Factsheet – Creating a positive birth space environment

Bruna Dias Alonso

Independent Midwife, Lecturer and Researcher based in São Paulo city (Brazil). BSc, MSc, and PhD

@brubsalonso

What we know

People at low risk of complications (i.e., healthy women and individuals with uncomplicated pregnancies) may choose any birth setting: obstetric units, birth centres (alongside midwifery units and freestanding midwifery units) or home (NICE, 2023). Obstetric units are always located within hospitals and offer access to medical care if needed, such as obstetric, neonatal, and anaesthetic care. In these places, midwives provide care to all individuals, while doctors are responsible for those at high risk (i.e., women and individuals with health conditions or who have more complex pregnancies) and for managing complications that arise during birth. Alongside midwifery units are typically situated within hospitals, either adjacent to the labour ward or delivery suite or on the same site in a separate building. In the latter case, transfers can be made by walking, wheelchair or bed. Freestanding midwifery units, on the other hand, are located independently, either on a separate site or within a community hospital. Transfers from these units typically occur by car or ambulance. In both alongside and freestanding midwifery units, called also as birth centres, care is led by midwives. Regardless of place of birth, women and people should be supported in their choice (NICE, 2023).

Despite the variety of institutional maternity care settings, there is a consensus that the environment surrounding a childbearing person significantly influences labour and birth. A calm, private and safe ambience is known to promote proper neuro-hormonal functioning, thereby supporting the physiology of birth (Buckley, 2015). When we talk about physiological labour and birth, we refer to a process that begins spontaneously and results in a non-instrumental vaginal birth, with both mother and baby remaining healthy. Furthermore, individuals must have a positive experience throughout the process (WHO, 2018).

Overall, a familiar and comfortable environment is associated with fewer medical interventions during labour and birth, as well as greater satisfaction with care (Hodnett, Downe and Walsh, 2012). But how are maternity settings responding to this evidence? In other words, how do conventional institutional environments—often perceived as impersonal—transform into more welcoming and supportive spaces? The key idea is that the birth environment should be adaptable to meet individual needs, including social and cultural considerations (Newburn and Singh, 2003). This adaptability can be reflected in various types of spaces, such as bedroom-like rooms, ambient rooms, or Snoezelen rooms. These spaces often incorporate multi-sensory elements, including visual, tactile, auditory, and olfactory stimuli, which can positively impact the labour and birth experience. Creating a positive birth environment involves attention to the physical space, including features such as comfortable furniture (especially the bed), access to a shower and ensuite toilet, the availability of immersion in water (e.g., birthing pools), sufficient space to move around, and the ability to control lighting, temperature, noise, and aromas. Cleanliness, privacy, and a sense of safety are also essential (WHO, 2018; Hodnett, Downe and Walsh, 2012; Newburn and Singh, 2003).

A review of ten studies involving 11,795 women found that alternative institutional birth settings (e.g., bedroom-like rooms and ambient rooms) were associated with several benefits. These included an increased likelihood of avoiding intrapartum analgesia/anaesthesia, achieving a spontaneous vaginal birth, breastfeeding at six to eight weeks postpartum, and reporting positive experiences with care. Additionally, the review noted a decreased likelihood of epidural analgesia, oxytocin augmentation of labour, instrumental vaginal birth, and episiotomy. Notably, no significant differences were observed in serious perinatal or maternal morbidity and mortality when alternative institutional birth settings were compared to conventional settings such as conventional hospital labour rooms (Hodnett, Downe and Walsh, 2012).

It is also evident that alternative institutional birth settings tend to favour midwifery-led continuity of care (Sandall et al., 2024) and continuous support (Bohren et al., 2017), both of which are key components of a positive birth environment as identified by women and people (WHO, 2018). Research shows that people receiving midwife-led care are more likely to have a spontaneous vaginal birth and express satisfaction with their care. Additionally, they are less likely to experience interventions and adverse outcomes, including regional analgesia, instrumental vaginal birth, preterm birth, fetal loss, and neonatal death (Sandall et al., 2024). 

 What we don’t know

According to the systematic review by Hodnett, Downe, and Walsh (2012), concluding the independent effects of the physical birth environment is challenging. This is because the design features of the alternative settings were confounded by significant differences in the organizational models of care.

Families: how to use the evidence

• A calm, private and safe ambience will support you during labour and birth, contributing to better outcomes for you and your baby, including a positive birth experience.
• A place of birth that allows you to be accompanied also contributes to better outcomes.
• If you are at low risk of complications (i.e. healthy with straightforward pregnancy), attendance at the alongside midwifery units or freestanding midwifery units is as safe as what is offered in obstetric units in hospitals. Planned home birth also be a safety option.
• Know the experience of other women and people who gave birth in different places.
• Ask your midwife or GP about the places available to you.
• Know all your available places of birth available

 Midwives and birth workers: how to use the evidence

• Ensure policies support women’s choice of birthplace
• Ensure policies support non-obstetric units (i.e. alongside midwifery units and freestanding midwifery units), as these settings result in positive mother and neonatal outcomes,^1,12 and the costs of care are also lower¹³
• Healthcare practitioners should routinely provide all women with full information about their birthplace at an opportune time, i.e. ensuring that women have the opportunity to discuss options, benefits, and concerns.^14,11
• Healthcare providers should support women’s choice¹¹
• Maternity care settings should provide physical environments that support hormonal physiology, creating a positive birth space environment through, comfortable furniture (especially the bed); shower and ensuite toilet; access to water immersion (birthing pool), space to move around, lighting control, heating control, noise, clean rooms and privacy⁷