normal setting of childbirth into medical institutions. Labour happened without family support, in the care and control of professional strangers 2 and with increasing use of interventions such as forceps and chloroform, birth was moved into operating-room-style single rooms, where it remained for decades.3 Calls for ‘humanizing birth’ were made in the 1960s seeking more home-like birth rooms and the inclusion of birth partners or supportive companions4.

Recently, there has been a push for a wider use of the salutogenic design principles and BUDSET guidelines in institutional birth space design 5. This paper will use the standard hospital birth and home birth sets to explore how these principles affect the

1 Tania Mcintosh, “A History of Childbirth in the UK – from home, to hospital, to COVID-19”, THE CONVERSATION, last modified: January 2021, https://theconversation.com/a-history-of-childbirth-in-the-uk-from-home-to-hospital-to-covid19-149587 2 Doris Haire, “Cultural Warping of Childbirth.” International Childbirth Education Association News 11, no. 1 (1972): 5-35.

3 Maralyn Foureur, J.D Harte. 2017. Health and Well-being for Interior Architecture. (New York: Routledge.) Chapter 9: Salutogenic Design for Birth: 1.1 Outline of Chapter Content.

4 Ank de Jonge, Birgit Y. van der Goes, Anita CJ Ravelli, Marianne P. Amelink- Verburg, Ben W. Mol, Jan G. Nijhuis, J. Bennebroek Gravenhorst, and Simone E. Buitendijk. “Perinatal Mortality and Morbidity in a Nationwide Cohort of 529 688 Low-Risk Planned Home and Hospital Births.” BJOG: An International Journal of Obstetrics & Gynaecology 116, no. 9 (2009): 1177-84.

5 Foureur MJ, Sheehy A, Forbes, IFW, Davis DL, Pandolfo B, Fenwick J, Verghese G, Leap, N, Homer CSE (20010). 2009. The BUDSet Tool: Birthing Unit Design Spatial Evaluation Tool (Version 2). Centre for Midwifery Child and Family Health, University of Technology Sydney, Sydney. http://www.uts.edu.au/sites/default/files/budset.pdf

4

emotional and physiological state of the birth-giver and how subtle spatial variables can affect relationships between the different characters of the set.

As the primary research method, several interviews with three mothers have been conducted and the outcomes will be used as supportive descriptions of childbirth. In January 2023 I assisted with the Birth Space workshop at the University of Brighton. It was carried out with first year midwife students as part of their BirthSpace module run

by Jo Gould, Senior Midwifery Lecturer, and Elizabeth Blundell, Senior Architecture Lecturer. During this three-day event, spatial collages were produced showing the students’ understanding of how optimised birth space can affect their midwifery practice and the psychology of the birth-giver. They represented their descriptions spatially via digital collages so two of them have been included in the essay. Alongside this, the two collages are represented as diagrammatic plans for additional clarity. The significance of furniture will be explored by analyzing some common furniture features of these contemporary birth spaces.

This essay is written from the perspective of someone who has not endured childbirth, so these interview encounters and workshop descriptions have provided a muchneeded source of information and opportunity for empathy. The interviewees have been kept anonymous and I have received permission to exhibit the workshop collages from the course leaders - all ethics guidelines will be followed to protect the privacy of the individuals involved.

5

Chapter 1: Medicalised Environments and Prospective

Birth Space Design.

Salutogenic Design

The underfunding of the NHS has had some role in the lack of sensitivity of birth space which has resulted in facilities that only seem to consider the physiological state of the body.6 7However, research has shown that a space that affects your emotions can have a profound effect on the pathology of normal birth. Harte and Foureur describe the concept of salutogenesis with three areas of consideration which aim to develop a sense of coherence for the expectants: ‘meaningfulness’ regarding the fulfillment of creating new life; ‘manageability’ as an awareness of the amazing abilities of the pregnant body; and ‘comprehensibility’ as understanding that because of this ability, a sense of trust, control and safety can be experienced8. With these considerations, the sensory variables of architecture can be adjusted to optimize the conditions of the birth environment accordingly.

It is portrayed in ‘Squaring the Circle’ that contemporary medicalised birth space is generally designed and constructed with an attitude of fear; the presence of large machinery and precautious surfaces results in pessimistic spaces that incite suspicion

6

Jonathan Barron, “Crumbling buildings and creaking systems: does the NHS invest enough in capital?” NHS Confederation, Last modified November 14, 2022. https://www.nhsconfed.org/articles/crumbling-buildings-and-creakingsystems-nhs-capital-investment.

7 Matthew Taylor, “We cannot continue to neglect mental health funding”. Blog post, NHS Confederation. January 19, 2022. https://www.nhsconfed.org/articles/we-cannot-continue-neglect-mental-health-funding 8 Maralyn Foureur, J.D Harte. 2017. Health and Well-being for Interior Architecture. (New York: Routledge.) Chapter 9: Salutogenic Design for Birth: 2.0 Salutogenesis and Pathogenesis.

6

in their users. 9 The concept of the ‘Fear Cascade’10 explains that fear inducing birth environments and the artefacts found within may have a significant impact on the neurophysiology of the labouring person by stimulating the brain to produce catecholamine hormones that can alter physiology and behaviour. This means that the more fear the birth-giver experiences, the slower and more irregular the contractions become.11 However, many women are reassured by situating their labour in hospital as interviewee 1 describes: “the idea of being in hospital felt safer and I didn’t want to risk being away during my first birth” 12. Downe and Byrom are not implying that birth should necessarily be transferred back to the home (however this is an option for many UK people) but the sense of familiar home should be brought to wherever the subject feels the safest.

Hospital Typology When discussing medicalised birth sets, the most potent image that comes to mind is that of a hospital bed: A woman laying back upon the raised bed with her legs suspended in stirrups ready to be assessed by a doctor. This imagined scene is a common reality with 68% of UK women birthing on their back according to a 2018 report and 36% with their feet in stirrups. 13 Hospital beds used in today’s maternity

9

Sheena Byrom, Soo Downe. 2019. Squaring the Circle: Normal birth research, theory and practise in a technological age.

London: Pinter & Martin Ltd UK. P184-185 10 Norman B. Schmidt, J. Anthony Richey, Michael J. Zvolensky, and Jon K. Maner.

"Exploring Human Freeze Responses to a Threat Stressor." Journal of Behavior Therapy and Experimental Psychiatry 39, no. 3 (2008): 292-304.

11 Sheena Byrom, Soo Downe. 2019. Squaring the Circle: Normal birth research, theory and practise in a technological age.

London: Pinter & Martin Ltd UK. Chapter 20: Healthy settings and birth: Birth centres as healthy settings P245.

12 Interview 1, Mother who experienced a hospital birth. Conducted by Esme Dowle (author). December 28, 2022 13 Declercq ER, Sakala C, Corry MP, Applebaum S, Herrlich A. Listening to mothers III: pregnancy and birth. J Perinat Educ. 2014;23:9–16.

7

care can be adjusted to facilitate a range of recumbent positions; this adjustable feature implies a passivity and inability for the parturient to control their own movement that is rarely seen in labouring people who are unmedicated. 14 Furthermore, these common horizontal positions have shown to negatively affect the biomechanics of normal birth by narrowing the pelvic outlet and increasing the probability of complication and therefore intervention. 15 The specialised beds are integral equipment for pre/post-natal examination; however, the resulting positions embody the notion that the birth is done to the passive woman rather than the woman actively performing the birth herself. Some accounts suggest that hospital beds restrict common dynamic labour positions which empower the parturient i.e. Interviewee 1’s description: ‘I just felt out of control when I was lying on the bed… I felt much better when I was standing or kneeling eventually’ 16. The bed directed her by guiding her limbs into predesigned angles to favour the convenience of the doctor. The position is disarming; her soft organs and belly overtly pointed up and her body is ungrounded with her feet higher than her head, immobilizing her. It is clear that this could lead to a sense of not being in control.

Contemporary hospital rooms still remain bed-centric despite the prominence of this furniture adversely affecting the mentality of the patient and the popular understanding that a range of dynamic positions is a more effective approach to

14

Maralyn Foureur, J.D Harte. 2017. Health and Well-being for Interior Architecture. (New York: Routledge.) Chapter 9: Salutogenic Design for Birth:4.1 Surveillance Rooms.

15 Borges M, Moura R, Oliveira D, Parente M, Mascarenhas T, Natal R. Effect of the birthing position on its evolution from a biomechanical point of view. Comput Methods Programs Biomed. 2021 Mar;200:105921. doi: 10.1016/j.cmpb.2020.105921. Epub 2020 Dec 29. PMID: 33422852.

16 Interview 1, Mother who experienced a hospital birth. Conducted by Esme Dowle (author). December 28, 2022

8

normal childbirth. 17 18 The layout of a generic hospital set (figure 1) is oriented around the bed, the focal point, as if a stage to be gazed upon. Found in the middle of the room attached to the wall and various machines, means the small amount of space available is consumed by a suboptimal layout that can’t be permanently changed.

Subsequently, the room shows a priority of the hospital bed and thus the supine position. Perhaps the hospital setting encourages the woman to relinquish control and become a passive participant. The overwhelming seriousness of medical space might leave the birthing person feeling incapable and unknowledgeable and the presence of the hospital bed could provide an option where they can lay back and let the professionals do their job. The primary use of this item in obstetrics shows a lack in understanding that labour is more optimal when a varied and dynamic series of body positions (active birth) is encouraged.

Berta, M., Lindgren, H., Christensson, K. et al. Effect of maternal birth positions on duration of second stage of labor: systematic review and meta-analysis. BMC Pregnancy Childbirth 19, 466 (2019). https://doi.org/10.1186/s12884-019-2620-0 18 Sheena Byrom, Soo Downe. 2019. Squaring the Circle: Normal birth research, theory and practise in a technological age.

London: Pinter & Martin Ltd UK. P221 17

9

Figure 1. Blackwater Law, ‘Typical Hospital Room found at Sheffield Hospital’, 2022, Sheffield Hospital.

10

Figure 2. Plan Sketch of the homebirth set. Provided by Interviewee 2 on January 22, 2023

11

The Active Birth Set Interviewee 2’s description of her labour positions implies a spontaneous flow of activities: ‘I was sewing whilst kneeling or in cross-legged position and I was aware of some mild contractions… I tried to doze but because it was quite painful, it wasn't comfortable in the bed so I was on kneeling forward over the couch, kneeling on the floor with a cushion under me'.19 Her statements and supportive sketch plan of her flat (figure 2) demonstrate that the movement was unrestricted and different rooms offered varying functionality. It’ indicative that labour is a spontaneous choreography which cannot be effectively confined to the passive supine position. In an active labour, the individual moves to soothe the varying discomfort they’re experiencing, this might be on all fours, squatting, sitting or just slowly walking. To encourage a more empowered birth experience, the room should facilitate this unpredictable and freeflowing movement.

In addition, it is standard practice for the midwives to adjust the medical room to accommodate active birth more appropriately as interviewee 1 explains: ‘the midwife put the mattress on the floor, so I was kneeling on the floor and my husband was on a chair in front and I was holding on to him.’20. The room exerted a resistance against her loose movement by requiring physical manipulation to suit her desired experience. The fact that the midwife must physically deconstruct the bed and redefine its function to provide a more versatile landscape for active labour shows that the default setting of hospital birth space doesn’t favor normal active birth but prioritizes intervention and

19 20

Interview 2, Mother who experienced a home birth. Conducted by Esme Dowle (author). December 29, 2022 Interview 1, Mother who experienced a hospital birth. Conducted by Esme Dowle (author). December 28, 2022

12

passivity. Instead, the space should be designed to facilitate a free-flowing movement where the birth-giver is listening to what their body needs in the moment rather than the midwives actively change the furniture every time someone needs to kneel.

Lighting as a Stimulant Lighting is a critical variable which has the potential to optimise or offset the progress of natural labour.21 Interviewee 3 wrote a poem about the glorious light she experienced through the window: ‘This January London with its scorching yellow light.

And the light becomes liquid, and I can see waves in the room with the hard bed and the liquid voice. It’s nice, and it’s legal.’22. Seemingly, regardless of the unfamiliar and medicalised space, the light triggered a sensual emotional response and became a potent feature of her memory of birth. This further confirms the importance of lighting design to transform a whole space relaxing the subject even when the sun doesn’t incidentally shine. ‘Squaring the Circle’, by Soo Downe and Sheena Byrom, has shown that light has a dramatic effect on the wellbeing and recovery times of some mental illnesses. 23 In the context of labour and post-partum activities, artificial lighting is associated with the release of adrenaline, preventing the normal positive feedback of birth hormones such as oxytocin. The appropriate lighting depends on personal preference, but in general, early labour requires a darker environment with a greater sense of privacy, and relaxation; just before the delivery, a brighter artificial lighting is

21

Sheena Byrom, Soo Downe. 2019. Squaring the Circle: Normal birth research, theory and practise in a technological age.

London: Pinter & Martin Ltd UK. P221 22 Interview 3, with a woman who experienced a hospital birth, poem received via email about a moment experienced during labour. January 19, 2023 23 Sheena Byrom, Soo Downe. 2019. Squaring the Circle: Normal birth research, theory and practise in a technological age.

London: Pinter & Martin Ltd UK. P224

13

required to stimulate adrenaline; then the post-partum bonding period is most effective with daylight to encourage the development of love. 24These stages can only be optimized by providing a variable lighting system that can be customized for the individual.

24

Sheena Byrom, Soo Downe. 2019. Squaring the Circle: Normal birth research, theory and practise in a technological age.

London: Pinter & Martin Ltd UK. P224

14

Chapter 2: Texture and Boundaries Tactility and Access of Oxytocin Oxytocin is an integral hormone of labour creating contractions to allow the cervix to dilate. Alongside the fact that its production can be inhibited by stress and fear, oxytocin can be stimulated by the sensation of skin-to-skin contact with a loved one and helps post-natal bonding of the parents with their newborn 25. Interviewee 1 gave a description of the textural palette of her hospital room: ‘Apart from the softness of the mattress and bedding everything was pretty cold and hard, as you would expect from a hospital, metal bits, drip stands hard floors, machinery. It was just nice to meet my baby and have the softness of my baby in contrast.’ 26 The textures are portrayed as uninviting so the potential for spontaneous contact with the rest of the room is restricted. The bed is soft and comforting and so texturally segregated from the rigid surfaces beyond.

In this setting, the birth-giver doesn’t own the surroundings or know where the boundaries of their access are drawn thereby becoming a permission seeker. The parturient must seek access from the permission granter (the midwife) to cross boundaries and touch surfaces; access the toilet; touch devices in the room; adapt the

25

Sunshine, Philip. “Psychologists say there are five types of love languages, but to newborn babies, only one really registers: physical touch.” Give Em Some Skin. Stanford Medicine, Last modified 2023. https://www.stanfordchildrens.org/en/health-topics/magazine/give-em-someskin#:~:text=%E2%80%9CThe%20skin%2Dto%2Dskin,of%20hypoglycemia%2C%E2%80%9D%20Crowe%20explains.

26

Interview 1, Mother who experienced a hospital birth. Conducted by Esme Dowle (author). December 28, 2022.

15

furniture to suit their preferences. The resistance exerted by these surfaces would further disrupt the parturient’s sense of control and autonomy over the space. The midwife might therefore be placed in a role of authority and is expected to lead the birth event.

Comparatively, in the setting of the home birth the social dynamic is reversed; the birthing person owns the surrounding surfaces and knows their resulting sensations; the visiting midwife becomes the permission seeker to access the surfaces and facilities that are unfamiliar to them. For the birthing person, the familiarity of the textures would reduce anxiety and empower them. Interviewee 2 described the textural palette of her home birth: ‘there was a soft light coming through slightly parted muslin curtains, it was important to have only natural materials like cotton linen and soft wools, I don’t want any unnatural fibers in contact with my skin. I think we had a wool carpet in the front room that I was kneeling on.’27 It is evident that she was in control of her soft textural surroundings and doesn’t need to hesitate over what she might touch.

27

Interview 2, Mother who experienced a home birth. Conducted by Esme Dowle (author). December 29, 2022

16

Texturally Dispersed Birth Suite During the ‘Birth Space Workshop’ at Brighton University, I observed the creation of collage 1 (figure 3). Features discussed in the session were represented spatially in plan drawing (figure 4). Notice how the arrangement of the furniture is dispersed, there is no obvious focal point which accounts for a range of individual experiences.

Additionally, the standard hospital bed is excluded as the students believed it was not an integral part of the labour suite but more a device used in pre/post-natal care.

There is an ambiguity to the purpose of the room which is an attempt to prevent the space from coercing the user to have pre-conceived notions of how they should birth but instead inspire improvisation to do what their body needs. Just as the focus of the furniture is dispersed, the textures similarly blend into one another. There are blurred boundaries between the tiled wet room zones and the carpeted landscape; a scattering of textural nodes might allow movement to become more instinctive and organic.

17

Figure 3. Birth Suite Collage created by first year midwife students from the university of Brighton in January 23, 2023.

18

Figure 4. Author’s interpretation of and response to collage 1 where features discussed in the workshop are symbolically represented in plan. Created January 28, 2023.

19

Grounding Incorporating the ground as a primary surface of contact is also more common in homebirths and its wider use could allow a greater sense of coherence during delivery.28 In Hospital setting, there is usually a harsh divide between the softness of the bed and the hard cold floor. There is no gradient of texture between the two so could limit the parturient's subconscious will to access to the rest of the room and they could become bedbound. Whereas in interviewee 2’s set, the surfaces of her home were a palette of textures that provided a range of options for activities and postures.

She explains: ‘I naturally sit on the floor, I prefer bare feet, that's probably just something to do with feeling like a good balance or grounded or something… Some part of me felt like I needed to be in contact with something that was firmer than for instance a bed, something that feels more permanent and stable.’ 29 On a lower plain, she is more immersed within her immediate surroundings, and can blend into the furniture topography of the room. It would seem less overt than being placed on a raised plinth-bed and so more private and unobserved. She may have a greater connection with the immediate surfaces and so can reflect upon her own presence in relation to her surroundings and as a result have a greater sense of coherence throughout.

28

Kerri-Lee Harding, “What is birthing on country and why is it crucial for Aboriginal women?” SBS, NITV Radio, last modified August 11, 2020. https://www.sbs.com.au/language/nitv-radio/en/article/what-is-birthing-on-country-and-why-is-itcrucial-for-aboriginal-women/h3jq78huo.

29

Interview 2, Mother who experienced a home birth. Conducted by Esme Dowle (author). December 29, 2022

20

Phenomenology The concept of salutogenesis has some similarities to Boys’ interpretation of phenomenology. In ‘Doing Disability Differently’ Boys defines phenomenology as ‘the study and exploration of the physical experiences of buildings, building materials and their sensory properties’. 30 Boys applies this description to broadening the spatial access of people with varying dis/abilities of which the principles would benefit the pregnant experience. Both concepts focus on optimizing the sensory reach of the user but salutogenesis goes further and attempts to pinpoint the stimulating features of physical space, such as texture, that can have this emotional/physiological effect.

Furthermore, Zumthor describes his phenomenological experience of architecture ‘as a bodily mass, a membrane, a fabric, a kind of covering, cloth, velvet, silk, all around me.

The body! Not the idea of the body – the body itself. A body that can touch me.’31 This statement draws attention to where the boundary between body and architecture is located. If the body is defined as the sensory reach of a person, then the surfaces/textures with the potential for touch are in effect apart of the sensory reach of the body. There is an ambiguity of where the boundary of the senses lies and so the architecture can be interpreted as an extension of the body.

Thus, as the sense of touch extends beyond the body to the stimuli of the room, birth space can be interpreted as an extension of the birthing body. This means that a lack of ownership over the birth space can be experienced as a lack of autonomy over one’s own body. Access to and autonomy over the textural landscape of the room is an

30

Jos Boys. 2014. Doing Disability Differently: An alternative handbook on architecture, dis/ability and designing for everyday life. Oxon, UK & New York, USA: Routledge. P80

Zumthor, Peter. Atmospheres, 11. Accessed July 11, 2015. http://ebookbrowsee. net/gdoc. php?id=466463785&url=982c587b925fe3103a612676616e5bd.

31

21

important consideration as it defines how in control of their own body the parturient feels. Interviewee 2 had definitive boundaries of touch in her home birth: ‘I didn’t need anyone to touch me, I didn’t seek that out. I wanted my own space to be in my body privately’32

32

Interview 2, Mother who experienced a home birth. Conducted by Esme Dowle (author). December 29, 2022

22

Chapter 3: Layout, Orientation, and Relationships Margherita Birth Centre

Figure 5: ‘The multifunctional corridor: space for movements, seating, playing in the margherita Birth Centre in Florence (IT) designed by the architect Bianca Lepori with the doctor Marco Santini (created by Setola N)’. exhibited in ‘squaring the Circle’, 2019

The margherita birth center is an example of birth space that primarily considers the access of the participants of the event into the private delivery room. 33 In effect, there is a gradient of privacy and permeability from the most private midwives’ quarters outwards to the most public and broadly accessed corridor. As shown in the plan

33

Sheena Byrom, Soo Downe. 2019. Squaring the Circle: Normal birth research, theory and practise in a technological age.

London: Pinter & Martin Ltd UK. P223

23

(figure 5), the prohibited staff facilities are central with direct separate access to every private birth room; these rooms form a ring around the midwifery center with a public circulation route around the outside of the layout. The thresholds into the birth rooms from the outer corridor have a protective cover which delays the entrance and warns the subject that someone is entering before the ‘intruder’ sees said birthing subject.34 This threshold is also lockable without restricting access of the midwives which develops a sense of trust and safety between the parturient and maternity staff and overall gives a greater sense of protection and control over who enters when occupying the space. The outer corridor has a variable program: Families can be entertained; mothers can breastfeed; expectants can walk out their contractions and socialize with their visitors without feeling that they are blocking important hospital corridors. 35 The architect has understood the social requirements and the spontaneous nature of natural birth and has created a circulation that nurtures family relationships and allows a casual ease to the unpredictable nature of active birth without detracting from the important medical efficiency.

34

Sheena Byrom, Soo Downe. 2019. Squaring the Circle: Normal birth research, theory and practise in a technological age.

London: Pinter & Martin Ltd UK. P220 35 Sheena Byrom, Soo Downe. 2019. Squaring the Circle: Normal birth research, theory and practise in a technological age.

London: Pinter & Martin Ltd UK. P224

24

An Informal ’Introductory Lounge’ The second collage (figure 6) produced from the birth space workshop illuminated a need for a more welcoming ‘introductory lounge’. It was discussed that instead of the standard reception desk, that acts as a hostile barrier between the hospital staff and the patients, the visitors could enter to see a round communal kitchen (figure 7) that fosters a greater sense of community, trust, and social support. The figurative barrier of bureaucracy between officials and civilians is broken down so that the midwives and visitors integrate more effectively.

It was explained by Jo Gould during the workshop session that to emotionally support a birthing person without intruding too much on their personal space the ‘art of drinking a cup of tea’ must be practised. This refers to their role of knowing when and how to insert themselves into a labour space and exude a positive energy to the rest of the room by casually drinking a cup of tea. Some midwives knit or write in the room of the labouring women in hope to comfort and reassure that the birthing process is a natural and normal event. This casualised introductory lounge has plenty of informal seating with privacy dividers that encourages families to feel at home and for these casual activities to occur.

25

Figure 6: collage 2 introduction lounge

26

Figure 7: Introduction lounge plan response

27

Minkovska’s Birth Set Stiliyana Minkovska’s birth set: ‘The Labour Silla’ (figure 8) proposes an alternative landscape in institutional rooms that understands the variation of active labour.36 The homogenous set doesn’t dictate the body with positional agenda but attempts to disperse the attention of the space to three different interacting devices. The sinuous surfaces form abstracted chairs that hint at a range of positional options without prescribing specific postures for the subject. Furthermore, each device provides space for the physical inclusion of the birth partner and allows opportunity for skin-skin contact which further helps stimulate the production of oxytocin.

Figure 8: Stiliyana Minokovska's Birth furniture, 2020

36

Stiliyana Minkovska. “The Labour Silla” last modified 2022. https://www.stiliyanaminkovska.com/labour-silla

28

Interviewee 1 described the variable positions that her body required during labour: ‘I wanted to lean forward a bit but wasn’t sure what to lean on… it was much better standing on my feet… holding onto the windowsill, which is probably about waist height, but couldn’t get comfy… I was kneeling on the floor and my husband was on a chair in front and I was holding on to him.’37 Evidently, no surface she encountered endorsed her desire of leaning forward and she felt a resistance. The hard rectilinear forms stood idle and monovalent whilst interviewee 1 sought out her most effective position. Perhaps she would have felt more supported by Minkovska’s furniture (figure 9); the organic padded levels have different heights to lean against and the broad tiered chair could provide a visibility and access for the midwife to examine without interfering with the connection to the ground.

In most homebirths, Minkovska's set are less useful. It is common for the birth-giver to carry out the labour in the shared living room and usually this space is already a soft enveloping landscape full of potential function.38 Interviewee 2 describes how her domestic furniture is functionally redefined during her labour: ‘I was baking in the kitchen… and my contractions became quite intense, so I was moving from one foot to the next whilst leaning against the kitchen counter…at one point I was hanging from the door frame to stretch out my back… I tried to doze off, but it became painful again, so I started kneeling on the floor with a cushion under my knees…. I was squatting on the floor and using the armchair in front of me to put my arms and body on.’ 39 A well-

37

Interview 1, Mother who experienced a hospital birth. Conducted by Esme Dowle (author). December 28, 2022.

Maralyn Foureur, Deborah Davis, Jennifer Fenwick, Nicky Leap, Rick Iedema, Caroline S.E. Homer. “The relationship between birth unit design and safe, satisfying birth: Developing a hypothetical model”. Journal of Midwifery 26 (May 2010): p522 www.elsevier.com/midw 38

39

Interview 2, Mother who experienced a home birth. Conducted by Esme Dowle (author). December 29, 2022

29

equipped medical space might provide specific devices such as hanging cloths and yoga balls to fulfil these functional requirements, but the home is a rich setting of innovation of which the furniture can be functionally redefined. Perhaps this is because the home simply has more furniture options, or the general association with the home is a liberation to exist in our natural unobserved states in comfort and privacy. The birth-giver owns the contents of their surroundings and knows the extent of their function. They don’t need to think twice before repurposing an object or exerting pressure. They have autonomy and agency over the immediate surfaces and therefore are more likely to access the furniture’s potential.

30

Figure 9: Styliana Minkovska Birth Chairs

31

Conclusion It is evident that most people give birth adequately in whatever birth set they inhabit. 40 The human body and mind has an impressive resilience to endure, innovate and improvise within this often-high pressure life-event. The salutogenic design approach aims to sensitise the birth set by tuning the environmental conditions to suit the desires of the user thereby cherishing the mental wellbeing of all the participants.

It was also assumed that the birth set is an extension of the birthing body and so a lack of agency and knowledge over the textile surfaces of the room is a lack of autonomy over one’s own body. The birthing person should have more control over what their skin comes into contact with as evidence demonstrates that your hormonal balance can subtlety but directly impact the physiology of the birth. As Crawford states: ‘Texture is the condition of possibility through which our bodies meet our environments. Texture is an activity, not a state of being’ 41 and this tension of possibility is perceived by our bodies, reacting via small but impactful hormonal changes.

During the workshop, it was illuminated that the individuals who are most familiar and equipped to assess this sensitive response to space is midwives. It was inspiring to see

40

Susanne Houd, Hans Christian Florian Sørensen, Jette Aaroe Clausen & Rikke Damkjær Maimburg (2022) Giving birth in rural Arctic Greenland results from an Eastern Greenlandic birth cohort, International Journal of Circumpolar Health, 81:1, p1 DOI: 10.1080/22423982.2022.2091214 41 Lucas Crawford, “The Crumple and the Scrape,” Places Journal, March 2020. Accessed 21 Dec 2022. https://doi.org/10.22269/200305

32

how the midwife students responded to the workshop with empathy and were able to use their training to devise very considered solutions to the common problems that users have with hospital space. Midwives are the continuum throughout all birth sets, adapting the furniture landscape and raising spirits just through their unobtrusive presence. Perhaps, with reference to the midwives’ experience, a more sensitive approach to design could inspire space that better nourishes the mental health of its users throughout a range of other architectural domains.

33

Glossary Term

Definition

Fear Cascade

the neurohormonal responses women may have to birth spaces that may be overtly or covertly considered to be unsafe or fear-inducing.

The term ‘furniture’ is defined in this essay as a device comprising surfaces that will come into physical contact with the subject’s skin and suggest a body position to assume.

Furniture

Normal (birth)

Parturient

Salutogenesis

Set

This essay explores the spatial context of physiologically normal births, i.e. the labour and birth of a newborn from a pregnant person, that has begun naturally and has received no invasive medical intervention.

An effort will be made to refer to the birthing person with gender neutral terms such as ‘parturient’ or ‘birth giver’. This is to be inclusive of people who may have non-conforming gender identities.

As defined by Harte and Foureur: an approach to health that focuses on factors that actively promote health and wellbeing, instead of the predominant approach, which focuses on pathogenesis.

More than one furniture item within a birthing space will be referred to as a ‘set’, which represents a typology of interacting furniture devices.

34

Image References Figure 1: Blackwater Law, ‘Typical Hospital Room found at Sheffield Hospital’, 2022, JPG, size:525KB, Sheffield Hospital: https://blackwaterlaw.co.uk/urgent-improvements-needed-at-sheffield-hospitals/, [accessed: February 1st 2023] Figure 2: Plan Sketch of the homebirth set. Pen on paper. Drawn and provided by Interviewee 2 and on January 22, 2023 Figure 3: Brighton University Midwifery Students, ‘Collage 1: Birth Suite’, Made digitally in Miro using images found on google, [accessed: January 23rd 2023] Figure 4: Dowle, Esme, ‘Plan Drawing Representing the Collage of the Birth Suite’, Made in Rhino 6 and Illustrator, created 28th January 2023 (Author’s own drawing) Figure 5: Setola N, ‘The multifunctional corridor: space for movements, seating, playing in the margherita Birth Centre in Florence (IT) designed by the architect Bianca Lepori with the doctor Marco Santini’. in ‘Squaring the Circle’, 2019, (London: Pinter & Martin Ltd), page 223 [accessed 20th December 2022] Figure 6: Brighton University Midwifery Students, ‘Collage 2: Introductory Lounge’, Made digitally in Miro using images found on google, [accessed: January 23rd 2023] Figure 7: Dowle, Esme, ‘Plan Drawing Representing the Collage of the Introductory Lounge’, Made in Rhino 6 and Illustrator, created 28th January 2023 (Author’s own drawing) Figure 8: Hitti, Natashah, ‘Stiliyana Minkovska reimagines hospital maternity wards as "interstellar" spaces’ Image by Felix Speller, Dezeen, 14th April 2020: https://www.dezeen.com/2020/04/14/stiliyana-minkovska-ultima-thule-maternity-design/ [accessed December 20th 2022] Figure 9: Hintz-Zambrino, Katie, ‘A Cosmic Labor & Delivery Design you Need to See to Believe’ Image courtesy of Stiliyana Minkovska, MOTHER, 15th July 2020: https://www.mothermag.com/stiliyanaminkovska-ultima-thule/ [accessed December 20th 2022]

35

Bibliography Books: • Boys, Jos. 2014. Doing Disability Differently: An alternative handbook on architecture, dis/ability and designing for everyday life. Oxon, UK & New York, USA: Routledge.

•

Byrom, Sheena, Soo Downe. 2019. Squaring the Circle: Normal birth research, theory and practise in a technological age. London: Pinter & Martin Ltd UK.

•

Ehrenreich, Barbara and English, Deirdre. 2010. Witches Midwives & Nurses. New York, NY: Feminist Press.

Ebooks: • Foureur, M, J.D Harte. 2017. Health and Well-being for Interior Architecture. New York: Routledge.

•

Zumthor, Peter. 2010. Atmosphere: Architectural Environments- Surrounding Objects, Berlin: Birkhauser. http://ebookbrowsee.net/gdoc.php?id=466463785&url=982c587b925fe3103a612676616e5b d.

Journal Articles: •

Attlee, Edwina. 2019. “The Woman Who Helps. Studies in the Maternal,” 11(1): 2, pp. 1–9.

DOI: https://doi.org/10.16995/sim.268

•

Berta, M., Lindgren, H., Christensson, K. et al. Effect of maternal birth positions on duration of second stage of labor: systematic review and meta-analysis. BMC Pregnancy Childbirth 19, 466 (2019). https://doi.org/10.1186/s12884-019-2620-0

•

Borges M, Moura R, Oliveira D, Parente M, Mascarenhas T, Natal R. Effect of the birthing position on its evolution from a biomechanical point of view. Comput Methods Programs Biomed. 2021 Mar;200:105921. doi: 10.1016/j.cmpb.2020.105921. Epub 2020 Dec 29. PMID: 33422852.

36

•

Crawford, Lucas. 2020. “The Crumple and the Scrape,” Places Journal, Accessed 17 Feb 2023. https://doi.org/10.22269/200305

•

de Jonge, Ank, Birgit Y. van der Goes, Anita CJ Ravelli, Marianne P. Amelink- Verburg, Ben W. Mol, Jan G. Nijhuis, J. Bennebroek Gravenhorst, and Simone E. 2009. Buitendijk. “Perinatal Mortality and Morbidity in a Nationwide Cohort of 529 688 Low-Risk Planned Home and Hospital Births.” BJOG: An International Journal of Obstetrics & Gynaecology 116, no. 9.

•

Foureur, Maralyn, Deborah Davis, Jennifer Fenwick, Nicky Leap, Rick Iedema, Caroline S.E. Homer. “The relationship between birth unit design and safe, satisfying birth: Developing a hypothetical model”. Journal of Midwifery 26 (may 2010): 520–525. www.elsevier.com/midw

•

Haire, Doris. 1972. “Cultural Warping of Childbirth.” International Childbirth Education Association News 11, no. 1

•

Schmidt, Norman B., J. Anthony Richey, Michael J. Zvolensky, and Jon K. Maner. "Exploring Human Freeze Responses to a Threat Stressor." Journal of Behavior Therapy and Experimental Psychiatry 39, no. 3 (2008): 292-304.

•

Susanne Houd, Hans Christian Florian Sørensen, Jette Aaroe Clausen & Rikke Damkjær Maimburg (2022) Giving birth in rural Arctic Greenland results from an Eastern Greenlandic birth cohort, International Journal of Circumpolar Health, 81:1, DOI: 10.1080/22423982.2022.2091214

Website Articles •

Barron, Jonathan, “Crumbling buildings and creaking systems: does the NHS invest enough in capital?” NHS Confederation, Last modified November 14, 2022. https://www.nhsconfed.org/articles/crumbling-buildings-and-creaking-systems-nhs-capitalinvestment.

•

Foureur MJ, Sheehy A, Forbes, IFW, Davis DL, Pandolfo B, Fenwick J, Verghese G, Leap, N, Homer CSE (20010). 2009. The BUDSet Tool: Birthing Unit Design Spatial Evaluation Tool (Version 2). Centre for Midwifery Child and Family Health, University of Technology Sydney, Sydney. http://www.uts.edu.au/sites/default/files/budset.pdf

•

Harding, Kerri-Lee, “What is birthing on country and why is it crucial for Aboriginal women?”

SBS, NITV Radio, last modified August 11, 2020. https://www.sbs.com.au/language/nitv-

37

radio/en/article/what-is-birthing-on-country-and-why-is-it-crucial-for-aboriginalwomen/h3jq78huo.

•

Mcintosh, Tania, “A History of Childbirth in the UK – from home, to hospital, to COVID-19”, THE CONVERSATION, last modified: January 2021. https://theconversation.com/a-history-ofchildbirth-in-the-uk-from-home-to-hospital-to-covid-19-149587

•

Minkovska, Stiliyana. “The Labour Silla” last modified 2022. https://www.stiliyanaminkovska.com/labour-silla

•

Scott, M, “How did birth move from the home to the hospital and back again?”, WHYY, December 13, 2013: https://whyy.org/segments/how-did-birth-move-from-the-home-to-thehospital-and-back-again/

•

Sunshine, Philip. “Psychologists say there are five types of love languages, but to newborn babies, only one really registers: physical touch.” Give Em Some Skin. Stanford Medicine, Last modified 2023. https://www.stanfordchildrens.org/en/health-topics/magazine/give-emsomeskin#:~:text=%E2%80%9CThe%20skin%2Dto%2Dskin,of%20hypoglycemia%2C%E2%80%9D%2 0Crowe%20explains.

•

Taylor, Matthew. “We cannot continue to neglect mental health funding”. Blog post, NHS Confederation. January 19, 2022. https://www.nhsconfed.org/articles/we-cannot-continueneglect-mental-health-funding

38

Appendix Interviews The transcript of the interviews have not been included to preserve anonymity of the interviewees as the subjects discussed were sometimes sensitive and revealing.

Interview 1 - with woman who experienced a hospital birth. This interview was conducted over WhatsApp with voice recordings.

Questions: • • • • • • • • • • • • • • • •

Can you describe your birth space?

What body positions did you recall labouring and birthing in?

What furniture items or body devices did you use during labour and birth?

How significant was the hospital bed in labour and birth?

How did it make you feel when you sat/lay in the hospital bed?

Was there lots of machinery in the room? How did that make you feel?

Did you feel that the room allowed a connection to your partner?

Did you feel in control?

Did you feel like you had access to the whole room?

What boundaries might you describe within the room? Were there prohibited surfaces/objects?

Did you feel confined to one position or location?

What surface textures might you remember?

How would you describe the textures of the hospital room?

Do you remember your initial reaction to the space and how it made you feel?

Why did you choose to give birth in hospital?

Are you happy that you chose to give birth in hospital?

39

Interview 2 - with woman who experienced a home birth. This interview was carried out in person and recorded using WhatsApp voice notes.

Questions: • • • • • • • • • • • • • • • •

Can you describe your birth space?

What body positions did you assume during labour and birth?

What furniture items or body devices did you use during labour and birth?

How significant was the ground in labour and birth?

How did it make you feel when you sat/lay on the ground?

Did you feel that you had to seek permission from the midwife for anything?

Did you feel that the room allowed a connection to your partner?

Did you feel in control?

What was the midwife’s role?

What boundaries might you describe within the room? Were there any prohibited surfaces/objects?

Did you feel confined to one position or location?

What surface textures might you remember?

How would you describe the textures of the room?

Do you remember what your feelings were about the birth space?

Why did you choose a home birth?

Are you glad you chose a home birth?

40

Interview 3 - another woman who experienced a hospital birth wrote a poem to record a moment in her labour. This was received over email. The correspondence is as follows: Esme: Hi [interviewee 3], I am writing my history essay at the moment on birth environments and was wondering if I could get you to give a short anonymous comment about the fluid light you experienced during your labour. I really enjoyed your poetic description of how the light came through the window. If you have the time, please could you write a sentence or two describing what you saw or felt? thanks so much and all the best, Interviewee 3: Hi Esme, I wrote this on the tube today, I hope it's good. It was strange and beautiful to try and remember the details of that moment, thanks for asking me to do that.

Best, I’m lying on a clinical bed and the midwife is speaking, speaking, speaking in this voice full of softness. She is about to break my waters. I’m about to break down in tears. The dizziness of the gas & air had been pumping through me and the building all morning.

“It’s free, and it’s legal; - Girl - Inhale and exhale inside this pump.” I inhale inside this London room. The window. The smell of cleaning products. Exhale. This January London with its scorching yellow light. And the light becomes liquid, and I can see waves in the room with the hard bed and the liquid voice. It’s nice, and it’s legal.

41

Correspondence via email with Jo Gould regarding permission to use collages: Dear Esme, Thank you for your email and thank you so much for joining the project. It was so valuable to have you with us and I know the student midwives felt the same; your name was mentioned in a very positive way via some of the evaluations that we received.

Libby has been away so we are planning to meet sometime after 20th February[… ]Can you let me know your best availability from 20th Feb for two to three weeks and hopefully we can find a day/time to suit. Absolutely fine to use the images; we have ethics permission to share images/quotes from the women/partner stories, so I am happy for you to use the collages in this way. I’m very happy the project has been helpful.[… ] See you soon and look forward to the project post-mortem!

Kind Regards

Jo Gould Senior Lecturer in Midwifery NMC Lead Midwife for Education University of Brighton

42