Fern Reproductive Health: The Future of Reproductive Healthcare Facilities

Fern Women’s Health: The Future of Reproductive Healthcare Facilities

Stella Psiakis Department of Interior Architecture, Endicott College IA489: Thesis I Professor Bischoff DECEMBER 9, 2022

2 Introduction The topic of abortion has been in the spotlight since the court case of Roe v. Wade in 1973. This landmark case declared the right to abortions legal in the United States until the 23rd week of pregnancy, ultimately preventing states from banning abortions before fetal viability (Liptak, 2021). Court cases since then have debated how the abortion timeframe should be organized, such as Planned Parenthood v. Casey, and states have passed laws limiting the accessibility of abortions, like the Gestational Age Act of Mississippi or Texas’s House Bill 2.

On June 24, 2022, the Supreme Court decided to overrule Roe v. Wade following the case of Dobbs v. Jackson Women’s Health Organization, which was initially aimed at restricting access in Mississippi. The state of Mississippi had asked the Court to overrule Roe v. Wade in totality, rather than just focusing on their state laws (ACLU, 2022). As a result, a domino effect occurred with numerous states instituting their own abortion and reproductive health bans, restricting access to what pro-choice supporters believe are essential human rights. Those seeking abortions in states with restricted access are now forced to travel out of state to receive proper care or turn to unsafe abortion practices when traveling is not feasible.

The impact of this overturn is chilling as abortions are not the only procedure impacted by the overturn. Even patients who suffer pregnancy related issues, such as ectopic pregnancies, might not receive proper care because of a state’s regulations on reproductive healthcare (McGovern, 2022). Laws are also in place against aiding or abetting abortion-seekers, illustrating how hostile and restrictive some states have become. On the other side of the argument, there are states in the US that are protecting or expanding access to abortions, acting as safe havens for those who must travel out of state for care.

3 Due to state restrictions, people are turning to organizations, like the Brigid Alliance, to help them locate abortion clinics in-state or out-of-state, as well as other support they might need in order to receive an abortion, such as lodging, travel costs, or childcare (McCann, 2022). The unfortunate reality is that organizations are only capable of putting patients up in hotels during the duration of their stay. Hotels lack a sense of home, comfort, support, and safety that these patients need as they are going through a traumatic, life-changing, and potentially lifethreatening procedure.

Thus, my proposal is to create Fern Women’s Health, an all-encompassing reproductive health center that offers short term residential suites for people traveling out of state for any aspect of reproductive healthcare. Fern would offer numerous services: abortions; well-women care that includes annual checkups and contraceptives; a maternity ward with labor and delivery care; an education hub for children, adolescents and parents; therapy; support groups and legal services. Fern would be the first facility of its kind to offer everything in house, making the environment seamless between all elements of reproductive healthcare, and to ensure the utmost protection and support for every patient. Physical safety for the patient and the facility would be examined in addition to supportive architectural and design theories that promote the well-being and comfort of individuals.

The Past To truly understand the impact of restricting access to abortions, it is important to examine the lengths to which people would go in order to get abortions in the time before Roe v.

Wade was passed. Before Roe, 20-25% of pregnancies ended in abortions, with roughly 200 people dying as a result of their abortion annually. The most common form of abortion was selfinduced, which included falling downstairs, ingesting poison, or using instruments to terminate

4 the pregnancy (Kelley, 2019). There was also an underground abortion network that consisted of safe houses that provided safe and affordable abortions. Some patients would travel out of the country or to New York, where abortion was made legal in 1970 (Nawaz, 2022).

Patients that lived closer to urban areas had easier access to abortion facilities as they were often in higher density locations. Distance to the nearest abortion clinic will continue to bar patient access: “We’re returning to this period where geography matters tremendously, that women in certain states will have the ability to exercise the right to abortion while its quickly disappearing and diminishing for women in rural states” (Kelley, 2019). Furthermore, minority groups remain disproportionately affected by these barriers to abortions, specifically people of color, low-income individuals, immigrants, and people with disabilities (ACLU, 2022). In the past few months, interviews have been conducted on what people think about the overturn and how it will impact individuals seeking abortions moving forward. Their responses were the same. Abortions are still going to happen, regardless of regulation; the only difference is that they will not be safe.

Laws have also been implemented over the last decade that regulate the architectural components of abortion clinics. These are Targeted Regulation of Abortion Providers (TRAP) laws. In Texas, the House Bill 2 was passed in 2013 to limit access to abortions, with a focus on requiring abortion clinics to meet the codes and regulations of ambulatory surgery centers in the state (Dickinson, 2020). This meant creating wider corridors and doorways and including exam rooms in the clinic’s programming. As a result, any existing abortion clinic that did not comply, due to the cost of renovations or even zoning laws, was forced to shut down (Dickinson, 2020).

In states where abortion care was already limited, regulations like these made it ultimately impossible to access safe abortion providers without going outside state lines.

5 The Present More than 10 states across the country implemented bans or restrictions that closed upwards of 50 clinics, leaving states that already saw a lot of non-resident patients expecting even more. The demand for abortion care services is not expected to decrease as a result of the regulations, meaning the number patients traveling to states that provide care is only going to increase (McCann, 2022). In 2020, around 9% of abortions in the United States were from people traveling out of state, with only 6% in 2011, emphasizing how restrictive abortion laws force patients to travel to receive care. States that were deemed hostile to abortion rights saw a 6% increase of people traveling out of state over the past decade. Neutral states saw a 3% increase and states that support abortion access only increased by 1% (Maddow-Zimet, 2020).

Evidently, it did not matter if a state was supportive or restrictive when it came to abortions, the total number of patients forced to travel out of state was staggering.

Figure 1: Map of states' support of abortion post-overturn. (Institute, 2022).

6 Figure 1 shows the United States, as of November 20, 2022, as a color-coded map highlighting the states that remain supportive of abortion care—from dark blue, teal, and light blue—and the states where abortions are banned—ranging from yellow, to orange, and maroon.

The closer the blue states are to yellow, orange, and maroon states, the more non-resident patients they have. The blue states are the prime location for a facility like Fern Women’s Health because they continue to support access to abortions and struggle to keep up with the influx of patients.

Illinois has always been viewed as a haven for patients seeking abortions because of its supportive laws and policies. This comes as a direct result of the Reproductive Health Act (RHA) that was passed in 2019, which “gives each person a fundamental right to make individual decisions about their own reproductive health” (ACLU, 2022). Reproductive health encompasses abortions in addition to contraceptives, birthing decisions, and post-partum care.

The most crucial component of the RHA is that it is illegal for Illinois to interfere with a patient’s access to reproductive health services, even if they come from out of state. Illinois is strategically located, as it is one of the only states supporting access to abortions in the Midwest (McCann, 2022). Thus, as states institute bans or restrictions, it will only grow as a landmark for abortion services.

Minnesota is another state that has remained in support of abortion access, yet with some minor restrictions. TRAP laws within the state are enjoined (or prohibited), public funding for abortion is provided, and obstructing clinic access is illegal (Center for Reproductive Rights, 2022). Abortions are banned after fetal viability, but patient and staff safety are still protected (Institute, 2022). In the upper Midwest region of the US, Minnesota has seen an increase in outof-state travelers seeking abortions as it is surrounded by states with restricted access, with

7 around 10% of patients traveling there for care even before the overturn. The Minneapolis-St. Paul area of the state has seen the greatest rush, with facilities in more remote regions of the state not being as greatly affected (Peterson, 2022). States like Minnesota and Illinois are prime locations for the Fern Women’s Health facility prototype because of their support of abortion access and influx of patients traveling there for care.

The Place Safety Precautions Human proxemics is an important consideration when it comes to designing a facility with controversial programming elements like offering abortions. Proxemics differentiates human spacing into four zones: intimate, personal, social, and public. As in any public space, humans grow uneasy when strangers enter their intimate and personal zones, ranging from inches away to an arm’s length. Thus, when a patient is attempting to enter an abortion clinic and they are being faced with angry protestors encroaching on their intimate or personal zones, it increases their levels of stress (Hall, 1966). It is important to use site planning and architectural and environmental barriers to restrict the level of unwanted interactions amongst patients and protestors.

A recent study conducted by Erin Carroll, a researcher who focuses on abortions, revealed how coming face-to-face with pro-life protestors outside abortion clinics lowers patients’ feelings of safety because of the perceived unpredictability of protestors (Carroll, 2021). As noted by the Center for Reproductive Rights, “In the decades since abortion was legalized in the U.S. … there have been eight murders, 17 attempted murders, 42 bombings, 181 incidents of arson, and thousands of incidents involving other criminal activities since 1977” (Center for Reproductive Rights, 2014). Within Carroll’s study, patients who were accompanied

8 by an escort or security guard felt reassured about their decisions, but at the same time were more concerned about their safety. To them, the need for an escort meant that their safety could be at risk (Carroll, 2021).

One way of working to resolve this abrupt and frightening confrontation between patients and protestors is through architectural and environmental planning. A safe entrance and exit to the facility as well as general safety throughout the healthcare experience should be the top priority. The introduction of buffer zones by state legislation has been shown effective in preventing violence and in protecting patients (Center for Reproductive Rights, 2014). Buffer zones prohibit protestors from gathering within a specified area surrounding a clinic. Some states have instituted quiet zones that work to mitigate the level of noise and subsequent harassment in a demarcated area, while others have passed acts like the Freedom of Access to Clinic Entrances Act of 1994. This act makes any intentional damage to property, injury, obstruction or threatening of patients trying to enter a clinic illegal.

Design techniques, like Crime Prevention Through Environmental Design, focus on using the natural environment to provide adequate site surveillance, access control to building entrances and exits, and reinforce the surrounding territory (National Crime Prevention Council, 2003). Architecturally, this could mean providing windows on the exterior walls for unrestricted visual access to see any potential threats to safety outside of the facility. Shorter hedges, planters, flower beds, and iron or chain-link fences are recommended for visibility reasons. Access control is using landscaping patterns to direct pedestrians and the creation of clear boundaries by incorporating fencing or art installations. Using “clear legibility, transparency, and directness” discourage vandalism and violence (National Crime Prevention Council, 2003, p. 5). These are known as psychological barriers as they alter the likelihood of criminal activity due to increased

9 awareness and visibility (National Crime Prevention Council, 2003). Material choices on the exterior are also incredibly important as the sustainability and the ease of cleaning are beneficial at locations with higher risk of property damage.

Within the facility, there should be unobstructed sight lines, adequate lighting, and no isolated pathways to ensure the greatest level of safety for patients and staff. The National Crime Prevention Council mentions the use of activity generators and mixed-use programming to lessen the chances of a building being a target for vandalism. This could be incorporated at a reproductive health center because it would no longer operate as just the location of a contested procedure, but instead it would attract people there for reasons other than abortions (National Crime Prevention Council, 2003). When designing a wholistic center that promotes safety and comfort while also providing contested abortion care, the site and architecture of the facility play a key role in mitigating the threats to patients and staff.

The Comfort of Home The interior of a reproductive health center requires the same level of consideration to foster feelings of control, safety, support, and care as the site and environment. A large pillar of Fern Women’s Health is a short-term residential component that supports: patients who traveled there and need a place to stay before and/or after their abortion, patients who are experiencing labor complications and need to be at a medical facility, and patients who are recovering from miscarriages, cesarian sections, or traditional births and require frequent monitoring. Creating a sense of territoriality within a healthcare facility allows patients to control their own space and promotes empowerment in their physical and emotional healing processes, fostering the same feelings as one’s own home. Territoriality, in terms of establishing a safe and comfortable place,

10 comes from patients organizing personal belongings and arranging themselves in a space to suit their needs (Wise, 2000).

Hospitals exude a cold and sterile environment that is not as conducive to the healing process as compared to when a patient feels at home. A home is not just the physical structure, “it is the creation of space and comfort,” meaning even a healthcare facility can feel like a home if it promotes the safety, control, and spatial cues found in residential sites (Wise, 2000, p. 306).

It is the way that the space is designed that allows for patients to inhabit the rooms in ways that make them feel more at home. Stark hospital rooms with minimal flexibility prevent expressions of territoriality and identity. Thus, elements of personalization can be incorporated into the shortterm residential spaces as well as exam rooms and delivery wards. As each user of the space brings their own range of needs to be met, it is imperative to place the control into the hands of the user (Jusan, 2005). This can be achieved through placing moveable, more residential style furniture inside of exam rooms and allowing patients to bring personal belongings to residential suites. Wood, textiles, drapes, natural light, and stone resemble a residential atmosphere which has been shown to remind patients of the familiar environment of their own home (Nilsson, 2020).

Personalization embodies the belief that users must be able to manipulate and alter their environments, marking their territory to reach the greatest levels of privacy and comfort (Jusan, 2005, p. 504). Climate control, TV control, and moveable furniture allow for patients to determine how they want their space to function and feel, much like they would in their own home (Ulrich, 2001). Customization in layouts and lighting can make an institutional space feel comforting and supportive for each of its inhabitants, regardless of their background or reasoning for seeking care.

11 Trauma-informed design is crucial in facilities where the users are coming from different backgrounds and different levels of trauma. The pillars of trauma-informed design are outlined by the 3 C’s of designing for health and healing: Choice, Community, and Comfort (Shopworks Architecture, 2020). To break the pillars down, choice is allowing the user of a building to control their level of privacy, organization of interior space, and proxemics. Community is represented in a space’s ability to foster meaningful connections and comfort is ensuring the users’ needs are met so that they are free of stress and able to reach their potential. Traumainformed design pinpoints trigger areas for user groups and works with the built environment to reduce the negative impacts placed on the users.

Feng Shui is a theory of design that promotes well-being through positive energies, restorativeness, and control. When a space feels unsettling to its inhabitants, the perceived imbalance reveals that a component of Feng Shui is missing. There could be an abundance of positive energy or an abundance of negative energy that could result in this feeling of discomfort.

Another aspect of Feng Shui is a respect for nature and its elements, mimicking the foundation of biophilic design (Bonaiuto, 2010). An interior shows respect for nature through curvilinear lines, access to plants, views of nature, and water features. Placing plants in corners of rooms helps to eliminate the number of viewable sharp edges, which are the physical representations of sha chi, the negative energy in Feng Shui (Bonaiuto, 2010). Biophilia is also a part of trauma-informed design because it promotes lower levels of stress as natural materials work to ground the user.

Nature is a multi-sensory experience that works to stimulate and distract patients simultaneously (Ulrich, 2001). Neutral color palettes, unobstructed views to the outdoors, and sustainable materials are examples of incorporating nature into a healthcare facility.

12 The Person Patient-Centered The demographic of a facility that offers services for women throughout their reproductive lifetime is far-reaching. Statistics reveal there is no single group who seeks abortions. An article in the New York Times had a headline that read, “The typical patient is already a mother, is in her late 20s, attended some college, has low income, is unmarried, is in her first 6 weeks of pregnancy, is having her first abortion, and lives in a blue state” (SangerKatz, 2021). When designing for a reproductive facility that offers abortions, the programming and design must be conducive to every user group and their needs. Some patients might be forced to bring their children with them, other patients might be traveling for their abortion alone, and some might be traveling with a partner or family member. Thus, programming must be supportive of the patient and whoever joins them. Strategies that could benefit patients and their travel partners include “convenient overnight accommodations … comfortable visitor waiting areas … outdoor gardens or sitting … [and] designing one wing so that companion animals can be accommodated” (Ulrich, 2001, p. 101-102). Walking trails, outdoor gardens, and courtyards activate the exterior realm for the patients and the visitors or traveling companions to use when they are waiting for an appointment to start or end.

The best way to support an individual is to satisfy their hierarchy of needs, which begins with basic requirements for survival and graduates to the higher level of self-actualization. A healthcare facility works to satisfy the needs of Maslow’s proposed second tier: an individual’s safety needs. These include personal, security, health, and property safety (Maslow, 1943).

Disrupted routines and loss of support can also affect an individual’s homeostasis, negatively impacting their hierarchy of needs. Maslow states, “being confronted with new faces, new

13 situations or tasks … will too frequently elicit the danger or terror reaction” (Maslow, 1943, p.

378). One theory that attempts to reduce stimuli and promote an environment conducive to healing is Ulrich’s theory of psychologically supportive design. Hard facilities, like institutions or hospitals, are known to be stress-inducing, which contradicts the main premise of why someone would go to a healthcare facility (Ulrich, 2001). Through reducing architectural stimulation and incorporating key elements of residential design, the patient is left feeling more empowered as they are in an environment that feels familiar to them.

The theory of salutogenesis emerges from the belief that healing must be focused on the improvement of one’s health and not through focusing on the risks of one’s condition. Doctor Wayne B. Jonas states, “Healing is a process that emerges from the whole person and is maximized when the practices and environments are present to support it” (Jonas, 2014, p. 82).

Jonas uses salutogenesis to explain the importance of connecting the built environment to the patient to support healing, regardless of what state they are in, physically or emotionally.

Salutogenesis builds onto the theories of supportive design and trauma-informed design with a more holistic approach. It works to mitigate the negative effects of trauma through the mind, body, social, and spirit using preventative care, restorative care, and palliative care (Jonas, 2014).

Preventative care is beneficial to the programming of a reproductive health center through the education center and abundant resources available to the public. By educating the public on topics of contraception, reproductive health, and safety, teens and young adults can be better equipped to make decisions about their bodies. The restorative care element reveals itself through the architecture and design of the facility. Restorative design supports the emotional needs of the patient without compromising the physical care they require. The incorporation of nature, art, aroma, and music, combined with acoustic controls and natural lighting, provide the

14 best outcomes for restorative care (Jonas, 2014). Calming textures, sounds, and visuals emanate a spa-like atmosphere that contradicts the stereotypically cold and unwelcoming characteristics of a traditional institution.

Human Instinct By examining the instinctual needs of mothers during childbirth to protect their child, designers can replicate that same level of care and security to comfort the patients at a healthcare facility. Research reveals that “mammalian mothers have instinctively always chosen to give birth in an environment perceived as safe, secure, and private” (Nilsson, 2020, p. 199). Privacy and safety are just as important to a newborn as they are to a patient receiving any form of medical care, especially an abortion. The exam rooms should have minimal distractions, soft materials, and warm lighting. It is also important that the exam beds are placed so that patients always have an unobstructed view of the door, as this increases their perception of control and decreases their levels of stress (Bonaiuto, 2010). A reproductive health center must reduce the amount of noise pollution and stimulating elements as they are shown to evoke feelings of fear and stress. This is especially important to Fern because both abortions and deliveries will be occurring there and hearing what another patient is going through can be traumatizing. Traumainformed design also supports the need for clear sightlines, wayfinding, and areas of prospect and refuge to enhance the patient’s sense of safety, security, and privacy (Shopworks Architecture, 2020).

Another female instinct is that of nesting, which is the need to create a safe and protected environment in which to give birth (Harte, 2016). The desire to organize is a common element of nesting which is translated into a patient’s need to familiarize themself with their environment and begin establishing their safe space. Providing users with the opportunity to modify their

15 room for the short time they inhabit it assists in recreating that sense of placemaking and comfort mothers look for when they are nesting. Cabinets for belongings, designated lounging, sleeping, and dining areas, and the ability to bring one’s own pillows or blankets to the short-term housing supports the patient’s natural instinct to protect themself in an unfamiliar environment (Harte, 2016).

Focusing the interior design on the empowerment and comfort of the user removes the degree of separation that is felt in institutional settings. Taking cues from the natural environment for color palettes, textures, and patterns helps to continue a sense of familiarity throughout the building, even if it is only a patient’s first time there. Because patients are going to be at Fern Women’s Health for a variety of reasons, acoustic privacy, clear wayfinding, customization, and emotionally supportive design are top priorities. The short-term residences will mimic the organization and personalization of a traditional home, so as to make a facility that is typically sterile and uninviting supportive of the healing and empowerment of the patient.

Conclusion Fern Women’s Health conforms to the evolving needs of the patient, differentiating the facility from those that currently exist, by using the passive nature of architecture to inspire and promote well-being for its users. Additional programming elements, like therapists, attorneys, and on-site childcare should be incorporated to create the most supportive environment for anyone seeking abortion care. By combining a wholistic reproductive health center with short term housing and support services, barriers that prevent people from receiving safe abortions begin to disintegrate. Fern stands as a precedent for how abortion facilities could function and survive in a society where women’s healthcare intersects with the community and supports the patients through every stage of their reproductive journey.

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