The medical model of birth

Although birth is a natural process it has been pathologised by the medical model of birth in an attempt to mitigate risk and improve outcomes. Whether this is counter-productive is a hotly debated issue between midwives and doctors. Birth is complex and multi-dimensional, and to be placed on your back on a hospital bed will impede the natural physiological birth process and increase the need for medical interventions, yet this is common in doctor-led deliveries. The ‘lithotomy position’ where the birthing woman or person is on their back in bed, with their legs in stirrups is a frightening prospect for many birthing people. The position (commonly used for medical procedures or examinations) is designed to make it easier for doctors to carry out interventions such as episiotomies, use of ventouse or forceps, or in stitching tears. There is little in this position to otherwise recommend it for the benefit of the person giving birth.

The arguments for active birth

In direct contrast to the lithotomy position described above, research shows that an active labour and birth – where movement is encouraged, and a squatting, kneeling or forward bending position in delivery is often adopted – helps to facilitate the normal physiological process of labour and birth and leads to better birth outcomes. Many women we spoke to were fearful of being on the bed with their legs in stirrups as this, to them, signified a loss of control and as if the birth was a “clinical procedure” and transformed the room into something that resembled “an operating theatre”. If complications do indeed arise, and medical interventions later become necessary, research shows that birthing women and people want to retain a sense of personal achievement and control. This may be difficult to achieve if the labour process up to that point has been restricted to the lithotomy position, and the ability to move around independently has been denied. Research also shows that birthing women and people who are free to move around were more able to feel safe and in control of their pain, rather than lying exposed on a bed where the position is one of being examined.

A normal, physiological birth is defined as follows:

1. The onset and progression of labour is spontaneous;
2. The biological and psychological conditions that promote effective labour are present;
3. The outcome is the vaginal birth of infant and placenta;
4. Skin to skin contact between mother and infant is facilitated;
5. The early initiation of breastfeeding is supported.

The freedom of movement in labour, and the birthing woman or person’s choice of birth position, is of key importance in establishing a normal, physiological birth which leads to physical, emotional and psychological benefits.

Equipment to facilitate active birth

A labouring body goes through many emotional, psychological and physiological stages in the process leading to birth. Common themes emerge when birthing women and people are free to move around and choose positions themselves: the circling of hips (sometimes called ‘spiralling‘), rocking, leaning forward or squatting. The labouring body, when free to follow natural instincts intuitively, seems to know the best positions to adopt in order to work with (rather than against) gravity and to facilitate the movement of the baby through the pelvis. Research confirms that maintaining upright, active positions in labour result in better outcomes for the birthing woman or person and infant, so providing a space and equipment that encourages and supports this is an important consideration in the design of birth spaces.

Equipment that can encourage and support an active birth can include (but is not limited to):-

1. 1. Ceiling slings;
   2. Birthing pools;
   3. Delivery stools;
   4. Beanbags;
   5. Floor mats;
   6. Grab rails;
   7. Peanut balls.

Important to note is that birthing pools offer both the benefit of free movement and also the soothing warmth and weightlessness of water and are very popular. Women we spoke to who gave birth in hospital were very keen to use one where possible (although these were not routinely available despite evidence as to their efficacy). As with all elements in the birth space, equipment should be adaptable and accessible for all abilities.

Additionally to the above, research finds that labouring women and people use hand behaviours such as grasping, pressing and rubbing and that these represent more than two-thirds of hand behaviours in labour. The rationale given is that this offers a sense of relief and control from a situation in which there is no escape, and in which higher controlling elements of the autonomic nervous system were interrupted. Another source suggests that sensations of pressure (such as gripping or rubbing) stimulates large diameter nerves which override or limit the sensation of pain. This is due to gate control theory: essentially that there is a finite amount of sensory data able to be processed at any one time, and the increase of sensations such as pressure or friction will decrease the amount of pain sensations able to travel through the ‘gate’ at any one time. Based on this evidence, equipment (such as tactile fabrics, grab rails, products to exert pressure on or pliable materials) that can be used to support this natural instinct would be useful in the design of a birth space.

By Zoe Markham. August 2020

What does this mean for the design of a birth space?

1. What are the important considerations to be made to facilitate, rather than hinder, movement in labour? The layout of the room should provide the space, and the equipment should provide the means, to enable free movement and to encourage natural birthing instincts. What would this look like?
2. What considerations should be made to make the space and equipment accessible for all? The adaptability of the space and equipment should be a consideration. Why is this important?
3. How can the focus of the room be shifted to make the bed less dominant in the room? Why is this important for encouraging an active birth?