As part of a new health care building project and the research project Room4Birth (R4B) as well, a birthing room at a hospital in the West of Sweden was built and furnished with physical features designed to be more adaptable to women´s personal wishes and needs during labour and birth. The physical environment can have an impact on both staff and birthing women’s experiences. A number of issues, related to the design and integration in overall hospital design, has been raised. This paper presents the design of this new birthing room, decision making concerning the room when planned and constructed and how the nine prominent features in the room has been assessed in relevance by women being cared for in the room. The purpose is to share experiences and knowledge to contribute to the development of birthing rooms and labour wards.
Type of the Paper: Peer-reviewed Conference Full Paper
Track title: User needs
The design and decisions when developing a special birthing room, at Sahlgrenska University Hospital, Gothenburg, Sweden
Lisa Björnson Skogström, RN, RM, MSc Midwifery 1,2,*, Göran Lindahl, M.Arch, PhD 1,4 , Helle Wijk, RN, PhD 1,3,4,5, Nicoletta Setola, M.Arch, PhD 6, Marie Berg, RN, RM, PhD 3,7, Anneli Falk RN, RM 2
1 Centre for Healthcare Architecture (CVA), Chalmers University of Technology, Gothenburg, Sweden
2 Department of Obstetrics and Gynecology, Sahlgrenska University Hospital, Gothenburg, Region Västra Götaland, Sweden
3 Institute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg, Sweden
4 Division of Building Design/Department of Architecture and Civil Engineering, Chalmers University of Technology, Gothenburg, Sweden
5 Department of Quality Assurance and Patient Safety, Sahlgrenska University Hospital, Gothenburg, Sweden
6 Dipartimento di Architettura Università di Firenze - Centro TESIS
7 Faculty of Medicine and Community Health, Evangelical University in Africa, Bukavu, D.R. Congo
(to be completed by the editors)
Names of the Topic editors:
Names of the reviewers:
Journal: The Evolving Scholar
Submitted: 15 Jul 2022
Citation: Björnson Skogström , L., Lindahl, G., Wijk, H., Setola, N., Berg, M. & Falk, A. (2022). The birthing room – the design and decisions of a special birthing room, at Sahlgrenska University Hospital, Gothenburg, Sweden [preprint]. The Evolving Scholar | ARCH22.
This work is licensed under a Creative Commons Attribution BY license (CC BY).
© 2022 [Björnson Skogström , L., Lindahl, G., Wijk, H., Setola, N., Berg, M. & Falk, A.] published by TU Delft OPEN on behalf of the authors.
Abstract: The physical environment can have an impact on women’s birth experiences and is suggested to also affect health care staff. As part of a new hospital building project and related to the research project Room4Birth (R4B), a specially designed birthing room was built at a hospital in Sweden. The so-called test room was built and furnished with physical features designed to be more adaptable to women´s personal wishes and needs during labour and birth. This paper presents the design and decisions made concerning the test room for birthing and how nine prominent physical features have been assessed by women giving birth in the room. The objective of the paper is to share experiences from the hospital building project and studies made in an interdisciplinary research project called Room4Birth (R4B) and as an effect of this argue for the need for active testing of healthcare physical environments. Furthermore, the paper aim to contribute to knowledge and development and planning of birthing rooms and labour wards.
Keywords: birthing; healthcare environment; healthcare design; labour ward; evidence-based design
1. Introduction, background and context
There is limited knowledge on how the physical design of birthing rooms affects labour, birth and childbirth experiences. In the planning phase of a new hospital building for maternity and neonatal care at a University Hospital in Sweden the need for test environments emerged and became reality. This was the driver for the initiation of the interdisciplinary research project Room4Birth (R4B) that intends to increase knowledge about how the physical design of the birthing room influence the maternal and neonatal outcome. The focus was on how the physical environment can contribute to a physiologically normal birthing process for both mother and child, and to an overall positive childbirth experience. Such knowledge is valuable both when existing birthing rooms are being refurbished and new ones being built (Berg et al., 2019). As part of the R4B study, this paper describes the project and study concerning a birthing room in a labour ward, at Sahlgrenska University Hospital, Sweden.
2. Framework, where do we start
2.1 Aspects of healthcare environments
To give birth is a crucial and meaningful event in women’s life (Parrat, 2002; Simkin, 1991)
in which the physical environment play an important role (Fahy et al., 2006) and can affect the experience of giving birth (Carlsson, et al., 2020; Nielsen et al., 2020; Nilsson et al., 2020; Setola et al., 2019), although the research-base is insufficient. The design of healthcare environments affects patients both physically and physiologically. It also contributes to improvements in quality of life (Ulrich et al., 2008) by supporting integrity, control, and a perception of being well taken care of (Fridell, 1998). Furthermore, the design of healthcare environments can have effects on the healthcare quality, safety, and satisfaction of staff (Sadler et al., 2011) both with regard to physical, phycological as well as social aspects (Ruohomäki et al., 2015). Research show that midwives are affected by their work environment and that poorly designed environments can lead to stress and subsequent negative effects (Symon et al., 2008). Medical led labour wards are experienced to have too much focus on the clinical design with insufficient space that is hampering the midwives work ability (Hammond et al., 2014). On the other hand, midwives working at midwifery led units, with the design and intention of providing a homely and comfortable birth environment express how it can affect their state of mind as well as their way of working in what they consider a more positive direction (McCourt et al., 2016).
2.2 Framework concerning birthing
In Sweden, approximately 115 000 children are born every year (The National Board of Health and Welfare, 2021). Maternity care in Sweden is state-funded, and almost all women give birth in hospitals (Lindgren et al., 2014) where a traditional birthing room, characterized by an emergency hospital design approach, is standard. This can evoke emotions of danger and abnormality (Carlsson et al., 2020). An unfamiliar and stressful environment characterized by emergency and high-tech can contribute to increased stress and decrease in endogenous release of oxytocin (Uvnäs-Moberg et al., 2014). Oxytocin is a crucial hormone during labour and birth, and beneficial because of its positive effects, e.g., enhanced well-being and contractions, decreased levels of stress, less anxiety, fear and pain (Uvnäs-Moberg et al., 2019). By lessening the visual intrusion of medical and technical equipment, the mixed messages between either giving birth as a natural event or a high-tech incident can be avoided (Harte et al., 2016).
Thus, the environment in which birth takes place is important for women´s childbirth experience and a birthing room perceived as safe, secure, and private can contribute to the natural progress of birth and decrease risks for adverse events (Buckley, 2015). Positive distraction in health care environments can also decrease stress, anxiety, and support recovery (Sadler et al., 2011). In the birth context, to capture women’s attention to better endure childbirth and maintain a sense of control (Nielsen et al., 2020; Setola et al., 2019) may enable a better experience than expected (Nilsson et al., 2020). Features of familiarity in the birth environment have been associated with shorter length of labour and decreased intensity of labour pain (Nilsson et al., 2020). Other factors suggested to affect the childbirth experience, is taking part in decisions (Gibbins et al., 2001; Henriksen et al., 2017) a trustful relation with a midwife (Eri et al., 2020; Karlström et al., 2015) and continuous presence of a supportive companion who encourage the woman to maintain self-confidence and control (Bohren et al., 2019). In contrast, a negative birth experience can contribute to post-partum depressions (Gottvall et al, 2002) or fear of giving birth (Bell et al., 2016; Nilsson et al., 2020). There is a global interest in improving the quality of maternity care (Oladapo et al., 2018; WHO, 2017; WHO, 2022). The recommendations are not only restricted to maintaining the health of woman and child but also for women to have a positive childbirth experience in clinically and psychologically safe environments, support from a birth companion and technically competent clinical staff (WHO, 2017). A more complete understanding of the relationship between physical design features and support of the birthing process is therefore desirable.
The overall objective of the study described in this paper is to contribute with knowledge about how future hospital-based birthing environments can be designed for improved experience for birthing women as well as improve work environment for midwifes and other health care staff. The particular objective of the paper is to argue for the need to build test environments in the planning phase of healthcare design projects. Implementation of test environments and research in this area is yet sparse. This descriptive paper is based on information from a new hospital building project in a university hospital in Sweden and the studies done within the research project Room4Birth (R4B) to point out the importance of test environments, this to strengthen both practice and research
3. The hospital project, the test room and the research study
This paper is based on documentation and interviews with stakeholders in a hospital building project that have been engaged in the planning of a test room. Furthermore, it is based on studies in the Room4Birth project, in particular a mixed methods study with questionnaire that women who gave birth in the test room received right after birth and interviews 1-2 years post-partum, focusing on experiences of the physical birth environment (Skogström et al., 2022).
3.1 A hospital project and development of a test room
As early as 2011, plans were initiated to expand and refurbish the existing building for maternity and neonatal care at Sahlgrenska University Hospital in Sweden. Due to extensive renovation costs, the plans were instead changed to developing and planning for a new building for maternity and neonatal care. Several development projects, feasibility studies and reports, as well as workshops with newly become parents, user associations and staff were performed. In addition, representatives from the hospital’s real estate and facility management department were included in the development of the new facilities and visits to other hospitals for inspiration and comparison was done. All of this aimed to identify and address as many needs and wishes as possible. In the early planning phase temporary test rooms, in e.g., existing conference rooms were built up and furnished, but were not perceived as realistic and could not be tested and evaluated in authentic situations with patients and staff. In the process, requests emerged for test rooms for both maternity and neonatal care units to be able to test the new rooms and evaluate, and possibly improve, them before final design and construction. There were no possibilities in the process to do this for the neonatal care, but on the maternity side a test room was realized in the current maternity ward building, in 2018. (Further described in forthcoming report on the hospital project, CVA 2023) Construction of the new health care building will start in 2023 and is expected to be completed in 2028 (Västfastigheter, 2022). The test room is part of an ongoing development and preparation for a new building encompassing birthing and maternity care.
3.2 The test room
The test room (Picture 2 below) is, in addition to general building regulations, designed partly based on spatial physical aspects for which evidence has been identified (Nilsson et al., 2020), and partly based on aspects identified in other projects and in labour care (Berg et al., 2019). Furthermore, the test room was based on inspiration from a labour clinic in Denmark (Lorentzen et al., 2019), and according to their design, the room was also equipped with a bathtub, placed in the birthing room itself and a media installation enabled selection of nature sceneries with accompanying sound. The test room is sized 23,8m2, with a small entrance hall of 3m2. When the light wood-like door opens, you first see a hall with a mirror and a hanger for clothes and a private bathroom with toilet and shower, directly to the left. The entrance hall contributes to lower noise from the corridor and that noise from inside the birthing room is not as noticeable in the corridor as from a regular room. Between the entrance hall and the birthing room is a drapery that shields the birthing room from the entrance and the corridor, with the aim to contribute to increased integrity for the woman and her companions in the birthing room. The test room is painted in soft pastel like colors and decorated with green textiles. The test room and the regular rooms (Picture 1 below) are designed based on the same medical safety considerations and the care is conducted in the same way. The test room has the same medical-technical equipment as the other rooms, but most of it is hidden behind wooden panels (Berg et al., 2019).
Picture 1. A regular room in the current labour ward with visible equipment.
Picture 2. The test room in the current labour ward, with projection on the wall.
Of all design features differing from the regular birthing rooms, the following nine prominent features were selected to be ranked by the women included in the R4B study.
1. Curtain between entrance hall and birthing room prevents visible contact when the door to the room opens onto the corridor in the ward. In the hall there is the opportunity to hang outerwear.
2. Full-length sofa with cushions is a place for the woman giving birth and the partner to be together and a space for the partner to sit or lie down and rest on. The sofa can be turned into a simpler bed. Hygiene – wipeable with disinfection possible as the material can withstand it. All textiles are removable and washable.
3. Adjustable chair for partner/support person/companion that can be moved in the room. Partner/support person is given the opportunity to sit comfortably in connection with supporting the woman giving birth in different positions or e.g., for massage or next to the bath.
4. Bathtub that can be moved in the room. The bathtub provides the opportunity for different positions both sitting, lying down and hanging with the arms over the edge or squatting. The hot bath is used for pain relief purposes and for childbirth if desired. The bathtub is also height-adjustable, which facilitates the staff’s work environment and comfort.
5. Lighting, general in the room, spotlights in the ceiling to create an environment according to the wishes of the users. There are also spotlights for staff in need of better work light.
6. Lighting, dimmable, adjustable light points around the room that can create an environment according to the wishes of the woman giving birth.
7. The projection on two of the walls, with accompanying sound, covering the window, in the birthing room with its own touch screen to control/choose from a number of nature films with different environments, landscapes and seasons with associated nature sounds or calm music where sound volume can be adjusted.
8. Medical technology covered by wood panels and bedspreads on the birthing bed, to hide technical equipment and a bedspread on the birthing bed that gives a more familiar/homely look in the room. All technology is easily accessible when needed.
9. Birth support rope, hangs down from the ceiling and can be used as support in upright positions.
3.3 The research study, R4B
Thus, the test room, was as such, initially built for the development of the design of the forthcoming healthcare building, but as the planning proceeded the Room4Birth research project (R4B) was established, and a collaboration between the planning group of the forthcoming healthcare building at the hospital and the research group was initiated. This contributed to the test room being further developed. For example, the test room was equipped with more homelike furniture, the birthing bed was placed along a wall with a bedspread and the chair for companion was replaced with one designed to support the partner’s active participation. In addition, a well visible birthing ball and a birth support rope from the ceiling was installed (Berg et al., 2019).
The hypothesis for the entire R4B project is that a birthing room designed with increased opportunities for personal adaptation can promote and enable a positive impact on the birth process and outcome by reducing stress and increasing the release of the body’s own oxytocin. This may lead to reduced need of medical interventions, an increased proportion of positive birth experiences and smaller proportion of fear of childbirth, and a reduction in negative effects on mother and child (Berg et al., 2019).
Several studies have been conducted within the Room4Birth project and several are ongoing. This includes a randomized controlled trial (RCT) (Goldkuhl et al., 2022), an ethnographic observation study (Goldkuhl et al., 2021), an interview study with staff (Andrén et al., 2021) and a mixed methods study regarding birthing women´s experience (Skogström et al., 2022). More information about the studies is available at the homepage: https://www.gu.se/en/research/room4birth. The RCT comprises first time mothers from 18 years of age in full term pregnancy with a single fetus, arriving to the labour ward in active labour and who understand either Swedish, English, Arabic or Somali. The aim is to compare effects of care given in regular birthing rooms, see picture 1, to care in the test room, see picture 2 (Berg et al., 2019). A Mixed Methods study (Skogström et al., 2022) with a quantitative questionnaire and semi-structured interviews, evaluating how birthing women experienced the physical features in the test room found that the birthing room was experienced as positive and exceeded the women’s expectations. It created a welcoming feeling and the women felt strengthened by the design, which shifted the focus to a more positive emotional state. The room was different from traditional hospital birthing rooms and had comfortable space for companions. The variety of physical features was appreciated.
Of the nine listed physical features above, the bathtub was ranked most important, followed by the projection of nature scenery with sound, and the dimmable lighting. However, it must be noted that the whole room as a concept was more important than physical features one-by-one. And the entire birthing room environment was as a supportive function part of the conclusion. Further there were suggestions for improvement regarding, for example, access to a visible window, fresh air and daylight (Skogström et al. 2022). After finalizing data collection do the different sub studies, the room is used equivalent to the regular birthing rooms. The birthing rooms in the new health care building, which is expected to be completed in 2028, will largely be designed as the test room but be somewhat updated after comments from different staff categories having worked in the test room.
4. What did we learn from the test room?
4.1 A comment on the test room
The mixed methods study by Skogström et al. (2022) showed the importance of the design of the test room, and many were the positive experiences. The birthing room designed to be more adaptable to women’s wishes and needs was found to be beneficial and supportive for women’s experience during labour and birth. It provided interaction with the environment, supported a shift of focus from pain to a more positive emotional state as well as maintained integrity (Skogström et al., 2022). Although framed by first time mothers, one could say, that there are numerous other situations to test. Even though this is logically sensible, it still does not diminish the meaning of the physical environment and the importance of it, also in other types of birthing situations. If context and culture is understood it is likely that several observations from studies, such as the R4B project, can be transferred to other settings (Lindahl et al., 2012).
4.2 Considerations about work environment in hospitals
In addition to the effects on birthing women it is also likely to be effects on staff and companions (Shen et al., 2004). In a situation where staff retention is a challenge, a work environment stimulating the work situation and context is one way of addressing this challenge (Sadatsafavi et al., 2014). However, the labour ward is not only the birthing room but also other areas for administration, contemplation, learning and exchange with colleagues, breaks and recuperation. A review by Setola et al. (2019) identifies several types of building spaces in maternity care that require more studies, among them the labour ward layout, the midwives’ desk, social rooms, and aspects of the birthing rooms. Thus, the ward layout and other spaces are aspects to investigate further.
When childbirth occurs in medical environments, women tend to interact with the environment in a passive way (Carlsson et al., 2020). Research that examines how the environment affects women’s childbirth experience is yet poor, despite the fact that the majority of citizens are at some point during their lifetime at a labour ward as a birthing woman, companion, or as staff.
4.3 Need for test rooms
In times of seeking evidence for particular designs there is of course a challenge to subdivide and collate functions and design features. The endeavor of defining data and outcomes must however be done, both based on quantitative and qualitative approaches, making research to identify data that can be identified as evidence even richer and more complex – as well as challenging.
An actually used test room for actual care is an arena seldomly available and nor commonplace but has a potential to develop into a very useful approach. Such an approach opens for a discussion on how we can utilize existing facilities in an everyday approach to build knowledge on effects of design of built environment on healthcare outcomes. This is useful from a wide range of perspectives, from technical and maintenece staff to healthcare wotkers to patients and relatives. An approach needing hospital business objectives to also include design of its facilities as an objective.
4.4 Further work
The need to refurbish or build new health care buildings is driven by care development, building life cycles, maintenance needs and changing requirements on operational effectiveness. Hospital building projects are complex and require extensive planning (SOU 2021:71). The buildings are also expected to meet a number of different requirements regarding economy, sustainability and flexibility and should also, ideally, be designed according to applicable evidence (CVA, 2021). Healthcare environments should also be designed to meet future demands, support safe and high-quality health care and improve the experience for patients (CVA, 2012). And, not least, the environment in hospitals should be able to meet the needs of every unique patient and their companion (Nordin et al., 2017) as well as offer a safe and stimulating workplace for healthcare workers as they spend more time at the hospital than patients (Berry et al, 2004). Strategies and processes of how to design environments for all the above requirements and stakeholders is a multidimensional and challenging research area with many gaps of knowledge, one which this paper aims to address – the design of the birthing room.
The data and tentative results from this project with the test room indicates that there are improvements to be made, not only for future birthing room designs (Andrén, et al., 2021; Goldkuhl et al., 2021; Skogström et al., 2022). Although the indications clearly point to a positive experience among the mothers giving birth in the test room more tests and evaluations need to be made to further understanding of design and its implications and effects. The design process, concerning the test room, also opens for a discussion on a more interactive design development of healthcare facilities in general.
With a focus on a mix of features providing the actual outcome of a design the discussion on evidence and effects become a challenge. Dependencies and relationships need to be systematically evaluated. The design approach with an actually used and systematically evaluated test room, where practically possible one might add, is therefore an interesting way forward in healthcare design work. In addition to this, there are plans to evaluate the test room further through a digital modelling tool enabling real time visualization and testing. With a platform in a real test room supported and evaluated by modelling tool, a multidimensional and interactive planning process is possible that can be used also in other projects, an integrated physical and virtual co-design is enabled (Sateei et al., 2021). The design of other birthing rooms can then benefit from modelling rooted in an actual case.
One of the drivers behind development of birth room design is a need of understanding effects of planning and design decisions on birthing rooms and maternity wards, due to lack of research specifically on these environments both regarding birthing women, companions, and health care staff. Further, issues related to culture of birthing, structures and organizing of healthcare systems are also relevant. The Room4Birth research project, and the studies of the test room, has raised a discussion on the environment where most women give birth, and most children starts life. It has proven that the design, spatial layout, functional aspects etcetera is not just a backdrop – it is real and spatial just as we are.
All authors of this paper have contributed through their different professional competence, knowledge and experience and have all together formed an interdisciplinary research team. The paper is related to a report that is in press by LBS, GL, HW and AF. Furthermore, it is related to a article published in HERD, march 2022, by LBS, HW, GL and MB. A collaboration has also been initiated between GL, NS and LBS, where they have jointly contributed to this paper and its interdisciplinary content. It is hereby confirmed that all co-authors have actively participated and collaborated in joint discussions and in addition contributed with own and other research input to complete this paper.
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