ANDREA LEANO • IND 5626 PROJECT PROGRAMMING • PROF. PHILIP ABBOTT

NATURAL BIRTH CENTER ANDREA LEANO • IND 5626 PROJECT PROGRAMMING • PROF. PHILIP ABBOTT

INDEX Review of Literature………………………………………………1 Typology…………………………………………………………30 Client Owner…………………………………………………….66 Location and Site……………………………………………….76 Client User………………………………………………………92 Goals and Objectives…………………………………………124 Quantitative…………………………………………………….127 Site documentation, building selection………………….….130 Mentor Session……………………………………………….133 Design Guidelines……………………………………………..135 References…………………………………………………….141

REVIEW OF LITERATURE

LITERATURE REVIEW INTRODUCTION Background Maternal mortality rates are increasing, not decreasing, in the United States, according to several recent reports. Deadly Delivery, a 2010 report by Amnesty International (http://www.amnestyusa.org/dignity/pdf/DeadlyDelivery.pdf), notes that the likelihood of a woman dying in childbirth in the U.S. is five times greater than in Greece, four times greater than in Germany, and three times greater than in Spain. In the article “Letter from Europe: Home birth reborn,” Sheila Kitzinger (2008) raises the question of “how in a culture that regulates child birth with prompt intervention, and sophisticated technology we have got into this mess”. (p.77) John Davis, Emeritus Professor of Child Health at Cambridge University, observes: “It is so often the unnerving atmosphere of a busy obstetric unit for a woman in labor that brings about the very problems that it is equipped to deal with” (Kitzinger, 2008, p. 77). Based on these studies, there appears to be an increased awareness on how the physical characteristics of birth centers and their tendency to resemble homelike environment designs, promote physical and psychological comfort of a regular day of work. Women valued teachings and experiences from previous generations as important knowledge to have their babies. Labor and delivery of the baby took place in the home environment surrounded by family and a midwife. “The laboring woman was comforted, encouraged, and supported throughout labor and for days and weeks after their infant was born” (Lothian 2001, p. 13). Natural birth was viewed as a journey that required patience, trust and confidence. (Lothian, 2001). The social changes of the twentieth century as well as scientific advances in medicine coupled with recognition of obstetrics as part of the medical profession led childbirth from the home setting to the institutional setting. (Lothian, 2001). As technology and management of childbirth increased, obstetrics became part of hospital care where physicians had all the modern tools needed to manage labor as well as the advantage of convenience, with all patients in one location. Judith Lothian in the article Back to the Future: Trusting Birth reaches to the conclusion that: “… the restriction of the hospital environment and obstetric care practices limited women’s ability to find comfort without the use of medication….as birth technology increased, interventions once reserved for complicated labors, such as intravenous lines, restrictions on eating and drinking, and confinement to bed, became routine for all women” (Lothian, 2001, p. 14) that consequently result in the relaxationof the mother during the delivery process. Centuries ago, childbearing was a woman’s activity. Having a baby was part of the natural process of a woman and even part 1

LITERATURE REVIEW Purpose of this study Since 1970 there has been a movement to change hospital environments from a sterile atmosphere to a more humanized environment. (Jimenez, 2010, p. 160)The tendency has been to recreate a home like environment. Even though steps have been taking to accomplish this, there is still a long way to go to improve the satisfaction level on women and the quality of the process of giving birth. Women have been taken into account as costumers of the healthcare environment. They are the ones that aside from selecting the place where to give birth also make decisions for the rest of the family to visit different doctors. (Eshelman, 2004, p. 2) The purpose of this study is to determine the features of the interior environment that contribute to the perception of hominess in a birth room setting. The idea is to be able to recognize the physical qualities of the space that support the relaxation of the mother and improve the birth experience. “Successful design in hospital birthing settings can contribute to women’s feeling of hominess by providing personal control over visual access, patient exposure, family visitation and the • Schuster, “…a client’s perception of the experience they wish for and seemingly get in giving birth at the center is the consequence of mind, body, and place”. (p. 5) • Research Questions • Central question: • What interior design characteristics contribute to the physical and psychological relaxation of mothers and babies for a better birth experience as well as the support of birth as a natural process? • Sub-questions: • What is natural birth? • What effects does the physical environment have on pregnant women? • What are the psychological effects of pregnancy in women? • What kind of relaxation methods help pregnant women relax during labor? • How is the homelike environment translated into a birth environment? • 6. How does the physical environment of the birth center support family and friends participation in the birth process? immediate environment” (Eshelman, 2004, p. 2) It is important for us as interior designers to understand the needs of the users and find the connection between the physical and psychological needs to the physical environment. According to Mary Lay 2

LITERATURE REVIEW Significance of this Study Women are exposed to physical and psychological changes during pregnancy and given the severity of the effects of depression; there are different ways in which the physical environment can support a healthier pregnancy, delivery and post delivery process by promoting higher levels of relaxation. (Jimenez, 2010) Pregnancy is a difficult time in which many women face problems of anxiety, stress, and depression. Women who present this kind of health problems are more likely to have premature births and low weigh births. (Mei-Yueh Chang, 2008, p. 2580). According to Dr. Janice H. Goodman, depression problems during the pregnancy or a shocking delivery experience can damage the bonding between mother and child, interfere with the development of a child, and cause chronic implications of a reoccurring depression in a woman’s life. (Goodman, 2009, p. 61) This study provides a view of how the health care design has been revolutionized to shift directions from a sterile environment to a more family centered atmosphere. According to Judith A. Lothian, “Of all medical specialties it is in the obstetrics and pregnancy and delivery of the baby where the environment promotes family participation. “Pregnancy, birth, and the postpartum period are milestone events in the continuum of life. These experiences profoundly affect women, babies, fathers, and families, and have important and long-lasting effects on society” (Lothian, 2001, p. 20) LITERATURE REVIEW Natural Birth Despite technological advances, there is many people who want to bring back the old practices of birth in which women are encouraged to experience birth as a normal, natural and healthy process. (Lothian, 2001). Unfortunately as the process of giving birth has gotten more technological, giving birth naturally is rather seen as a diagnosis of a medical condition. Today giving birth to a baby is seen more of a risky procedure in which the presence of medicine has become a must without allowing the mother to really experience her body and embrace pregnancy as a natural cycle and process of life. The introduction of medicines such as picotin and epidural prevent women to respond to the needs of their bodies and to embrace the natural process of labor. Lothian explains in her article “Back to The Future: Trusting Birth” the importance of the different stages of labor and how feelings of pain gynecology in which clinical practice is least likely to be supported by scientific evidence”(p.17).Based on this lack of evidence, it is important to have a deep understanding of women’s needs during 3

LITERATURE REVIEW indicate women how to deliver their babies. “The active participation of the mother is an important, if not essential, part of natural birth. Anatomically, the mother’s movements in response to contractions facilitate rotation and descend of the fetus and protect the cervix and the birth canal” (Lothian 2001, p. 16). Lothian also makes emphasis on the baby’s participation at the moment of labor, how the physical closeness of the mother and child right after birth can help the mother, not only the newborn’s sucking but also the child’s touch and massage of the mother’s breast promote the oxytocin release necessary for breastfeeding and potentially crucial for preventing postpartum hemorrhage (Lothian 2001,). There is extensive evidence that supports the idea, that the way in which the physical environment is arranged supports natural delivery. According to Ronald L. Cole, M.D. in his book “The Gentle Greeting” the most important factor is a calm, loving, and joyful atmosphere in the birthing room. “ My experience shows that the most crucial factor contributing to a successful, non-traumatic birth is the environment that promotes a nice emotional atmosphere surrounding all the participants in the pregnancy and birth experience: parents, family, friends, stands for and how much medical intervention is involved. He makes emphasis on the fact that the term is in an ever evolving change and that providers and consumers have to fight for the reformation of the concept in order to make natural a real natural process. (Young, 2009) A vast range of practices have been introduced to start, accelerate, monitor, and numb the physiological process of labor, thereby making the concept of practice of normal child birth an ever changing and ever expanding process (Young, 2009). Young concludes his article by stating “Now, as cesarean delivery rates escalate alarmingly all over the world, perhaps it really is the time for a rebirth of natural childbirth” (Young, 2009, p. 2) It is easy to describe the components of those natural and normal births - physiological labor and delivery, no drugs or medical interventions, a spontaneous delivery, no episiotomy, minimal mother-baby separation, and early and exclusive breastfeeding. But today in most Western countries, having this type of natural birth is an unusual event in a hospital, and most likely to occur with a midwife at home or in a free-standing birth center (Young, 2009) “The midwifery model of birth defines birth as a low-tech natural process and most laboring women as well prepared to succeed if they are allowed to listen to their own bodies and articulate their own needs”. (Schuster, 2006, p. 14). For the most part, midwifes physicians, and nurses” (Cole, 1998, p. 116) According to Diony Young in his article What is Normal Childbirth and Do We Need More Statements About It? Each country has a different concept of what natural 4

LITERATURE REVIEW let the mother design their own experience of giving birth. Birth is considered a family event, and the participation of the family is encouraged depending on the preferences of the mother. Midwifes follow the mother’s plan of giving birth, unless they see any risks that would require the mother to be transferred to a medical facility. “Midwifes call this philosophy the whole woman approach, offering clients emotional, psychological, and physical support and considering the mother and baby a unit: what is good for the mother will benefit the baby and vice versa” (Schuster, 2006, p. 15) The great advantage of having a midwife throughout the process of pregnancy is the bonding between the mother and the midwife. Prenatal appointments are not limited to keeping record of the physical changes of the mother and baby; it is also time to talk about any emotional changes in the mother or any other pregnancy related issue. Women get to ask any questions to the midwife or talk about any of their concerns. The importance of this relationship is the bonding that it creates between women. Such bonding creates a feeling of familiarity to the mother in respect with the staff members and the actual place of birth. experience. The rates of women suffering from depression are really high and studies show how the effects of the depression can damage the bonding between mother and child, interfere with the development of a child, and chronic implications of a reoccurring depression in a woman’s life. (Janice H. Goodman P. , 2009). The is a tendency in women to avoid any kind of treatment when they suffer from depression. According to studies, there are many reasons that explain why women have such reactions. Some women feel ashamed to admit their depression during such happy moments of their lives. Others fear what their families will think of them. There is also a tendency to avoid treatment due to lack of transportation or help with the care for their others kids. Having a better understanding of what prevents women from getting treatment will help find solutions for those problems and create a program that supports their different conditions, improve treatments and improve the overall health of childbearing women. (Goodman , 2009) “A traumatic or unsatisfactory birth can lead to postpartum depression or post-traumatic stress disorder, in which women relieve their labor in dreams and flashbacks that trigger extreme distress” (Jimenez, 2010, p. 160) Pain during Labor and the environment In an attempt to define the ways in which women can have a more relaxed and friendly delivery of the baby, Psychological effects of pregnancy and the environment Men and women have a tendency to suffer from depression from time to time. Women have a greater chance to suffer from depression because of the childbearing 5

LITERATURE REVIEW it is important to also analyze how the procedures use during delivery affect a woman. The different procedures used during delivery can be enhanced and supported by the design of the birth room. Judith A. Lothian make emphasis on going back to old techniques of giving birth naturally, perhaps the environment should represent a more natural environment that can shape women’s perception of the delivery of babies. There is also emphasis on the emotional support that family and friends can offer to mothers during delivery and the positive outcomes this has to a better delivery. Such participation of family and friends can be reinforced and reflected in the built environment by making their participation as comfortable as possible. (Lothian, 2001). “…when clients [mothers] realize the physical and psychological consequences of structures and objects, they reconnect with their physical bodies, associate mental attitudes with physical sensation, and sustain a counter disclosure about birth” (Schuster, 2006, p. 1) Baby Haven is a free standing birth center designed by Sarah Stanton. Stanton designed Baby Haven to support the midwifery model where medical instruments are hidden and only used in case of emergency. Stanton Haven clients perceive the effect of the low lighting, the quite, and the smells from the kitchen on their minds and bodies. They attribute their ability to relax during labor to the center’s homelike décor and the sensations it provokes”. (Schuster, 2006, p. 17) Clients in this birth center suggest that the ability of their bodies to relax within the space helps them deal with pain during labor. According to Stanton, “avoiding the psychological sensation of fear makes the physical sensation of pain manageable,….and the most effective way to avoid fear is to birth in a place similar to home, where one feels safe and in control” (Schuster, 2006, p. 18) Baby Haven is a perfect example in which the process used to give birth along with the support of the physical environment improved women’s experience of birth by relaxing them and encouraging them to embrace the natural labor process. Stanton intended for her clients to be able to relax psychologically enough to manage pain physically when she designed Baby Haven (Schuster, 2006) As interior designers we have the opportunity to shape the process of giving birth, by the way we arrange the environment. According to Mary Lay Schustape people’s mentality of birth being a medical procedure reflects both cultural and material arrangements and thus is a physical representation of relationships and ideas. (Schuster, 2006, p. 1) Mary quotes RoxaneMountford and her extension on Henri Lefebvres’s expresses her intent in the design of a birth center that supports a natural process, but it is important to see how the design affects client’s minds and bodies. (Schuster, 2006, p. 17)” Baby 6

LITERATURE REVIEW theory of social space to argue that “particular spaces can move people both by suggesting symbolic associations and by causing us to form relationships with each other and the space through its structure” (Schuster, 2006, p. 5) Mary proceeds to explain that “….spaces, therefore, have “heuristic power over their inhabitants and spectators by forcing them to change both their behavior and sometimes, their view of themselves” (Schuster, 2006, p. 5) Hospital environment vs. Homelike environment Mother’s Perception of Hominess Despite the continued claim by health care professionals that the hospital is the safest place for all women to give birth, with most citing the need for continuous surveillance in case of emergencies, there has been no evidence that the hospital is safer than other birthing alternatives for the low-risk , childbearing woman. Other health care professionals argue that childbearing is not a sickness but a life event in the life of a woman in which the hospital setting designed to treat the ill does not support the needs of women to embrace labor as a family event. Veitch and Arkkelin suggested that the mere mention of the words hospital brings thoughts of long sterile hallways, stainless steel utensils, banks of (Leather, 2003). The cold environment of the hospital might create negative feelings of fear as a result of being in an environment associated with death and suffering. These negative feelings can in turn raise levels of stress for the users of the space. (Leather, 2003) Throughout the years, there has been an intention to change the healthcare environment to one that not only supports the functionality of the space but also one that utilizes the interior design to improve the experience of the user. This approach has been taken into account directly into the maternity care unit. The tendency has been to recreate a home like environment. As women have been taken into account as costumers of the healthcare environment, they are the ones that aside from selecting the place where to give birth also make decisions for the rest of the family to visit the different doctors. (Eshelman, 2004) “Successful design in hospital birthing settings can contribute to women’s feelings of hominess by providing personal control over visual access, patient exposure, family visitation, and immediate environment” (Eshelman, 2004, p. 1) “Complex psychological and social outcomes result from giving birth and a woman’s satisfaction with her child birth experience may have immediate and long-term effects on her health and her relationship with her infant” (Vania Jimenez, 2010, p. 160) In general, life-monitoring equipment, people in white uniforms rushing to and fro, specialized rooms for specialized functions, wheelchairs lined up at elevators, and the smell of rubbing alcohol and disinfectant 7

LITERATURE REVIEW there seems to be a discontent across the board on how women perceive the birth environment. In many cases women end up choosing a place to have their babies, not based on what they like but on what they believe is the most safeenvironment for their babies. (Jimenez, 2010). The involvement of interior design should be more present in the redesign of birth rooms. Different hospitals have use different techniques at making the birth room a more home like environment, but for the most part the modifications are limited to the use of wall covering and drapery. (Eshelman, 2004). The contradiction between what mothers to be want and what they choose, clearly suggests an opportunity for interior design intervention In order to evaluate the tendency of interior designers to recreate the birthing room as a homelike environment, it’s important to define what home represents and how it influences mother’s psychology. According to John Ruskin: “[home] is the place of peace; the shelter not only from injury, but from all terror, doubt, and division. In so far as it is not this, it is not home… it is then only part of the outer world which you have roofed over…” (Gifford, 2007, p. 254) and social meaning for us, and we likely also experience belongingness, happiness, self-expression, and good relationships within it. According to Robert Gifford there are six dimensions that enable us to experience such feelings: haven, order, identity, connectedness, warmth, and physically suitable. This definitions of home bring thoughts to my mind as to how mothers to be, relate to this feeling of shelter and protection at the moment of delivering their baby. According to Bordo in her study of bodily integrity, the essence of the pregnant woman is “her biological, purely mechanical role in preserving the life of another” (Schuster, 2006, p. 8). It is important for interior designers to understand mother’s perceptions as they move through the space and their expectations of safety that supports their role as mothers. Re-conceptualization of the Labor Room: A homelike environment is very important for the way the space is perceived from the mother and family as a whole. The idea of a birth room resembling a home environment promotes birth as a family event instead of an illness. According to Jung-Hye Shin, Lorraine E. Maxwell and Paul Eshelman; “The birthing experience has been described as a normal, healthy process which occurs during the lives of most women” (Eshelman, 2004, p. 1). Shin, Maxwell and Eshelman also state in their study, that the design of birth rooms should be viewed as the ability of the built environment to Another definition states that home is “the rich set of evolving cultural, demographic, and psychological meaning people attach to that physical structure” (Gifford, 2007, p. 255). Home has great personal 8

LITERATURE REVIEW • support family events. (Eshelman, 2004). When analyzing the six dimensions of home, we can see how these concepts take form in the physical environment and can be perceived as we move through the space. • Six dimensions of home: • Home is a haven that surrounds us with privacy, security, refuge, and protection from the slings and arrows of life outside it. • Order: Home helps us to know our place in the world. This ordering is not only spatial, but temporal; home is strongly related to our sense of continuity. • Home is central to our identity. As social creatures, home includes for us a sense of family kinship, ethnic belonging, and socioeconomic status. Home is thus an important part of who we are. Through self expression and personalization, the home comes to resemble or represent our selves. • Through order and identity home means connectedness, the patterns of spatial and temporal order help us feel connected to certain people, to the place, to the past, and to the future. We feel part of a family or group, and part of a culture. • means more than the material physical aspects of the house. It means the physical form and structure of the house matches our psychological needs. • Spatial meaning and aesthetic quality are tools of Interior Design that help improve the experience of the space and at the same time support the function. In the case of hospitals a lot of emphasis has been put into a functionally successful design. When creating a space that gives a feeling of haven and order , it s important to take into account spatial continuity that provides the right privacy levels, transitional spaces that can be controlled by the users as well as openness to the outside and inside of the architectural structure. (Eshelman, 2004). Too much or too little privacy can cause stress to the mother by creating feelings of isolation or a sense of crowding. One way to achieve the right connection between spaces is with the use of special continuity and transitional spaces. In a study on Mothers perception of Hominess, suggested that doorways without transitional spaces are less homelike than those with more transitional space. Additionally, rooms with physical barriers tend to be more homelike than those in which the space is more exposed. (Eshelman, 2004). • Exposure to daylight has a tremendous positive effect on people. Research indicates that openness to the outside through widows can give patients something to do, help orient them through the time of the day, • Home is warmth. This grows out of the preceding qualities, but goes beyond them. This warmth is like that of the hearth, but is symbolic and interpersonal. • Home is physically suitable. Obviously, this 9

LITERATURE REVIEW season and weather, and even give them pleasure. In the case of expectant mothers, daylight and fresh air can help mothers to relax, and control their circadian cycle. In the other hand, lack of daylight can result in lethargy, depression, increased rate of suicide, and seasonally affected disorder. (Eshelman, 2004). It is important to keep in mind the right size and location of widows. According to Eshelman, “The number and size of windows in a hospital setting can affect the user’s feeling of boundary and involvement” (Eshelman, 2004, p. 2)Studies suggest to stay away from floor to ceiling windows in order to avoid a feeling of exposure. This supports Ching’s theory on space that can be too open. “In interior environments, when the space looses a sense of enclosure, it becomes too diffuse and begins to merge with adjacent spaces. (Eshelman, 2004) Consequently, people might tend to lose their sense of security. A home only becomes a home when we recognize a series of items that represent personal belongings that create a set of meanings and reinforce our identity. There is a need in health care facilities to provide space for people to customize their spaces so they feel a connection to the space and avoid feelings of isolation. • means more than the material physical aspects of the house. It means the physical form and structure of the house matches our psychological needs. • Spatial meaning and aesthetic quality are tools of Interior Design that help improve the experience of the space and at the same time support the function. In the case of hospitals a lot of emphasis has been put into a functionally successful design. When creating a space that gives a feeling of haven and order , it s important to take into account spatial continuity that provides the right privacy levels, transitional spaces that can be controlled by the users as well as openness to the outside and inside of the architectural structure. (Eshelman, 2004). Too much or too little privacy can cause stress to the mother by creating feelings of isolation or a sense of crowding. One way to achieve the right connection between spaces is with the use of special continuity and transitional spaces. In a study on Mothers perception of Hominess, suggested that doorways without transitional spaces are less homelike than those with more transitional space. Additionally, rooms with physical barriers tend to be more homelike than those in which the space is more exposed. (Eshelman, 2004). • Exposure to daylight has a tremendous positive effect on people. Research indicates that openness to the outside through widows can give patients something to do, help orient them through the time of the day, Personalizing the space can also raise the levels of privacy even for temporary stays. (Gifford, 2007). According to a study on the comparison of standard hospital labor rooms versus a more residential birthing 10

LITERATURE REVIEW person who gives her care, and by the environment in which she gives birth” (Lothian, 2001, p. 20). The moment of having a baby is a memory that stays with a mother for the rest of her life. Creating a nice memory is a combination of the experience of the mother during labor, the interaction with each of the participants of the birth process and the experience of the environment. Home is directly related with the feeling of family warmth. It is in the home where we built unforgettable memories that stay for the rest our lives and make us who we are. Creating a home warmth feeling in the birthing room, depends on the mothers opportunity to give birth as she wishes in an environment in which she feels nurtured and secure, and her emotional well being, privacy, and personal preferences are respected. The physical suitable aspects of the home environment can be translated into the birthing room as a toll that can increase the relaxation of the mother if those match her psychological needs. Birthing rooms that are associated with the home environment are those that offer privacy, promote social support, allow freedom, and control, are calming, and include scenes of nature and other visual and auditory stimuli that create positive spiritual connection. (Whitehouse, 2001). Operable windows are an important mechanism to improve control over ventilation, temperature and exposure to the outside. Studies suggest that sliding doors and French doors tend to be perceived as homier when compared to fixed windows and small awning windows. (Eshelman, 2004). Lighting plays a very important role in setting the mood of the room. Mothers perceive the effect of the low lighting as their ability to relax and cope with pain. (Schuster, 2006). It is also important to have different sources of lighting such as task lighting for family member’s activities (i.e. reading) and good amount of natural light as well s full spectrum artificial light. Relaxation Methods during Pregnancy and Labor Knowledge Dissatisfaction in women starts with the lack of information they received when deciding where to have a baby and pregnancy in general. How much knowledge a mother has, influences the outcome of delivery. Studies show that the majority of women don’t know how to proceed when deciding where to have a baby. Most of them go to a hospital based on their notion of safety and risk, even though they don’t like the environment. Fort the most part women think the epidural is the only pain relieve method there is. Informed women feel they have more options to decide emotional responses (Hodnett, 2009). Research suggest that exposure to natural settings may reduce stress, engenders feelings of peace, hope, upliftment, joy, reflection, relaxation, enrichment, and 11

LITERATURE REVIEW where to have their babies and what methods for pain relieve they want to choose. In general women find it very confusing on how to proceed during and after the pregnancy. (Jimenez, 2010) Consistently with other research findings, the more control women feel over the situation, the more confident they feel on their performance during delivery. Water Different studies indicate that giving birth in water has many positive effects not only on the mother, but also on the fetus and on the family in general. Water birth improves comfort and mobility. The mother has much greater ease and freedom to move spontaneously and to change position to assist the descent of the baby. (Jessiman, 2009)It also promotes deeper relaxation. As a woman relaxes deeply in water, her hormones kick in and she starts progressing faster and with more rhythm; labor becomes more efficient. (Jessiman, 2009)One of the most important effects of water during the delivery of the baby is the fact that it water minimizes pain effectively that for most women other pain control methods are no longer needed. As mentioned before the control of the mother over pain relieve anxiety and promotes relaxation. As the mother family bond. (Jessiman, 2009).Miller argues that if Midwifes are really committed to restoring normality in birth then every women without major complications should be offered the opportunity to labor and give birth in water. (Jessiman, 2009, p. 586) Music “…non-pharmacological preventive intervention for antenatal stress, anxiety and depression should be considered of significant importance [to avoid risk of the fetus and mother]” (Chang, 2008, p. 2581). There is a need to understand how to address the problem of depression and offer adequate support to pregnant women. The fact that pregnant women cannot take any medication during pregnancy or during lactation gives a lot of power to alternative solutions. Studies indicated that women who listened to music rated substantially lower level of stress, anxiety and depression. Music does not only influence pregnant women to be more stable emotionally but also any depression patient in general. Music’s healing properties are based on neutralizing negative emotions and elevating harmony and inner peace. “…advantages for music therapy applied in pregnancy and childbirth on anxiety reduction and stress, as well as providing pain management during childbirth” (Chang, 2008, p. 2581) Acupuncture Studies indicate that acupuncture helps relieve the pain feels more relaxed, it is possible to promote family relationships. When the mother's pain is dramatically reduced, many fathers eagerly take a more active role in the delivery, resulting in a greater 12

LITERATURE REVIEW but not the intensity, regardless of the method use; women experience the same amount of pain. The difference lies in the way women perceived the process of birth. Women who use acupuncture as pain relieve feel in more control of the situation than women who use other pharmacological methods. According to Lisa Borup,” [women] feeling of control contributes to a good birth experience” (p. 11). In other words if the mother is more relaxed, she is likely to have more control and consequently be more able to cope with the pain. Based on Borup’s studies, women who use acupuncture have a faster recovery than women who use conventional techniques. The lacks of side effects make the recovery a lot easier. (Borup, 2009) Conclusion Interior design impacts, influences and affects our world in many ways and in many different aspects. With the intention of improving the quality of life, increasing productivity, and protecting health, safety, and welfare of the public, the professional Interior Designer uses evidence based design to create a set of design rules that support users needs in different settings. When designing the ideal place for mothers to deliver babies, it is of extreme importance for designers to recognize successful design can potentially reduce or avoid medical intervention and help women embrace birth as a natural process by encouraging the capability of their bodies’ natural design to give birth. The birth room is our first experience in the world and therefore it should afford a nice transition from the womb of the mother into the physical environment. It is in the design of the room that the birthing experience becomes a family event and allows for the participation of family members during the entire process by creating comfortable spaces that meet their needs. The Literature review suggests the great importance of having control in order to provide relaxation to the women. Mother’s control over the environment as well as decision making seems to provide comfort and to relax woman during the process of giving birth. This relaxation in turn creates less of a need for women to seek pain relieve in medical procedures and instead rely with confidence on their ability to give birth naturally. The literature showed women’s preferences for the different space qualities that recreate a home like environment. The studies’ results show that one of the most important elements for women is those in which they have control to satisfy their needs such as, operable windows. Women feel a sense of control over the environment; they feel like they have been given an option. Control over social contact thru the use of different environments is also important. The idea of a those qualities of the space that create a comfortable setting for a successful delivery of the baby. The physical characteristics of the space have such influence on pregnant women that a 13

LITERATURE REVIEW women been able to control when she is able to see her family and friends, increases her sense if privacy. Transitional spaces at the entrances play an important role as well. Having a transition in between the door and the bed lets mothers know when someone is in the room without having to be exposed right way. It is also important to have an understanding of the different techniques and methods in which women can achieve higher levels of relaxation during pregnancy and labor, in order to shape the environment in a way that supports and promotes such techniques. The literature suggest different methods such as music, water, nature, and acupuncture as ways to provide comfort, relieve pain and improve relaxation. Perhaps the introduction of a good sound system in the design of birthing rooms would be of great importance as well as the introduction of a comfortable pool. The presence of nature seems to a key element to increase relaxation levels not only for the mother and baby but also for the family and even staff members. Further research is needed to test the previous findings. The next step will be to develop a grounded theory through the qualitative research of birth centers • Design characteristics related to home like environments in the birthing room: • Spatial Continuity: right privacy level vs. isolation • Entrance transition Space: transition spaces using semi- transparent wall allowing occupants to see and hear visitors approach before they enter the room to avoid exposure. • Openness towards the outside (degree of enclosure, operable windows): access to natural views and daylight as well as adequate window treatments for light and privacy control. Operable windows are an important mechanism to improve control over ventilation, temperature and exposure to the outside. • Personalization of the Space: display surfaces for personal mementos • Family Alcoves: Alcoves to provide comfort and privacy to family members • Outdoor spaces: private patios to provide patients access to natural light and outdoor spaces. • Materials: that are both residential and durable. • Lighting: Mood low lighting in the birthing room. Task lighting for family member’s activities, (i.e. reading). Good amount of natural light as well as full spectrum artificial light. dedicated to promote birth as a natural process. Semi structured interviews will be conducted in both cases, followed by visual assessments of the environments. 16

LITERATURE REVIEW The study was able to determine a buffering effect of self-efficacy. Self-efficacy is a term that the authors used to refer to people’s beliefs about their capabilities to produce effects. The idea was to find out how social contact influences pregnant women and helps them reduce their levels of stress and anxiety that lead to depression Stress was induced by the Trier Social Stress Test, TSST, which is known for its naturalistic exposure to a socio-evaluative stressful situation. According to references in this article this standardized stress test induces a significant activation of physiological and psychological responses to stress in healthy females and patients. Their results revealed that higher self-efficacy is related to lower perceived stress. The authors used to different terms to compare the different social influences on women: daily uplifts and daily hassles. Daily uplifts are positive and favorable experiences, and reflect small, pleasant daily occurrences, whereas daily hassles can be defined as daily annoyances that provoke stress and anxiety. The analysis revealed a significant interaction of daily uplifts and stress levels, higher daily uplifts were associated with lower perceived stress during pregnancy To sum up, these results indicate that psychosocial resources seem to act as a buffer on HPA and ANS stress responses, thereby protecting pregnant women under stress conditions and helping them to avoid maladaptive physiological responses. AdaNierop, Petra H. Wirtz, AlikiBratsikas, Roland Zimmermann, Ulrike Ehlert. (2008). Stress-buffering effects of psychosocial resources on physiological and. Elsevier , 261-268. Journal: Elsevier Journal A global company headquartered in Amsterdam, employing more than 7,000 people in 24 countries. They are a founding publisher of global programs that provide free or low-cost access to science and health information in the developing world. Elsevier's roots are in journal and book publishing, where they have fostered the peer-review process for more than 125 years. Today they are driving innovation by delivering authoritative content with cutting-edge technology. Title: Stress-buffering effects of psychosocial resources on physiological and psychological stress response in pregnant women Author(s): AdaNierop, Petra H. Wirtz, AlikiBratsikas, Roland Zimmermann, Ulrike Ehlert All authors are from the Department of Clinical Psychology and Psychotherapy, University of Zurich, Binzmu¨hlestrasse Summary: The main objective of this study was to identify the potential effects of psychosocial resources on physiological stress response in pregnant women. 17

LITERATURE REVIEW Relation to the present study: This article is of great value to my project. Part of the programming of the birth center I intent to design includes a series of different activities such as yoga, aerobics, swimming, and prenatal classes that will help women to create those daily uplifts to reduce levels of anxiety and depression. In previous literature I found information on how one of the causes for depression during and after pregnancy is the change of life style women face and difficulties coping with such changes. Having the opportunity to meet with other pregnant women to share similar experiences will also emphasize the uplift moments. Such socialization will potentially increase the self-efficacy mentioned in this article, on pregnant women. Quotes: “There is clear evidence that high levels of perceived stress and anxiety during pregnancy are associated with several negative health consequences, like gestational complications, spontaneous abortion, preterm labor, low infant birth weight, postpartum depression and negative developmental outcome in infancy” p.261 against harmful consequences of heightened stress levels” p.261 “Self-efficacy can be defined as people’s beliefs about their capabilities to produce effects” p.261 “In addition, studies indicate that high self-efficacy is significantly related to lower intensity of perceived pain during childbirth” p.262 “Women with high childbirth fears seem to have a significantly lower perceived self-efficacy, and low perceived self-efficacy was found to be a predictor of psychological trauma of childbirth ...higher self-efficacy resulted in higher birth weight” p.262 “Daily uplifts represent the second potential stress-buffering resource of interest in this study. Daily uplifts are positive and favorable experiences, and reflect small, pleasant daily occurrences, whereas daily hassles can be defined as daily annoyances” p.262 “Daily hassles belong to the stress provoking factors, whereas daily uplifts seem to be more of a stress-moderating factor” p.262 “…there appears to be a demand for studies taking into consideration factors such as psychosocial resources which might play an important role in protecting the pregnant woman and her unborn child 18

LITERATURE REVIEW Lisa Borup, R. W. (2009). Acupuncture as Pain Relief During Delivery: A Randomized Controlled Trial. Blackwell Publising Ltd. , 5-12. Journal: Birth Birth: Issues in Perinatal Care is a multidisciplinary, refereed journal devoted to issues and practices in the care of childbearing women, infants, and families. It is written by and for professionals in maternal and neonatal health, nurses, midwives, physicians, public health workers, doulas, psychologists, social scientists, childbirth educators, lactation counselors, epidemiologists, and other health caregivers and policymakers in perinatal care. Title: Acupuncture as Pin Relief During Delivery: A Randomized Controlled Trial Publisher: Blackwell Publishing Ltd. Author(s): Lisa Borup, RM, Winnie Wurlitzer, RM, MortenHedegaard, MD, PhD, Ulrik S. Kesmodel, MD, PhD, and Lone Hvidman, MD, PhD Summary: A study was done with 620 Danish women for of acupuncture helped women to have a more relaxed birth experience. The results indicate that acupuncture helped relieve the pain but not the intensity, regardless of the method used women experienced the same amount of pain. The differenced laid in the way women perceived the process of birth. Women who used acupuncture as a pain reliever felt in more control of the situation than women who used other pharmacological methods. The fact that women had more control over the situation with the used of acupuncture created a more relaxed delivery. Another important observation was the post partum process in which women who has used acupuncture had a faster recovery than women who used conventional techniques. The lack of side effects of acupuncture made the recovery easier. Relation to the present study: Being the purpose of this study to analyze natural process of having a baby and embracing natural procedures to avoid the use of intrusive methods, the information in this article is very valuable. It is important to know the different ways of how to reduce the pain during delivery. This article also reinforces on the idea that having control over the delivery process increases relaxation of women during birth. In previous articles read, also agree on the fact that having control over the environment provides relaxation and reduces anxiety in women. alternatives of pharmacological and invasive methods for pain relive. The idea was to measure the effects of acupuncture during the delivery and postpartum recovery. They also wanted to prove whether the use 19

LITERATURE REVIEW Quotes: “Acupuncture during labor reduced the need for pharmacological and invasive methods, mainly nitrous oxide, ephedrine, and sterile water papules, without affecting the birth outcome” (10) “The women in the acupuncture group tended to report a lower score [of pain] 2 hours postpartum” (11) Women in the acupuncture group tended to report a higher degree of relaxation and control…” (11) ” [women]…..feeling of control contributes to a good birth experience” (11) 20

INTRODUCTION • PROJECT OVERVIEW

INTRODUCTION • PROJECT OVERVIEW NATURAL BIRTH CENTER Based on different studies on the way birth is being handled in different countries, there is a need for a redefinition of birth; a new definition in which the natural design of the female body is taken into account as capable of delivering babies without medical intervention. Research suggests that the physical environment has a direct connection in the way women perceive birth and their ability to relax. In other words, the feature elements of the birthing room have the ability to shape women’s perception on birth by embracing the delivery of the baby as a natural process. Such perception is achieved by the effects of the physical environment on higher levels of relaxation for the mother and baby. A relaxed mother helps decrease pain which in turn reduces or in many cases avoids medical intervention. Birth as a natural process is not only a lifetime event in the life of a woman but also for the family as a whole. Natural birth centers promote birth as a family event in which the participation of family and friends is encouraged. 21

INTRODUCTION • PROJECT OVERVIEW TYPOLOGY: HEALTHCARE / HOSPITALITY The nature of maternity units is healthcare, but in this project the intention is to take maternity to the next level and achieve the perfect combination of a hospitality / residential facility that satisfies women’s needs and provides comfort and safety during and after their pregnancy and delivery process. The “client”/ owner of the facility would benefit from a program that not only leaves profit from the delivery of babies but also from other activities. Providing all services for pregnant women in one single facility will increase the demand for such birth center. The idea is to provide a place that serves as a birth center and also as a sort of fitness club / spa for pregnant women. The “user”, pregnant women who attend to the birth center will be able to have all services in one place to satisfy their needs, women will no longer have to schedule different appointments in different places to perform all activities desired. They will have the opportunity to visit their midwife/ doula / doctor and following that, attend to yoga classes, get a spa treatment, assist to prenatal classes, or enjoy coffee with other pregnant women without having to move from one facility to another. 22

INTRODUCTION • PROJECT OVERVIEW Such facility would include different programs for women during their pregnancy such as: Yoga classes, Prenatal couple classes, Aerobics, Spa Coffee shops Children care Research suggest that depression during and after pregnancy is a result of feeling overwhelmed with all the changes in their life’s and in many cases not having help from family members. Having the opportunity to meet with other women and share similar experiences can decrease the chances of depression. (Goodman , 2009) • Potential activities: • Public • Coffee shop (Social Place) • Day Care • Lobby • Walking areas • Semi public • Yoga Room • Kitchen • Family rooms / waiting areas • Kids care • Kids care office • Kids restrooms • Reception • restrooms • Private • Birthing Rooms • Birthing room restrooms • Spa treatment rooms • Offices • Medical equipment room • Semi Private • Pools • Sun Rooms (for babies) • Activity rooms for couples 23

INTRODUCTION • PROJECT OVERVIEW 24

INTRODUCTION • PROJECT OVERVIEW LOCATION: SHANGHAI, CHINA • When selecting the best location for the design of a birth center, China became the best option for the following reasons: • Highest rate of cesarean section in the world ( Rates tend to be higher in the eastern region including Beijing, Shanghai, and Tianjin) • Pregnant women lack of education • Economic Growth • Healthcare industry manipulation to increase rates on cesarean section • Rates of caesarean section in many countries have increased beyond the recommended level of 15%, 1 almost doubling in the last decade, especially in high-income areas such as Australia, France, Germany, Italy, North America and the United Kingdom of Great Britain and Northern Ireland . Similar trends have also been documented in low-income countries such as Brazil, China and India, especially for births in private hospitals. Advanced health-care technologies are becoming more widely available in different regions of China. • The number of caesarean-section births has increased sharply especially in the eastern region, which covers the major cities of Beijing, Shanghai and Tianjin. Recent evidence also shows increasing demand for caesarean section among young, educated women residing in urban areas. Many Chinese couples now delay childbearing, aim to have not more than one birth experience and opt for delivery by caesarean section to avoid pain. Data from hospital-based studies in urban China showed rates of caesarean section of between 26% and 63% during the late 1990s. Another population-based study reported a substantial increase during the last three decades, from 4.7% to 22.5%. These trends are expected to persist in view of the unparalleled economic growth and rapid expansion of private health care and health insurance systems across China. Apart from the clinical indications for caesarean section – breech presentation, dystopia and suspected fetal compromise – there is growing evidence that many women choose delivery by caesarean section for personal reasons, particularly in profit-motivated institutional settings that may provide implicit or explicit encouragement for such interventions. Following health-care reforms introduced in the 1990s, a large proportion of Chinese women, including those from the less-developed western region, now seek early antenatal and delivery care in health institutions 25

INTRODUCTION • PROJECT OVERVIEW more than 10 000 Yuan (approximately US$ 1312) in major hospitals in big cities. While fees are not typically paid by mothers directly to obstetricians, in the context of a diversifying health economy in which institutions benefit from increasing activity there are performance-related incentives for staff in some hospitals, depending on the number of procedures and the revenue that physicians generate for their hospitals. The rise in rates of caesarean section in China presents problems of both equity and scale. Some of the increase in demand could be financed by patients, and might have taken place in new or expanded private hospitals particularly during 1990–2002, when the contribution of public funding to local public health revenues declined by almost two-fifths. However, current models of community-based health insurance that typically involve low premiums but high payments at the time of use have tended to benefit wealthier urban households more than poorer rural households. The present findings are consistent with the national pattern of a steady increase in caesarean sections in China, a country where health-care services are undergoing rapid expansion and modernization. There is a huge demand for the procedure across urban and rural areas of China in the context of the overall acceptance of the “one-child norm”. The finding that women with only one child were more likely to undergo a caesarean section may reflect women’s perceptions regarding the efficacy of the procedure as a means to ensure newborn survival and to avert the risks of birth complications or stillbirth. Women are increasingly inclined to opt for delivery by caesarean for nonmedical reasons such as fear of labor pain, concerns about date or time of birth that are traditionally believed to be auspicious and the belief that delivery by caesarean ensures protection of the baby’s brain. Aside from the medical benefits and risks of caesarean delivery for individual women, an important consideration is the economic impact of this new trend. Data gathered during evaluation activities in one of the study areas in 2005 indicated that the cost of caesarean delivery is approximately 2000–3000 Chinese Yuan (approximately US$ 262–394) in rural areas. This includes the cost of the actual delivery, a 1-week hospital stay, food and transportation. The corresponding costs in an urban facility range from 5000 to 7000 Yuan (approximately US$ 656–918) to 26

INTRODUCTION • PROJECT OVERVIEW maternity care models and active involvem-ent of new mothers in the development of local health services that emphasize birth as a normal process have so far received limited attention in China. Doctor recommendations as well as some pregnant Despite a rise in private or insurance-based funding, there is an inevitable additional burden on the public health system, especially on the training and deployment of obstetricians, theatre nurses and anesthesiologists able to meet the demand for surgery. Other infrastructure such as hospital beds, operating theatres, and laboratory and transfusion services will also be placed under strain as demand increases. Given the emergence of secondary-level hospitals as major providers of caesarean section, efforts to contain the increase based on clinical review and monitoring will need to consider case mix, i.e. the complexity of cases seen. In a British study, 34% of the variance in rates of caesarean section could be ascribed to case mix differences. Service frameworks and clinical guidelines are important policy instruments for containing inappropriate medical practice, and they are now receiving attention in China. However, even where implemented, international experience shows that guidelines are not always observed by obstetricians: incomplete compliance with United States of America national women's reluctant attitude towards natural birth are regarded as important factors behind China's high cesarean sections rate, a report from the Beijing- based magazine China Economic Weekly showed. A survey by the World Health Organization (WHO) revealed earlier this year said nearly half of all births in China are delivered by cesarean section, the world's highest rate, while the recommended level is no more than 15%.Natural birth is medically believed to be the ideal way of delivery and C-sections should be performed only when a vaginal delivery may put the baby's or mother's life or health at risk. The WHO study found that women undergoing C-sections that are not medically necessary are more likely to die or be admitted into intensive care units, require blood transfusions or encounter complications that lead to hysterectomies, according to an earlier report of the Associated Press. guidelines on caesarean delivery for suspected fetal distress in labor was commonplace. Other avenues that might have the potential to contain the rise in caesarean delivery such as promotion of midwifery-led 27

INTRODUCTION • PROJECT OVERVIEW Some doctors also pointed out the price of natural delivery in public hospital set by government is indeed so low that it could not even recover the costs of performing it, the magazine said. Avoiding medical disputes is also an important reason that drives doctors to recommend C-sections. Natural birth costs much more time and involves more medical workers than C-sections, and doctors have to stay alert and concentrating for hours at a time, ready to deal with any accident. On the other hand, a C-section usually takes only one hour and is more controllable for doctors, which means lower possibility of accidents and therefore fewer medical disputes. As for those expectant mothers, many of them are reluctant to suffer the pain of a natural birth and believe it is easier to regain their figure after a C-section than after a natural birth. "Half of C-sections are performed at the demand of expectant mothers," a doctor who did not give his name told China Economic Weekly. In addition, there are also some women who opt for surgery to choose a "lucky" delivery date or year. The magazine said the C-section rate from the 1950s to 1970s was only 5% in China. It rose dramatically from 30% to 40% in 1980s and has ranged from 40% to 60% since the 1990s. Reasons for elective C-sections are not simple but mixed in China, as in many cases hospitals and expectant mothers have different considerations when they have to make a decision between natural birth and C-sections. Financial incentives do motivate some hospitals to perform C-sections, and some doctors recommend surgery to women for this reason."If all expectant mothers choose natural birth, we will go broke," Dr Guo from a town-level hospital in Henan province told China Economic Weekly. Guo said prices for natural birth and C-section are about 500 yuan ($73) and 1,000 yuan ($146) respectively in the hospital he works for. All the wages of doctors and nurses in his department are directly proportional to the whole department's income. The price differentiation also exists in large cities. In Guangzhou, the price for natural birth in top level hospitals is about 3,000 yuan ($440) and for C-section is at least 6,000-7,000 yuan ($880 to 1026), according to a report by Xinhua News Agency. "Besides, C-sections also mean the greater use of medial equipment and medicines, which means more income to hospital and sometimes more 'off-the-books income' to some doctors," Dr. Gao Ling from Beijing Amcare Women's and Children's Hospital told China Economic Weekly. 28

INTRODUCTION • PROJECT OVERVIEW SHANGHAI China may be taking its first tentative baby steps to change its landmark one-child policy. In particular, Shanghai has indicated a relaxation in the policy by encouraging couples to have two children. China is rethinking the “one child norm” not because it has failed but because it actually worked. In fact its success is China’s biggest problem today. Rigorous implementation has seen China’s average fertility rate falling below replacement levels. As a result, China as a whole may be having around 1.4 to 1.5 births per woman, with Shanghai registering a low of 0.96. Official estimates claim that the policy has prevented more than 400 million births since its inception. But this has brought in its wake several disturbing social and economic challenges. China’s gender gap has steadily grown worse from a relatively normal ratio of 108.5 boys to 100 girls in the early ’80s to now stand at 123 boys for every 100 girls. This has also gone on to worsen the deeply-entrenched cultural preference for a male child. The stringent implementation of the one-child The policy-induced crisis means that the country will have to grapple with a whole set of social, productivity and fiscal challenges. To begin with, growing gender gaps have set off an intense competition for wives. It is estimated there could be as many as 40 million “surplus” men in China by 2020 unable to find a wife. Hence a highly organized criminal network of trafficking in girls and women: anywhere between 2000 and 3000 girls and women kidnapped a year. Particularly perverse is the rising incidence of baby bride trafficking, where armed gangs are kidnapping baby girls for farmers who want wives for their sons when they grow up. China is already home to half the elderly in Asia, with those above the age of 65 expected to rise to 320 million by 2040. A fast ageing society will also induce a prolonged period of labor pains. It is estimated that China’s labor force could peak by 2016 and structural shortages of labor could become an endemic feature of the economy. Inter-generational tensions are also on the rise as the one-child policy grapples with what has come to be known as the 4-2-1 problem. This means that there will only be one child left in a family to care for two parents and four grandparents. norm has resulted in a sharp spike in “gendercide” through illegal prenatal sex determination and sex-selective abortions. 29

TYPOLOGY: HEALTHCARE

HISTORIC DEVELOPMENT OF HEALTHCARE The original facilities for the sick were most likely temples dedicated to “healing gods.” Imhotep was the Egyptian healing god while Asclepius was revered in the Greek civilization. Prayers, sacrifices, and dream interpretations played a role in their healing process, but the ancient physicians also stitched wounds, set broken bones, and used opium for pain. Plans for a 5th century BC temple in Athens dedicated to Asclepius show a large room 24 x 108 for multiple dreamer-patients. Some believe the earliest dedicated hospitals were in Mesopotamia, while other researchers believe they were at Buddhist monasteries in India and Sri Lanka. Ancient writings indicate that the Sinhalese King Pandukabhaya had hospitals built in present day Sri Lanka in the 4th century BC. The oldest architectural evidence of a hospital appears to be at Mihintale in Sri Lanka which can be dated to the 9th century AD. The extensive ruins suggest there were patient rooms which measured 13 x 13 which is surprisingly close to the patient rooms used today. (Gormley, 2000) homes, a practice that continued for hundreds of years. The Romans provided us with the root of the word “hospital” from the Latin word “hospes” for host or “hospitium” meaning a place to entertain. While medical schools were established in Greece in the 6th Century BC, there is general consensus that the first teaching hospital with visiting physicians and scholars from Egypt, India, and Greece was founded at Gondisapur in present day Iran in 300 AD. Among the early, well-documented healthcare facilities were the Roman military hospitals. The plans for the one in Vindossa in present day Switzerland built in the 1st century AD shows small patient rooms with ante rooms built around While the Greeks were recognized as the originators of “rational” medicine, they did not have hospitals. The physicians made calls and treated patients in their Google 2010 30

HISTORIC DEVELOPMENT OF HEALTHCARE courtyards. Each room was thought to hold three beds indicating the ward concept was used early in the history of hospital development. One source indicated that similar hospitals may have also been built for gladiators and slaves due their financial value, however public hospitals were not available and physicians made house calls. (Gormley, 2000) As the Roman Empire turned to Christianity, the Church's role in providing for the sick became firmly established. After 400 AD, many monasteries were constructed generally including accommodations for travelers, the poor, and the sick. The monarchs of the 6th century reinforced this role with emperors, such as Charlemagne, who directed that a hospital should be attached to every cathedral that was built in his empire. Religious institutions continued to provide most of the healthcare to the poor in large, open wards, while physicians continued the practice of making house calls to the upper class. The religious influence in early healthcare is illustrated by duties of the Warden (Administrator) of St Mary's The wards housing multiple patients continued to be expanded and became the standard for the public hospitals for many years. Often the wards were configured so the sick could see the altar to assist with their recovery. The cross-shaped plan, which is thought to have originated in Florence, Italy, in the 1400s, achieved this goal with the altar in the middle and multiple wards radiating from it. The plan is similar to many hospitals today with the nurse's station rather than the altar at the center. (Gormley, 2000) As the wards became larger, they often became more dangerous. By the mid 1700s the “Hotel-Dieu, one of the earliest and largest hospitals in Paris, had deteriorated to horrific conditions” (Gormley, 2000). Some wards had over 100 beds with multiple patients per bed. The wards were dark, poorly ventilated, unsanitary, and often located adjacent to other wards with infectious patients. The answer to this problem was the new “pavilion” plan, which was first implemented in the Hospital. (Gormley, 2000) Hospital in England in 1390. “He was required to not only satisfy himself of the seriousness of the medical complaint, but to also hear the confession of the patient before admission.” (Gormley, 2000) 31

HISTORIC DEVELOPMENT OF HEALTHCARE Lariboisiere built in 1854. This approach was consistent with the improvements pioneered by Florence Nightingale after seeing a mortality rate of over 42% at a military hospital in Turkey during the Crimean War. The pavilion plan provides fresh air and daylight, which improved patient recoveries and reduced infections. This plan retained the multiple patient ward approach, which was sometimes called the Nightingale Ward. The pavilion plan was used on two notable facilities, St Thomas Hospital in London and later on Johns Hopkins in Baltimore with 24 beds per ward. (Gormley, 2000) As North America was explored and settled, the ward approach to hospital design was imported. The oldest hospital on the continent was built in Mexico City in 1524. The first North American Hotel-Dieu (House of God) was built in Quebec in 1639 with one 10-bed ward. In 1672, a second ward with 24 beds was added, which permitted segregation by gender. In the 13 colonies, Bellevue Hospital in New York was built in 1743 accommodations. Even at the old monastic hospitals, nobles could have better housing by making donations. The approach was expanding in the late 1800s and the first “pay” hospital was opened in London in 1842 with eight single-bed rooms. At Johns Hopkins, there were two pay floors with 13 single rooms on each floor and one semiprivate room. The other option for a private room that was becoming accepted was the separation room for infectious, dirty, or hysteria cases. (Gormley, 2000) With the improvements in hospital facilities and the advancements in medical practices and technology, the public and religious hospitals started to become the choice for both the upper classes as well as the poor. The perception was fading that “home was where the sick should be treated and hospitals were associated with pauperism and death”. Even though the perception of hospitals was changing, the use of multiple-bed wards continued. There were numerous attempts to improve the ward layout and to adapt the wards to multistory buildings. In 1910, the Superintendent of the Mt. Sinai Hospital in New York City developed a plan with 26-bed wards that were connected vertically on multiple floors . and Pennsylvania Hospital in Philadelphia received a charter from the crown in 1751. (Gormley, 2000) There were exceptions to staying in a ward. One option that had been available for years was to simply pay for better 32

HISTORIC DEVELOPMENT OF HEALTHCARE to conserve land and help reduce travel distances related to separate pavilions. He did include quiet rooms, three of which were private. The Beaujon Hospital built in France in 1935 was one of the early multistory facilities with 13 floors. It contained 16-bed wards and private rooms as well. The need for private rooms in public hospitals was increasingly being recognized. (Gormley, 2000) In spite of this recognition, the wards continued to be the predominant design approach. The number of patients per ward, however, was dramatically declining. During the rebuilding of a portion of St. Thomas Hospital in London in the 1950s, the largest ward contained four beds. The Montefiore Hospital in New York City built in 1955 has a unique layout with modules containing two- to four-bed wards and one private room sharing two toilets. Thompson and Golden's 1975 book on the history of hospitals quotes an unnamed hospital planner that said in 1962: “The semiprivate patient rooms will be as antiquated in • maximum number of beds-per-room shall be one unless the functional program demonstrates the necessity of a two-bed arrangement”. This is clearly the trend in the United States as almost all new general hospitals are being built with private, hotel-style patient rooms even if not required by the local codes. (Gormley, 2000) • Private rooms are not a given in many European countries and Canada. The British National Health Services (NHS) has a Web site with an interesting description of the differences between a hospital ward and a private room. While it quickly points out that many would prefer a private room, it is not always possible unless “we are paying to go private.” The advantages of a single occupancy room are obvious and include privacy, less noise, and reduced risk of no socioecomial infections. Interestingly, the disadvantages of a private room are also noted. These include: • - the patient may suffer from the lack of social interaction in a private room; • - It is easier to get a nurse's attention without using a buzzer; and • - It is more likely that someone will notice if you fall on the way to the toilet. 5 to 10 years as the four-bed wards are today”. While the planner's timing was overly optimistic, the prediction is coming true as the 2006 Guidelines for the Design and Construction of Hospitals states: “In new construction, the 33

HISTORIC DEVELOPMENT OF BIRTH CENTERS Hopefully, this brief history of hospitals helps illustrate the tremendous advances over the past 2,000-plus years from the temples and pauper wards to private rooms. The challenge facing us now, as in the past, is how to continue to improve the quality of the patient environment by providing cost-effective and innovative solutions. (Gormley, 2000) The new inclination of hospitals in the past few years is very diverse. What we have witnessed in many of these iconic, groundbreaking hospitals is the adaptation of a whole series of other building types to healthcare. We have hospitals that, when you hear the vocabulary, sound more like shopping malls—such as, “one-stop care.” We have hospitals that are based on the Greek healing temples and are more like religious facilities in their approach. We have other hospitals that are really focused on the hospitality side of things. They are birthing centers and spa-like atmospheres. Designers and architects at the onset know they are doing a healthcare facility but they reach out to other building types as a means Google 2010 As women gave birth, they sought and received care from supportive others. At an unknown point in the cultural evolution, some experienced women became designated as the wise women to be in attendance at birth. Thus, the profession of midwifery began. Indeed, as historians have noted, midwifery has been characterized as a social role throughout recorded history, regardless of culture or time. Biblical recognition of the functions of midwives included several verses recounting the experiences of two Hebrew midwives who refused to kill male infants in defiance of the King of Egypt. of providing a design strategy that will work for the kind of care desired or the culture of the organization they are designing to. (Gormley, 2000) 34

HISTORIC DEVELOPMENT OF BIRTH CENTERS • midwives routinely used herbs and potions, as forerunners of today's modern pharmaceuticals. The midwives of these centuries generally continued to learn by the apprentice model. As an apprentice, skills and knowledge were shared from generation to generation but without the development of a formalized system of university education. Therefore, midwives did not benefit from the scientific inquiry that developed early in medical schools. Eventually midwifery in most affluent countries developed formalized programs, although apprenticing still may be part of some. • Like clinics, birth centers arose on the coasts of the U.S. in the 1970s, as alternatives to heavily institutionalized health care. Today, use of birthing center facilities is generally covered by health insurance. Several of the practices which were innovated in birth centers are beginning to enter the mainstream hospital labor and delivery floors including: • - Bathtubs or whirlpools for labor and/or birthing • - Showers for mothers to labor in • - Hospital acceptance of the mother choosing to walk during labor, use a labor/birthing ball, not use pain medication during labor and rooming in of the infant after birth • - Beds for family members to stay with the mother during labor and birth Other verses in the Bible also make passing references to midwifery attendance at birth, implying that it was ubiquitous. Historians have found the practice of midwifery referred to in other papyri as well as in ancient Hindu records. In Greek and Roman times, midwives functioned as respected, autonomous care providers to women during their reproductive cycles. Some qualifications for the practice of midwifery began to evolve during this period. For example, in Greece the midwife was a woman who had born children herself. This requirement has remained a commonality in the practice of midwifery throughout several cultures and exists even today. "Midwife" is a word which in English was translated to mean "with woman", implying the supportive, not interventive, functions of the practitioner. In French a midwife is a sage femme, or a "wise woman". A general thread in all of the references regarding ancient midwifery was support of the woman in labor. Labor was perceived as a basically natural process. The profession of midwifery continued without major changes throughout the centuries, even through the Dark and Middle Ages. In their practices, 35

HISTORIC DEVELOPMENT OF BIRTH CENTERS not just safe but at times safer than hospital birth because of its judicious use of technology, licensed professionals and connection to the health care system. There are certain requirements that a woman needs to meet in order to be able to birth at a birth center. First, she must have an uncomplicated, low-risk pregnancy. Twins, vaginal births after cesarean section, and breech babies are not allowed to be delivered at free-standing birth centers. Free-standing birth centers require hospital backup in case complications arise during labor that require more complex care. However, even if a delivery cannot happen at the birth center due to a high-risk pregnancy, birth center midwives might provide prenatal care up to a certain week of gestation or at the hospital alongside an obstetrician. The nationwide organization supporting and promoting birth centers is the American Association of Birth Centers (AABC). Many birth centers nationwide, like hospitals, chose to become accredited through the Commission for the Accreditation of Birth Centers (CABC). There are strict guidelines for this accreditation to support birth centers as a place for normal birth. These include things such as no continuous fetal monitoring in labor to allow women full mobility. Michel Odent, Introduced in the 1970s the concept of birthing pool, in order to replace drugs in the case of difficult births. Michael also introduced in the 1970s the concept of home-like birthing room in maternity hospitals Malet on, Michael founded the Primal Health Research Centre (London, UK). The objective is to test the assumption that human health is shaped during the ‘primal period’, which includes fetal life, perinatal period, and year following birth. Google 2010 There has been much research in recent years to support out of hospital birth especially birth center birth- as 36

CASE STUDIES GENERAL INFORMATION The Hollywood Birth Center is located in Hollywood Florida; it is an independently owned freestanding birthing facility. The philosophy of this institution is based on “a home away from home” environment for expectant parents. They offer different services and techniques for the delivery of babies based on the mother’s preference. All techniques are natural and their intention is to stay away from medicine and intrusive procedures as much as possible. The institution also provides different ways to relax mothers such as aroma therapy, massage tools and birth balls and stools. The environment in Hollywood birth center provides facilities for family and friends to accompany the mother during and after the process of delivery Debbie Marin is the owner of the Hollywood Birth Center and has been a licensed midwife for over 20 years. In 1983 Debbie had her first daughter, a water birth at home in a state where direct entry midwifery was not legal. That experience was just the beginning. For several years Debbie attended births as a lay midwife and in 1998, upon midwifery law to allow more licensed midwives to practice in Florida including serving as president of the Broward chapter of Friends of Midwives. She wrote a midwifery curriculum that was implemented in a National School of Technology in South Florida and was the clinical director, administrator, teacher and a student in that program. The two classes of women she graduated have gone on midwives in Florida. Debbie opened The Hollywood Birth Center in 1993 has since trained countless midwives. She has dedicated her life to empowering women and keeping birth safe. returning to Florida she attended the South Florida School of Midwifery for 3 years. Debbie was instrumental in helping to change the 37

CASE STUDIES • A Birth Center • A birth center’s philosophy is based on choice. They promote the mothers choice of where and how she wants to deliver the baby. The center gives mothers the option of having the baby in the birth center or in a conventional hospital atmosphere but always accompanied by the midwife and pregnancy coach. Staff will also accompany the mothers through the entire process from prenatal care to labor and birth. • Wayne P. DiGiacomo MD, FACOG Owner/Director founded the birth center in 1889. "Dr. D" as he is usually known, provides multi-level delivery options such as a birth center birth and a hospital birth. Dr. DiGiacomo is a fellow of American College of Obstetrics and Gynecology, a member of Broward Medical Society. He is unique in that he believes that nature intended women to deliver babies without a lot of medical intervention. He believes that women have better and healthier results if you let nature take its course. Dr. D believes in the natural birth process therefore he along with Deborah DiGiacomo Licensed Midwife, founded Coalition for Childbirth Choices. 38

CASE STUDIES SITE VISITS The spaces selected are spaces in which the physical environment resembles more of a residential than a health care environment. Both facilities were visited several times to observe different issues during the study. Observation of the space through pictures took place in order to list the different design elements that support a homelike environment and the relaxation of the mother. The images taken from each birth center were presented to 3 randomly chosen women. Women were informed of the general purpose of the study and how the environment can potentially relax mothers during delivery, in order to create a better perspective of their decisions. Images presented to the participants ranged from pictures of all the birthing rooms in each facility to common areas such as family areas, waiting areas, kitchens and bathrooms. The pictures were not presented as two different piles according to the center. All pictures from both centers were mixed. The idea was for participants to rate individual features of the environments and not the entire allowed a lapse of time to view the pictures several times. After the general view of the pictures, they were asked to rank the pictures before them. Participant women were asked to separate the pictures into 3 different piles labeled: Most Homelike, Sort of homelike and Not Homelike at all. None of the aspects of a home environment discussed in this study were discussed with the participants, the intention was for them to rate the different pictures based on their impressions of a home environment and to avoid influencing their decisions. Once all the pictures were rated, they were once again separated by center in order to find put which birth center was rated as a homier environment. center as a whole. By doing this, the participants rated individual qualities of the space that created a homelike environment. All participants were 39

CASE STUDIES throughout the space the use of acoustical ceiling tiles also implies a hospital or an institutional environment. Based on the results of Hollywood Birth Center and the comments made by the women participating, the Hollywood Birth center was perceived as a homier environment for the following reasons. All medical equipment was concealed in the birthing room’s closets. All Birthing rooms have their own set of equipment but it’s only taken out when need it. There were very few labels if none throughout the space, none of the restrooms had any labels indicating gender. For the most part all ceilings were made out of drywall. There were only 3 different conditions that were rated as For the most part, both centers were perceived as homelike environments, although Hollywood Birth Center presented higher rates than A Birth Center did. The main difference between the two centers was the presence of medical equipment in the different areas of A Birth Center. Also, based on the opinion of the participants, the presence of safety signs inside of the birthing room implied a hospital environment. The ceiling played an important role as well; even though the center has the same height 40

CASE STUDIES NOT Homelike at all, those included areas in which he furniture layout reassembled more of a waiting area and the birthing room that had the plastic Jacuzzi. Built in Jacuzzis tend to be perceived as homier than plastic Jacuzzis. 41

HOLLYWOOD BIRTH CENTER Totality and Unity In general the building addresses issues of totality and unity. The overall design of the building and its different spaces supports the functional requirements of a natural birth center. The overall design is successful at creating a homelike environment and supporting birth as a natural process. It also supports the administrative part of the business and even though birth is promoted naturally, medical equipment is present in the center but is kept concealed in order to reinforce the natural process; such equipment is only taken out in the birthing rooms in case of emergencies. All different areas of the building have a direct relationship with one another. There is connectedness by the way the center is set up. All different component parts of • Activity types and numbers indicated: • Reception and administrative offices. • Waiting area • Family rooms / waiting areas • Birthing rooms • Massage room • Barefoot room / couples activities / yoga room • Bathtubs • Check up rooms • Kitchen • Acupuncture room • Retail the building such as waiting areas, reception, birthing rooms, kitchen and restrooms present homelike qualities that unify the space. Google 2010 42

HOLLYWOOD BIRTH CENTER • Site • Entry: • The entry to Hollywood Birth Center is very successful at representing a homelike environment as a first impression. As you walk into the center the first environment is a small waiting room connected to the reception window. Even though the window is very typical of healthcare environments in which you arrive sign your name in and then wait to be called, the rest of the room overpowers that window and gives a sense of a home environment. The furniture arrangement and quality are those to be found in living rooms area. The space is decorated with side tables, plants and curtains on the windows that allow partial lighting come in making it a very cozy atmosphere. One of the walls has pictures of the most recent babies Picture by Andrea Leano born in the center. This display sends messages of familiarity. Picture by Andrea Leano 43

HOLLYWOOD BIRTH CENTER • Views and approach: • The location of the birth center is on Hollywood Boulevard, inside of a shopping center. The exterior views do not represent much importance to the birth center, which is surrounded by parking adjacent to Hollywood boulevard. The approach to the building does not afford for an appropriate first impression to a birth center. Hollywood boulevard has a lot of activity and the adjacency to such busy street does not reflect the tranquil environment of a birth center. There seems to be and adaptation of the birth enters in a commercial area. Google earth 2010 • Exterior elevations and perspectives • The exterior of the building is made out of concrete, some of the columns are visible but it is hard to tell which of those are structural elements or more of a decorative feature. The building in general represents a commercial facility which is reinforced by the location and adjacent spaces. The center has tried to include some elements to the outside to give clues of what’s inside the building; such elements include two rocking chairs and plants at the entrance of the building. The warm color of the building also helps soften up the institutional look. As mentioned before the exterior of the building is not the most adequate for the function of the space, none of the less the center has been successful at recreating the space as a homelike environment. Picture by Andrea Leano 44

HOLLYWOOD BIRTH CENTER • Interior: • In general, the overall features of the space are very engaging and complete. The colors throughout the space are neutral but at the same time very sudding and relaxing. All birthing rooms have a different color to offer mothers different choices when giving birth. The entire center is formed by a series of intimate rooms that sort of create different experiences. In their goal of making this space a home away from home experience, Hollywood center provides a kitchen area fully equipped with refrigerator, microwave, oven, toaster and coffee maker along with a lounge area for the family and friends comfort. The family room area is very nice. It has different activities for family members including toys for kids. The addition of different pictures throughout the facility strongly presents the facility as a homelike environment; it shows the many memories that took place in the center. The use of wood floors gives a warm feeling to the environment along with the dim lighting throughout the space. Even Picture by Andrea Leano though the light is dimmed, they can be controlled to afford different needs. Such lighting is also included in the birthing rooms in which the mother has the opportunity to control them lighting to satisfy her needs, likes and Picture by Andrea Leano 45

ANDREA LEANO • IND 5626 PROJECT PROGRAMMING • PROF. PHILIP ABBOTT