Thursday, January 8, 2009

Effect of the environment on labour and birth

Over the next few days I will be talking about the design of the birth unit that Deborah Davis and I are currently working on for the Second Life Education New Zealand project. We are taking especial care to follow birth unit design principles espoused by people such as Bianca Lepori (2008) because we believe that the environment has an impact on how labour unfolds and the outcomes of birth.

Supporting normal birth
In other words, we believe the hypothesis that a cold, unfriendly hospital environment may impede labour, which in turn leads to a higher likelihood of medical intervention. In contrast, a home-like environment is more likely to result in normal birth.

It is particularly important for us to support any measure that encourages normal birth in this day and age of rising interventions such as cesarean section. So we hope that our virtual birth unit will get people thinking and talking about birth, the birth environment, and how the environment can be exploited to keep birth normal.

What does the research say?
I haven't been able to find much research about the impact of environment on birth. Yet, the concept of the desirability of 'home-like' birthing rooms has been around for some time. I remember getting very excited in the mid to late 1980s when we re-decorated our birthing rooms at Salisbury with Laura Ashley (very posh and expensive) wall paper. This is it, we thought, women are going to do so much better now. Ironically, whilst the rooms had state of the art wall paper, they also still had the hospital bed right in the center of the room, CTG machine next to it and so - I'll come back to this later in this post.

Image: 'Lucile Goetter, bienvenue chez nous' Raphael Goetter

Cochrane review

The main research article I have found is a Cochrane review: Home-like versus conventional institutional settings for birth (Hodnett et al, 2005). This review concludes that there is a 'modest' decrease in medical interventions and an increase in maternal satisfaction, vaginal birth and breastfeeding. However, the reviewers also noted a slight rise in perinatal mortality resulting in a caution that midwives need to be mindful of complications.

What is difficult to differentiate in the research is what actually affects outcomes: the environment or management of care. As far as midwifery care is concerned, Fourer and Hunter (2006) refuted the claim in the review that birth is unsafe in a birth unit by pointing out faults in the original research - in one study, no account was taken that the 'bad outcomes' had taken place after transfer from birth unit to hospital.

If you wish to know more about the safety of birth units and midwifery care, I suggest you read the latest Cochrane review: Midwife-led care versus other models of care for childbearing women.

What writers have suggested over the years is that the hospital environment increases stress and anxiety, which impedes labour and increases the pain felt by women (Robertson, 2003). [For a more detailed review of the cascade of pain and effects of stress, read Foureur and Hunter (2006)].

In contrast, the more homely birth unit is believed to encourage 'nesting', which is a process of making a place safe for the arrival of the baby - where the baby can be protected from harm (Walsh, 2006a).The features that make this nesting possible is a sense of welcoming to the unit; an ambiance of warmth, trust, nurturing and love. It also means protecting the woman from intruders such as unwanted staff. In Walsh's ethnographic study of a birth unit, women and midwives talked about the feeling that the women could relax compared to the hospital. They had an instinctive feeling that the unit was the right place to birth. The women also appreciated that the unit was calm, had an air of being un-busy, and had easy parking (Walsh, 2006b).

The concept of nesting is one that has been taken up by the Royal College of Midwives in the UK as part of their campaign for normal birth.

Mammals try to find warm, secure, dark places to give birth - and human beings are no exception. But it is the feeling of security and confidence that is important to us, rather than the environment itself. And if we can find ways to help women to feel more private and confident, we will greatly improve the likelihood of them having a normal birth.

Learning from home birth
Probably one of the key advocates for looking at the birth environment from an architectural point of view is Bianca Lipori. Bianca interviewed women had home births and found that they birth in empty, protected areas which mirrors the behavior of all mammals. If left to their own devices, women birth somewhere that is inconspicuous (not on a bed in the middle of a room visible from the entrance/door), and surrounded by furniture that allows them to position themselves in a way that makes use of gravity and relax their pelvic floor, be it kneeling, hanging, squatting or standing. She says:

Women who can give birth naturally do not need particular colors, nor beautiful furniture that reminds them of their homes. They need a space in which to express themselves, in which to wait; they need the space-time to let it happen. The only thing they really need is not to be forced into a particular position. Even pain dissolves with movement; pain killers are a consequence of stillness.

In my next post I will look at the design features that Bianca Lipori advocates in a birth unit.


Foureur, M. & Hunter, M. (2006). The place of birth. In S. Pairman, J. Pincombe, C. Thorogood & S. Tracy (Eds.). Midwifery. Preparation for practice (pp. 94 -111). Sydney, Australia: Elsevier.

Hodnett, E., Downe, S., Edwards, N., & Walsh, D. (2005). Home-like versus conventional institutional settings for birth. Cochrane Database of Systematic Reviews, 1. Art. No.: CD000012. DOI: 10.1002/14651858.CD000012.pub2. Retrieved 9 January, 2009, from

Lepori, B. (1994). Freedom of Movement in Birth Places. Children’s Environments, 11, 2, 1-12. Retrieved 8 January, 2009, from

Lepori, B., Foureur, M., & Hastie, C. (2008). Mindbodyspirit architecture: creating birth space. In K. Fahy, M. Foureur & C. Hastie (Eds.), Birth territory and midwifery guardianship (pp 95-112). Edinburgh: Elsevier.

Robertson, A. 2003. The pain of labour. A feminist issue. Retrieved 9 January, 2009, from

Walsh, D. (2006a). Improving Maternity Services: Small Is Beautiful - Lessons from a Birth Centre. Radcliffe: Oxford.

Walsh, D. (2006b). Maternity care: revisioning risk for normal childbirth. In A. Symon (Ed.), Risk and choice in maternity care (pp89-100).
Edinburgh: Elsevier.


Anonymous said...

Okay, cider in hand.

I'll be professing my adoration for you for a few days to come over this post.

Space. Holding the space for women. That is my job. During a transfer to hospital. I made sure to be right by the mama... got her husband to lean in close, so as to lessen the harsh lighting. I guess we tried to keep her space as best we could. Not easy once we were shoved in that crappy room... but we tried. The 'ldrp' rooms (labour, delivery, recovery, postpartum) have a rocking chair and pretty prints, a shower area... yeah. But the space we hold with that woman is more important.
oooooh. I'm going places with this one!

Sarah Stewart said...

I can't wait to show you the plans & see what you say about them.

M-H said...

This reminds me of an amusing story that a friend who is a midife here in Sydney at RPA told me. During a very hot Sydney summer they were having trouble with their air conditioning in the labour rooms, to the extent that conditions for labouring women were not really very pleasant - for example sweat was dripping off staff onto patients. It can be difficult to get maintenance done in a big hospital, and the aircon was apparently not easy to fix. However, the first woman to use a room after it was eventaully fixed was a Chinese woman, and her husband was very insistent that the aircon be turned off, as apparently it is very bad Feng Shui to have wind blowing on you during childbirth.

Sarah Stewart said...

Fascinating, M-H. Just goes to show you can't make assumptions & must take everyone on their own individual level.