Friday, October 09, 2009


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” 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” 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.

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 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 @ and I will repost the best ones.


  1. I remember reading some birth story in the past, in which the birthing mother's doula, midwife, friend, or nurse used a triangular rubber door stop so that the birthing mother could have privacy -- it prevented anyone from just barging right in, but required them to announce themselves and *request* admittance. Perhaps something like that could be used to alter a surveillance room... at least a little bit.


  2. Honestly for me, it was not about the laboring environment, but the people surrounding me. My first concern was safety for me and my baby. Because of my life experiences, this meant the hospital was the safest place for me to give birth. It is where I felt the safest. I delivered at one of the counties most premier hospitals for my first birth, and I never felt so alone.
    For my second birth, I delivered in a small community, no frills hospital with a bunch of caring women. It was the people surrounding me that made my birth special, not the room

  3. It comes down to the question that has been floating around in my head lately; How can we make birth more satisfying to the laboring woman but keep a life line of safety close by? I guess my best answer is a freestanding birth center right next to the hospital that can do a 10 minute cesarean section. I think atmosphere has a lot of impact on people.

  4. Pinky--I think that is a great idea because it would meet most people's concerns about safety combined with the low intervention rates of FSBCs. I just read Dr. Fischbein make the same proposal recently:
    "We may yet see the eventual shift to choice and a free market that responds by making home birth and birthing center birth a viable option. Possibly even leading to little specialty free standing maternity centers that support natural childbirth and midwifery while having a functioning operating room for that 5-10%. Just maybe a natural process like birth can be removed from large hospitals that treat pregnancy as a disease. The demise of the hospital based model of labor and delivery in America would not be a bad thing."

  5. I gave birth in a birth center that was actually integrated into the hospital, though entirely separate from L&D. It was on the same floor, right around the corner, but had separate staff and rules, as well as set up and rooms. The birthing rooms looked like bedrooms basically, each with a huge bathroom (all including tubs because they did water births there). Leaving the room, you enter a big common space that looked exactly like someone's kind of dumpy living room, a waiting area for family. It was adjoined with a kitchen, so you could keep your snacks in the fridge, etc. Yet in the rare necessity of transfer, you just wheeled out maybe 50 feet and viola! L&D. It was the best of all worlds. But I hear the hospital keeps trying to shut it down - this won't surprise anyway - because it's not as profitable as L&D.

  6. Rixa, Thanks for posting about this. I am quite intrigued by the Birth Territory book and am excited that we'll soon be reviewing it at Science & Sensibility.

    I'm loving the comments so far. I completely hear what Reality Rounds is saying, and the importance of the people in the birth setting is incorporated into the Birth Territory Theory as "Jurisdiction" which is comprised of two subconcepts: "integrative power" versus "disintegrative power" and "midwifery (or medical) guardianship" versus "midwifery (or medical) domination". The authors have a nice article in the Journal Women & Birth introducing the theory.

    In the end, I think it is the combination of the place and the people that sets the stage for a healthy, safe, and natural birth and increases satisfaction. And the wrong setting OR the wrong people can derail a normal birth. It's sad that as anonymous said, many settings that provide the exemplary model are not profitable in our existing payment structure.

  7. You might be interested in some of the photos of birth environments on my blog-


  8. Kathleen Fahy10/12/09, 7:43 PM

    I am delighted to see our theory of Birth Territory being discussed here. Amy is correct that our concept of Birth Territory was chosen (rather than environment) because it includes notions of power and how it is used within the environment. Caregivers can either add to and strengthen the woman or overide her and deminish her power. When we reduce women's power we reduce their ability to give birth using their own power. One thing about 'safety'. When I work on delivery suite which is on the same floor as the OR it take more than 30 mins on average to organise a C/S. We have to have a clean and vacant OR, available anaesthetist, available obstetric and assisant, scrub nurse. So 30 mins is an ideal time but very seldom does 30 mins make the difference (that's Hollywood and Obstetric fear stuff so don't get spooked!). Where I am in Newcastle, Australia, we have a free standing midwifery only staffed Birthing Centre 20 mins from the major hospital: we have great relationships with our publically employed obstetricans and good transfer procedurers; the midwives can transfer with the women. We also have had about 50 publically funded homebirths within 30 mins drive of the main hospital. You are probably wondering how 'dangerous' this midwifery model of care is. For low-risk women who book at the birthing center (which co-author Carolyn Hastie set up and managed)there normal birth rate is about 95%. The nearby major maternity unit with a great reputation has about a 67% normal birth rate for a matched group of women. The birth center women have a 3% Postpartum hemorrhage rate compared with 12% for a matched group of woman at the major maternity unit. Ahhh, were is is really safer to give birth???

    Kathleen Fahy

  9. Selina, great blog--added to my reader! I love what you're doing and would love to hear more about it.

    Kathleen--I'm glad to hear from you. I do like your term of "territory" quite a bit, since it gets past the superficial notion of decor & wallpaper as being the significant part of birth environment. I'm ILL'ing your book and hope to read it soon. And of course it's fantastic to see how so many women in the midwife-run birthing center are giving birth normally and safely!

  10. I love that you call for change both within and outside of the system. Missed you this weekend.

  11. I once interviewed Michele Odent about his birthing center in France. He felt that the atmosphere should be similar to where the baby was conceived: low lights, romantic, soft, safe feeling. Similarly, Ina Mae Gaskin feels there is a place for sexuality and sensuality in birth: touching, caressing, kissing. There isn't much room for intimacy in today's businesslike "Let's get this baby born" efficiency, is there? No tolerance for calm, dim, slow, quiet, passionate intimacy. (Author of "Great Expectations: Your All-in-One Resource for Pregnancy & Childbirth")


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