Wednesday, December 28, 2011

optimal space for birthing?

There is a special interest branch within midwifery and maternity care that overlaps with design and architecture disciplines, exploring the creation of optimal spaces for birthing. I have been reminded of this field of interest, when reading a recent post by my colleague and friend Carolyn Hastie, who writes the thinkbirth blog. Carolyn refers to, and provides a link to a presentation on optimal birth spaces by Maralyn Foureur, Professor of Midwifery at the University of Technology of Sydney (UTS). I wrote in the comments to thinkbirth:
I have seen some wonderfully designed spaces in which women can give birth. I have also seen women give birth beautifully (and, I would say, optimally) in settings that would seem to contravene every goal of the optimal birthing space ideology.

The woman's own nesting, which I believe is hormonally driven more than the result of intelligent planning and preparation, seems to be the key. Nesting can include the choice of setting, as well as the choice of people who make up that woman's birthing team. Nesting also enables the woman to change her plan if her situation requires it, without losing the ability to proceed normally.
I don't want to be critical of the optimal birth space ideology.


The reality in my world is that each birth space is often very different from what the woman had planned or wanted, yet women are able to give birth in that wonderfully spontaneous way, without any regrets.

It would be naive to imagine that a woman's home is automatically the optimal birthing space for her.

I need to do a postnatal visit now, but hope to get back to this post later, and write some more.

[Melbourne readers may know that a private hospital in Hawthorn had recently set up a beautifully designed birthing facility, which has closed its doors after just a few months' operation, because the plan was not working, and there were too few women making bookings.]

NESTING and optimal birthing conditions
Nesting is one of those normal physiological functions that everyone knows about, but rarely pays much attention to.   While researchers have for a couple of decades looked seriously at the impact of the love hormone oxytocin, and the 'fight-or-flight' adrenal hormones, on the birth and mothering behaviours of laboratory animals, nesting doesn't seem to raise research interest or dollars.

A woman anticipating the birth of her child will usually have a 'to do' list, including stocking and preparation of food and other consumables, washing and setting out baby clothes, and packing a bag for herself and her baby in preparation for a stay in hospital, or 'birth kit' items in readiness for giving birth at home.  This process of getting ready would be recognised broadly as 'nesting'.  I have known some who feel the need to clean windows, and sweep, vacuum, and dust almost obsessively in the days leading up to the labour.  This is all intentional nesting, driven mainly by the woman's intellectual grasp of the enormity of the job that lies ahead.

With the establishment of spontaneous labour, physiological nesting becomes more pronounced.  Women who thought they would like to have the other children present for the birth of their sibling will often withdraw into a secluded space.  Women who have a plan to call a trusted midwife will often call her, just to check that she is able to come when called.  Nesting can continue until the peak of first stage, often called 'transition', when the woman must give up conscious control and surrender to the work of bringing her child out of her body. 

Women who plan to go to hospital to give birth face a nesting conflict.  It goes something like this:
"If I go to hospital too early my labour might fizzle.  If I stay at home I won't want to move when the labour becomes strong."  It's their natural nesting drive that makes them want to find the place where they will give birth - not the street address, but the actual room, with its contents, and the actual people with whom she will need to communicate.

Women who are booked at a modern hospital Birth Centre, where there are well-designed birthing rooms, often experience a conflict about the availability of a room.  They know that if the rooms are all in use when they arrive, they will be admitted to a standard hospital suite.  They have heard stories about how often this might happen.  Other matters of 'nesting' concern might focus on the times of shift changes in the hospital. 

I have, on occasion, been called to a 'planned' home birth, only to find that the woman and her home show no sign of nesting.  This dysfunctional nesting is, I think, a sign that the woman's sensitivity to natural instinctive urges has been in some way shut down.  The woman's labour can continue without nesting, and the baby can be born, "ready or not!"

Returning to the initial question of this blog: is there, and what is, an optimal space for birthing?
I would refine the question further, and add the word 'physiological' - the space for medically managed care in labour and childbirth must be very different from the space that enables and supports and protects physiological processes.  Here are a few ideals for that space:
  • a place that the woman has chosen to be in
  • a place that the woman is happy to continue in, as labour progresses
  • a place where the woman can receive care, support, and guidance from a trusted midwife, and other chosen people
  • a place where the woman is able to cover windows, dim lights, and make other physical adjustments when she wishes
  • a place that allows the woman to feel private and unobserved
  • a place where the midwife, as the responsible professional at the time, is confident that the wellbeing of mother and baby are being protected.

As with all other basic life events, "the best laid plans of mice and men ..."  There can be no guarantees.  The only people who we can be sure will be at a birth are the mother and her baby. 

The optimal space for physiological birthing in suburban Melbourne should not be very different from the optimal space for physiological birthing for Inuit women in Nunavik in the Arctic Circle.  The type of bed or birthing pool; the colour of the walls or the pattern of the furnishings - these things can be nice, but are of little significance to the woman giving birth.  The woman's feeling of unintruded privacy, as she reaches the point of surrender, knowing that her midwife is *with* her, is the essence of optimality. 

Your comments are very welcome.


Carolyn Hastie said...

Hi Joy, you are right of course and so are those who are seeking to find out what is involved in creating optimal birth spaces for birthing women. As always in life, it is AND :)

I don't think anyone is saying that home is the right space for all women to give birth - some women I've had the privilege of working with have been intensive care and theatre nurses and are much more comfortable with bright lights and monitors. There are many many nuances that affect a woman's birthing physiology and after being in PNG, working in Port Moresby maternity - the physical space is not high on the agenda for most women there - so there are many factors to consider. That doesn't mean of course that we shouldn't seek to make birthing spaces more attractive and more in line with what women say they want. As for the birth centre in Melbourne that didn't take off, I remember when the birth centre at Crown Street started, it was the same, but once women became familiar with the idea, it was booked out very quickly. I wonder if 'they' gave it enough time or were there other factors that put women off that haven't surfaced yet? All in all, it's very interesting and very important. Every woman is different, with different needs, desires, beliefs and personalities. A 'cookie cutter' aproach to anything to do with birthing women is the problem; getting back to woman centred maternity care and ensuring each woman can choose what happens to her and where she births is key to an optimal experience for her. Jenny Parratt has called this 'genius birth'. The woman emerges from her experience feeling like a genius, however and whereever the birth happens.

Joy Johnston said...

You're so right Carolyn.

The birthing facility I referred to that has closed its doors was set up with a very medical focus, apparently to cater for the top end of town. I have added a link. As I understand it the model assured women that there would be an obstetrician, anaesthetist and paediatrician on site 24/7.

I like the concept of genius birth, but the pathway to having that amazing sense of achievement is, I think, linked to an the woman's intention to proceed naturally, and only handing over to managed care if there's a very good reason.

Carolyn Hastie said...

Hi Joy, in terms of Jenny Parratt's concept of 'genius birth' and how I've used it in my work, is that however birth goes, when the woman's desires and needs are fulfilled, the woman emerges from her experience feeling like a genius. That means that whether a woman chooses to birth normally on her own two feet in an undisturbed way, or whether she wants a caesarean or epidural or whatever, she makes an informed and supported decision regarding what happens to her and feels in control and a 'genius' because she has been and felt honoured and acknowledged for her particular needs and choices. I'm sure you'd love our book "Birth Territory and Midwifery Guardianship" available through all good booksellers and also the concept is explained fully in my dissertation "Putting women first" available online here
It's a great read :)
Thanks for the conversation, these concepts, ideas and practical realities are so important and need discussing.

Susan said...

Is it the simple yet disheartening fact that the majority of women,, not all, have had drummed into them through media and horror stories that hospital births are the safest? Such a shame that the Melbourne facility was closed.

I strongly believe that the tide is turning and women are now educating themselves more and asking the questions that women once would never had dared as the obstetrician was the person who knew it all and was always right.
Yes they are certainly very knowledgeable and such a very important part of the journey of birth but are they always woman centered?

As a student midwife I am making it my long term goal to inform the ways that women feel about birth and allowing them to explore their options as they are very much entitled to do.

I believe that a woman is able to create her own space in which ever environment she is placed in but for the woman to have choices in what she would prefer is fantastic.

Glenda Gleeson said...

interesting discussion my initial thoughts are related to our multicultural society in Australia. Enabling a birth environment that takes into account significant aspects of a womans culture is primary to creating a space for a safe and empowering birth experience. Huge challenge for all of us involved in midwifery whereever we are in world. Thanks for your stimulating thoughts. Glenda Gleeson