Place of birth: why it matters where you labour

What a difference a space makes. SARAH TENNANT investigates birth spaces past and present, and the thinking behind their architecture and design.

Winston Churchill once said “We shape our buildings, thereafter they shape us”. I’ve been wondering how that theory translates to the buildings within which we give birth.

A maternity ward conceals the high-tech equipment in each delivery room – electronic foetal monitor, gas and air canister, newborn resus kit – behind a painted screen, and labouring women’s requests for pain relief drop by 7%.

A woman in labour arrives at the hospital 6cm dilated, and is shown to her room; her labour stalls for three hours.

Another woman is at the end of her tether, crying out for an epidural. The midwife says “Okay, but the pool’s just about full; how about we try that first?” The baby is born naturally in water an hour later.

What’s going on here? Short answer: the physical space in which a woman labours – its brightness, equipment, windows, doors, even its scents – can all have a profound effect on her labour and birth. As research accumulates on birth spaces, designers of birth centres and maternity wards are changing the way they build based on what labouring women actually need. To find out what that is, let’s look at where women used to birth.

Born in a manger
If you’d asked me recently where women gave birth before the advent of hospitals and birth centres, I would have guessed at home. As it turns out, that’s only partly true. Certainly many did, but a surprising number of cultures relegated birth to purpose-built, private structures.

The smallest of these is the birthing hut, a generally temporary and often ramshackle affair that appears in cultures across every inhabited continent. Whether built by the Māori, the Inuit or the Bangladeshis, birthing huts generally share several features in common: they are small, they are situated at some distance from the village, and they are private. In many cases, the huts are also single-use, being burned down after the birth is complete.

Birthing huts have a distinct ambivalence to them. They can be interpreted as symptomatic of societies which view childbirth as unclean and women as unworthy of compassion – and certainly many early anthropologists were horrified at the isolation and crudeness of the huts. But they can also be viewed as a way for women in very cramped, close-knit communities to get the peace, quiet and rest they needed away from the hustle and bustle of village life. Plus, despite being architecturally uninspiring, these huts can be well-equipped for natural birth. The birth huts of the Comanche Indians had holes in the floor, into which hot stones and aromatic herbs were placed; the labouring woman would squat over the steam for a kind of medicated pain relief. Outside the hut, stakes were driven strongly into the ground in a widely-spaced row. The mother paced up and down the row with her midwife; when a contraction came, she could lean on a stake for support.

Then there are societies which dispense with buildings altogether. Many tribal women, particularly in Africa, view childbirth as a rite of passage equivalent to men’s coming-of-age ordeals. When labour begins they walk out into the bush and give birth alone and unaided. They return triumphantly as mothers, their experience left private and mysterious in the forest.

In other cultures, existing dwellings are pressed into use for birthing-houses when necessary. In Finland, every family owns a bath-house or sauna; during labour it is a convenient, private and hygienic place to give birth. Cultures with taboos around menstruation often have ‘monthly tents’ or a ‘monthly hut’, which – being ritually impure and forbidden territory for men anyway – are obvious places to give birth.

Then there are birth spaces defined simply by a piece of traditional equipment. A rope thrown over the rafters of a hut or the branch of a tree can provide counter-pressure for a woman to heave on during contractions and pushing. A worn birthing stool, or a pair of birthing bricks to squat upon, could be taken from house to house by a midwife or kept by a family as an heirloom.

In traditional British homebirths, a space within the home would be selected as the ‘borning room’ – often the master bedroom or a spot near the best fire – and partitioned off if necessary for privacy. Women often birthed on a nest of straw, as it soaked up any gory fluids and could be hygienically tossed onto the fire afterwards – in fact, being ‘in the straw’ was a euphemism for childbirth before the more genteel ‘brought to bed’ came along and became popular.

In France, country women would even sometimes give birth in the stable, which had not only straw aplenty but warmth from the horses, privacy from family and the rest of the household, and – regrettably – tetanus.

Many different spaces, many different cultures, but the common elements of these birth spaces are the same things researchers are learning women need today: namely privacy, safety and some measure of comfort.

In fact, humans aren’t even special in this regard. Many otherwise highly social animals, such as sheep and chimpanzees, seek out privacy when in labour. Prey mammals have an uncanny ability to halt the birth process mid-labour if they feel themselves observed or unsafe. And many digging mammals create chambers specifically for birthing and child-rearing, separate from the main burrows.

So what does that mean for us today?

Privacy
For an animal, privacy means being in a space away from predators who might eat their newborn baby. Humans worry less about being eaten and more about being annoyed, bossed or interrupted, but the principle’s the same.

A well-designed birth space, then, will make the labouring woman feel unobserved. Ideally the door will lock, or at least the building will have a strict knock-first policy; a dog-leg entrance to the room or a curtain can help foster feelings of privacy.

Even windows can be a problem – as Auckland mum Hannah van Ballegooy put it, “My first birth was in a hospital which had a lovely view over the city, but I felt like if I could see out, they could see in, and was imagining people in the Sky Tower looking through those pay-as-you-go binoculars and peering into my hospital room. (They most likely would have regretted that, but I just couldn’t shake the feeling!)”.

Interestingly, while trendy hospitals are ditching poky, dingy hospital rooms for spacious airy ones, that may not be the way to go for delivery suites. Birth writer and obstetrician Michel Odent has observed that women may actually feel more secure in smaller, dimly-lit rooms; in fact, they often seek out smaller spaces within a room to give birth, such as the bathroom or a corner beside the bed. Actually, if you’ll forgive me and Ina May Gaskin, a good rule of thumb for birth is “Would you feel comfortable enough to poop here?”. If you couldn’t poop in a brightly lit ballroom-sized bathroom with doors on every wall, well, chances are you won’t feel at ease birthing in that kind of space either.

The trouble with a small, cosy space, of course, is that it’s confining. Walking is super helpful during labour; so ideally, a birth space will also include a private corridor of sorts where women can pace without being gawked at by the public.

Safety
For some women, safety in childbirth means “as much life-saving technology and expertise as possible, close at hand”. And certainly those things are great, though studies show that in New Zealand, a low-risk woman is just as safe in a birthing centre or attended at home as she is in a hospital.

But the question at hand isn’t whether or not the technology should be available; it’s whether or not it should be visible. And the short answer is it shouldn’t be. Because to our mammal brains, safety in labour doesn’t mean ‘machine that goes ping’, it means ‘everything is normal and I am in control’. And it’s hard to feel normal and in control when you’re staring at machines you’ve never seen before – though they do look suspiciously like something from a documentary on the moon landing.

Luckily, modern hospitals are starting to hide their ‘hospital-ness’ inside cabinetry and behind screens, putting the focus of the room back on the low-tech, DIY labour aids – Swiss balls, birthing pools and stools. Birthing centres do it too – my last birth took place in
a room with a hotel-like appearance, from whose smooth homely panelling baby-weighing stations, Entonox canisters and suturing equipment magically popped out as needed like cup-holders from a dashboard. It was nifty.

In a pinch, of course, you can make even a sterile and lacklustre space less intimidating with your own décor. Some women fling their own throws over the machinery and use scented room sprays, photographs and their own pyjamas to make a space feel more like home.

Comfort
When I quizzed my friends about their birth space preferences, a few people were sceptical about the whole concept. Surely during childbirth you’re not going to care where you are? It’s not like whale-song and scented candles will make 36 hours of back-breaking labour seem like a walk in the park.

And I get it – space is only one aspect of labour, and atmosphere affects some women more than others anyway. As my mother put it, “The only time I gave birth in a nicely decorated birthing room, I was preoccupied with counting the holes in the acoustic tiles on the ceiling during a rather rapid and ferocious labour. The décor was wasted on me.” Indeed (and sorry, Mother). But birth spaces don’t just have décor; they have equipment. And having the right tools for the job, so to speak, really can make or break a labour.

Ask any five women about their favourite labour aids and you’ll get five enthusiastic opinions. Some women wax eloquent about a deep, round tub to birth in; others love TENS machines; and others swear by the epidural – the whole epidural and nothing but the epidural.

Since you can never know beforehand exactly what you’ll want in labour, a well-designed birth space will have options. A music station is good; so is a Swiss ball, a tub, a shower with a hand-held nozzle (and unlimited hot water!), a mini-fridge/freezer for ice chips, and plenty of surfaces at different levels to lean against.

Personally, I love hot wheatie bags – which can be used in any birth space, but a microwave close at hand is extremely useful! – and birth slings, a modern take on the rope around the rafters. A wide, doubled strip of tough fabric, the sling is hung from a hook in the ceiling by a carabiner. Knot the two strips down low, and you can sit in it like a swing and rock; knot it higher up and you can dangle in it by your armpits, which is much more relaxing than it sounds. Pulling madly on it while standing upright and pushing out my baby was probably the highlight of my three childrens’ worth of labour experiences thus far; and it couldn’t have happened without the equipment. (In my next labour I tried to birth without the sling, hugging my husband like a tree-trunk for support instead; but not being able to pull directly downwards, it didn’t work at all, and I was uncomfortable and aggrieved. Lesson learned.)

We shape our birth spaces, and afterwards our birth spaces shape our births. So if you’re pregnant and still considering where to give birth, ignore the distinctions of ‘home’, ‘hospital’ and ‘birth centre’ for a moment and think about the spaces themselves. Will you feel safe? Will you have privacy? Will you have as many pain relief and distraction options as you need? And if you still can’t decide, consider the all-important factor noted seriously in Healthcare Design Magazine: will the placement of the electrical sockets allow you to charge your phone within reach of the bed?