Center for Health Facilities Design and Testing

Image by Sara Kennedy

By: Brooke A. Karlsen, MSN, BSN, RN, NEA-BC

Maternal care was an early clinical interest for me and this interest inspired me to pursue nursing so many years ago. As a student in the certificate program in Leadership and Innovation in Health + Design at Clemson University, I am enjoying studying the connections between healthcare policy, nursing and the design of the built environment. Last semester, I had the opportunity to undertake research on an area of public health policy and explore its connection to the built environment. I chose to study maternal mortality and morbidity and its relationship to the design of the built environment. In conducting the research, I was saddened to see the trends in the U.S. and feel called to do what I can in my new career, blending my extensive experience in healthcare with planning, design and construction to make a difference through the built environment.

I learned that the maternal mortality rate in the U.S. has risen consistently since data collection began from 7.2 deaths per 100,000 in 1987 to 17.3 in 2017. The maternal death rate exceeds that of 40 other countries and the U.S. is one of only eight countries worldwide and the only developed nation where maternal mortality has actually increased over the past three decades. Additionally, for every maternal death there are estimated to be 70 cases of severe morbidity, and many more near misses that are not quantified. With up to 60% of maternal deaths being categorized as preventable, there has been heightened interest in the clinician, patient and institutional factors that contribute to poor maternal outcomes, and to identify potential areas for intervention.

While there is a large body of literature outside of obstetrics linking care environment with patient outcomes, there is limited research on the impact of the physical environment of obstetric care on maternal morbidity and mortality. What I did learn from the limited research found on birth environments, is that there are three important built environment themes which promote normal physiological birth processes, influence the need for medical interventions, and effect cesarean section rates. The three areas that architects, clinicians and healthcare administrators should consider for design and research in birth settings are the overall aesthetics of maternal care environments, the design of the birth room as well as unit layout and design. These influences, in turn, impact maternal mortality and morbidity, both directly and indirectly.

Aesthetics

The overall aesthetics of the birth experience are important in helping to avoid triggering a fear cascade in the laboring woman, which is known to affect the birth processes by disrupting the normal physiological hormonal response in labor. The aesthetics of the space are extremely important and include all the areas the woman will encounter throughout hospitalization, and should be designed to promote relaxation. Included are the use of warm colors, textured surfaces, a homelike look for furnishings and fabrics as well as the use of soft lighting, natural light, and views of nature. Artwork, posters or symbols using the female archetype, located in strategic places in birth rooms or the unit where the laboring woman might walk, have been shown to be calming and helping to decrease stress.

Birth Room

The birth room contributes to the normal physiological processes of labor. Labor progressing naturally on its own lessens the need for medical interventions. In addition to the birth room aesthetics, birth rooms must have the essential technical equipment such as fetal monitoring capabilities and neonatal care equipment immediately available. However, for some, its’ presence might trigger anxiety or fear, so housing it in concealed cabinetry unless needed is recommended. Similarly, access to emergency supplies in the room is essential to prevent delays in necessary care, but like other technical equipment, should be concealed whenever possible. Another aspect that can trigger the fear cascade is lack of privacy. The spatial filter, which is the interface between the public corridor and the room itself, is a design element to consider. Privacy curtains, half walls, or doors angled in a way that protects the inside of the room from view from the hallway can be utilized to enhance the sense of privacy.

Features of the birth room layout contribute to the normal physical mechanisms of labor. The room’s size, shape and layout configuration should allow for flexibility to change the room for the different phases of labor and to facilitate the woman utilizing the space in a way most comfortable for her. The laboring woman needs to be able to move around and assume varied positions, so having space for optimal equipment such as birthing stools, bean bags, gym mats, wall bars, along with accessible bathrooms with showers and birthing tub is necessary. The amount of time the woman spends lying in bed impacts the progression of labor (less being better), therefore, the ability to easily move the bed out of the way should be factored into the design. Because continuous labor support is linked to successful outcomes of labor, having sufficient space in the labor room for the supporter and their belongings should be prioritized. Lighting and temperature of the rooms should be capable of being controlled by the woman and or her supporter.

Unit Layout/Design

Beyond the spaces that the laboring woman encounters during the birth process, the overall unit layout has important implications for minimizing morbidity. Because obstetric hemorrhage is a leading cause of maternal death and morbidity, managing hemorrhage requires ready access to life-saving equipment, medications and blood products. In particular, birth units should regularly reassess current practices, logistics, and locations of blood products relative to where they might be needed. At “baseline” blood storage be in the same building as the labor unit, but a “better” practice would be storage on the same floor, and “best” practice would be storage of blood product right outside the cesarean section operating room.

Additional insight into the importance of unit layout emerged from the Ariadne Lab and Mass Design Group’s exploratory study linking facility design with cesarean section rates. High cesarean rates having been identified as a key factor in the increasing maternal morbidity and mortality rates. They concluded that more deliveries per labor room, fewer labor rooms per operating room, higher ratio of overflow beds to labor rooms, longer distances between spaces, proximity of on-call rooms, and lower percent of support areas designated as collaborative spaces, were all associated with higher cesarean delivery rates. Limited unit or facility capacity, high workload, and limited accountability for decision–making all contribute to the clinical decision to perform a cesarean section. Normal vaginal delivery is both space and clinical resource-intensive, whereas a cesarean delivery requires only a few hours of clinical attention. When under pressure to make more space for incoming patients, or in times of staffing shortages, a decision point of whether to continue to attempt vaginal delivery or expedite things by performing a cesarean birth is reached. Thus, design elements can play a significant role in that decision.

Conclusion

Despite the limited number of robust studies on the built environment for labor and delivery, the research that exists supports the essential role of the built environment in promoting physiologic labor processes and reducing maternal morbidity and mortality. These initial studies provide some direction for healthcare planners and designers. However, further research is much needed! Looking to the practices and processes from other countries who have succeeded in reducing the alarming mortality and morbidity rates should also be pursued.

Image by Faequa Uniza Rahman

By Anjali Joseph

The Environmental Design Research Association came into being in the 1960s, led by a group of forward-thinking activists and environmental design researchers who believed that architects and designers held a social responsibility to create environments that supported human behavior and intentions, well-being and performance for everyone. This highly multi-disciplinary and inclusive community includes psychologists, social science researchers, architects, landscape architects, interior designers, design researchers and students with a range of interests and focus areas. EDRA members represent many different countries and are leaders in the field of environment and behavior studies, evidence-based design, facility evaluation methods, sustainability, active living, participation, community planning, universal design, diversity in design, workplace design and informatics, design education, and digital technologies. Anyone interested in engaging in conversation around the design of the physical environment and its impacts on human behavior and performance has a home in the EDRA community.

I first attended EDRA in 2003 as a doctoral student at Georgia Tech. I vividly recall standing nervously in front of my poster during a session at EDRA. I remember the many friendly EDRA members who stopped by to provide words of encouragement and advice. At another EDRA conference, at the urging of my advisor Craig Zimring, I organized a workshop session on active living for environments for aging. With Craig’s support, I was able to recruit many leading EDRA researchers including Habib Chaudhury, Atiya Mahmood, Benyamin Schwarz and Gerald Weisman. As I found then and it continues to be the case, the EDRA community is generous in sharing their knowledge and willing to mentor and support young students and early career professionals. These interactions and countless others at EDRA helped me gain confidence as a speaker and researcher and helped me make connections that have served me well during my career.

EDRA creates so many opportunities for students and professionals to enrich their careers and expand their knowledge about environmental design, just like it did for me as a student. The values and philosophy of EDRA resonates with so much of what we do at the Clemson School of Architecture and the Center for Health Facilities Design and Testing. For all these reasons and many more, Clemson University and EDRA 53 co-chairs (Dina Battisto, B.D. Wortham- Galvin and I) are deeply honored and excited to be hosting the 53rd Environmental Design Research Association (EDRA) Annual Conference in 2022 in Greenville, SC!

The theme of the 2022 conference is Health in all Design: Promoting health, equity, sustainability and resilience through environmental design. As we emerge from a global pandemic, it has become imperative that environmental designers and researchers consider health – a state of complete physical, social and mental well-being over time – as a critical goal for all design projects. The pandemic has highlighted the importance of the built environment in promoting safe and healthy lifestyles by providing access to outdoors and green areas for physical activity, good air quality and building layouts that support hygienic practices indoors, and ergonomic design that promotes wellness in workplaces. The pandemic has also highlighted stark inequalities – black, indigenous and people of color (BIPOC) communities have been disproportionately impacted in terms of mortality, illness and unemployment. Providing access to safe and affordable housing, healthcare and health-promoting resources has never been more critical for these communities. Greenhouse gas emissions resulting from human activity including transportation, building construction and operation are contributing to climate change, and future designs should not only impact individual and community health but also help improve planetary health. Inclusive of sustainability and cities’ abilities to help sustain diverse environments, cultures, and economies locally and globally, resiliency which implies the ability of a community to anticipate and recover from challenges is needed now more than ever before. Through ‘Health in all Design’, EDRA 53 will bring together a multidisciplinary community of practitioners and researchers to engage in a conversation about the role of built environment in promoting health, equity, sustainability and resilience as we move beyond the pandemic.

Greenville is a prime example of our proposed theme: Health in all Design. Through an engaged public private partnership, the city of Greenville was revitalized to include a range of health-promoting community resources including walking and biking trails and parks such that it is listed among the 10 most livable cities in the US. Further, the city plans to implement smart city concepts in the near future to support health and well-being of its residents. Clemson University’s College of Architecture, Arts and Humanities (CAAH) and its allied programs that are encompassed by EDRA – landscape architecture, city planning, historic preservation, architecture and health, and resilient urban design – are deeply engaged in conversations locally and globally around health, equity, sustainability and resilience. The Interdisciplinary Ph.D. program in Planning, Design and the Built Environment (PDBE) in CAAH also includes a concentration in Built Environment and Health. The graduate program in Architecture + Health at Clemson focuses on studying how architectural environments impact health and how to create architectural settings that support the health and well-being of individuals and larger populations. The Master’s program in Resilient Urban Design (MRUD) prepares individuals to engage complex cultural, market, and government policy forces through sustainable and resilient urban form. Further, we integrate professional degree programs and research programs to foster lively discussions around blending design, theory and practice. The focus of these programs as well as the broader mission of the landscape architecture and architecture programs at Clemson align well with the goals of EDRA and the theme of this conference.

This proposed theme invites abstracts that focus on research, projects, methods, and designs that envision a safer and healthier post-pandemic world. Thus, the theme will manifest in various session tracks that might include:

Health, Equity, Resilience and Sustainability: How are we generating knowledge to address the great challenges of the time, like: public health issues, an increasingly digital society, climate change, social inequities, overpopulation, stewarding tangible and intangible heritage, an increase in both waste and pollution (soil, air, noise, water), natural resource depletion, access to affordable housing, access to food and water, loss of biodiversity, loss of cultural diversity, urban sprawl, etc.? How do we rely upon simultaneity and adjustability to manage these challenges both locally and globally?

Designing for Diverse Populations: How are we considering the needs of post-pandemic? What impacts did our buildings, communities and natural environments have on vulnerable populations including children, ethnic minorities, young adults, the elderly, people with mental disorders, people with physical disabilities during the pandemic? How will the lessons learned during the pandemic shape the design of future environments for diverse populations?

Designing for Health: How do design and planning professionals approach and define health and well-being as a core part of their practice? How does it affect their methods? What are the emerging design tools (data, simulation, virtual) and how are they being deployed in design projects?

Activism & Advocacy: What are the methods, conversations, and outcomes for those researching and designing under the auspices of design activism, action research, public service, and public education? We encourage not only success stories but also critical discussions of pitfalls and “failures” that serve as learning opportunities for this work.

Trans-disciplinary: How are professionals and academics crossing boundaries to address emerging issues of health, equity, sustainability and resilience in a post-pandemic world? What are the means for doing this? What critiques emerge when blurring and/or borrowing from multiple disciplines?

Pedagogies/Methods: What are the ways in which teaching promotes design and research excellence, innovation, and/or activism? What methodologies are being embraced by environmental design faculty in order to innovate and stimulate their research? How are emerging design tools (data, simulation, virtual, etc.) being used in the classroom and/or in research?

Join us June 1-4, 2022 to discover more about ‘Health in all Design’ and what we can learn from experts in environmental design. EDRA holds a special place in my heart and I am very excited to bring EDRA to Greenville and Clemson. To get involved with EDRA events, explore publications, and expand networking opportunities click here.