BIRTH CENTER:
a working method for designing a
maternity health care facility
by
Gale Beth Goldberg
B.Sc.,
in Landscape Architecture,
University of Wisconsin at Madison
1972
submitted in partial fulfillment of the requirements
for the degree of
Master of Architecture
at the
MASSACHUSETTS
INSTITUTE OF TECHNOLOGY
June, 1979
Signature of A uthor ................................---------
-..
....................
...-.
Christie Coffin, Thesis Supervisor
Visiting Assistant Professor of Architecture
Certified by .......................................
Accepted by ......................................
0
Department of Archi "cre
79
May 1
lmre Halasz, Chairman
Departmental Committee for Graduate Students
Copyright 1979,
Gale Beth Goldberg
CF
TEH;qn'LOG'y
AUG 14 1979
LIBRARIES
ABSTRACT
BIRTH CENTER:
A working method for designing a maternity health care facility
Gale Beth Goldberg
Submitted to the Department of Architecture on May 11,
ments for the degree of Master of Architecture.
1979,
in partial fulfillment of the require-
It examines the birth place in both a hisThis thesis explores a variety of birth environments.
people have sacred birth rites, rituals,
cultures
different
In
context.
cross-cultural
and
torical
midwives, doctors, and medical and
world,
the
of
parts
different
In
customs, and ceremonies.
of other milieux. In America,
variety
a
and
homes,
in
non-medical personnel practice in hospitals,
home.
and
hospital
to
the birth center is a safe, childbirth alternative
how it works, where to have one, who
The design of a birth center depends on many factors:
staffs the facility, who comes here, what happens here, and what makes it a special place. A
working method for designing a birth center considers these functional aspects of a birth center,
the architectural program issues, and a range of architectural place-making intentions.
This collection of information about childbirth and birth places is intended to be a useful resource
to anyone interested in designing a maternity health care facility using architectural expressions in
imaginative ways.
Thesis Supervisor:
Title:
Christie Coffin
Visiting Assistant Professor of Architecture
z
ACKNOW LEDGMENTS
I am very grateful
To Christie Coffin,
to the many people who were helpful and supportive in this thesis project:
my thesis advisor,
for sharing
so many interesting and thoughtful ideas,
and for her constant encouragement and enthusiasm.
To Ed Allen, a very special person, who has influenced my thinking in many wonderful ways
throughout my education at M.I.T.
To other members of the M.I.T.
Johnson,
Darleen Powers,
family who so willingly gave me their help and insights:
Robert Hughes,
Lynn Converse,
Paul
and Shun Kanda.
To my editor, Jessica Lipnack, who contributed much clear and concerned thinking.
To my composers, Lynn Schwartz and Barbara Scholl,
thesis would be considerably less than it is.
To my parents,
Mike and
Ethel Goldberg,
without whose labor and patience this
and my brother,
Larry,
for their generous support in
so many loving ways.
And
to Shelly Davis, Joan Zimmerman, Dr. Shelley Kolton, Leslie Weisman,
whose valuable contributions have encouraged me throughout.
Helena McDonough,
S
TABLE OF CONTENTS
A B ST RA CT ...............................................................................
.2
A C KNO WLEDG M ENT S ......................................................................
FO REW O RD ...............................................................................
.5
PAST TRENDS AND PRESENT CHANGES .............................................
WHAT IS A BIRTH CENTER .........................................................
1 9
A WORKING METHOD FOR DESIGNING A BIRTH CENTER ............................
2 0
OTHER ISSUES FOR EXPLORATION
7 9
ILLUSTRATIONS
..................................................
8 6
..........................................................................
FO O T NO T ES ..............................................................................
8 7
BIBLIOGRAPHY
8 9
...........................................................................
APPENDICES
Reading,
Pennsylvania
A:
McTammany Associated Nurse-Midwifery Center,
B:
Birth Center Lucinia,
C:
Birth Center Architecture Design Studio, University of Oregon,
Christie Coffin, instructor
D:
Chatham Family Birth Center, Chatham,
E:
Scheme for an In-Hospital Delivery Unit
F:
Maternity Center Association,
Childbearing Center
G:
Mt. Zion Hospital and Medical Center, San Francisco,
Birth Center Policies and Procedures
Cottage Grove, Oregon
NYC:
North Carolina
Conditions Precluding Management at
California:
Alternative
4
FOREWORD
"In the beginning. . .
- The Bible
birth is the most primitive and basic
Giving
the
human
being.
new
function of the origin of a
birth
the act of giving
species,
In
has very real and intense physical feelings
many
with
connected
intimately
emotions.
The appearance of life is a central mystery
Throughout history, much
of the universe.
magic
and
speculation,
birth.
have
Family
in
expression
some
religion,
all
been
philosophy
and
connected
with
rituals
find
community
and
ceremony
Because
the
psychosomatic
flourish
with
fatigue,
and
of
pain
fear,
ten-
aspects
loneliness,
sion and body dysfunction,
celebration.
1
it suggests that
special qualities are needed for a supportive
birth environment.
The place where borning
(birthing) occurs should be especially pleasant and
relaxing,
be familiar,
and
not be
15
This 'healthy' environment
frightful or alien.
as
depends
the
upon
much
reveal
Scientific studies
place.
people
as
the
sensi-
the
childbirth is interconnected with the physical
New Age
and
ment and of the importance of the surround-
entitled ".. .Birth,"
2
Jessica Lipnack, mother
place of childbirth.
tivity of the mammalian female to her environings in childbirth.
This social aspect of
the family.
children:
a
of
author
has said that the symbo-
lic importance of the birth-place has diminChildbirth
ished as cultures have evolved.
decentralized
more
This thesis began with an interest in where
then
became
circumstances
back
into the home.
own
rituals.
under
and
how
and
childbirth takes
with
article
magazine
place.
what
I became intrigued
the idea of a birth center as another
The
childbirth
concept of giving birth in a special place is
operation.
choice for the childbearing
populace.
in society,
rooted
became
to
returned
of
place
the
a
distinct
hospitals
place
for
of
left at home.
into the
bought
their
location
the
families were
The
moved
created
Families
Once
and
notion of a
Peoples of
They
instead
the world prepare important places for their
safe,
hospital birth, and were left out of the
an ancient and cultural practice.
births.
in
They may set aside a birth hut, as
process.
Guinea
hospital
the primitive culture of the
where the laboring woman goes and
Arapesh,
or for as long as it takes
stays a few days,
her
to
father
New
feel
in
strong
enough
the Arapesh
to
leave.
culture has
birth hut for this time period as well.
The
his own
3
recent
in
Only
years
have some
forced to change
policies been
due
Women and men have
to consumer pressure.
only recently raised serious objections to the
"centralized,
childbirth
Birth
risky,
institutionalized,
(which
has)
routinized
the norm...
become
a (set of)
4
This is
pathological procedure(s)."
has
come
to
be seen
as
concept of birth
part of a process of professionalizing health
center has its roots in wanting to enrich the
and social services which is a larger trend
The
present-day
cultural
American
significance to the people who have
the most care,
in society.
love, affection for their
6
Another
response
to
been "alternative"
responded
consumer
birth centers.
as free-standing,
birth places.
demand
has
They have
out-of-hospital
They are found in both urban
and rural situations.
But why would someone choose a birth center
instead of a hospital or their own home for
their birth experience? What is it about this
place that would attract people to it?
qualities of size -of
place,
efficiency of operation,
sense
economic
do you want in a birth center?
trade-offs -Which
related to people,
What
hospital
rituals
Which administrative,
should
medical,
be
absent?
and personnel
policies need to be built into a birth center?
What
type
of
relationship
will
the
birth
center have to everyday life?
This collection of background information and
current attitudes
and
and
ideas about childbirth
the birth place offers no firm solutions
and leaves much to be explored, questioned,
and
answered.
I can only hope that it will
be a beginning ...
7
PAST TRENDS AND PRESENT CHANGES
"... sacredness is a way to communicate the
extreme importance of a symbol to the
society.
When a symbol represents something
considered
essential
to
human
experience, its preservation is of paramount importance.
By deeming it sacred,
a symbol becomes inviolable, insuring its
survival through time."
-
Lisa Heschong, "Thermal
Delight in Architecture"
It
is important to place the present-day con-
cept
of a
birth center
cross-cultural
in
practices
around
in
its historical and
context.
Ancient
primitive
societies
the family
and other
witches,
ally
'with-women'),
aunts,
and
setting
was
as
religious ceremony,
was,
and
is,
healers
midwives (liter-
grandmothers.
very much
centered
women
in the community:
translated
childbirth
mothers,
Birth
a matter
in
for
magic,
rites and ritual.
often
a
special
this
There
birth
hut or
tent where the mother in labor would come to
have
her
child.
would
be
present
The
women
throughout
attendants
all
stages
of
labor and delivery to give the mother constant
support
and
educated
encouragement.
The
local village community took care of the birth
process
in
very
human
natural childbirth along,
wisdom
and
in
a
by
helping
not only with their
constant emotional
also in creating a calm,
atmosphere,
terms
support,
but
secure, and trusting
clean,
comfortable
and
prepared environment.
Primitive birth hut
8
Always
there have been certain spiritual and
religious traditions and ceremonies intimately
associated with
the
baptismal
water,
the experience of childbirth:
blessing
the ritualistic
his or her parents,
and
the
joyful
of
the
bonding
newborn
of a
by
baby
to
the naming of the child,
birth-day
celebration
with
special foods and drinks and people gathered
together in a special place.
This protected environment must be made to
include
appropriate
light,
sounds,
smells,
ventilation, and thermal comfort to complement
the sense of place and ritual.
provision of thermal
a
way
to
emphasize
comfort,
the
"Perhaps the
and delight,
importance
of
is
the
place
for
others
enrich one's experience of the place,
people. . . thermal
thus increasing its value."
In the
Islamic culture,
fire
is rekindled on
the
birth
hold.6
a
is
Newborn bathing ritual
and
5
the symbolic hearth-
the special
occasion of
new member of the house-
This domestic ceremony is very much
symbol
fire
of the
qualities
of
life,
warmth
leaves remains,
cycles,
and
and rebirth.
light,
it grows,
it
it
consumes
The
and
sparks magically,
9
until
it
is
used
up
is
exhausted.
The
The last coal turns cold.
flame goes out.
Warmth
and
an essential
comfort for childbirth.
sae"
built into rfa*ica'ed
interior of house
has electric heater, smooth-
finished wood surfaces.
Headrests, lounge pads make
saunas more comfortable.
Designer: Sal Iniguez.
quality of
thermal
The Finnish culture
placed great importance on the sauna, both
in their routine life, and during the festivals
7 The historian, Viherjuuri,
of the Finns.
tells about the sauna:
V
it1
that reference to the sauna is
found in ancient folklore (and
this) proves that it was generally
known before the beginning of
modern times.. .they went to the
sauna every day to cleanse themselves; there they prepared for
great festivals, and there they
bathed for wedding ceremonies...
many a child was born in the
sauna, and many an old nn and
woman carried there to die.
While
longer
many
of
observed,
the
the
old customs
Finns
are
no
continue
to
regard the sauna with a "certain reverence,
a reflection of the ancient traditions." 9
From
Australia
South America,
to
China,
from
Africa
to
women of different cultures
have chosen a special place and a special
3i0
A supportive environment
position for birth.
will allow the mother to assume a position of
her
for
comfort
gave birth
ritually
cultures
various
in
Women
birth.
in a squatting
In
position, on the ground (humi positio).
a more remote past of the Greeks and Romans,
birth
certain
of
statues
goddess
Eileithia,
Damia and Auxeia represented them on their
in
knees
the
of
position
texts of the time,
giving
Egyptian
In popular
on the ground.
birth
woman
a
the expression "to sit on
the ground" meant to give birth. 1 1
In
another
culture
South Pacific,
earlier
village
on
Island
Fiji
in
the
there is a modern version of
A
customs.
collection
of
birthing rooms are arranged near the hospital
and
connected
are
Each
with
an
open
veranda.
room contains the essential enclosures
and openings,
and
Mexican Goddess Tlazolteotl
all other things needed
for the birth are brought here.
The mother-
to-be is responsible for getting other birth
attendants
together:
a midwife,
helpers and friends and family.
in
the
blankets,
food,
and
the
clean
whatever
linens,
else is
and other
They bring
the
warm
necessary.
11
Once the child is born,
rituals are performed
and everyone joins the celebration.
12
In Mexico, too, birth is very much considered
a
pleasant
social
Berry
Brazelton
girl's
first
some
twenty
friends.
which
affair.
"Pediatrician
T.
tells of witnessing a young
delivery
or
in
thirty
Mexico
of
her
along
with
family
and
This
concerned,
involved
included
the babies
and children
the family,
group,
made up a moral support section
for the young mother-to-be.
They cheered
her on through the entire labor and birth."
Worldwide
of
childbirth
13
practices have focused
on the family and the immediate community.
Aztec Earth Goddess
These are the people who will love and care
for the child,
that they
and
should
therefore it
be
his or her arrival.
included
makes sense
in welcoming
The childbirth gestalt is
at once very physical and very social.
In
colonial
America,
childbirth
was
very
much
like
time.
Midwives attended births at home.
network
needed
of
it
was
in
England
experienced
social
structure
women
around
at the same
provided
the
A
a
birth.
12
Richard
and
typical
Dorothy
Wertz
reconstruct
birth scene in their book,
a
Lying-In:
A History of Childbirth in America:
The family
by
prepared
purchasing
for the birth
childbed linen,
if
they could afford it.
This was a
layette,
often
so
valuable that
women bequeathed it... and it was
used for successive births within
the same family.
In early colonial
days the birth took place in the
borning room,
which was often a
small
room
behind
the
central
chimney, partitioned off from the
living
areas
and shielded
from
drafts.
In
larger
homes
the
master bedroom served this purpose.
The borning room was also where
the mother and child stayed during
the lying-in peri q,
household bustle.
away from the
b
at ight was <ltvtloptd I1
s:xiCCIIh cenitiry. hli ilore elabora ic o
van
eve
i ,70,
1 i.
hasisan d(itlsldlbic seil, ha~dI gi ips, M1id a w;I n
tndrik
1oing
p)
lor1 Ihe baby.
Colonial
women probably labored
comfortable
posture
and
this
perhaps
was
the
midwife
brought
"birth
eval
stool."
times,
laboring
time,
their
woman's
some,
For others,
along
back,
For
beds.
a
collapsible
used since medi-
designed
to
while
support
at
the
the
same
capitalizing on the force of gravity to
assist in the birth.
birth
place.
This chair,
was
in the most
stool
designed
was
for
Another feature of the
that
the
it
had
midwife's
a
cut-out
access
to
seat
the
An adaptatioln of the birth chair, in ise in rural sotithern ()hio 1 in the early
iiii1it'h century (It).ili h
"sand's
lap wis also used as a suihstute for the
ith stool. Note th iinan-iiiidwil' II inci illtistioiio at the right.
birth
canal.
kneeling
below.
only
The
position
to
would
receive
assume
the baby
a
from
The mother wore long skirts that not
protected
her
midwife
warm.
version
ladies'
Some
of
her
As
late as
the
solace"
women
modesty,
birth
was
1799,
chair,
used
preferred
to
in
but
also kept
an
adjustable
the
"portable
Phildelphia.15
use other people
for physical support of their back and legs
during
the labor process.
In the late 1880's
on the frontier of the Midwest,
there is men-
tion of a husband substituting for the birth
stool as he held the laboring mother on his
lap.
She sat there,
and he pressed on her
abdomen to ease the labor.
16
Another culture rooted in the frontier plains
of
America,
the
Native
also selected a protected
or a shelter
Indian
her
child
parents
for
their
Indians,
spot in the woods
births.
A newborn
is named after the first thing
see
after
baby's delivery (hence,
Bear,
American
looking
up from
the names
19th century birth stool in use,
with midwife aiding in delivery.
the
Running
Swift Fox, Sparkling Brook).
14
In
the
more
nation,
there
maternity
not
pay
were
remote
was
health
for
service
parts
much
need
for adequate
Where
people could
doctors
a
in
rural
care.
inadequate
provided
and
to
midwives
and government
do
so,
emerged
and
medical
from
respected
care.
the
Nurse-
tradition
professional
nursing
tradition
independent
midwifery.
that
to
of
organization
maternity
York
care was
City.
The
tion (MCA)
rather
sought
funds
nurse-midwifery
much-needed
American
of the
founded
Maternity
than
of
from
the
7
One
provide needed
in 1918
Center
in
New
Associa-
provided prenatal care in poor,
urban neighborhoods as well as in some poor
rural communities
in their outreach project.
The MCA also brought knowledge and wisdom
to
uneducated
continues
to
mothers.
train
nurses in midwifery.
has
been
operating
Today,
qualified
the
public
Since 1975,
MCA
health
the MCA
a -childbearing center in
their converted townhouse on the Upper East
Side of New York.
Part of the original
Frontier Nursing Service
Midwives practiced freely in American households until the nineteenth century.
In 1925,
Mary
Frontier
Breckinridge
founded
the
.1
Nursing
Service
Kentucky.
(FNS)
She
in
Leslie
to
her home state
returned
County,
of Kentucky after having studied midwifery
in London at the British Hospital for Mothers
and
Babies.
\
xv* V
X
U
She deliberately chose to work
in this remote area of Appalachia, accessible
only by horseback,
or midwives
where no trained doctors
practiced.
She wanted to pro-
vide help to mothers who had the most needs
and
the
least
her
own
nurse-midwives.
years,
the
care.
Breckinridge
Frontier
community
support
quarters,
its
In
the
Nursing
to
help
hospital,
Breckinridge
part of a
build
and
throughout
develop
because
areas.
new
Idealistic-
the
This
roads
The Frontier Nursing Service
outpost
FNS
of philanthropic
remote
had
its head-
six
envisioned
network
ensuing
Service
clinics up in the Kentucky hills.
ally,
trained
and
as
services
did
not
highways
made it possible to gain access to centralized
hospitals.
Currently,
FNS
uses
centralized
hospitals for delivery of babies although the
nurse-midwives
normal births.
18
By
of
the
twentieth
occured:
end
still
retain
the
second
century,
American
a
control
decade
radical
medical
over
of
change
colleges
the
had
were
16
young
training
to
men
be
obstetricians.
Since
This resulted in a movement against midwives
for
the
in the homes of women
has
been
"legally"
practicing
the
nation.
moved
into
across
were
of
idea
hospitals
care where women
the
women
laboring
male-conceived
new,
of
(centralization
health
came to the place of the
there came along other medicalized
doctors),
equipment,
drugs,
When
and routines of institution-
al flavor.
Kingdom,
United
professional
Netherlands,
the
and
Germany,
midwives
have
In
births.
handled
the majority of normal
Holland,
greater than 70 percent of mothers
have had their babies at home with midwives,
while in England,
in
hospitals.
in
home birth
Flying
equipped
England,
the
women
choosing
an excellent backup'
Squads.
birth
They
ambulances,
are
specially
including
a
so that the Flying Squad is essen-
doctor,
tially
For
9
is available at all times through the
service
famed
most midwives now practice
a
mobile
emergencies.
operating
room
for
birth
there
delivery of babies,
a lack of continuity and
humane-
ness in the experience of childbirth.
have
women
Under
rule of hospital procedures,
hierarchical
the
been
denied control
their
over
own experiences. They have become alienated
from their bodies,
and thus from themselves.
Many women in the United States who became
do not remember
after World War I
mothers
In contrast, for many years in Scandinavia,
the
labor and
into hospitals
movement
American
the
experiences;
birth
when
they were given drugs
woke
and
after
up
the
could,
they
in early
labor
how
their
baby
born?
was
this
institutional
atmosphere advertised as "safe,
fast, easy,
became
Women
and
efficient,
often,
in
passive
in
scientific."20
Here,
all
too
the pregnant woman has found herself
the
world.
midst
unfamiliar, and
an
of
strange
The life-saving knowledge of medical
personnel
is
legitimately
respected
and
essential to complications in birth (Caesarean,
for example).
Fortunately,
there are women
who have had good childbirth experiences in
a hospital setting.
They have had wonderful-
ly personal and attentive care and treatment
by the hospital staff, almost in spite of the
physical
place
itself!
The medical workers
17
who
focus- on
specific
needs,
individual
overcome
patients
the
and
less
their
positive
aspects of the surrounding, neutral environment.
What
is objectionable about hospitals
is that for generations,
America
awed
by
have been,
the
power
birthing women in
at times,
of
deceived and
obstetrical
science
especially when its intentions are to "correct
nature according to human design."
21
1
8
WHAT IS A BIRTH CENTER
"When people are moving so often
and selecting their homes with so
little relation to other people, it
seems important to build new institions in which women who are having babies at about the same time
may keep in touch with each other
and with the newest precepts from
the clinic and consulting room.
Where such a group is composed of
relatives, old friends, or neighbors
it
who know each other well,
resembles the reassuring circle
that characterized primitive and
village life."
-
Margaret Mead quoted in
Pregnancy, Birth, and
the Newborn Baby
One only has to trace woman's changing role
in
the
the
home
at
borning
in
care
health
were
their
and
time,
parallels
the
women
Colonial
movement.
of
and
movement
women's
most
see the
to
society
American
rooms
became the place to have babies.
The family
women
(midwives,
grandmothers)
aunts,
mothers,
in
experienced
other
and
home
the
early 1900's,
until
the
the birth was centered in the
and most of the
household,
domestic
Up
birth.
during
were present
tradi-
tional rituals and rites associated with birth
here.
pened
together
and
When
with other
non-medical,
pital,
all hap-
and celebrating)
naming,
(baptism,
the
support
into
grouped
doctors
people,
medical
a fully-equipped hos-
the pregnant mother of the early part
of the twentieth century came to the doctors'
place of business to give birth.
Here,
for
some fifty or more years,
women most fre-
quently gave birth alone.
During the labor-
ing hours, fathers sat in the waiting room or
paced
the
long
corridors
in
anticipation.
1 9
into
the
to
as
world
the
was
Johnson"
"Baby-boy
Church.
announced
"Paul
Brian
Ill" via the mail or by phone.
Johnson,
you
Baptism moved
siblings were absent.
Other
your
wanted
child
If
in the
Medical practices
this procedure.
also fostered such routine,
hospital
across-the-board
as
procedures
opted
choosing
for
birth
homebirths
at
were
home.
Women
satisfied
with
not
having the ominous emergency equipment of
hospitals present in their homes.
you
circumcised,
returned to the hospital or visited a doctor's
office for
parents
general
Some women are most uncomfortable with the
idea
of
a
homebirth
right for
them.
to
of
think
and
They
medical
do
not
feel
have been
it
is
socialized
practitioners
as
people
trust to deliver good
health
of
whom
you can
mother and child immediately following birth.
care.
This belief along with other justifiable
needs
and
When
or
episiotomies,
anesthesia,
parents
began
to
separation
challenge
these
And if a fam-
of their childbirth experience.
to have the father present and
ily wanted
hospital policy said no fathers in the delivery
they were going to have their babies
By about the late
elsewhere.
birth regained
popularity.
1960's,
home
Once again,
the
family could decide who they wanted present
at the birth:
grandparents,
Because
congenial
home
father, siblings, aunts, uncles,
a
was
midwife
and/or
a familiar
atmosphere,
interpersonal
occurred,
insist on having
will
their
make
some mothers
babies
in hospitals.
they sought to take back control
practices,
room,
desires,
sharing
was
and
a
place
place
doctor.
with
a
where
celebration often
and was a main focus for family --
Hospitals have been the birthplace of iatrogenisis:
by
complications
medical
instances
procedures.22
where
women
are
that
introduced
There
have
been
are
some
used
as
guinea pigs in the testing ground of obstetrical
medicine
interventions,
but
also
in
in hospitals.
The cascade of
not only in the use of drugs,
high-tech
equipment
of
fetal
monitors and the like, has made for unpleasantness and potentially harmful situations in
hospital
obstetrical
wards.
Birth
in
the
hospital is treated like surgery, and delivery
like an operation.
20
Here,
the eight-hour staff shifts account for
the lack of continuity of care.
Until
recently,
the mother giving birth in a
hospital would find herself lying flat on her
back on a delivery table that was equipped
with
stirrups
arms.
This
the
and
straps
dorsal
"lithotomy"
for
position
position),
her legs and
(also
while
known
as
making
it
easier for the doctor to sit on a low stool at
the end of the table and monitor the mother's
and
baby's
delivery,
labor.
progress
did
not
and
to assist in
facilitate
the
the
mother's
This practice is symbolic of hospital
thinking
where
problems are solved on the
basis of the doctor's convenience.
The "lithotomy"
the
removal
position (developed first for
of
bladder
stones)
for
giving
birth became popularized by Louis XIV.
desired to watch,
hidden
behind
as his mistresses gave birth.
posture
has been
Caldeyro-Barcia,
criticized
He
a curtain,
The lithotomy
by
Dr.
Roberto
Lithotomy position
president of the Internation-
al Foundation of Obstetricians and Gynecologists.
that
He has written that the "only position
could
be
worse
for
a
woman
would be to hang by her feet."
23
in labor
211
The
hospital
the
essence
newborn
environment
of
baby
controlled,
sterile
contrast
which
he
Leboyer,
book,
that
or
childbirth.
into
a
the
womb
mother's
has
exited.
his
the
room
womb:
poetic
should
be
placed
temperature
mother's
womb.
is
is
and
akin
However,
from
moving
recommends
and
into
in
Frederick
environment
warm
A
temperature-
that
for
delivery
against
environment
she
noted
simulate
whose
to
work
Birth Without Violence,
a
baby
"natural"
enters
direct
can
a
to
should
dark.
The
warm
bath
that
of
its
for the first time,
4vi.
Leboyer is advocating this procedure for the
baby's comfort.
the
father
He gives no consideration to
or mother in their participatory
24
roles in childbirth.
On the other hand,
Dick-Read,
in
his
childbirth expert Grantly
book
Childbirth Without
Fear,
first published in the United States in
1944,
advocates the importance of the father
being
birth.
in
He
of a poor,
pain,
that
tensions of
constant
attendance
recognized,
through
during
Hospital labor room,
with fetal heart monitor in use
the
observance
London woman giving birth without
when
fear
resistance
is absent,
will
associated
be minimized and
, 9
5
the
baby
will
be born
with
more ease
and
comfort.
By the 1960's,
being
raised
health care consciousness was
with
the
movement.
American
to
both
examine
hospital birth.
community's
help of the women's
women
the theory
were
and
beginning
practice of
They questioned the medical
insistance
that
women
should
give birth in the doctor's institution.
Hospital
birth
became
a
regime
against which many women began a
Maternity operating room,
critical struggle,
questioning the
need for such extensive manipula-
tion,
Bridgeport Hospital,
questioning the safety of the
procedures,
and
demanding
Bridgeport,
Connecticut
that
birth be an experience that permitted them a sense of self-fulfillment.
25
The costs of a typical hospital maternity stay
of four days were already high, in a $500 to
$700 range,
average
three
maternity
times
insurance
childbirth
longer
and steadily rising.
is
as
much.
policies
in
the
stay
will
costs
Colonial
her apron
to
services.
(Might
pay the
twice,
Soon,
all
cover
third-party
Today, an
the
even
medical
cost
payments.
woman
reaching
local midwife
the anonymity
of
No
into
for her
of payment
be associated with the anonymity of service?)
Two-part maternity bed,
American manufacture
23
Recent
innovations
birthing
practice
for
demand
consumer
about
come
have
American
current
in
Women
change.
Estimated Percentages of Births Taking Place in Hospitals,
1930-1970
through
and
100
men are exposing and effecting some measure
of
change
operate
the
in
how
and
way
facilities
birthing
medical
associated
care
is
0
Ia
80
0
C
In the past few years,
delivered.
have
to this
responded
hospitals
pressure
consumer
by instituting "alternative birthing centers"
which
60
are little more than cosmetic solutions
0
40
Za.
in the hospital.
for a home-like environment
20
in concept, the mother is able to
Although,
labor and deliver and recover in this room,
the "birth
room"
disguise,
with
is but a delivery room in
emergency
the
hidden away out of sight.
equipment
1930
1935
1940
1945
1950
1955
1960
1970
Sources: Donnell M. Pappenfort, Journey to Labor, Chicago, 1964,
Table 15, p. 49; AMA Council on Medical Education and
Hospitals, Hospital Service in the U.S., IX-XV (Chicago: 1936).
Regulations often
require a laboring woman to move out of this
room
if
she
has
been
It
birth-augmentation.
given
can
any
type of
be argued
that
all hospital rooms should be like birth rooms;
but pretty curtains,
tures,
throw rugs,
not make
with
a good
changing
the
colored
walls
and pic-
and easy chairs alone do
birth experience!
immediate
change must be evident in
Along
environment,
the policies and
procedures of the hospital adminstration and
staff.
24
A
an
a midwife and others)
present,
has
family
the
and
home
at
is desirable for
there is familiarity of
a number of reasons:
place,
The
birth.
labor/delivery/recovery
of
choice
families
which offers
hospital
a
to
alternative
(with
birth,
to home
return
the
advocate
women
of
number
growing
over
control
who is
the cost is considerably less
the notion of an indepen-
By the early 1970's,
classes
economic
in
Oregon
and
Pennsylvania to New York,
from
birth
between,
viable
Families
alternative
were
now
range
wide
centers
were
for
American
able
to
seek
of
well
was
the populace
of
From
underway.
a
serving
birth center
dent
California,
and places
becoming
a
mothers.
out
these
community-service centers which provide the
than a hospital birth.
best of two worlds--the safety of the hospi-
Home birth has largely been the only choice
to
Christian
Scientists,
non-believers
birth
of
The Amish
women.
poor
available
among others,
medicine,
have
for
But for the indigenous
in the home.
population of mothers who do not feel secure
in
having
cannot find
a
home
their
births
at
home,
or
who
qualified attendants to assist at
birth,
what
other
alternatives
and the atmosphere of the home.
and
who are
opted
tal,
to
The alternative of a birth center was introduced
as
a type
of
"Maternity
Hotel"
by
Lester Hazell in her book Commonsense ChildThese places would serve only as a
birth.
maternity center.
Marion Sousa gives a good
description of the motel
in her book.
Child-
birth at Home:
home or hospital do they have?
A woman who visited the Maternity
Motel would see one team of midsives, nurses, doctors, physiotherThe
apists and mother's helpers.
team would get to know not only
the expectant mother, but also her
husband and children. The Maternity Motel's baby-sitting nursery
would also care for her children
during check-ups and later, when
she went into labor.
25
When the mother checked into the
Maternity Motel to have her baby,
could come right
her husband
along with her and stay in her
During
room.
birth proposed this plan not just
As a
as a utopian pipe dream.
cultural anthropoligist, she studied
over
the
During her research,
she
childbirth
the
labor,
early
author of Commonsense Child-
The
customs
all
couple could order from the rest-
world.
aurant's menu or visit the cocktail
and
lounges
Television
lounge.
collected the best features of many
obstetrical hospitals from several
Then she incorporated
countries.
these features into her descriptioq
Motel.
Maternity
the ideal
of
game
rooms would also help labor
to pass quickly.
When it
was time
the
for the baby to be born,
parents could return to their motel
where .the baby could be
room,
If the delivery
born in bed.
it could be
normally,
proceeded
nurse-midwife.
a
by
assisted
she
however,
After the birth,
would
leave
enjoy
the
the
new
family
baby
alone
to
together.
When the couple felt tired, the
father could carry the baby down
to the nursey for the night, so a
nurse
could
watch
him
(or
her).
During the day, baby would return
to the parents' room; older brothers and sisters could visit him (or
her) as much as they wished.
Since the Maternity Motel functions
like a luxury hotel, appointments
with a masseuse and hairdresser
the
when
scheduled
be
could
mother
(or
partner)
wants
them.
Because the Maternity Motel also
provides the best obstetrical care,
a physiotherapist
with
sessions
would be scheduled so that the
mother could get started on a
postnatal exercise program.
I
can
imagine
a
wonderful,
hotel
being
Victorian
style
maternity
center similar
above.
charming,
adapted
to the
old
a
for
one detailed
I especially think the following fea-
tures are worth reiterating:
e continuity of care
* child care provision
e concern for family-centered experience
with immediate bonding after the baby's
birth
a long-labor diversions
* separation of baby from parents only
at night during which time,
watches the baby
a nurse
e sibling visitation
* the luxuries of an elegant hotel.
Although
there isn't
yet a Maternity Motel
along every highway in America,
there has
been some progress in the realities of maternity centers:
26
to
1960
Maternity
the
1970,
Institute
in
Catholic
Sante
Fe,
New Mexico, operated a childbearing
center called La Casita as an adjunct
to its home birth service which had
been operating for a quarter of a
After ten years of opercentury.
ation, La Casita closed because of
financial problems.
But it was only a short time before
In
another center was opened.
1972, Su Clinica Familia was opened
near the Mexican border in Texas,
providing a maternity center for the
indigenous Chicana population. The
center
soon attracted
the attention
of white women in the vicinity who
In 1974, the
also use its services.
Nachis Natural Childbirth Institute
in Culver City, California, opened
its doors and recently celebrated its
500th
birth.
In
1975,
three
more
centers were opened, one in Oregon,
one in New Mexico, and one in New
York City.
The greatly
venerated
Childbearing Center of Maternity
Center Associates, an organization
with 60 years experience in providing safe alternatives to childbearing
women, is housed in a converted
townhouse)
century
(turn-of-the
brownstone on East 92nd Street in
Manhattan and is the location of
most of the significant data-gathering on the safety of out-of-hospita
non-physician-attended childbirth. 7
months
few
A
From
(March
ago
I visited
1979),
and
the Maternity Center Associates (MCA),
a
attended
led
session
parent
orientation
by Betty
Hosford,
fied
Nurse-midwife).
the
Upper
away
minutes
located on
and
11
hospital,
back-up
mothers
is
York,
New
its
from
where
Hill,
Lenox
of
(Certi-
CNW
The MCA,
Side
East
open-house
who
babies
need to be transferred are taken in emergenThe
cies.
has
MCA
rowhouse
since
renovated
the
level,"
"garden
below
story
in
in 1918.
founding
it
one-half
located
housed
been
this
They
which
the
is
street
for their Childbearing Center.
level.,
At the garden level of the structure, there
one
rooms;
birthing
two
are
family
room
which can be converted into birthing rooms,
if
necessary; two exam rooms; two lavatories;
and two-person
dressing
large
one
shower
room that is equipped with safety hardware;
a
laboratory;
area;
work
centralized
clean
and dirty
and
kitchen/supply/
storage areas;
non-dispensible)
supply
(dispensible
storage;
emergency equipment alcove; and a
janitorial
(one
closet.
The
is painted orange,
two
birthing
rooms
and one is painted
27
each have a single bed with matching
blue)
steel counter-
stainless
bedspreads,
colored
tops running all along two of the four walls
a stainless steel
of the room,
which
heater,
electric
portable
sink,
is
and a
used
to
to the parlor/waiting area.
an
elegant,
floor,
The overhead lights
reference
Floor lamps are used so the
There
room can be darkened for the birth.
is one window that looks out into the wellgarden
tended
area.
room
Each
also has
many storage cabinets, a lounge chair, and a
throw rug on top of a linoleum floor.
is also an emergency exit at this level.
There
and
a
with
a
wooden
wood-paneled
conference room located above the first floor
classroom.
are fluorescent.
a fireplace,
and
space
gathering
floor-to-ceiling windows,
high-ceiling,
raise the ambient room temperature immediate-
ly following the birth.
large
At this level are
offices.
The third floor has an extensive
four
and
library
administrative
the house,
floor of
On the fourth
there are more offices for general MCA use.
On
the
resident
fifth
floor is an
very comfortable
It
nurse-midwife.
on-call,
for the
apartment
is
all
spacious and designed
and
to accommodate the parents' needs.
The
birth rooms must meet certain health regula-
On of the objectives of MCA is to remove the
they are not as imagi-
medical mystique about childbirth and to help
Unfortunately,
tions.
natively designed as I had hoped.
level
the
area,
the street,
up from
first floor of
houses an administration/office
building
a
the
One-half
parlor:
waiting
and
information
area, a multipurpose room used for orientation
classes and
childcare,
and
one exam
with adjacent bath and dressing area.
Hosford,
CNM,
room
Betty
believes it would be better if
there were one or two additional exam rooms.
Climbing
the
elegant,
curving
parents
gain
health
and
clients
are
risk-factors
use
the
confidence about their
pregnancy,
needs.
During
carefully
screened
which
center
for
would
their
not
medical
for
certain
allow them
to
birth experience.
The center is for women who are expected to
have 'normal'
childbirth experiences.
Women
with complications are referred to an obstetrician who is affiliated with the MCA.
staircase to
the second floor, one has a visual connection
28
All births take place either in
the birthing
in the case of simultaneous birth,
rooms or,
in a convertible famiy room that can accommoAttendants at the birth are
date the birth.
according
upon
decided
desires of the family.
to
the wants
and
There is a baby-sitter
one
part-time
Since
its
has
emergency
is
oxygen,
blood
volume
equipment
expanders,
available:
intrave-
nous equipment, emergency drugs, a portable
stretcher, and an isolette (portable enclosed
newborn environment) for emergency resuscitation and/or transferral of the newborn,
if
necessary.
The charges of the Childbearing Center for
its services are $885.00, which include the
cost of all laboratory tests routinely given to
all mothers and two home visits by the
Visiting Nurse Service, as well as professionThe classes offered by the MCA
al services.
include nutrition,
changes,
progress.
and
exercise, early pregnancy
self-care to assess pregnancy
The medical personnel include two
pediatric consultants, three registered obstetricians/gynecologists,
and
four
full-time,
about
to 500 annual births.
work
250
births
Center
annually,
A strong social net-
has developed and parent groups meet
regularly.
screening
There
the Childbearing
they have the capacity to have up
although
together
available for young siblings.
opening,
averaged
nurse-midwives.
certified
Center,
procedures
To get
at
an
the
refer to Appendix F.
idea of
the
Childbearing
A WORKING METHOD FOR
DESIGNING A BIRTH CENTER
The
following
familiar
collection
of design
information
intended
is
with the process of architectural design.
interested
for
people who are
not
necessarily
Any individual or group of people who is
in developing a birth center could use the workbook and kit of parts to aid them in
making spatial decisions for their ideal birth center.
sample model based on the architecture program
There are drawings,
which follows.
descriptions,
and a
The design activity outlined in
the instructions will hopefully be both enjoyable and educational for all participants.
ARCHITECTURE
PROGRAM FOR A BIRTH CENTER
(This program is based on an architectural design studio exercise given at the University of
Oregon, Christie Coffin, professor.)
1.
GENERAL REQUIREMENTS:
The birth center would be a community or neighborhood facility, perhaps attracting people
The center should accommodate diversified lifestyles and birthfrom other nearby regions.
approachable, welcoming, accommodating, comfortable, funcbe
should
It
ing techniques.
well within the surrounding environment.
fit
and
open,
but
tional, secure
2.
SPATIAL REQUIREMENTS:
a.
CLINIC SPACES
Reception/Waiting/Children's Play Area
Business Office
Staff Office
Director's Office
Workroom
Pharmacy
Exam Rooms (2-4)
Consultation Rooms (1-2)
Lavatories, as needed
Lounge Area
350 sq.
180
325
120
80
40
each 100
each 100
each 55
80
sq.
sq.
sq.
sq.
sq.
sq.
sq.
sq.
sq.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
00
sure to include necessary storage spaces for medical and office supplies,
equipment, and housekeeping materials.
e Be
e The staff office will be used by 2-4 nurse-midwives,
special
a consulting obstetrician,
a
Not all of
pediatrician, a nutritionist, a physical therapist, and other nurse aides.
areas.
desk
share
may
and
basis
a
full-time
on
center
the
at
are
these people
e All spaces should be barrier-free,
b.
accessible by handicapped persons.
EDUCATION SPACES
Classroom Area
240 sq. ft.
Exercise Area
240 sq. ft.
" These activities could take place in one large room.
" There should be adquate seating for 10-20 people.
" Local community groups may use this space for meetings.
* Storage areas should include places for chairs, table(s), exercise mats,
equipment and demonstration materials.
c.
audio-visual
BIRTH SPACES
Birth Rooms (2-3)
Kitchen/Family Areas (2-3)
each 240 sq.
each 250 sq.
Resting Room (1-2)
Utility and Housekeeping
Emergency Equipment Storage
Baths (2-3)
each 100
80
100
each 65
ft.
ft.
sq. ft.
sq. ft.
sq. ft.
sq. ft.
e Provide storage for linens, towels, other materials.
e Don't forget outside access!
d.
COMPUTING GROSS AREA
(TOTAL BUILDING AREA)
1.
Add together the NET areas for above.
2.
For circulation and thickness of walls,
3.
Add another 20% - 25% of the NET area for storage.
4.
Add totals from Steps 1, 2, and 3, to get estimate of GROSS AREA.
add 25% - 50% of the computed NET area.
31
3.
FUNCTIONAL RELATIONSHIPS
e The CLINIC,
EDUCATION,
and BIRTH spaces will be used largely by the same staff.
* There should be privacy considerations given to the BIRTH spaces according to the
desires of the family.
* The medical staff should be able to monitor activities in the BIRTH area with relative
ease.
3
2.,
INTRODUCTION
TO THE WORKBOOK
For purposes of this study,
I have broken down the larger concept of a birth center into smaller
This is an artificial division to aid in understanding the parts and the whole, and need
pieces.
There are three inter-connected Domains:
not be visible in the actual building.
including medical and administrative areas
e
CLINIC,
o
EDUCATION, including childbirth and exercise classroom areas,
orientations, conferences, and outreach programs
e
BIRTH,
and space for community
including birthing rooms and family areas
There are possibilities of one or more
These domains are not necessarily spatially distinct.
domains to overlap (CLINIC and EDUCATION, for example) and/or to interpenetrate each other
(CLINIC and BIRTH, for example).
There are specific
Each Domain is made up of Places where a particular activity situation occurs.
For instance, in the CLINIC, the WAITING/RECEPTION/
Places contained within each Domain.
come and go, people wait, people make appointments,
people
where
a
Place
is
AREA
CHILD'S PLAY
may play quietly together or separately with
children
and
people refer to childbirth information,
supervision close-by.
A
Territory
is a collection of
Places.
For example,
a private Territory
could include the birthing rooms, a bath suite, and a family area.
would function well together, spatially and socially.
in the BIRTH
This grouping
Domain
of rooms
This
On the following page is a diagram of the CLINIC, EDUCATION AND BIRTH Domains.
was
consideration
Important
territories.
and
drawing shows relative positions of areas, places,
adjacency
given to the logical and desired movement from one place to another, and to particular
requirements (a birth room and bath suite close to housekeeping and emergency equipment storage).
This diagram should not dictate an only solution, rather it is one suggested arrangement.
33
INSTRUCTIONS FOR USING THE WORKBOOK
1.
Decide on the domain you wish to begin designing:
2.
Study (and discuss) the diagrammed relationships drawn at 1/16" scale.
attention to the specifics of the domain you are designing.
3.
Imagine these spaces in use:
o
EDUCATION,
or BIRTH.
Pay particular
Who uses each place?
(mothers,
pregnant women, mates, children, babies, visitors,
friends, and others, certified nurse-midwives, nurse attendants, aides, administrative
and housekeeping personnel,
tors)
doctors,
nutritionist, pharmacist,
body movement instruc-
*
What are they doing?
e
How do they come into a particular place?
e
How do they move through the space?
*
Could a handicapped person move about without encountering any architectural barriers?
"
What is happening in this place?
"
How and when do the players interact with one another?
"
What additional support spaces should be close-by?
*
What is the sequence of events here?
e
Where do these events take place?
(For this part of the exercise, refer to 1"
time charts, and behavior maps.)
4.
CLINIC,
scale plans and axonometric drawings,
activity/
Perhaps each person present can take on the role of one of the players, and then walk-through
and act-out various scenarios for a specific time period:
A prenatal visit:
including a mother, her 2 -year-old
and administrative personnel.
A labor-delivery in progress at the birth center:
grandmother
and
uncle,
certified
A childbirth education class on a weekday evening:
instructor, and an assistant.
child,
a certified nurse-midwife,
mother, father, 7-year-old sibling,
nurse-midwife,
8
mothers,
and other close friends.
8
support-persons,
an
5.
Read the paragraphs
questions:
next to the 'a"
scale plans on each page,
o
What activities happen here?
*
What type of character do you want this place to have?
*
What architectural devices will you employ?
a.
How do you want to use windows:
for views,
and answer the following
for light, to catch a cool,
summer
breeze?
b.
do you want natural light into it
What qualities of light do you want in a room:
from the side, from above? Where will interior light sources originate?
c.
What colors will make a person feel good to be here? What colors will you use to
make a warm and cozy place? A cool place? A bright and cheerful place?
d.
What types of finish materials will be durable, as well as easy to clean and maintain?
What finish materials will give a sense of warmth and comfort?
e.
How do you want to use plants?
For outside gardens:
* symbolically and ritually in plantings?
* in an enclosed garden?
* in a half-hidden garden?
o in an annual garden?
* as a green-screen/trellis?
For the inside:
* special groupings to separate and screen adjacent activity
areas?
* hanging window plants?
* to help create a pleasant atmosphere
f.
What materials of construction will you use to give desired acoustics in each room?
o
absorptive materials such as wood, brick, heavy fabrics (bed spreads,
quilts, pillows), carpeting, soft cushiony furniture, acoustical ceiling tiles?
o
wall insulation?
wall,
insulation around windows,
doors, electrical outlets in an exterior
heating and cooling equipment?
35
a
6.
audio devices:
room control?
stereos,
radios,
communications systems?
will there be individual
What types of residential-scale furniture will you use in contrast to the usual institutional
variety?
7.
Make a checklist of those characteristics you want to include from Step 6.
Free associate. Be imaginative.
as you are designing specific places.
8.
Now you are ready to construct a -"
into position.
scale model.
Refer to it often
Pick up furniture pieces and place them
Add 1" scale people (refer to Step 4).
9.
Add other furnishings (carpets and other floor coverings, wall hangings and other decoration,
and plants).
10.
Define the perimeters of territories and places by determining wall heights and their location.
Use pins
Cut pieces of corrigated cardboard to represent wall definitions and enclosures.
and glue to secure the pieces to a homasote baseboard.
11.
Place indoor places so they set up desired relationships with outdoor spaces by locating
windows along south-facing walls,
more open gardens.
or where they can face onto interior courtyards or onto
Place openings where you want views and/or ventilation.
12.
Remember to include special spaces such as niches, alcoves,
13.
Add any necessary storage places.
14.
How might the ceilings and roofs be?
15.
e
How high is the ceiling or roof?
*
Do you want different ceiling heights in special places?
e
What shape is the ceiling or roof?
Flat?
Domed?
and bay windows.
Sloped?
The
You may find that certain design decisions may not work as well as you intended.
process of design is not linear, therefore, make any necessary adjustments and modify
arrangements.
36
I
1
46
D
ICD
D
CENTER~
WORK-OOK
APKIL 10, 1979
by
M.AR"a
TEl
Arowmear/
PLAY
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41
CJLINIC
RECEPTION, WAITING, CHILDREN'S PLAY
350 - 400O
f-'
-7
Acti'\i
wnFI ~, flS)
oirva
fi4hn
opy 2intrywmln1S
oucj- me4i c~l 'norvcahor
ohildrn9
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of pksacci
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f
f
-_
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l
20'1
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0
mm
mm
Archtctw&rcl
qa 3rlercx4
fii
Inlntnto
eZM
to cCMOAC i1 fatmlie1cc,,
* ph~pcat.11 reL4f4. a' 'ootrol
cCAV~r of- btkilti
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t~ri~
ma65
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from core/ widt v(5!b / %n Ahrezcin~
awto
* Ope//V~f,
ti roMlCi O 4i1i nook
* heatribJ- a ke
*lot', of r1ltLral light
beovl
rclafio1~1'ip +ot o'at'ee AmW
ve/rgj vie'l&/ arid e.5*hj rcc-ogniz.~bVe,
kn1 lin tv parkn retaos a,
ovlaootr pla4J ar(Av ig
dtM6
r nr ~e
zit'k r fa~b
~43
CLINIC
RECEPTION
CLINIC
200 ft'
WAITING
CHILDREN'S PLAY
go ft
70 fet
c-
0
6 ft
4
mm
44
Ar(,ctK6c
p*mt 0of-
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wortfaeo
Copil~ mazbif'iY(/
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14 io[ eap 1xn4 rerrj:
4imjrel
CLINIC
BUSINESS OFFICE & RECORDS
Sbiling , inforrqaVkon
gahering
- rezrd ke
180 f e
- te4&eAhoning~
- opging , irig , gpn
I
141
- weA-ortceA
and organriA
to rec 4rd
-eg Xe
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btv,(re;
L~
13_
0
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mrpAWW
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cff&.e' JrvuppA
nfc
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4
oryat ze6
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M
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tmt
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rhayp' oukor deck oxrm,
4-7
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CLINIC
STAFF OFFICE
71
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4-8ft
48
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nterif our5
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49
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LOUNGE
AREA
CL-JIINIC
131RTH
* '~itii~recivinS conv&r,*Paton ,
PAW Of. -fime/
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DIRECTOR'S OFFICE
CLINIC
Activite:
120 fW
- meetnng
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Characker
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an
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CONSULTATrION
ROOM(:NI
(-,'IINIC
d*cv,5onAkf with 2 iv '3 vcolcl in Am~ 4ttk;
.)
(other, mrate, nurw~-mio~we', rwutrvh' ri,V
4
eschsiriy
converriatio1 4fl ( rrrmcdi
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of m~ca ryrf tor r oord,5
Cwaracfe~r of Place,;'tlct.m
100 {t*
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disp~aq of re-f ercncel
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55
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EXAM
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PHARMACY
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KITCHEN &
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250 it'
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KIT OF PAKTS
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SCALE PEOPLE
7 7
LA1NC THE WOKK00k.
EXAM ROOM MODEL
37 e6HFMr:S' fr-OR
U-C-MPTlON/v
WAIF- INa/ CH ILPREMS PLAY
PLAN WrTN
78
OTHER ISSUES FOR EXPLORATION
midway between the expensive, heavily
equipped hospital, ready for every emergency, and the normal household, capable of
handling minor illnesses, but without the
space or equipment for handling childbirth ...
"...
such a solution would
be in the nature of a
There has been less resistance to the concept
of a birth center in the parts of the United
States where there is not adequate service of
the medical profession to the more rural ar~d
the medical
In general,
remote communities.
small nursing home:
established as an
integral part of a unit, say, two hundred
and fifty to five hundred families; attached
perhaps to a local medical clinic, which
trained in a hospital-based medical philosophy
needs
have not
so
many
of
the
same
facilities.
Confined in such a place, a mother would
have access to her other children, could be
visited easily by her husband, and could be
looked after by relatives or neighbors,
except where special care was required:
important economy.
restore
the
missing
an
Such a solution would
human
element lost through what Dr.
element,
an
Richardson,
the
Victorial
hygienist,
once
mordantly
described as the 'warehousing of disease."
- Lewis Mumford in The Urban
Prospect
practitioners
of
who
been
birth
the
been
have
conservative and
and
in their support
enthusiastic
center
educated
Doctors
concept.
are
a certain amount of
have
fear that they will be driven out of business
by
this
welcome
terribly
are
They
alternative.
here,
where
made
not
they
serve
mostly as backup consultants to the midwives.
They are dubious about the safety of operation
in
they fear,
the facility which,
house an incomplete "medical
equipment arse-
that may prevent certain emergency
nal, "28
like Ceasarean sections or blood
procedures
transfusions
centers.
concept
could
will
be
from
of
Proponents
contend
performed
being
that
minimized
by
the
the
in birth
birth
potential
center
risks
including a careful
79
screening
procedure
high-risk
mothers
which
from
admission
alternative birth center.
Center,
San
"Conditions
an
Alternative
California;
Francisco,
precluding
management
Center,"
Maternity
New York,
New York.)
Childbearing
Association,
an
Mount Zion Hospital and Medi-
Birth Center,
cal
to
Appendix for
(See
for
Policies and Procedures
exclude
would
consideration
is
to
and other institutions, have chosen
renovate
labor
"birthing rooms."
that
this
is
When a
to
a
(Crite-
and
built
wallpaper,
boom 1950's,
full
feeling
with
mothers.
In
in
closets
or
by
hospital
baby-
their childbirth places;
a result,
each
the
other
Boston
hospitals are
for
area
pregnant
alone,
such
Hospital,
Beth
Israel
and New
Hospital,
Mount
England Memorial
primary
few
first,
reason
are
conceal
the
add
There is
storage
things:
post-World War II,
rocker,
to
wards
for Women,
Auburn
equipment
bring in
attempt
rooms
major metropolitan hospitals as Boston Hospital
some
a
maternity
and
and maybe a plant or two.
change
As
competing
lounge chair
The birth rate has been de-
of
are not being utilized to their
capacity.
chang-
by interior spe-
and pictures on the wall,
efforts
the
solution,
They may add color to the room with paint,
These
larger
ad hoc
cialists to create a more home-like atmosphere.
units.
the
during
are
introduction
by the
an
These rooms are "designed"
usually
creasing
of
gical hospital practice.
a rug,
birth centers.
more
the
minutes.)
threatened
more
approach to overall obstetrical/gynecolo-
a comfortable
somewhat
or
Center
proximity
hospitals
one
rather than evidence of an emerging,
ria include a maximum travel distance of 5-10
the
into
The author's contention is
ing
in
backup hospital for emergency cases.
Understandably,
rooms
and
birth center is deciding where to locate, one
important
Hospital,
indicative
medical
built-in
of
to
two
that hospitals are converting
for
and second,
this
change
that the
in attitude
has been consumers' demanding a less hostile,
sterile,
and interventive environment during
their childbirth experience.
is necessary for
hospitals
Economically, it
to institute this
more humanizing approach into their otherwise
less
personalized
environments.
and
Some
more
institutionalized
consumers
choosing to
8 0
have
their
babies
in a
hospital
are
setting
if it
using the option of the birthing room,
They not only want to use the
is available.
but they
room for their labor and delivery,
also want familiar faces to be present rather
and mothers
than strange medical personnel,
Englewood
Cliffs,
nurse-midwife
Medical
New
director
Associates
to
hospital.
However,
deliver
establishing
a
moved from labor bed to delivery table,
labor
room
to
delivery (operating)
recovery (lying-in)
from
room
to
permitted
Clinic
babies
was
at
clinic
doctors
New
Metropolitan
birth
ately after birth.
in
the
was
auspices of a doctors'
to be
the certified
there
want their babies bonding with them immediMothers don't want
of
Birth
privileges
with
Jersey,
denied
the
no
local
problem
under
group practice,
Jersey
considerable
and
the
since
elsewhere
leeway
in
regard
are
to
what occurs in their own offices. 3 0
room.
Unfortunately,
these
situations point to
the
Not only are the hospitals finding objections
difficulties in convincing Eastern metropolitan
to
medical
the
birth
center
State
Public
Health
been
unsuccessful
State
Health
idea,
so
are
the
There have
agencies.
petitions
Departments
birth centers.
but
to
for
particular
licensure
of
This may be seen as a sym-
bolic gesture on the part of the governmenby
denying
a
birth
tal
bureaucrats
the
chance to serve as a "beacon
in
of reform
the business of giving birth. "29
York City,
center
In New
a major medical education center
of the country, the Maternity Center Association,
has met with considerable difficulty in
a two-year battle to get permission to operate
their
Childbearing
Center.
Close
by,
in
communities
to
birth center concept.
the
Birth
Center
give support
Currently,
Task
Force,
to the
in Boston,
which
been working together for a year,
has
is prepar-
ing a report for submittal to the State Public
Health
agencies
alternative
to
establish
whether
an
be licensed as
birth center could
an ambulatory care facility, a medical clinic,
or
as
Family
a
doctor's
office.
Life Center,
The
which is affiliated with
the Boston Hospital for Women,
plans
ahead
with
need"
proposal
author
can
only
Brookside
is also going
to submit a "certificate of
to the
same
speculate
agencies.
The
that two groups
8 I
will be competing for perhaps,
one opportunity for a "model
initially, only
* a
birth center" in
with
place
an
healthful
important,
focus on childbirth in a neighborhood
the Boston area.
where
setting
religious
There is less opposition towards birth centers
cultural,
and
ritual,
celebrations
and
events
could occur;
in the rural areas of the country because for
a long
time,
formally trained midwives and
" a
resource
lay practitioners have been welcome in doctor-
where
less areas.
educated
Texas,
In towns such as Raymondville,
where the Su Clinica Familia services
a largely poor,
backwoods population,
is only one doctor and no hospital.
people
the
become
range
center
better
of child-
there
" a
place
where
neighbors,
for the economically handicapped,
sonnel,
and some
none at
family,
friends,
and
together with medical per-
could
share and
be mutually
supportive;
Laws are often less restrictive in these
parts of the country.
Mexico,
pass
a
fire
Maternity
Health
In Albuquerque,
" a "swap shop" for mothers to exchange
New
the single requirement for a maternity
and
inspection.
Center
officials
in
have
At
the
expediting third-party Medicaid
the State
helpful
been
ture.
Southwest
Albuquerque,
also
in
payments. 31
People who choose the birth center as an al-
ternative
Perhaps one approach to counteract the op-
a
would
birth
community:
be to point out the
center
could
bring
benefits
into
the
would
do
so
because they
could
have connections to important and significant
rites,
position
baby clothing and furni-
recycle
31
have five beds or fewer and
home is that it
that
could
about
easier acceptance here because the service is
all.
information
birth alternatives;
There is
type of health care is better than
and
traditions,
experiences.
return
to
about it?
and cycles of their
life-
How many people today actually
their
birthplace,
or
even
think
They may have been born there,
82
If
but they don't have reasons to go back.
this birthplace,
a family somehow "imprinted"
maybe by planting a fruit tree, some flowers,
warm,
friendly,
they would have left something
being
put
there that they could watch grow and change
place.
or a garden,
over
with
absent in a hospital situation, would
events,
help
of
kinds
These
center.
birth
the
associated
ceremonies
and
parties
birth-day
annual
would
there
Perhaps
time.
attractive,
any
to
addition
beneficial
and
positive,
center an
birth
the
make
not
will
practitioner
(Actually,
supportive
and
it would be nice to think
that architects and designers do influence a
non-productive
person's
that
argue
type
the
if
development
design
of design attitudes
are conscientiously
suggests
of
I would
behavior.
the
applied in
a
center,
birth
a
thesis
this
intentions
architectural
and
better place will result.
neighborhood or community.
by
merely
person
pleasant
a
become
necessarily
trustful
a
in
impersonal
and
distant,
insensitive,
An
I believe the trans-
lation of design intentions could fit either in
wonderful
how
matter
no
Realistically,
a
place might be in its physical attributes, the
building
alone
cannot assure a good
High-quality,
experience.
personal,
birth
economic policies, and efficient facility opercontribute
ation
all
birth
center.
A
to
good
making a
medical
successful
person
can
give good health care service almost in spite
of the immediate environment,
well-thought-out,
if need be.
A
properly planned and pre-
pared place will, of course, aid the situation.
But,
be,
no matter
there
need
how
to be
terrific a place might
good
people
or in the building of a new birth center from
the ground up!)
medical
sound administrative and
care and treatment,
the adaptive re-use of an existing structure,
as well.
advantages of approaching
The
event
"normal"
to
the
range
range from
from
are
confident,
that
results
as
a
the psychological
at
centers
birth
one-half to two-thirds
that of a
Women who choose the birth
hospital birth.
center
Costs
practical.
birth
surrounded
and
in
by
a
self-controlled
a
less
more
calm,
atmosphere
warranted
medical
interference.
83
.1~
In the urban and rural communities of America,
and within the hospital system,
there is
growing support for this type of approachable
and
There
benevolent
is potential
childbirth alternative.
for the
birth center
become a more legitimate alternative.
to
But, if
a hospital has control over the birth center,
we must not allow the birth center to look
like a hospital.
View
The idea of a birth center is an interesting
architectural
the
problem
introduction
There
are
of
many
because
a
new
it
with
existing
as I have discussed throughout
this thesis.
The birth center as a decentra-
maternity
health
Hospital Development,
Connecticut
type.
institutions,
lized
Bridgeport
Bridgeport,
considers
building
problems
of
care facility
can
fit
into an urban or rural context by implementing
creative
include
functional
collection
architectural
programmatic
and
of
decisions
issues,
aesthetic
information
as
objectives.
on
well
that
as
This
birth centers
View of
the great French prison at
Fresnes
might be useful for a community task force
or
any
interested
health
care
activitists.
84
Clinic Building, Wellesley Friendly Aid Association,
Wellesley Hills, Massachusetts
85
ILLUSTRATIONS
PAGE
8
Milinaire, Caterine,
9
Milinaire,
Birth Facts and Legends, p. 286.
Birth Facts and Legends,
p.
286.
Milinaire, Birth Facts and Legends, p. 290.
t
O
Viherjuuri,
2
Arguelles, Miriam and Jose, The Feminine,
3
Wertz,
Richard W. and Dorothy C.,
4
Wertz,
Lying-in:
5
Arms, Suzanne,
Sauna, The Finnish Bath, p.
Immaculate Deception,
p.
243.
2 1
Arms,
Immaculate Deception,
p.
61.
2
Arms,
Immaculate Deception,
p. 141.
2
4
Wertz,
Lying-In:
Immaculate Deception,
Arms,
Southmayd,
spacious as the sky, p. 7.
A History of Childbirth in America,
A History of Childbirth in America, p.
1 6
2 3
85.
p. 244.
Henry J. and Geddes Smith,
Small Community Hospital, p.
Lying-in, p. 135.
$ .1
Southmayd,
8 4
Hopkins, Alfred,
8 5
Southmayd,
Small Community Hospitals,
14.
p. 198.
Prisons and Prison Building,
Small Community Hospitals, p. 341..
p. 51.
181.
p. 15.
FOOTNOTES
IDick-Read, Grantley, Childbirth
2
Eliade,
3
Lipnack, Jessica,
Mircea,
Without Fear.
The Sacred and the Profane.
"Some Thoughts on a Book About Birth Centers,"
p.1.
4 Ibid.
5
Heschong,
Lisa,
6
Ibid.,
p. 93.
7
lbid.,
p.
Delight in Architecture,"
p.
70.
73.
8 Vieherjuuri,
9 Heschong,
"Thermal
H.J.,
Sauna, the Finnish Bath, p.
op. cit.,
10 Eliade, op. cit.,
p.
16.
p. 74.
141.
11Ibid.
12
Coffin,
Christie,
personal communication.
1 3 Sousa,
Marion,
1 4 Wertz,
Richard and Dorothy, Lying-in, p. 13.
15
Childbirth at Home, p.
15.
1bid.
16 lbid.,
p. 15.
87
17
Wertz,
1 8 Arms,
op.
cit.,
p.
217.
Suzanne, Immaculate Deception,
243, and Wertz, op. cit., p. 217.
p.
1 9 Bean,
Constance, Methods of Childbirth.
20
op.
Arms,
cit.,
p.
52.
21 Ibid.
22
Illich,
Ivan, Medical Nemesis.
23Lipnack, Jessica,
24
op. cit. , p.
Sousa, op. cit.,
2 7 Lipnack,
28
Norwood,
2 9 lbid.,
3 0 1bid.
31
32
(October,
1977): 33.
p. 39.
Ilbid.,
2 5 Wertz,
26
"A Special New Age Report on... Birth," New Age,
173.
p. 76,
77.
"Some Thoughts.. .on Birth Centers," op. cit.,
"Birth Centers:
p. 2.
A Humanizing Way to Have a Baby,"
Ms.,
(May,
1978): 92.
p. 89.
, p. 92.
Ibid.
Weisman, Leslie Kanes,
paper (1977).
"Birth Centers:
Restoring Women's Birth-Rights,"
unpublished
88
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92
APPENDIX A
McTAMMANY ASSOCIATED NURSE-MIDWIFERY
READING,
CENTER
PENNSYLVANIA
INTRODUCTION:
In response to an increasing number of childbearing families requesting an alternative to
traditional maternity care, in 1977 McTammany Associated expanded its obstetri-c gynecologic
practice to include nurse-midwifery services.
Today, we are pleased to welcome you to the
opening of the Nurse-Midwifery Center.
FACILITY:
The Nurse-Midwifery Center will house the professional offices of the nurse-midwifery
practice; a home-like birth unit for low risk mothers seeking a home and family-oriented
setting for childbirth; a conference room and library for nurse-midwifery students, nurses
and childbirth education.
STAFF:
The nurse-midwives of McTammany Associates are registered professional nurses graduated
from a program of study in one of the fourteen universities offering nurse-midwifery education.
They are certified
by the American
College of Nurse-Midwives
by national examination and
licenses to practice in the Commonwealth of Pennsylvania by examination by the Board of
Medical Education and Licensure.
They have been approved for staff privileges to practice
nurse-midwifery
tees.
at Community General
Hospital by the Medical Staff and the Board of Trus-
MEMBERS OF THE STAFF:
Myra Farr, CNM
Esther Mack, CNM
Sandra Perkins, CNM
Allison Seward, Registrar
J. Robert McTammany, M.D.
Thomas M. Ebersole, M.D.
Eunice K. Ernst, CNM Consultant
SERVICES:
Pregnancy testing, Prenatal care, Childbirth education, Post-partum care, Newborn care,
Family planning, Attendance of families registered for care at home, at the center, or in the
hospital, Gynecologic exam and pap test, Counseling for women's health.
9 3
All women
registered for prenatal
care are seen at least once by the physician.
Medical
complications
are
Other social,
economic and family problems are referred to the counseling services of McTam-
referred
to
the
obstetrician/gynecologist
for
diagnosis
and
treatment.
many Associated or other appropriate agencies or organizations in the community.
PHILOSOPHY OF CARE:
The philosophy of the Nurse-Midwifery Division of McTammany Associates embodies the following benefits:
1.
The childbearing families have a right to comprehensive maternity care.
2.
That women have a right to seek care that not only is medically safe for themselves and
their baby, but that fits their life-style and recognizes and respects their individual,
social, spiritual, and economic needs.
3.
That because the family is the cornerstone of our social structure, maternity care must
support and promote unity within the family.
4.
That childbirth is a peak life experience. It is viewed as a healthy process.
Confidence
is the physiologic function of the body to cope with childbirth is promoted in all aspects
of care.
5.
That childbirth is a critical period in the initiation of positive family-child relationship.
Separation of family members,
indicated.
6.
therefore,
is to be avoided unless medical intervention is
That nurse-midwives have a responsibility to inform women and childbearing families of
their options in the form of care plans, all procedures, and treatments.
the responsibility to make informed decisions about their care.
The family has
7.
That education is an essential, integral part of midwifery care and the childbearing
families are able to assume responsibility for health maintenance and effective utilization
of medical care.
8.
And that maternity care should be provided at cost.
94
1
ra
aw
CMA
ah
liws VAre.
4etch rvu4e
c
mIAMW
MY
-1/1 INPINGA) PA.
-kss, A upm*) Nt=z,
95
APPENDIX B
L
13IR-H
I,
Cl-ITEK -, LUCANIA
AcA HO9YT -TD1*
1MOl FF6e
64r1-Ax 6P.OVV) OKP-GN
~I
N
~V
(from& birth -Cert)rer(', eyere,e
V
it
)
90
BIRTH C5NTEK;-o LIACINIA
COTTArae (:WVE:, OP40 4 -
C
APPENDIX
CEKRRO
GORDO
THE HEALTH CONCEPT
Our culture i' for centurteumod ip.
xCrratrtLdo Ranch 5 to be the home of a newton that al
eord
h%bousesame 2 0
peo lhe goals of tfas amuni
ire
nerg
aid to I.I
'kmui t tunmpact.on the land, to .tn:<re
does not iLntendto be'
y iy itmetyi ah ehoiher The ,rvuioty
a .0flent, bud at doe, uat to make tne best uie of ts rututn
r e d of 45 penile the toun a)ll te day be the piace
u~eethie '(nhabdAnt
MrAG
4
OT THEL AN L)
e rioordo120 acre
1 bebutt uon Ihese
have
beencarefuLty ae teed o
nighdadut
lt
*
tutt or
r
tIll
pu
to1,
Luttdt, a
the impadt
tdinp.
L4
oat
t
.1,
tr
brth twe runimij- empAr.
ig
aiable
tfat
rr
t
.t,
tMr
h
ohe
lcu tn:xtI
Jrm Oedearg tefoorc anti
trjd'ta,'
a.t
of the prqxynd
Londrion
e
upon
ha e ir -uper
an
e
the
t
ds
n:iaLito.
dr.Lide L un, .etd:>l n
uc trtr
: neroi .iia feuture'
uitd
J.rnt
.
h- fouten frts o rtln
otte
ti
-- t
Ithe m
:neort .eg otem
tut
tnI r
trom ce t rrn
f
h
pert upto 'the iaqag
Groef Itr "
m i
er emewoot te ct -- eirn to Lm. ai b rLe'tsittl
be
r-,ita iriere.r pr.-K
Fbmt,6
heatC!' AIL
_Lusll
ai,
center.
I
&
o
sotar
I
I I
ii
There
anpng
e
;-aK
'sT
Lt'
th'
f!.L
r
I
I : I
I'
'P
L, 4 .. o,
n t
It
-
t~
f -
Al
r
'tt
h'
t1z
Wellolhild tlna
id hio t ir
e
I t&t
-r.
r idol
Nutnho to and feutth . la ,
Nutrtht,
space
rand
be u'e
o .1
.1
t It
It
r
A te'ai txII.t
eoIm roArnIs
t
. i to
I", tile
li. It1 ftt tlt
m .
,
ortsl'
,I
Ie d-'
i
rea
It
*
am5
Id
t It
r,,
taftrtm'm
fot'r
mgtert5
t
e
Iteithbaoil kit lwIl
th...1 _I141
h
.
-Io xirthroorns-.e
f . I
-
t i ;
ri'tf
ir I m.
,1.1to
r
-one thfit
I a oitie
a 1'
be th r
7 Lab-oe to eatm r A aint. Oht
8 Ptrrnic - nex to ab
> itaff room - auty from pubI treI
1,
. iq ,
- places to stec. It I
to lrerc,te r m do
f t t n itbI I I,
-I m
tf r th Raim
Mr
One fal 4 room1tI with a, tob toth'ttt tritI
'n'citlted fmme ther if
I t t...i
1) r
- in
ext
,ue
Welt. tuibj,4 Itoni
ihree
l
n
tlit
nilat
Totlts Mate and tetanle
-clos eto ent rtan, e
b kecordn office close tor en'IteI
4 Waiing momnathplay spce
clone to censulttig
Exam Realm
5 two eonuhgt ro 4 oomrs
ey-
U
4
Fbd,,
LOUJR PROGRAM
Enttrui e Realm
idniempca of Dot h
mmw
is hvrA. ulki iored 'Iul,
)in
o-r. tne .:I
or a po II , iUd Se 14 W,tndag and
r- rne c tnnn
forme' or ea-- it. '
Ared
fir id
ix, rmt rf !rj jXAi't
rtnee'
artS rcrere '
j, the rr.- L4
0i
hr
.
pr.
bit th honie
thl
the
a
. ..
54Jc
i t the btt r4.I,' La'
that ta l. t be vadever
onj,
a
t
0
the proe
f .Ir
birth an a sickness- r rnethng unrutfaL We bise .reperILs
ptaced birth in the ".etttri-j mv hote treated for trentingt it
the hospital
QuaPoponach to the prolen A j(-aI treq i rth place t, I
alnowlie dqe birth tns a pat fel ytq healthg aond rti ar at
and totherefore pitIt
a i'ethngq that hc bett
Ire. itet
maintamn heatth rathe t
io tAlettt -(
e tit 1h u w i
I IH-al th BIItq
t awh
birth t pi re por t t
Ao
to help people to take come of tt.r ' A
tirT WI
Iith
lhe htul lre
1 inLt heo ice thr F( 'ing11111
birth cOrtint andt farnii 1lcit-iki .- 1n,
P'r entat catr
ami (tt-erm
o
-
ofthe
eoredAnt .
t
'.
.I
..
.Lo
rm
r'eLr-ltl
'
98
.
1
99
1Oo
101
APPENDIX
D
Exhibit 12: Schematic Design: Chatham Family Birth Center
Second floor plan juxtaposed with existing plan. layout
(WoL*9ej of. demaiire Weller A6hbi1cl)
Existing
Proposed
102
Exhibit 11: Schematic Design: Chatham Family Birth Center
First floor plan layout juxtapo sed with existing plan layout
E xisting
Proposed
103
APPENDIX
COMMON
E
XiSTltd4G PFJATICE) O/&|CoM
UNIT
N-,
0
0
0
0
0
E FCR A
LArr[ELP S1ATE5
uNEr (IN--HOGPTAL,
P@LI& HEALTH %V1c
DELIVERY
4
4
104
APPENDIX F
Maternity Center Association
Demonstration Project in Out-of-Hospital Maternity Care
Conditions precluding management at Childbearing Center
The following Criteria will be applied to all women by professional staff during the
antepartum, intrapartum and postpartum periods.
A cumulative score of 2 points on the Initial Score Sheet indicates the women is at a
risk incompatible for project care. Accepted women will be continuously evaluated for presence
of any listed antepartum, intrapartum or postpartum criteria and be referred or transferred to
the back-up facility or physician.
Developed by the Medical Team Staff of the Childbearing Center; originally approved for distribution by the
Medical Advisory Board of Maternity Center Association, November 15, 1976.
Subject to change based on experience.
Revised 11/22/77
10 5
Problem Descrintion
V--
1.
core
So
rbe
ecito
16. Thyroid diseasea. History of thyroid surgery
b. Enlarged thyroid gland with symptoms of thyroid
disease based on T3 or T4
c. Current use of thyroid related medications
E-Respiratory
17. Asthma and/or chronic bronchitis within the last
5 years
F-Other Systems
18. Bleeding disorder and/or hemolytic disease
19. Sensitivity to local anesthetics ("caines")
20. Previous radical breast surgery
21. Other serious medical problems
Initial Data Base
Socio-Demographic Factors
1. Chronological Age: 35 & over primigravida
40 & over multigravida
2. Permanent residence outside specified
target area
Documented Problems in Maternal Medical History
A-Cardio-vascular
3. Chronic Hypertension
4. Heart Disease
5. Pulmonary Embolus
B-Urinary System
6. Renal disease moderate to severe including
nephritis or 1 episode of chronic renal
disease7. One episode of pylonephritis prior to this
pregnancy
8. Two episodes of cystitis prior to this pregnancy and evidence of asymptomatic bacteruria
( t 100,000 colony count)
C-Psycho-Neurological
9. Previous psychotic episode adjudged by
psychiatric evaluation
10. Current mental health problem adjudged significant by psychiatric evaluation and/or required use of drugs related to its management
11. Epilepsy or seizures
12. Required use of anticonvulsant drugs
13. Drug addiction (heroin, barbiturates, alcohol
etc.), current use of addicting drugs, or current therapy related to these additions
14. Severe recurring migraines
D-Endocrine
15. Diabetes Mellitus and/or gestational diabetes
Problem Description
Documented Problems in Maternal Obstetrical.History
2
2
1
2
2
2
2
2
1
2
2
1
1
22. EDC less than 12 months from date of previous
delivery
23. Previous Rh sensitization
24. Parity of 4 or more
25. Infertility problems
a. Workup and counseling more than 3 years prior
to this pregnancy
b. Use of fertility drugs to achieve this preg.
26. Previous abortions:
a. 3 or more spontaneous (( 28 weeks)
b. 1 septic
27. Previous uterine surgery including C-section and
cone biopsey (if previous tubal pregnancy & enrollment before 16 weeks accept conditionally)
28. Previous placenta abruptio
29. Previous placenta previa and/or significant third
trimester bleeding
30. Severe hypertensive disorder during previous preg.
31. Postpartum hemorrhage apparently unrelated to management
32. History of prolonged labor:
a. Primipara-Stage 1>24 hre; Stage 2>3 hrs; and/oi
Stage 3 > 1 hour.
b. Multipara-Stage 1>18 hrs; Stage 2> 2 hrs, and/oi
Stage 3}1 hr.
106
Score
1
1
1
1
2
2
2
2
2
2
2
1
2
2
2
2
2
2
2
2
2
2
2
Materni
Center Association ChiJ.dbearing Centet
Problem De
It
~~-~
A'roblem De
Jri
, -icnr2
Documented Problems in Previous Infants
54. Symptoms of gestational diabetes affirmed by
abnormal glucose tolerance curve
33. Stillbirth (>28 weeks gestation)
55. Development of unexplained vaginal bleeding
34. Birthweight:
56. Abnormal weight gain (cl2 or >50 lbs.)
57. Non-vertex presentation persisting past 37th
a. < 2500 grams
b. >4000 grams
week of gestation
35. Major congenital malformations
58. Laboratory evidence of sensitization in Rh
36. Genetic/metabolic disorder
negative women
59. Postmaturity (42 weeks/294 days gestation)
Maternal Physical Findings
60. Development of any other severe obstetrical,
medical and/or surgical problem
37. Gestation more than 22 weeks
61. Development of genital herpes affirmed by culture
38. Weight for height outside intervals on at62. Circumstantial factors: Medical Team Staff
tached chart
decision, after taking into account and review
39. Clinical evidence of uterine myoma or malof all of the family circumstances, including
formations, abdominal or adenexal masses
make-up, general physical condition, and total
40. Polyhydramnios or oligohydraminos
situation, that the childbearing in this case
would be best accomplished under the supervision
41. Cardiac diastolic murmur, systolic murmur
grade III or above and/or cardiac enlargeof a physican in a more traditional medical
ment
setting, i.e.,
42. Pelvimetry indicative of inadequacy to dea. Lack of available support person to be in the
home during the first 3 postpartum days
liver an infant of 3100 gm.
b. Lack of source of pediatric and/or obstetrical
follow-up after 28 weeks of gestation
Laboratory/Radiologic Findings
c. Consistent non-attendance at classes and/or
43. a. Hct less than 31%
office hours
b. Hct less than 28%
44. SS Hemoglobin
III. Intrapartum/Postpartum Transfer Factors
45. Pap smear class 3 or greater with positive
colposcopy
63. Premature labor (less than 37 weeks gestation)
46. Evidence of active tuberculosis
64. Premature rupture of membranes (greater than 12'
hours before onset of regular contractions)
II. Antepartum Referral Factors
65. Non-vertex presentation
66. Evidence of fetal distress
47. Hct less than 34% if entering the 37th week
a. Abnormal heart tones
of.gestation
b. Meconium staining
48. Multiple gestations affirmed by sonogram
67. Estimated fetal weight less than 2500 gm. or
49. Evidence of fetal chromosomal disorder in
greatar than 4010 gus.
amniotic fluid
68. Development of hypertension
50. Development of symptoms of pre-eclampsia
69. Failure to progress in labor:
51. Intrauterine growth retardation
a. First stage: lack of cteady progress in dili52. Thrombophlebitis
tation and descent (Friedman graph) after 24
53. Pylonenhritis
hours in primipara & 18 hours in mIl tIrj1"0
7
MATERNITY CENTER ASSOCIATION CHILDBEARING CENTER
Acceptable Wei.hts for Women-Over 25* at LMP
Problemn
Descrintion
Problem Description
Score
Score
2
70.
71.
72.
73.
74.
75.
b. Second stage: more than 2 hours without
progress in descent
c. Third stage: more than 1 hour
Prolapse of cord
Soft tissue problems
a. Severe vulvar varicosities
b. Marked edema of cervix
Intrapartum blood loss greater than 500 cc and/or,
postpartum hemorrhage
Development of other severe medical/surgical
problem
Evidence of active infectious process
Any condition requiring more than 12 hours of
postpartum observation
V. Infant Transfer Factors
76. Apgar score less than 7 at 5 minutes
77. Signs of pre or post maturity
78. a. Weight between 2200 and 2499. (Pediatrician
to.determine whether hospitalization is
necessary)
b. Weight equal to or less than 2199.grams
79. Respiratory problem
80. Jaundice
0
81. Persistenthypothermla (less than 97 F, rectal
life)
of
after 2 hours
82. Exaggerated tremors
83. Major congenital anomaly
84. Any condition requiring more than 12 hours
observation post-delivery
Type of Frame
Height without
Shoes
4'8", (56")
(57",)
4'10" (58")
4'11" (59")
(60")
5'1" (61")
5'2" (62")
(63")
5'13"
5'4"1 (64")
5'5" (65")
5'6" (66")
5'7 " (67")
5'8" (68")
5'9" (69")
5'10" (70")
5'11" (71")
6'0" (72")
6'1"' (73")
Small
Medium
Large
92-98
94-101
96-104
99-107
102-110
105-113
108-116
111-119
114-123
118-127
122-131
126-135
130-140
134-144
138-148
142-152
146-156
150-160
96-107
98-110
101-113
104-116
107-119
110-122
113-126
116-130
120-135
124-139
128-143
132-147
136-151
140-155
144-159
148-163
152-167
156-171
104-119
106-122
109-125
112-128
115-131
118-134
121-138
125-142
129-146
133-150
137-154
141-158
145-163
149-168
153-173
157-177
161-181
165-185
*For women less than 25, subtract 1 pound for
each year under 25
Underweight - prepregnant weight 10% or more below
standard weight for height and age+
Overweight - prepregnant weight 20% or more above
standard weight for height and age+
+Pitkin, Roy M. "Risks Related to Nutritional Problems
in Pregnancy" Risks in the Practice of Modern Obstetrics, 2nd Ed., Editor: Silvio Aladjem, St. Louis:
1975; C. V. Mosby Co., pg. 168.
10 8
APPENDIX
G
Mount Zion Hospital and Medical Center LUU'
ALTERNATIVE BIRTH CENTER
La
1600 Divisadero Street, San Francisco/Telephone (415) 567-6600
Mailing Address: Post Office Box 7921, San Francisco, California 94120
Policies and Procedures
DEPARTMENTS OF OBSTETRICS
AND PEDIATRICS
CRITERIA FOR ADMISSION
1.
Al I patients must have prenatal supervision by a licensed
physician, either a private attending obstetrician, clinic
physician, or nurse midwife under a physician's supervision.
2.
No findings suggestive of increased risk of complications
du ring labor, delivery or immediate postpartum period should
be
present.
prepared childbirth
3.
All patients must attend some type of
classes (Lamaze, Bradley, etc.)
4.
All patients should participate in the orientation program
provided by the Mount Zion staff for use of the Alternative
Birth Center.
5.
All patien ts must understand that if their labor status changes
to ore of high risk, transfer to the regular labor and delivery
area wi I I be necessary.
'109
6.
All
mothers who
companied
wish to use
the Center
are expected to
be
ac-
by a support person.
7.
All patients must sign an informed consent form accepting the
risks involved in delivering in the Alternative Birth Center
prior to admission to the Center,
8.
A specific plan for family participation,
agreed
9.
in
upon
if
desired,
must be
advance.
The infant's pediatrician must
for care of the newborn.
be agreeable to the criteria
3/77
HIGH RISK FACTORS EXCLUDING
ADMISSION TO THE ALTERNATIVE BIRTH CENTER
Social factors:
< 3 prenatal visits
Maternal age:
Primipara
>
35 years or Multipara
> 40 years
Pre-existing Maternal Disease
Chronic hypertension
Moderate -+
severe renal disease
Heart disease Class ll-IV
History of toxemia with seizures
Diabetes
* Anemia - Hgb 4 9.5 gm
Tuberculosis
Chronic or acute pulmonary problem
Psychiatric disease requiring major tranquilizer
Previous Obstetric History
*
Previous stillbirth
Previous Cesarean section
Rh sensitization
Multiparity > 5
Previous infant with RDS at same gestation
1 10
Present Pregnancy
Toxem ia
Gestational age < 37 weeks or > 42 weeks
Multiple pregnancy
Abnormal presentation (Primipara with a floating head will need
evaluation by her obstetrician)
3rd trimester bleeding or known placenta previa.
Prolonged ruptured membranes > 24 hours
EFW
5 lb or > 9 lb.
Contracted pelvis, any plane
Pelvic pathology
Adenexal masses
Pelvic tumors
Uterine malformation
Genital herpes
Polyhydramnios
Treatment with Reserpine, Lithium or Magnesium
Induction
Spinal or epidural anesthesia
Any other dcGife or chronic maternal
illness, which,
in the opinion
of the medical staff would increase the risk to the mother or infant.
*May use Center with I.V. during labor
4/76
1 1 1