A car birth, a bus birth, a yurt birth, an en caul birth, and a mother-supported birth

This reminds me of a Dr. Seuss book...

I can give birth in a car
I can give birth in a bus
in a yurt
with the caul
with my mom

A car birth
An Australian family pulls over onto the side of the road and has their baby in front of an apple shop.

A bus birth

An Ohio family has their baby in a converted school bus. 

A yurt birth
Through June 18, you can have your baby in this fully-equipped yurt in the middle of the Amsterdamse Bos. No charge to use the yurt. Sponsored by Birth Project: Look Again, which is hosting a number of activities in June. More information here.

An en caul water birth
The father lifts the caul off his daughter's face after she is born. Watch the video and read the birth story.

A mother-supported birth
A mother supports her daughter having her second home birth

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Looking for people who attend outdoor births

I've been corresponding with a documentary producer who would like to feature outdoor births. They're looking for people with some experience attending or facilitating birth outdoors--midwives, doctors, birth centers, etc. More information below:

~~~~~

I work in project development Matador, a television production company in Los Angeles whose founders have produced series such as NBC’s The Biggest Loser, Discovery’s Storm Chasers and Dual Survival. We are primarily focused on creating documentaries and unscripted television series for a wide variety of cable channels and media outlets, and have funded series and projects with A&E, Discovery Channel, Lifetime, CNN, and NBC, amongst other networks.

We're currently developing a documentary series with a female-skewing cable channel about DIY birth practices- most notably, outdoor births in unique locations. We're currently looking for experts in this field to potentially consult on the project, or help offer guidance on production. Be it midwives, physicians, doctors, birthing centers, etc, anyone who has some experience with outdoor births, we would love to speak with them. We're still formatting the arc of the documentary series, but the basic idea is to follow the journey of one mother/father team as the prepare to have a child in their 3rd trimester of pregnancy. Wanting to get away from the confines and experience of giving birth in a hospital, we would document their experience of taking on this process themselves, and eventually having the child outdoors. Documenting this in a "fly on the wall" approach, we would be very hands off, and attempt to simply follow and respectfully document these expecting parents as they take on this incredible journey in unique settings that much of America hasn't experienced before.

In order to take this project to the next level, we need to identify some experts in this field and speak with them about how to go about this. If there is ANYONE who has experience with this practice, and would be willing to chat briefly, I would LOVE the opportunity to connect. My contact information is below.

Happy Holidays!


Sam Brown | Director, Development| Matador

—————————————————————————————

1041 N. Formosa Ave., Writers Bldg. Suite 11

West Hollywood, CA | 90046 | 818-261-5689 OR 323-850-3100

sam@matadorcontent.com | www.matadorcontent.com

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Master bedroom tour

I've been in high gear getting house projects done before the baby arrives. Over Christmas break, we repainted the master bedroom. The "before" color was an awful gray/brown/olive green. It was really dark and drab, a non-color that sucked the life out of the room.

I wanted something really calm and soothing and fresh. I tried tons of greens, aiming for a shade that was not sage and not minty. Sherwin William's "Shagreen" ended up being the perfect color. It's even more vibrant in real life.

You can see into the master bathroom on the left. It has a large jacuzzi tub/shower, toilet, and sink.

I'm not necessarily set on using the duvet & curtains long-term. I made them when was desperate for something to cover the bed & windows (before we had blinds), and the fabric was discounted to only $2/yard. It's growing on me, though.

I love the light fixture. I bought the same one for our library downstairs. It used to be on Amazon for around $100, but I couldn't find it the last time I checked. The crib was $10 secondhand and has all of my birth supplies. You can see Dio's birth quilt on the antique rocking chair. I'm going to mount it in our upstairs hallway.

The birth pool will go along this large wall between the bedroom & closet doors. 

I bought an old frame at a thrift shop, took out the glass, and spray painted it white. A line of hooks across the top turned it into a necklace holder. The dresser is from an antique store in Iowa City, where I did my PhD. I bought the shalwar kameez and dupatta on Ebay years ago for $20. They're made of hand-embroidered silk. Back when I was an A-cup, I could just barely squeeze into the top. There's no way I can get into it now! It was a great Halloween costume or fun party outfit...

ps--I just found "before" pictures from the real estate listing.

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More on birth centers and maternity centers

I'm currently reading Birth Territory and Midwifery Guardianship: Theory for practice, education, and research by Kathleen Fahy, Maralyn Foureur, and Carolyn Hastie (Butterworth Heinemann (Elsivier): Books for Midwives, 2008). Just today Science & Sensibility featured a review of the book by guest blogger Dr. Katharine Hikel. The review is worth reading--as is the book--but I wanted to highlight this particular excerpt when she discusses birth environments and brings up the idea of a freestanding maternity center: taking the entire birthing wing outside the hospital.

But what is the best birth environment? In a chapter called “Mindbodyspririt architecture: Creating birth space,” architect Bianca Lepori describes her designs for hospital-based birth rooms that are meant to enhance, not counteract, women’s abilities to give birth. She created suites of rooms with “Space and freedom to move; to be able to move to the dance of labor; to respond to the inner movements of the baby; to walk, kneel, stretch, lie down, lean, squat, stand, and be still.” The rooms have “Soft and yielding surfaces; or firm and supportive surfaces; different textures; the right temperature; soft curves; darkness or dim light.” A birthing woman can be ‘immersed in water, flowing or still; respected, safe, protected, and loved.” Access to the suite is through an antechamber; the bed is farthest away from the lockable door, and not visible from it, so that privacy is respected.

Lepori’s birth architecture reproduces the comforts of home. There is access to the outdoors, and private walking places. There are birth stools, exercise balls, bean bags, hooks for hammocks or ropes for stretching. Tubs and beds are large and accessible from both sides. There are accommodations for families. There are comfortable chairs for nursing. Medical equipment – supplies, oxygen – is tucked behind a screen or put in a closet. A refrigerator and light cooking equipment is available. This ‘birth territory’ certainly outshines the typical hospital OB floor; though it begs the question: Why not just stay home?

The answer, of course, is that, for those four to ten percent of births that truly need intervention, the OR is right there. It’s better not to have to transport a woman who’s labor has turned complicated; it makes sense – for many – to have all the birth territory under one roof.

This birthing-suite design indeed takes into account the all-encompassing, body-mind-spirit event of childbirth. It honors laboring, birthing women and families; it respects the process. It worked well for a designated maternity hospital in New Zealand – a facility already designed for childbearing. But most US hospitals are multi-use facilities; and though obstetrics is among the best money-makers for hospitals, childbirth is the only event that occurs there that is not related to illness or trauma.

The real question is, why not remove birth completely from the pathology-centered hospital model? Why not redesign birth territory to maximize best outcomes, minimize intervention, and replace the present medicalized view of birth as a disaster waiting to happen with the more normative, expectant-management, midwifery view? Move the whole shebang, from the waiting room to the surgical suite, out of the hospital and back into the community where it belongs.

The idea of a freestanding maternity center--one that has an OR and in-house OB and anesthesia, but that is completely separate from a hospital--is new. No one has ever done this before that I know of, and so no one knows how it would/should/could function. Would it be identical to hospital-style maternity care? Would women go there? Would being free from the confines of a hospital and all of its rules and regulations open up a space for a real change in maternity care?

One of the best ways to explore this new idea and offer up your own questions and ideas is to come to the Controversies in Childbirth Conference in Tampa, on February 19-21, 2010. The conference oragnizier, Alan Huber, just wrote more about the concept of freestanding maternity centers today, in a post called Birth Centers Versus Homebirth.

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Sanctum/Surveillance

I went to Amy Romano's presentation at the Lamaze Conference about "Optimizing Labor Progress: What the Research Does and Does Not Tell Us." She cited a recent book that proposed a theory of birth territory. In Birth Territory and Midwifery Guardianship, Kathleen Fahy, Maralyn Foureur, & Carolyn Hastie discuss "sanctum" and "surveillance rooms" for giving birth. An excerpt from the book (the language is sometimes a bit dry, but the ideas are very compelling):

“Birth territory” is comprised of a physical terrain of the birth space over which jurisdiction or power is claimed for the woman. The terrain denotes the physical, geographical and dynamic features of the individual birth space impacting on women and babies. Jurisdiction refers to power and how it is used in the birth space and beyond, including the way maternity services are organized and managed. Birth territories affect how women feel and respond as embodied beings; either they feel safe and loved or fearful and self-protective. The aim for the midwife is to skillfully create optimal environments within which women feel safe and where normal labor and birth physiology remain undisturbed.

In particular, birth territory refers to the features of the birth room, here termed the “terrain,” and the use of power within the room, here termed “jurisdiction.”


Terrain
“Terrain” is a major sub-concept of birth territory. It denotes the physical features and geographical area of the individual birth space, including the furniture and fittings that the woman and her attendants use for labor and birth. Two sub-concepts, “surveillance room” and “sanctum,” lie at opposite ends along this continuum called “terrain.”

Sanctum
“Sanctum” is defined as a homely environment designed to optimize the privacy, ease and comfort of the woman; there is easy access to a toilet, a deep bath and access to or a view of the outdoors. Provision of a door that can close and lock from the inside meets the woman’s need for privacy and safety. The more comfortable and familiar the environment is for the woman, the safer and more confident she will feel. And experience of “sanctum” protects and potentially enhances the woman’s embodied sense of self; this is reflected in optimal physiological function and emotional wellbeing.

Surveillance room
“Surveillance room” is the other sub-concept of “terrain.” It denotes a clinical environment designed to facilitate surveillance of the woman and to optimize the ease and comfort of the staff. This is relevant to the concept of “jurisdiction” (discussed below) and it is consistent with Foucault’s notion of disciplinary power. A “surveillance room” is a clinical-looking room where equipment the staff may need is on display and the bed dominates. It has a doorway but no closed door, or the door has a viewing window so the staff can see into the room (not so the woman can look out). The woman has no easy access to bath, toilet or the outdoors.

Proposition
The more a birth room deviates from a “sanctum,” the more likely it is that the woman will feel fear. This deviation from the “sanctum” will in turn reduce her sense of self—it will be reflected in inhibited physiological functioning, reduced emotional wellbeing and possibly emotional distress.

Jurisdiction
“Jurisdiction means having the power to do as one wants within the birth environment. “Power” is an energy which enables one to be able to do or obtain what one wants. Power is essential for living; without it we would not move at all. Power is ethically neutral; this is consistent with Foucault’s notion of power which he argued was productive; not necessarily oppressive. Power can be used to get others to submit to one’s own wishes. Health professionals who want women to submit to their authority (to be docile) normally use a subtle form of coercive power that Foucault called “disciplinary power.” The concept of jurisdiction is directly relevant to “midwifery guardianship” which is the topic of the next chapter in which the theory of birth territory continues to be developed.

To illustrate, here are photos of my own sanctum and a surveillance room in my local hospital.

Sanctum checklist: 

• homely, comfortable and familiar environment
• room designed to optimize privacy, ease and comfort
• easy access to a toilet (there's a small full bath, which you can see in the bottom photo)
  
• a deep bath
• access to or a view of the outdoors (I can look out the window or just walk downstairs and go outside)
• a door that can close and lock from the inside

Surveillance room checklist

• a clinical environment designed to facilitate surveillance of the woman 
• optimizes the ease and comfort of the staff
• equipment the staff may need is on display
• the bed dominates (note the bed's central location, framed by the linoleum inlay)
  
• It has a doorway but no closed door, or the door has a viewing window so the staff can see into the room (not so the woman can look out). You can't lock the door to the room, or the door to the bathroom, which has been the case with every hospital birth room I've been in.
  
• The woman has no easy access to bath, toilet or the outdoors (this hospital room has a bath and tub. The window looks out on a parking lot. There are some trees off in the distance, but I don't think we can argue this constitutes "access to the outdoors.")
  

I have some questions and requests:

• How can we create a sanctum within a clinical/institutional environment--for all those women who can't/don't wan't to give birth in an out-of-hospital setting?
• Do you have any photos that illustrate a sanctum or a surveillance room? If so, please email them to me (stand.deliver @ gmail.com) and I will repost the best ones.
  

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The business of being born

Childbirth is a big business. A recent article in the Minneapolis Star Tribune, Definitely, Not Your Mother's Maternity Ward, explores the multimillion dollar maternity wing renovations in the Twin Cities area done in the hopes of luring in potential customers. Rain showers, iridescent tile, whirlpool tubs, massages, wi-fi, and spa services are some of the amenities available in the updated birthing rooms. Click here for a list of the featured hospitals and amenities mentioned in the article.

At Ridgeview Medical Center in Waconia, women can now give birth in rooms with whirlpool tubs and wi-fi. At Fairview Southdale, new moms can hire a massage therapist or a portrait photographer. Even Hennepin County Medical Center has upgraded its maternity ward, with pastel decor and a deep tub for water births. All three are part of a major marketing offensive by hospitals to win a coveted demographic: mothers....

Many women have taken childbirth preparation to a new level. Bombarded by marketing from retailers such as Babies "R" Us and websites such as babycenter.com, and inspired by reality shows such as "Maternity Ward" and home birth videos on YouTube, this generation has grand ideas about labor and delivery.

Some tour multiple hospitals before deciding where to deliver. Insurance policies mostly let women go where they want, though they might be constrained by where their doctor can practice. "[Childbirth is] a business that's very competitive," said Ted Blank, director of marketing at HCMC. "It's a planned thing and they have the luxury of shopping around."...

Obstetrics doesn't enjoy the fat profit margins of specialties such as orthopedics or heart care. But it makes up the difference in customer loyalty. For many women, it's their first time in a hospital. "If that's not a positive experience, they're not likely to come back," said Meri Beth Kennedy, birthplace director at Fairview Southdale, which redid its maternity wing a year ago....

The marketplace is so competitive that Fairview Southdale has an advisory board made up of women who have given birth there. To read the rest of the article, click here. The article is 4 pages long, so be sure to read the whole thing.

When I was a graduate student, I took the tour of the new maternity wing and NICU at our large university hospital. Much of the PR material emphasized the maternity wing's hotel-like amenities, such as room service, internet access, and "custom beds" (which are the same kind used in just about every other hospital, the Stryker Adel). I was quite happy to see large whirlpool tubs in every labor room. Waterbirths were allowed, although when I was there none of the midwives or doctors were really doing them. I hope that has since changed. Overall, I was definitely underwhelmed with the multi-million dollar renovation.

What I want in a maternity service isn't the outward signifiers of a home or hotel--spa services or flat screen TVs or beautifully decorated rooms. I want policies that encourage physiological labor and birth, that follow evidence-based practice, and that, most of all, uphold women's autonomy and respect their need for dignity and privacy. The room's decor is largely irrelevant to me. The changes I want to see in maternity rooms cost little or no money, but are probably harder to introduce than the most expensive spa services. Things like rooms that promote movement and non-supine positions, policies that follow the best evidence, or nurses and doctors and midwives who are used to seeing women laboring unattached--free from monitors, IVs, and catheters.

In the Star Tribune article, Jeanette Schwartz, clinical director of Woodwinds, remarked that the new maternity renovations are "about customer service. It's all about giving moms choices in their care."

Really? In a country where almost 50% of hospitals ban women from having VBACs, where it's unusual to be allowed to labor without constant fetal monitoring or IV access, and where the majority of women receiving episiotomies were not consulted before they were cut, the rhetoric of "choice" rings hollow. Until I can freely choose those things and more, I will happily forego the "massages, manicures and nicer linens" and stay put in my own house where the real choices are mine to make.

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Beds and birth rooms

Henci Goer recently wrote about a pilot study examining the effect of birth room design & furniture on the progress of labor. In her Science & Sensibility post, The Labor Environment: “Many things that count cannot be counted”, Goer discussed the study's design:

The June 2009 issue of Birth contains the results of a pilot study gauging the effects of modifying the labor room to encourage mobility, reduce stress and anxiety, and discourage routine medical intervention. Investigators randomly allocated 62 healthy women in spontaneous labor to either a modified room or the standard labor room. Women attended by midwives or doulas were excluded from participating, effectively creating a study population not predisposed to be mobile in labor.

Changes to the labor environment were relatively modest. The most radical innovation was to remove the labor bed, replacing it with a portable double-sized mattress and pillows in the corner of the room on the floor....Rooms were also equipped with a birth ball, a chair that promoted sitting upright or leaning forward, an LCD projector with a selection of movies of calming nature images, an mp3 player with a selection of music, and a chart illustrating upright labor and birth positions. All labor rooms had a private bathroom and lacked windows. No nursing alterations were made other than mandating intermittent auscultation, leaving the overhead light off, keeping the door closed, and putting a sign on it asking people to knock before entering.

As Goer noted, the results were promising, although the sample size was quite small (it was just a pilot study):

The trial was too small to draw firm conclusions, but the results certainly support conducting a larger one. Sixty-six percent of the women in the modified room reported spending less than half of their time in labor in bed versus 13% of women in the standard room, and only 35% spent three-quarters or more of their time in bed versus 87% of women in the standard room. (The bed was brought back at the woman’s - mostly for epidural analgesia - or caregiver’s request.) Women in the modified room were significantly less likely to have oxytocin augmentation (40% vs. 68%), and those who had it got it later in labor. Women also had somewhat shorter labors on average and longer times to initiation of analgesia/anesthesia.

I found another article discussing this research at VOA News: Re-Thinking Delivery Room Design Eases Labor. The lead researcher, University of Toronto nursing professor Ellen Hodnett, conceived of the study after noting women's behavior when they were giving birth at home. They moved around a lot and used household furniture to aid their labors. She commented:

They used a dining room table to lean over. They used the bathtub. They walked around the garden. They were moving, or on all fours, or side-lying on a mat on the floor… a variety of things…And that struck me, even then, that there were more opportunities, more ways for a woman to help herself to be more comfortable and perhaps her labor to be more effective if she were not confined to a bed.

Particularly interesting were Hodnett's comments on how the presence of a bed in a central location predisposes women to staying in bed, rather than moving around:

Doctors and midwives agree it's better for a woman to move around while she's in labor. Walking and changing position makes her more comfortable and helps the labor progress. But in many countries, women giving birth in hospitals are often instructed to lie in bed while their labor progresses.

University of Toronto nursing professor Ellen Hodnett observed that in many modern - and even some not-so-modern hospitals - a bed was at the center of the labor room.

"That bed is a problem," Hodnett says. "Because it's a central focus of the room, and it sends messages that that's where you're supposed to be in labor. And yet, we have pretty good evidence that spending long periods of time in bed, particularly confined in the way that a hospital labor bed confines you, is not conducive to normal, healthy labor progress."

Goer also noted how the presence of a delivery bed influences women's mobility in labor:

The investigators noted that the bed is a major reason for lack of mobility. Its prominence conveys that it is the appropriate place for laboring women, and a woman in bed offers ready access for interventions, an observation backed up by research. (Both Listening to Mothers surveys reported that few women were mobile after hospital admittance. In the first survey, two-thirds of the women gave as a reason that they were “connected to things” and more than one-quarter said they were “told not to walk around.”)

Switching from a delivery bed in the center of the room to a large, low mattress with several pillows in the corner of the room was something that French obstetrician Michel Odent did when he became the head of the maternity department at Pithiviers, France in the 1970s:

Before: Typical French delivery room

After: birth room & pool room

In hospital birthing rooms I have visited personally, the bed is the central focus of the room. Even the flooring and ceiling materials emphasize the bed's central role in the drama to unfold: inlaid patterns around the bed circumscribe the area where birth is allowed to occur, and the spotlights on the ceiling further dictate the location of birth. These photos are from the new UIHC maternity wing in Iowa City, where I did my PhD. Notice the inlaid pattern in the flooring around the bed and the spotlights in the ceiling:

And these photos of my local hospital's LDRP rooms. Again, notice the inlaid pattern in the flooring that outlines and emphasizes the centrality of the bed. The room revolves around the bed: the couch and rocking chair face it, the monitoring equipment surrounds it, and the lights focus on it:

I would love to see pictures of the modified birth rooms from Hodnett's study. Sometimes simple and inexpensive changes are better than the newest high-tech bed.

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"Homelike" birth spaces: a photoessay

These are photos I took for a research paper about the meanings of "home" in institutional birth spaces. The first set of pictures are from the University of Iowa's new Maternity Center. The second set are from a freestanding birth center in Des Moines, the Almost Home Birth Center.

UI Maternity Center
Text reads:
Labor/Delivery/Recovery room.
Labor & Delivery rooms adjacent to NICU.
Technology is hidden but still accessible.
Internet access.
Rooms offer a home-like environment.
Custom beds.
Whirlpool bath.
A La Carte menus available.
DVD/CD players.
Beautiful views from many rooms.
The "home-like environment" of the L/D/R room
The Stryker Adel bed, covered and uncovered
Hallway

Equipment closet inside room

Sliding artwork

Tub

Almost Home Birth Center
Birth Room 1

Birth Room 2

Tub

Bathroom
Living/waiting room

Library/reading room

Kitchen

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