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Birth environments for women with complex pregnancies: A mixed-methods systematic review

Open AccessPublished:April 14, 2022DOI:https://doi.org/10.1016/j.wombi.2022.04.008

      Abstract

      Background

      Birth environments can help support women through labour and birth. Home-like rooms which encourage active birthing are embraced in midwifery-led settings. However, this is often not reflected in obstetric settings for women with more complex pregnancies.

      Aim

      To investigate the impact of the birth environment for women with complex pregnancies.

      Methods

      This was a mixed-methods systematic review, incorporating qualitative and quantitative research. A literature search was implemented across three databases (Medline, CINAHL, Embase) from the year 2000 to June 2021. Studies were eligible if they were based in an Organisation for Economic Cooperation and Development country and reported on birth environments for women with complex pregnancies. Papers were screened and quality appraised by two researchers independently.

      Findings

      30,345 records were returned, with 15 articles meeting inclusion criteria. Studies were based in Australia, the UK, and the USA. Participants included women and health professionals. Five main themes arose: Quality of care and experience; Supportive spaces for women; Supportive spaces for midwives; Control of the space; Design issues.

      Discussion

      Women and midwives found the birth environment important in supporting, or failing to support, a positive birth experience. Obstetric environments are complex spaces requiring balance between space for women to mobilise and access birthing aids, with the need for medical teams to have easy access to the woman and equipment in emergencies.

      Conclusion

      Further research is needed investigating different users’ needs from the environment and how safety features can be balanced with comfort to provide high-quality care and positive experiences for women.

      Keywords

      Statement of significance

      Problem
      Women with complex pregnancies have less choice over birthplace. Birthing rooms are often designed to facilitate medical emergencies rather than physiological birth processes.
      What is already known?
      Birth environments can influence women’s outcomes and experience. Women prefer rooms that are homely and relaxing, aiding birth physiology. These types of birth rooms are commonly based in midwifery led settings and are not available to all women.
      What this paper adds?
      Designing to provide flexibility in the space will accommodate women’s needs and other room users. Balancing the provision of a supportive environment with suitability for medical emergencies is vital.

      Introduction

      The policy for maternity care in England, the UK National Health Service (NHS) Better Births National Maternity Review, describes quality maternity services as safe, clinically effective and providing a good experience [

      NHS England. Better Births: Improving outcomes of maternity services in England – A Five Year Forward View for maternity care. 2016. 〈https://www.england.nhs.uk/publication/better-births-improving-outcomes-of-maternity-services-in-england-a-five-year-forward-view-for-maternity-care/〉 (accessed Dec 2021).

      ]. For women with straightforward (low-risk) pregnancies this high-quality care may be provided in midwifery-led settings, such as birth centres (which can either stand alone or as a separate space within a hospital). Midwifery-led settings are associated with lower rates of medical interventions during labour and birth without increasing risk to mothers or babies [
      • Birthplace in England Collaborative Group
      Perinatal and maternal outcomes by planned place of birth for healthy women with low risk pregnancies: the Birthplace in England national prospective cohort study.
      ,
      • Hodnett E.D.
      • Downe S.
      • Walsh D.
      Alternative versus conventional institutional settings for birth.
      ]. Numbers of births in midwifery-led settings in England have trebled since 2010 to 14% of all births in 2018[
      • Walsh D.
      • Spiby H.
      • Dodwell M.
      • et al.
      Mapping midwifery and obstetric units in England.
      ], and many women state a preference for midwifery units[
      • Hollowell J.
      • Li Y.
      • Malouf R.
      • et al.
      Women’s birth place preferences in the United Kingdom: a systematic review and narrative synthesis of the quantitative literature.
      ]. However, this still leaves the vast majority (86%) of births in England taking place in obstetric-led units [
      • Walsh D.
      • Spiby H.
      • Dodwell M.
      • et al.
      Mapping midwifery and obstetric units in England.
      ], with higher rates in countries such as the USA and Australia (98.4% and 93.6% respectively) [
      • MacDorman M.F.
      • Declercq E.
      Trends and state variations in out-of-hospital births in the United States, 2004-2017.
      ,
      • Homer C.S.E.
      • Cheah S.L.
      • Rossiter C.
      • et al.
      Maternal and perinatal outcomes by planned place of birth in Australia 2000 – 2012: a linked population data study.
      ]. Obstetric-led units are located within hospitals and have a more medical focus compared to midwifery-led units. Women who give birth in obstetric-led units include those with complicated pregnancies (higher risk) that may require medical care (up to 62% of births) [
      • Danilack V.A.
      • Nunes A.P.
      • Phipps M.G.
      Unexpected complications of low-risk pregnancies in the United States.
      ], but it also includes women at low risk of complications who have either chosen obstetric settings, had limited choice of birthplace, or who have been transferred during labour. Birthing options that respect women’s values are essential components to optimise the quality of care, alongside any necessary clinical interventions, but are not consistently provided worldwide [

      World Health Organisation. WHO recommendations: intrapartum care for a positive childbirth experience. Geneva: World Health Organization; 2018. Licence: CC BY-NC-SA 3.0 IGO.

      ].
      Midwifery-led units (which can be located alongside obstetric units or freestanding) place considerable importance on environmental design. Compared to obstetric-led units, they are generally designed to be more home-like environments, with supportive facilities to promote a physiological birth with minimal clinical intervention. Typically a midwifery-led unit may include facilities in the room such as birthing pools, double beds, mood lighting, birthing aids (e.g. stool, ball, mats), domestic furniture; all designed for a homely, relaxing feel more akin to a hotel room than a hospital room [
      • McCourt C.
      • Rayment J.
      • Rance S.
      • et al.
      Place of birth and concepts of wellbeing: an analysis from two ethnographic studies of midwifery units in England.
      ]. The benefits of a home-like environment have been discussed since the 1970 s, placing less importance on the hospital bed and concealing medical equipment [
      • Fannin M.
      Domesticating birth in the hospital: “family‐centered” birth and the emergence of “homelike” birthing rooms.
      ]. The design of conventional hospital (obstetric-led unit) labour rooms is similar to the design of other hospital rooms, the bed being a central feature with visible medical equipment for ease of access [
      • Hodnett E.D.
      • Downe S.
      • Walsh D.
      Alternative versus conventional institutional settings for birth.
      ]. Hospital birthing rooms have been described by women as clinical and stark, and in such spaces, women take on the role of a patient and interact with the environment in a passive way [
      • Mondy T.
      • Fenwick J.
      • Leap N.
      • et al.
      How domesticity dictates behaviour in the birth space: Lessons for designing birth environments in institutions wanting to promote a positive experience of birth.
      ]. More domestic birth environments enable women to claim ownership of the space[
      • Mondy T.
      • Fenwick J.
      • Leap N.
      • et al.
      How domesticity dictates behaviour in the birth space: Lessons for designing birth environments in institutions wanting to promote a positive experience of birth.
      ] and are thought to assist the progress of labour by helping women to feel calm and preventing an adrenaline response to an unfamiliar environment [
      • Stenglin M.
      • Foureur M.
      Designing out the fear cascade to increase the likelihood of normal birth.
      ]. Adrenaline disrupts the production of oxytocin during labour causing labour to slow down or stop, and reduces blood flow to the placenta potentially leading to fetal distress [
      • Stenglin M.
      • Foureur M.
      Designing out the fear cascade to increase the likelihood of normal birth.
      ]. The overall effect can be increased medical intervention during labour and childbirth [
      • Stenglin M.
      • Foureur M.
      Designing out the fear cascade to increase the likelihood of normal birth.
      ].
      The design of midwifery-led units can be more focussed on supporting and empowering the woman than on clinical functionality for emergency situations. The design of obstetric units is more complicated and needs to create a balance between the quality of the environment as a supportive factor to women, and the safety of an environment designed for clinical intervention. Optimising safety and promoting a calming, protective space requires a thorough consideration of the needs of women, their families, maternity care providers and interactions between them.
      The aim of this mixed-methods systematic review was to investigate the impact of birth environments with a specific focus on women with complex pregnancies. This included exploring the experiences, views and evaluations of women and healthcare professionals. This work informed new guidance for the intrapartum care of all women in all settings [

      Royal College of Midwives. Blue top guidance: Midwifery care in labour guidance for all women in all settings: Professionals guidance. 2018 〈https://www.rcm.org.uk/media/2539/professionals-blue-top-guidance.pdf〉 (accessed Dec 2021).

      ,

      Royal College of Midwives. Blue top guidance: Midwifery care in labour guidance for all women in all settings: Information for women and families. 2018 〈https://www.rcm.org.uk/media/2540/mothers-blue-top-guidance.pdf〉 (accessed Dec 2021).

      ].

      Methods

      A mixed-methods systematic review was undertaken using a segregated results-based convergent synthesis design [
      • Aromataris E.
      • Munn Z.
      Joanna Briggs Institute Reviewer’s Manual.
      ,
      • Heyvaert M.
      • Hannes K.
      • Onghena P.
      Using mixed methods research synthesis for literature reviews: the mixed methods research synthesis approach.
      ,
      • Pearson A.
      • White H.
      • Bath-Hextall F.
      • et al.
      A mixed-methods approach to systematic reviews.
      ]. Segregated designs require individual syntheses of quantitative and qualitative evidence to be conducted prior to the final mixed-method synthesis. The review protocol was registered on the PROSPERO database: CRD42018090013. The review is reported according to PRISMA reporting guidance [
      • Page M.J.
      • McKenzie J.E.
      • Bossuyt P.M.
      • Boutron I.
      • Hoffmann T.C.
      • Mulrow C.D.
      • et al.
      The PRISMA 2020 statement: an updated guideline for reporting systematic reviews.
      ].

      Search strategy

      A comprehensive search strategy was developed by an information specialist (JE) for Medline, Embase and CINAHL databases using information from scoping searches to refine search terms. The literature search was undertaken in January 2018 and updated in June 2021. An example (Medline) search strategy is included as supplementary material. Papers were included in the review if they met the following criteria: (i) published in English, (ii) based in an Organisation for Economic Cooperation and Development (OECD) country, (iii) reporting quantitative or qualitative primary research (iv), published January 2000 to June 2021, (v) reporting experiences, views and evaluations of birth settings for women with complicated pregnancies. Papers which only reported views, evaluations and experiences of low-risk (straightforward) pregnancies, low-risk birth settings (home, midwifery-led unit), operating theatre and recovery rooms, unplanned or transfer environments were excluded.
      Duplicates were removed and one researcher (KE) screened the titles and abstracts for relevance. Full-text papers of the remaining citations were then retrieved and independently assessed against the inclusion and exclusion criteria by two researchers (GS, KE), with a third researcher (HS) moderating any ambiguity or disagreements. Data was extracted using a pre-piloted form and was completed independently by two researchers (GS, KE).

      Quality assessment

      The quality of studies included in the review was evaluated by two researchers (GS, KE) using Joanna Briggs Institute levels of evidence[

      Joanna Briggs Institute (JBI). JBI Levels of Evidence. 2013. 〈https://joannabriggs.org/sites/default/files/2019–05/JBI-Levels-of-evidence_2014_0.pdf〉 (accessed Dec 2021).

      ] and appropriate established critical appraisal tools depending on study design [

      Critical Appraisal Skills Programme. CASP Qualitative Checklist. 〈https://casp-uk.net/wp-content/uploads/2018/01/CASP-Qualitative-Checklist-2018.pdf〉 (accessed Dec 2021).

      ,
      • Boynton P.M.
      • Greenhalgh T.
      Selecting, designing, and developing your questionnaire.
      ,
      • Pluye P.
      • Gagnon M.P.
      • Griffiths F.
      • et al.
      Scoring system for appraising mixed methods research, and concomitantly appraising qualitative, quantitative and mixed methods primary studies in Mixed Studies Reviews.
      ,
      • Higgins J.
      • Green S.
      ]. Following this, studies were categorised as low, medium or high quality. Although no studies were excluded on the basis of quality, the quality assessment was undertaken to enable a critical consideration of the strengths and limitations of the evidence [
      • Aromataris E.
      • Munn Z.
      Joanna Briggs Institute Reviewer’s Manual.
      ].

      Data analysis and synthesis

      For qualitative data, QSR NVivo software was used to assist two researchers to independently dual-code and analyse data into key themes and sub-themes following a thematic synthesis approach (GS, KE) [
      • Thomas J.
      • Harden A.
      Methods for the thematic synthesis of qualitative research in systematic reviews.
      ]. There was insufficient data to complete a planned meta-analysis, therefore a narrative description of the quantitative findings was produced. The qualitative and quantitative themes were discussed with the review team. Themes were compared, contrasted and, where possible, integrated to create a final set of synthesised findings (Fig. 1) [

      Popay J., Roberts H., Sowden A., et al. Guidance on the Conduct of Narrative Synthesis in Systematic Reviews. A Product from the ESRC Methods Programme 2006. 〈https://www.lancaster.ac.uk/media/lancaster-university/content-assets/documents/fhm/dhr/chir/NSsynthesisguidanceVersion1-April2006.pdf〉 (accessed Dec 2021).

      ,
      • Noyes J.
      • Booth A.
      • Moore G.
      • et al.
      Synthesising quantitative and qualitative evidence to inform guidelines on complex interventions: clarifying the purposes, designs and outlining some methods.
      ].
      Fig. 1
      Fig. 1Qualitative and quantitative data synthesis.

      Findings

      We screened 30,345 studies by title and abstract (studies were screened by hand) and 36 articles were selected for full-text review, 2 were not retrieved (Fig. 2). A table of excluded studies is included in the supplementary material. Fifteen studies were included: Eight qualitative [
      • Hammond A.D.
      • Foureur M.
      • Homer C.S.E.
      The hardware and software implications of hospital birth room design: a midwifery perspective.
      ,
      • Hammond A.D.
      • Homer C.S.E.
      • Foureur M.
      Messages from Space: an exploration of the relationship between hospital birth environments and midwifery practice.
      ,
      • Hammond A.
      • Homer C.S.E.
      • Foureur M.
      Friendliness, functionality and freedom: Design characteristics that support midwifery practice in the hospital setting.
      ,
      • Seibold C.
      • Licqurish S.
      • Rolls C.
      • et al.
      ‘Lending the space’: midwives perceptions of birth space and clinical risk management.
      ,
      • Townsend B.
      • Fenwick J.
      • Thomson V.
      • et al.
      The birth bed: a qualitative study on the views of midwives regarding the use of the bed in the birth space.
      ,
      • Davis D.L.
      • Homer C.S.
      Birthplace as the midwife’s work place: how does place of birth impact on midwives?.
      ,
      • Lyndon A.
      • Malana J.
      • Hedli L.C.
      • Sherman J.
      • Lee H.C.
      Thematic analysis of women’s perspectives on the meaning of safety during hospital-based birth.
      ,
      • Plough A.
      • Polzin-Rosenberg D.
      • Galvin G.
      • Shao A.
      • Sullivan B.
      • Henrich N.
      • et al.
      An exploratory study of the relationship between facility design and the provision of childbirth care.
      ], 5 mixed methods [
      • Symon A.
      • Paul J.
      • Butchart M.
      • et al.
      Maternity unit design study part 2: perceptions of space and layout.
      ,
      • Symon A.
      • Paul J.
      • Butchart M.
      • et al.
      Maternity unit design study part 3: environmental comfort and control.
      ,
      • Symon A.
      • Paul J.
      • Butchart M.
      • et al.
      Maternity unit design study part 4: midwives’ perceptions of staff facilities.
      ,
      • Newburn M.
      • Singh D.
      Creating a Better Birth Environment: Women’s views about the design and facilities in maternity units: a national survey.
      ,
      • Sherman J.P.
      • Hedli L.C.
      • Kristensen-Cabrera A.I.
      • Lipman S.S.
      • Schwandt D.
      • Lee H.C.
      • Sie L.
      • Halamek L.P.
      • Austin N.S.
      Safety learning laboratory for neonatal and maternal care. understanding the heterogeneity of labor and delivery units: using design thinking methodology to assess environmental factors that contribute to safety in childbirth.
      ], and 2 quantitative[
      • Shin J.H.
      • Maxwell L.E.
      • Eschelman P.
      Hospital birthing room design: a study of mothers’ perception of hominess.
      ,
      • Austin N.
      • Kristensen-Cabrera A.
      • Sherman J.
      • Schwandt D.
      • McDonald A.
      • Hedli L.
      • et al.
      Analyzing the heterogeneity of labor and delivery units: A quantitative analysis of space and design.
      ].
      Fig. 2
      Fig. 2PRISMA Flow Diagram– Birth environments for complex pregnancies.

      Study characteristics

      The study characteristics are detailed in Table 1. Studies were conducted between 2003 and 2020 in Australia (n = 7) [
      • Hammond A.D.
      • Foureur M.
      • Homer C.S.E.
      The hardware and software implications of hospital birth room design: a midwifery perspective.
      ,
      • Hammond A.D.
      • Homer C.S.E.
      • Foureur M.
      Messages from Space: an exploration of the relationship between hospital birth environments and midwifery practice.
      ,
      • Hammond A.
      • Homer C.S.E.
      • Foureur M.
      Friendliness, functionality and freedom: Design characteristics that support midwifery practice in the hospital setting.
      ,
      • Seibold C.
      • Licqurish S.
      • Rolls C.
      • et al.
      ‘Lending the space’: midwives perceptions of birth space and clinical risk management.
      ,
      • Townsend B.
      • Fenwick J.
      • Thomson V.
      • et al.
      The birth bed: a qualitative study on the views of midwives regarding the use of the bed in the birth space.
      ,
      • Davis D.L.
      • Homer C.S.
      Birthplace as the midwife’s work place: how does place of birth impact on midwives?.
      ], the United Kingdom (n = 5)[
      • Davis D.L.
      • Homer C.S.
      Birthplace as the midwife’s work place: how does place of birth impact on midwives?.
      ,
      • Symon A.
      • Paul J.
      • Butchart M.
      • et al.
      Maternity unit design study part 2: perceptions of space and layout.
      ,
      • Symon A.
      • Paul J.
      • Butchart M.
      • et al.
      Maternity unit design study part 3: environmental comfort and control.
      ,
      • Symon A.
      • Paul J.
      • Butchart M.
      • et al.
      Maternity unit design study part 4: midwives’ perceptions of staff facilities.
      ,
      • Newburn M.
      • Singh D.
      Creating a Better Birth Environment: Women’s views about the design and facilities in maternity units: a national survey.
      ] and USA (n = 4) [
      • Lyndon A.
      • Malana J.
      • Hedli L.C.
      • Sherman J.
      • Lee H.C.
      Thematic analysis of women’s perspectives on the meaning of safety during hospital-based birth.
      ,
      • Plough A.
      • Polzin-Rosenberg D.
      • Galvin G.
      • Shao A.
      • Sullivan B.
      • Henrich N.
      • et al.
      An exploratory study of the relationship between facility design and the provision of childbirth care.
      ,
      • Sherman J.P.
      • Hedli L.C.
      • Kristensen-Cabrera A.I.
      • Lipman S.S.
      • Schwandt D.
      • Lee H.C.
      • Sie L.
      • Halamek L.P.
      • Austin N.S.
      Safety learning laboratory for neonatal and maternal care. understanding the heterogeneity of labor and delivery units: using design thinking methodology to assess environmental factors that contribute to safety in childbirth.
      ,
      • Shin J.H.
      • Maxwell L.E.
      • Eschelman P.
      Hospital birthing room design: a study of mothers’ perception of hominess.
      ,
      • Austin N.
      • Kristensen-Cabrera A.
      • Sherman J.
      • Schwandt D.
      • McDonald A.
      • Hedli L.
      • et al.
      Analyzing the heterogeneity of labor and delivery units: A quantitative analysis of space and design.
      ]. The majority of papers were assessed as being of high or medium quality (Table 1), but some were rated as low quality due to methodological and reporting concerns. Study participants included both women and clinicians (predominantly midwives). Studies investigated the impact of the birth environment on midwives and midwifery practice [
      • Hammond A.D.
      • Foureur M.
      • Homer C.S.E.
      The hardware and software implications of hospital birth room design: a midwifery perspective.
      ,
      • Hammond A.D.
      • Homer C.S.E.
      • Foureur M.
      Messages from Space: an exploration of the relationship between hospital birth environments and midwifery practice.
      ,
      • Hammond A.
      • Homer C.S.E.
      • Foureur M.
      Friendliness, functionality and freedom: Design characteristics that support midwifery practice in the hospital setting.
      ,
      • Seibold C.
      • Licqurish S.
      • Rolls C.
      • et al.
      ‘Lending the space’: midwives perceptions of birth space and clinical risk management.
      ,
      • Townsend B.
      • Fenwick J.
      • Thomson V.
      • et al.
      The birth bed: a qualitative study on the views of midwives regarding the use of the bed in the birth space.
      ,
      • Davis D.L.
      • Homer C.S.
      Birthplace as the midwife’s work place: how does place of birth impact on midwives?.
      ,
      • Symon A.
      • Paul J.
      • Butchart M.
      • et al.
      Maternity unit design study part 2: perceptions of space and layout.
      ,
      • Symon A.
      • Paul J.
      • Butchart M.
      • et al.
      Maternity unit design study part 3: environmental comfort and control.
      ,
      • Symon A.
      • Paul J.
      • Butchart M.
      • et al.
      Maternity unit design study part 4: midwives’ perceptions of staff facilities.
      ]; the impact of the birth environment on women’s experiences [
      • Davis D.L.
      • Homer C.S.
      Birthplace as the midwife’s work place: how does place of birth impact on midwives?.
      ,
      • Lyndon A.
      • Malana J.
      • Hedli L.C.
      • Sherman J.
      • Lee H.C.
      Thematic analysis of women’s perspectives on the meaning of safety during hospital-based birth.
      ,
      • Symon A.
      • Paul J.
      • Butchart M.
      • et al.
      Maternity unit design study part 2: perceptions of space and layout.
      ,
      • Symon A.
      • Paul J.
      • Butchart M.
      • et al.
      Maternity unit design study part 3: environmental comfort and control.
      ,
      • Newburn M.
      • Singh D.
      Creating a Better Birth Environment: Women’s views about the design and facilities in maternity units: a national survey.
      ]; and the design of birthing rooms [
      • Lyndon A.
      • Malana J.
      • Hedli L.C.
      • Sherman J.
      • Lee H.C.
      Thematic analysis of women’s perspectives on the meaning of safety during hospital-based birth.
      ,
      • Plough A.
      • Polzin-Rosenberg D.
      • Galvin G.
      • Shao A.
      • Sullivan B.
      • Henrich N.
      • et al.
      An exploratory study of the relationship between facility design and the provision of childbirth care.
      ,
      • Sherman J.P.
      • Hedli L.C.
      • Kristensen-Cabrera A.I.
      • Lipman S.S.
      • Schwandt D.
      • Lee H.C.
      • Sie L.
      • Halamek L.P.
      • Austin N.S.
      Safety learning laboratory for neonatal and maternal care. understanding the heterogeneity of labor and delivery units: using design thinking methodology to assess environmental factors that contribute to safety in childbirth.
      ,
      • Shin J.H.
      • Maxwell L.E.
      • Eschelman P.
      Hospital birthing room design: a study of mothers’ perception of hominess.
      ,
      • Austin N.
      • Kristensen-Cabrera A.
      • Sherman J.
      • Schwandt D.
      • McDonald A.
      • Hedli L.
      • et al.
      Analyzing the heterogeneity of labor and delivery units: A quantitative analysis of space and design.
      ]. The qualitative and quantitative findings are presented together in five main synthesised themes.
      Table 1Characteristics of included studies (n = 15).
      Author (Year)Aim of studyDesign and methodsSample and settings / countryQuality assessment
      Hammond et al. (2014a)
      • Hammond A.D.
      • Foureur M.
      • Homer C.S.E.
      The hardware and software implications of hospital birth room design: a midwifery perspective.
      To explore the perspective of midwives to discover how the design of hospital birth rooms impacts on their work.Qualitative ethnography: video reflexive interviews.Sample: n = 8 midwives

      Setting: Tertiary hospitals, Sydney, Australia.
      High
      Hammond et al. (2014b)
      • Hammond A.D.
      • Homer C.S.E.
      • Foureur M.
      Messages from Space: an exploration of the relationship between hospital birth environments and midwifery practice.
      To explore the relationship between birth environment and the practice of midwifery.Qualitative critical realist: interviews.Sample: n = 16 midwives

      Setting: Large hospital in Australia.
      Medium to high
      Hammond et al. (2017)
      • Hammond A.
      • Homer C.S.E.
      • Foureur M.
      Friendliness, functionality and freedom: Design characteristics that support midwifery practice in the hospital setting.
      To explore the design characteristics of hospital birth rooms that support midwives and their practice.Qualitative critical realist: photo elicitation interviews.Sample: n = 16 midwives

      Setting: Large hospital in Australia.
      High
      Seibold et al. (2010)
      • Seibold C.
      • Licqurish S.
      • Rolls C.
      • et al.
      ‘Lending the space’: midwives perceptions of birth space and clinical risk management.
      To explore midwives’ perceptions of birth space and clinical risk management and their impact on practice in different facilities.Qualitative: exploratory descriptive, using focus groups.Sample: n = 18 midwives

      Setting: Metropolitan hospital in Australia.
      Medium to high
      Townsend et al. (2016)
      • Townsend B.
      • Fenwick J.
      • Thomson V.
      • et al.
      The birth bed: a qualitative study on the views of midwives regarding the use of the bed in the birth space.
      To describe midwives’ perceptions of the birth bed.Qualitative: InterviewsSample: n = 14 midwives

      Setting: Maternity unit in Australia.
      High
      Davis et al. (2016)
      • Davis D.L.
      • Homer C.S.
      Birthplace as the midwife’s work place: how does place of birth impact on midwives?.
      To explore the way that birthplace impacts on midwives in Australia and the United Kingdom.Qualitative: Focus GroupsSample: n = 12 midwives. Setting: UK and Australia.High
      Lyndon et al. (2018)
      • Lyndon A.
      • Malana J.
      • Hedli L.C.
      • Sherman J.
      • Lee H.C.
      Thematic analysis of women’s perspectives on the meaning of safety during hospital-based birth.
      To explore women’s birth experiences to understand their perspectives on patient safety.Qualitative: InterviewsSample: n = 17 women

      Setting: Community recruitment, USA
      High
      Plough et al. (2018)
      • Plough A.
      • Polzin-Rosenberg D.
      • Galvin G.
      • Shao A.
      • Sullivan B.
      • Henrich N.
      • et al.
      An exploratory study of the relationship between facility design and the provision of childbirth care.
      To explore key mechanisms of how facility design affects clinicians in providing childbirth care.Qualitative: Interviews and DelphiSample and setting: managers at 12 birth centres and hospitals in the USA.Medium
      Symon et al. (2008a)
      • Symon A.
      • Paul J.
      • Butchart M.
      • et al.
      Maternity unit design study part 2: perceptions of space and layout.
      To discover which design features contribute most and least to satisfaction levels among service users and providers.Mixed methods: Survey and focus groups.Sample: Survey; n = 559 women and n = 227 midwives. Focus groups; n = 7 women, n = 5 staff.

      Setting: 9 maternity units, UK.
      Medium to low
      Symon et al. (2008b)
      • Symon A.
      • Paul J.
      • Butchart M.
      • et al.
      Maternity unit design study part 3: environmental comfort and control.
      To investigate the issues of comfort in and control over the interior environment, from the perspectives of both mothers and midwives.Mixed methods: Survey and focus groups.Sample: Survey; n = 559 women and n = 227 midwives. Focus groups; n = 7 women, n = 5 staff.

      Setting: 9 maternity units, UK.
      Medium to low
      Symon et al. (2008c)
      • Symon A.
      • Paul J.
      • Butchart M.
      • et al.
      Maternity unit design study part 4: midwives’ perceptions of staff facilities.
      To examine the perceptions and experiences of those using and working in different types of unit.Mixed methods: Survey and focus groups.Sample: Survey of midwives (n = 227). Focus groups (n = 5 staff).

      Setting: 9 maternity units, UK.
      Medium to low
      Newburn and Singh (2003)
      • Newburn M.
      • Singh D.
      Creating a Better Birth Environment: Women’s views about the design and facilities in maternity units: a national survey.
      To explore what aspects of room design mattered to women, and whether the physical environment affected their experience of labour.Mixed methods: Survey - multiple choice and open ended questions.Sample: n = 1944 women

      Setting: Community recruitment, UK.
      Medium
      Sherman et al. (2020)
      • Sherman J.P.
      • Hedli L.C.
      • Kristensen-Cabrera A.I.
      • Lipman S.S.
      • Schwandt D.
      • Lee H.C.
      • Sie L.
      • Halamek L.P.
      • Austin N.S.
      Safety learning laboratory for neonatal and maternal care. understanding the heterogeneity of labor and delivery units: using design thinking methodology to assess environmental factors that contribute to safety in childbirth.
      To implement design thinking to understand how design of labour and delivery units impact safety.Mixed methods: Observation, measurements, and interviewsSample: ~30 clinicians.

      Setting: 10 Labour and Delivery units in the USA.
      Medium
      Shin et al. (2004)
      • Shin J.H.
      • Maxwell L.E.
      • Eschelman P.
      Hospital birthing room design: a study of mothers’ perception of hominess.
      To investigate how interior design elements in birth environments can foster a home-like feeling desired by women and their families.Quantitative: Survey – 7 point Likert scale rating of birth room designs.Sample: n = 35 women

      Setting: Community recruitment, USA.
      Medium
      Austin et al. (2018)
      • Austin N.
      • Kristensen-Cabrera A.
      • Sherman J.
      • Schwandt D.
      • McDonald A.
      • Hedli L.
      • et al.
      Analyzing the heterogeneity of labor and delivery units: A quantitative analysis of space and design.
      To quantify space and design of labour and delivery units.Quantitative: Evaluating physical space and equipmentSetting: USA Labour and Delivery units.Medium

      Theme 1: quality of care and experience

      Eight studies reported findings about the relationship between the environment and the quality of care and experience [
      • Hammond A.D.
      • Foureur M.
      • Homer C.S.E.
      The hardware and software implications of hospital birth room design: a midwifery perspective.
      ,
      • Hammond A.D.
      • Homer C.S.E.
      • Foureur M.
      Messages from Space: an exploration of the relationship between hospital birth environments and midwifery practice.
      ,
      • Hammond A.
      • Homer C.S.E.
      • Foureur M.
      Friendliness, functionality and freedom: Design characteristics that support midwifery practice in the hospital setting.
      ,
      • Davis D.L.
      • Homer C.S.
      Birthplace as the midwife’s work place: how does place of birth impact on midwives?.
      ,
      • Plough A.
      • Polzin-Rosenberg D.
      • Galvin G.
      • Shao A.
      • Sullivan B.
      • Henrich N.
      • et al.
      An exploratory study of the relationship between facility design and the provision of childbirth care.
      ,
      • Symon A.
      • Paul J.
      • Butchart M.
      • et al.
      Maternity unit design study part 2: perceptions of space and layout.
      ,
      • Symon A.
      • Paul J.
      • Butchart M.
      • et al.
      Maternity unit design study part 3: environmental comfort and control.
      ,
      • Newburn M.
      • Singh D.
      Creating a Better Birth Environment: Women’s views about the design and facilities in maternity units: a national survey.
      ]. Midwives’ dissatisfaction with birthing room layouts was described, such as the need to move the bed from the centre of the room to create space for active birthing [
      • Hammond A.D.
      • Homer C.S.E.
      • Foureur M.
      Messages from Space: an exploration of the relationship between hospital birth environments and midwifery practice.
      ]. Midwives’ discomfort with the layout sometimes resulted in them spending time adapting the environment or layout rather than welcoming the woman into the room. Lack of provision in the birthing space for the midwife to write notes or sit was also reported to affect midwives’ ability to be continuously present in the room [
      • Hammond A.D.
      • Foureur M.
      • Homer C.S.E.
      The hardware and software implications of hospital birth room design: a midwifery perspective.
      ,
      • Plough A.
      • Polzin-Rosenberg D.
      • Galvin G.
      • Shao A.
      • Sullivan B.
      • Henrich N.
      • et al.
      An exploratory study of the relationship between facility design and the provision of childbirth care.
      ]. The proximity of the room to other areas, e.g. central nursing station, could also contribute to the ability of staff to respond quickly to care needs [
      • Plough A.
      • Polzin-Rosenberg D.
      • Galvin G.
      • Shao A.
      • Sullivan B.
      • Henrich N.
      • et al.
      An exploratory study of the relationship between facility design and the provision of childbirth care.
      ].
      Both women and midwives valued the flexibility and space of rooms as an important factor for optimising the birth experience and quality of care [
      • Hammond A.D.
      • Homer C.S.E.
      • Foureur M.
      Messages from Space: an exploration of the relationship between hospital birth environments and midwifery practice.
      ,
      • Hammond A.
      • Homer C.S.E.
      • Foureur M.
      Friendliness, functionality and freedom: Design characteristics that support midwifery practice in the hospital setting.
      ,
      • Newburn M.
      • Singh D.
      Creating a Better Birth Environment: Women’s views about the design and facilities in maternity units: a national survey.
      ]. Unwelcoming environments were described as making women feel less relaxed which could impact on their progress in labour [
      • Hammond A.
      • Homer C.S.E.
      • Foureur M.
      Friendliness, functionality and freedom: Design characteristics that support midwifery practice in the hospital setting.
      ,
      • Davis D.L.
      • Homer C.S.
      Birthplace as the midwife’s work place: how does place of birth impact on midwives?.
      ]. A room with a more homely ambience enhanced women’s sense of freedom to move around and enabled midwives to practice in a flexible and spontaneous way. In spaces that were too small, midwives felt constrained and unable to use their skills to support women in different labour positions [
      • Hammond A.D.
      • Homer C.S.E.
      • Foureur M.
      Messages from Space: an exploration of the relationship between hospital birth environments and midwifery practice.
      ]. An association was also reported between women’s comfort and the likelihood of a straightforward birth and the authors state that although this does not prove cause and effect, it is likely that staff helping women to find comfortable positions is a facilitative factor for a straightforward birth [
      • Symon A.
      • Paul J.
      • Butchart M.
      • et al.
      Maternity unit design study part 3: environmental comfort and control.
      ]. Staff-perceived quality of care was significantly correlated with positive opinions about the ward layout, comfort in the work environment, and perceived space for women [
      • Symon A.
      • Paul J.
      • Butchart M.
      • et al.
      Maternity unit design study part 2: perceptions of space and layout.
      ]. Similarly 94% of women felt that the physical environment affected how easy or difficult it was to give birth [
      • Newburn M.
      • Singh D.
      Creating a Better Birth Environment: Women’s views about the design and facilities in maternity units: a national survey.
      ].

      Theme 2: supportive spaces for women

      One of the key themes reported in nine studies was need for environments to be supportive spaces for women [
      • Hammond A.D.
      • Foureur M.
      • Homer C.S.E.
      The hardware and software implications of hospital birth room design: a midwifery perspective.
      ,
      • Hammond A.D.
      • Homer C.S.E.
      • Foureur M.
      Messages from Space: an exploration of the relationship between hospital birth environments and midwifery practice.
      ,
      • Seibold C.
      • Licqurish S.
      • Rolls C.
      • et al.
      ‘Lending the space’: midwives perceptions of birth space and clinical risk management.
      ,
      • Davis D.L.
      • Homer C.S.
      Birthplace as the midwife’s work place: how does place of birth impact on midwives?.
      ,
      • Lyndon A.
      • Malana J.
      • Hedli L.C.
      • Sherman J.
      • Lee H.C.
      Thematic analysis of women’s perspectives on the meaning of safety during hospital-based birth.
      ,
      • Symon A.
      • Paul J.
      • Butchart M.
      • et al.
      Maternity unit design study part 2: perceptions of space and layout.
      ,
      • Newburn M.
      • Singh D.
      Creating a Better Birth Environment: Women’s views about the design and facilities in maternity units: a national survey.
      ,
      • Shin J.H.
      • Maxwell L.E.
      • Eschelman P.
      Hospital birthing room design: a study of mothers’ perception of hominess.
      ,
      • Austin N.
      • Kristensen-Cabrera A.
      • Sherman J.
      • Schwandt D.
      • McDonald A.
      • Hedli L.
      • et al.
      Analyzing the heterogeneity of labor and delivery units: A quantitative analysis of space and design.
      ]. Midwives and women stressed the importance of having access to birthing aids to support labour and promote a physiological birth, however these were sometimes difficult to access or locate [
      • Hammond A.D.
      • Foureur M.
      • Homer C.S.E.
      The hardware and software implications of hospital birth room design: a midwifery perspective.
      ,
      • Newburn M.
      • Singh D.
      Creating a Better Birth Environment: Women’s views about the design and facilities in maternity units: a national survey.
      ]. Numerous aspects were identified to make birth environments more acceptable for women including comfortable furniture for women and partners, cleanliness, privacy, en-suite bathrooms and control over who entered the room [
      • Symon A.
      • Paul J.
      • Butchart M.
      • et al.
      Maternity unit design study part 2: perceptions of space and layout.
      ,
      • Newburn M.
      • Singh D.
      Creating a Better Birth Environment: Women’s views about the design and facilities in maternity units: a national survey.
      ]. Women also felt they could relax when they were able to stay in one room for their whole hospital stay [
      • Newburn M.
      • Singh D.
      Creating a Better Birth Environment: Women’s views about the design and facilities in maternity units: a national survey.
      ]. Some women felt a double bed could help support them to get into different positions whilst also enabling their partner to rest [
      • Symon A.
      • Paul J.
      • Butchart M.
      • et al.
      Maternity unit design study part 2: perceptions of space and layout.
      ,
      • Newburn M.
      • Singh D.
      Creating a Better Birth Environment: Women’s views about the design and facilities in maternity units: a national survey.
      ]. Women and their partners also liked access to refreshments and distractions to pass the time [
      • Newburn M.
      • Singh D.
      Creating a Better Birth Environment: Women’s views about the design and facilities in maternity units: a national survey.
      ]. There were mixed opinions on having a clock in the room due to some people wanting to have a sense of time, and others feeling like they did not want to know how long they had been there [
      • Shin J.H.
      • Maxwell L.E.
      • Eschelman P.
      Hospital birthing room design: a study of mothers’ perception of hominess.
      ].
      The importance of homeliness and ambience in birth environments was frequently discussed in the studies. A particular focus was for the environment to be aesthetically pleasing and not feeling like a clinical space, although some women in the studies found medical equipment reassuring [
      • Hammond A.D.
      • Foureur M.
      • Homer C.S.E.
      The hardware and software implications of hospital birth room design: a midwifery perspective.
      ,
      • Hammond A.D.
      • Homer C.S.E.
      • Foureur M.
      Messages from Space: an exploration of the relationship between hospital birth environments and midwifery practice.
      ,
      • Seibold C.
      • Licqurish S.
      • Rolls C.
      • et al.
      ‘Lending the space’: midwives perceptions of birth space and clinical risk management.
      ,
      • Davis D.L.
      • Homer C.S.
      Birthplace as the midwife’s work place: how does place of birth impact on midwives?.
      ,
      • Lyndon A.
      • Malana J.
      • Hedli L.C.
      • Sherman J.
      • Lee H.C.
      Thematic analysis of women’s perspectives on the meaning of safety during hospital-based birth.
      ,
      • Symon A.
      • Paul J.
      • Butchart M.
      • et al.
      Maternity unit design study part 2: perceptions of space and layout.
      ,
      • Newburn M.
      • Singh D.
      Creating a Better Birth Environment: Women’s views about the design and facilities in maternity units: a national survey.
      ]. This also included environment factors such as having natural light, ambient lighting, fresh air, and controlling the temperature [
      • Hammond A.D.
      • Foureur M.
      • Homer C.S.E.
      The hardware and software implications of hospital birth room design: a midwifery perspective.
      ,
      • Davis D.L.
      • Homer C.S.
      Birthplace as the midwife’s work place: how does place of birth impact on midwives?.
      ,
      • Symon A.
      • Paul J.
      • Butchart M.
      • et al.
      Maternity unit design study part 3: environmental comfort and control.
      ]. Women had concerns about not wanting to hear others in labour and feeling uncomfortable about being overheard themselves [
      • Davis D.L.
      • Homer C.S.
      Birthplace as the midwife’s work place: how does place of birth impact on midwives?.
      ,
      • Newburn M.
      • Singh D.
      Creating a Better Birth Environment: Women’s views about the design and facilities in maternity units: a national survey.
      ]. Also noises from medical equipment (e.g. fetal monitoring) were frightening to some women [
      • Lyndon A.
      • Malana J.
      • Hedli L.C.
      • Sherman J.
      • Lee H.C.
      Thematic analysis of women’s perspectives on the meaning of safety during hospital-based birth.
      ]. Similarly, design elements affecting privacy and contact with people outside the room affected women’s feelings of homeliness [
      • Shin J.H.
      • Maxwell L.E.
      • Eschelman P.
      Hospital birthing room design: a study of mothers’ perception of hominess.
      ], control [
      • Davis D.L.
      • Homer C.S.
      Birthplace as the midwife’s work place: how does place of birth impact on midwives?.
      ,
      • Shin J.H.
      • Maxwell L.E.
      • Eschelman P.
      Hospital birthing room design: a study of mothers’ perception of hominess.
      ], and safety[
      • Lyndon A.
      • Malana J.
      • Hedli L.C.
      • Sherman J.
      • Lee H.C.
      Thematic analysis of women’s perspectives on the meaning of safety during hospital-based birth.
      ] and may also interrupt the flow of hormones necessary for effective labour progress [
      • Davis D.L.
      • Homer C.S.
      Birthplace as the midwife’s work place: how does place of birth impact on midwives?.
      ]. Women tended to dislike any type of interior window or lack of transition space into the room [
      • Shin J.H.
      • Maxwell L.E.
      • Eschelman P.
      Hospital birthing room design: a study of mothers’ perception of hominess.
      ]. Women rated room designs as less home-like if they felt they would be immediately visible to those entering the room, even if there was a physical barrier such as a half-height wall [
      • Shin J.H.
      • Maxwell L.E.
      • Eschelman P.
      Hospital birthing room design: a study of mothers’ perception of hominess.
      ]. Rooms with visual as well as physical barriers (e.g. full-height partition wall) were rated as more homely as long as the transition space was not so large that it impacted on room size [
      • Shin J.H.
      • Maxwell L.E.
      • Eschelman P.
      Hospital birthing room design: a study of mothers’ perception of hominess.
      ].
      The importance of women having enough space to mobilise and try different birthing positions was described in several studies [
      • Hammond A.D.
      • Foureur M.
      • Homer C.S.E.
      The hardware and software implications of hospital birth room design: a midwifery perspective.
      ,
      • Hammond A.D.
      • Homer C.S.E.
      • Foureur M.
      Messages from Space: an exploration of the relationship between hospital birth environments and midwifery practice.
      ,
      • Hammond A.
      • Homer C.S.E.
      • Foureur M.
      Friendliness, functionality and freedom: Design characteristics that support midwifery practice in the hospital setting.
      ,
      • Seibold C.
      • Licqurish S.
      • Rolls C.
      • et al.
      ‘Lending the space’: midwives perceptions of birth space and clinical risk management.
      ,
      • Symon A.
      • Paul J.
      • Butchart M.
      • et al.
      Maternity unit design study part 2: perceptions of space and layout.
      ,
      • Newburn M.
      • Singh D.
      Creating a Better Birth Environment: Women’s views about the design and facilities in maternity units: a national survey.
      ]. The ability to walk around was highly important to 89% of women, but only 61% of those in hospital units felt able to [
      • Newburn M.
      • Singh D.
      Creating a Better Birth Environment: Women’s views about the design and facilities in maternity units: a national survey.
      ]. Women also felt that compared to any other single factor, having freedom and space to move around was most important to encourage the type of birth they wanted [
      • Newburn M.
      • Singh D.
      Creating a Better Birth Environment: Women’s views about the design and facilities in maternity units: a national survey.
      ]. A lack of flexibility in the space, including inadequate storage for birthing aids and personal possessions, was reported as making the rooms cluttered and difficult to work with [
      • Hammond A.
      • Homer C.S.E.
      • Foureur M.
      Friendliness, functionality and freedom: Design characteristics that support midwifery practice in the hospital setting.
      ,
      • Symon A.
      • Paul J.
      • Butchart M.
      • et al.
      Maternity unit design study part 2: perceptions of space and layout.
      ,
      • Newburn M.
      • Singh D.
      Creating a Better Birth Environment: Women’s views about the design and facilities in maternity units: a national survey.
      ]. Labour rooms varied dramatically in size and layout, both within and between units, some rooms were found to be more than double the size of others [
      • Austin N.
      • Kristensen-Cabrera A.
      • Sherman J.
      • Schwandt D.
      • McDonald A.
      • Hedli L.
      • et al.
      Analyzing the heterogeneity of labor and delivery units: A quantitative analysis of space and design.
      ]. One study suggested that room size may not be as important as the design and flexibility of the room [
      • Symon A.
      • Paul J.
      • Butchart M.
      • et al.
      Maternity unit design study part 2: perceptions of space and layout.
      ]. Equipment and furniture varied in different rooms and units [
      • Austin N.
      • Kristensen-Cabrera A.
      • Sherman J.
      • Schwandt D.
      • McDonald A.
      • Hedli L.
      • et al.
      Analyzing the heterogeneity of labor and delivery units: A quantitative analysis of space and design.
      ]. Birthing aids such as floor mats, extra pillows, or bean bags were easily accessible to only a third of women who gave birth in hospital compared to 9 out of 10 women who birthed at home [
      • Newburn M.
      • Singh D.
      Creating a Better Birth Environment: Women’s views about the design and facilities in maternity units: a national survey.
      ]. Some women with complex needs could also not be able to use mobility aids due to the restrictions of some monitoring equipment [
      • Newburn M.
      • Singh D.
      Creating a Better Birth Environment: Women’s views about the design and facilities in maternity units: a national survey.
      ].
      Birthing pools were highly valued by midwives and women to promote physiological birth [
      • Hammond A.D.
      • Foureur M.
      • Homer C.S.E.
      The hardware and software implications of hospital birth room design: a midwifery perspective.
      ,
      • Newburn M.
      • Singh D.
      Creating a Better Birth Environment: Women’s views about the design and facilities in maternity units: a national survey.
      ], but some design features limited women’s independence getting in and out of the pool [
      • Hammond A.D.
      • Foureur M.
      • Homer C.S.E.
      The hardware and software implications of hospital birth room design: a midwifery perspective.
      ]. There were particular problems with the high sides of the pool and steep steps making it difficult for women to get in and out without support [
      • Hammond A.D.
      • Foureur M.
      • Homer C.S.E.
      The hardware and software implications of hospital birth room design: a midwifery perspective.
      ]. Women felt they were less likely to have access to birthing pools in hospital compared to midwife-led units [
      • Newburn M.
      • Singh D.
      Creating a Better Birth Environment: Women’s views about the design and facilities in maternity units: a national survey.
      ].

      Theme 3: supportive spaces for midwives

      Nine studies reported findings relating to how supportive the birth environment was for midwives [
      • Hammond A.D.
      • Foureur M.
      • Homer C.S.E.
      The hardware and software implications of hospital birth room design: a midwifery perspective.
      ,
      • Hammond A.D.
      • Homer C.S.E.
      • Foureur M.
      Messages from Space: an exploration of the relationship between hospital birth environments and midwifery practice.
      ,
      • Hammond A.
      • Homer C.S.E.
      • Foureur M.
      Friendliness, functionality and freedom: Design characteristics that support midwifery practice in the hospital setting.
      ,
      • Seibold C.
      • Licqurish S.
      • Rolls C.
      • et al.
      ‘Lending the space’: midwives perceptions of birth space and clinical risk management.
      ,
      • Townsend B.
      • Fenwick J.
      • Thomson V.
      • et al.
      The birth bed: a qualitative study on the views of midwives regarding the use of the bed in the birth space.
      ,
      • Davis D.L.
      • Homer C.S.
      Birthplace as the midwife’s work place: how does place of birth impact on midwives?.
      ,
      • Symon A.
      • Paul J.
      • Butchart M.
      • et al.
      Maternity unit design study part 2: perceptions of space and layout.
      ,
      • Symon A.
      • Paul J.
      • Butchart M.
      • et al.
      Maternity unit design study part 3: environmental comfort and control.
      ,
      • Symon A.
      • Paul J.
      • Butchart M.
      • et al.
      Maternity unit design study part 4: midwives’ perceptions of staff facilities.
      ]. Similarly to women, midwives often did not have enough space, flexibility of layout, or provisions to support their role [
      • Hammond A.D.
      • Foureur M.
      • Homer C.S.E.
      The hardware and software implications of hospital birth room design: a midwifery perspective.
      ,
      • Hammond A.D.
      • Homer C.S.E.
      • Foureur M.
      Messages from Space: an exploration of the relationship between hospital birth environments and midwifery practice.
      ,
      • Hammond A.
      • Homer C.S.E.
      • Foureur M.
      Friendliness, functionality and freedom: Design characteristics that support midwifery practice in the hospital setting.
      ,
      • Seibold C.
      • Licqurish S.
      • Rolls C.
      • et al.
      ‘Lending the space’: midwives perceptions of birth space and clinical risk management.
      ]. Midwives described adapting the room for the woman and thus restricting their own space required to complete their tasks [
      • Hammond A.D.
      • Foureur M.
      • Homer C.S.E.
      The hardware and software implications of hospital birth room design: a midwifery perspective.
      ,
      • Hammond A.D.
      • Homer C.S.E.
      • Foureur M.
      Messages from Space: an exploration of the relationship between hospital birth environments and midwifery practice.
      ]. The main factors described were lack of storage for birthing aids, the woman’s personal possessions and medical equipment, and the bed dominating the middle of the room [
      • Hammond A.D.
      • Foureur M.
      • Homer C.S.E.
      The hardware and software implications of hospital birth room design: a midwifery perspective.
      ,
      • Townsend B.
      • Fenwick J.
      • Thomson V.
      • et al.
      The birth bed: a qualitative study on the views of midwives regarding the use of the bed in the birth space.
      ]. Flexibility in the room was valued by midwives, the room had to function well for active birthing but also for medical emergencies and complex care [
      • Hammond A.D.
      • Foureur M.
      • Homer C.S.E.
      The hardware and software implications of hospital birth room design: a midwifery perspective.
      ,
      • Hammond A.
      • Homer C.S.E.
      • Foureur M.
      Friendliness, functionality and freedom: Design characteristics that support midwifery practice in the hospital setting.
      ,
      • Seibold C.
      • Licqurish S.
      • Rolls C.
      • et al.
      ‘Lending the space’: midwives perceptions of birth space and clinical risk management.
      ]. Fold-down seating was suggested as a way to provide a place for the midwife whilst maintaining the flexibility of the space [
      • Hammond A.D.
      • Foureur M.
      • Homer C.S.E.
      The hardware and software implications of hospital birth room design: a midwifery perspective.
      ].
      Working conditions were frequently raised as impacting midwives physically and through workplace stress [
      • Hammond A.D.
      • Foureur M.
      • Homer C.S.E.
      The hardware and software implications of hospital birth room design: a midwifery perspective.
      ,
      • Hammond A.D.
      • Homer C.S.E.
      • Foureur M.
      Messages from Space: an exploration of the relationship between hospital birth environments and midwifery practice.
      ,
      • Symon A.
      • Paul J.
      • Butchart M.
      • et al.
      Maternity unit design study part 3: environmental comfort and control.
      ]. Midwives needed to get into a variety of positions to assist births which can be uncomfortable or not well supported by the physical environment [
      • Hammond A.D.
      • Foureur M.
      • Homer C.S.E.
      The hardware and software implications of hospital birth room design: a midwifery perspective.
      ]. Factors such as ambience, thermal comfort, and cluttered conditions in birthing rooms contributed to workplace stress [
      • Hammond A.D.
      • Homer C.S.E.
      • Foureur M.
      Messages from Space: an exploration of the relationship between hospital birth environments and midwifery practice.
      ,
      • Davis D.L.
      • Homer C.S.
      Birthplace as the midwife’s work place: how does place of birth impact on midwives?.
      ]. Room temperature could often be too warm for women and midwives, however the temperature requirements of newborns must be considered [
      • Symon A.
      • Paul J.
      • Butchart M.
      • et al.
      Maternity unit design study part 3: environmental comfort and control.
      ]. Midwives preferred natural and ambient lighting, feeling that harsh lighting contributed to a difficult working environment [
      • Symon A.
      • Paul J.
      • Butchart M.
      • et al.
      Maternity unit design study part 3: environmental comfort and control.
      ]. One study reported a weak correlation between the midwives’ overall job satisfaction and midwives’ perceptions of whether noise levels were a problem (rs=−0.162; p < 0.05) [
      • Symon A.
      • Paul J.
      • Butchart M.
      • et al.
      Maternity unit design study part 3: environmental comfort and control.
      ].
      Positive perceptions of room layout and comfortable work environments were found to have a weak but significant correlation with midwives’ job satisfaction [
      • Symon A.
      • Paul J.
      • Butchart M.
      • et al.
      Maternity unit design study part 2: perceptions of space and layout.
      ]. Two-thirds of midwives agreed that the clinical area was spacious enough for them to perform their duties, but less than half agreed that computer equipment for entering clinical records was located in the right place [
      • Symon A.
      • Paul J.
      • Butchart M.
      • et al.
      Maternity unit design study part 4: midwives’ perceptions of staff facilities.
      ]. Midwives also reported that being in a hospital setting and culture changed the way they worked, for example the need to ‘look busy’ meant that they felt less comfortable spending time just being with the woman than they did in home or birth centre settings [
      • Davis D.L.
      • Homer C.S.
      Birthplace as the midwife’s work place: how does place of birth impact on midwives?.
      ].

      Theme 4: control of the space

      Seven studies reported that it was sometimes unclear who controlled the space in birth environments, mostly concerning the different, and sometimes conflicting, priorities of women, midwives and doctors [
      • Hammond A.D.
      • Homer C.S.E.
      • Foureur M.
      Messages from Space: an exploration of the relationship between hospital birth environments and midwifery practice.
      ,
      • Seibold C.
      • Licqurish S.
      • Rolls C.
      • et al.
      ‘Lending the space’: midwives perceptions of birth space and clinical risk management.
      ,
      • Townsend B.
      • Fenwick J.
      • Thomson V.
      • et al.
      The birth bed: a qualitative study on the views of midwives regarding the use of the bed in the birth space.
      ,
      • Davis D.L.
      • Homer C.S.
      Birthplace as the midwife’s work place: how does place of birth impact on midwives?.
      ,
      • Lyndon A.
      • Malana J.
      • Hedli L.C.
      • Sherman J.
      • Lee H.C.
      Thematic analysis of women’s perspectives on the meaning of safety during hospital-based birth.
      ,
      • Symon A.
      • Paul J.
      • Butchart M.
      • et al.
      Maternity unit design study part 3: environmental comfort and control.
      ,
      • Newburn M.
      • Singh D.
      Creating a Better Birth Environment: Women’s views about the design and facilities in maternity units: a national survey.
      ]. Women often did not have control and privacy in the birth environment, particularly in hospital settings [
      • Davis D.L.
      • Homer C.S.
      Birthplace as the midwife’s work place: how does place of birth impact on midwives?.
      ,
      • Lyndon A.
      • Malana J.
      • Hedli L.C.
      • Sherman J.
      • Lee H.C.
      Thematic analysis of women’s perspectives on the meaning of safety during hospital-based birth.
      ,
      • Newburn M.
      • Singh D.
      Creating a Better Birth Environment: Women’s views about the design and facilities in maternity units: a national survey.
      ]. Fathers’ and partners’ needs were also often overlooked, giving women more concerns during labour and potentially devaluing the father’s or partners’ role [
      • Newburn M.
      • Singh D.
      Creating a Better Birth Environment: Women’s views about the design and facilities in maternity units: a national survey.
      ]. Studies describe midwives trying to make the space the woman’s by adjusting the room, but sometimes feeling conflicted in the hospital setting [
      • Hammond A.D.
      • Homer C.S.E.
      • Foureur M.
      Messages from Space: an exploration of the relationship between hospital birth environments and midwifery practice.
      ,
      • Seibold C.
      • Licqurish S.
      • Rolls C.
      • et al.
      ‘Lending the space’: midwives perceptions of birth space and clinical risk management.
      ,
      • Townsend B.
      • Fenwick J.
      • Thomson V.
      • et al.
      The birth bed: a qualitative study on the views of midwives regarding the use of the bed in the birth space.
      ,
      • Davis D.L.
      • Homer C.S.
      Birthplace as the midwife’s work place: how does place of birth impact on midwives?.
      ]. Some midwives feared reprimand from senior colleagues for altering the position of the bed and were reluctant to take control of the room layout [
      • Townsend B.
      • Fenwick J.
      • Thomson V.
      • et al.
      The birth bed: a qualitative study on the views of midwives regarding the use of the bed in the birth space.
      ].
      There were different opinions on who should have control of temperature given the different needs of women, midwives and babies. Whereas few mothers knew if they were able to control the environmental temperature, most midwives indicated that they definitely could not control the temperature and were unable to adjust the flow of air within their working environment [
      • Symon A.
      • Paul J.
      • Butchart M.
      • et al.
      Maternity unit design study part 3: environmental comfort and control.
      ].

      Theme 5: design issues

      Seven studies highlighted design issues that could help improve the birth environment for women, staff, and birth partners [
      • Hammond A.D.
      • Foureur M.
      • Homer C.S.E.
      The hardware and software implications of hospital birth room design: a midwifery perspective.
      ,
      • Hammond A.
      • Homer C.S.E.
      • Foureur M.
      Friendliness, functionality and freedom: Design characteristics that support midwifery practice in the hospital setting.
      ,
      • Lyndon A.
      • Malana J.
      • Hedli L.C.
      • Sherman J.
      • Lee H.C.
      Thematic analysis of women’s perspectives on the meaning of safety during hospital-based birth.
      ,
      • Plough A.
      • Polzin-Rosenberg D.
      • Galvin G.
      • Shao A.
      • Sullivan B.
      • Henrich N.
      • et al.
      An exploratory study of the relationship between facility design and the provision of childbirth care.
      ,
      • Symon A.
      • Paul J.
      • Butchart M.
      • et al.
      Maternity unit design study part 2: perceptions of space and layout.
      ,
      • Sherman J.P.
      • Hedli L.C.
      • Kristensen-Cabrera A.I.
      • Lipman S.S.
      • Schwandt D.
      • Lee H.C.
      • Sie L.
      • Halamek L.P.
      • Austin N.S.
      Safety learning laboratory for neonatal and maternal care. understanding the heterogeneity of labor and delivery units: using design thinking methodology to assess environmental factors that contribute to safety in childbirth.
      ,
      • Shin J.H.
      • Maxwell L.E.
      • Eschelman P.
      Hospital birthing room design: a study of mothers’ perception of hominess.
      ]. These included the layout and space of the birth room, as well as the furniture, equipment, and workspace provision [
      • Hammond A.D.
      • Foureur M.
      • Homer C.S.E.
      The hardware and software implications of hospital birth room design: a midwifery perspective.
      ,
      • Hammond A.
      • Homer C.S.E.
      • Foureur M.
      Friendliness, functionality and freedom: Design characteristics that support midwifery practice in the hospital setting.
      ,
      • Sherman J.P.
      • Hedli L.C.
      • Kristensen-Cabrera A.I.
      • Lipman S.S.
      • Schwandt D.
      • Lee H.C.
      • Sie L.
      • Halamek L.P.
      • Austin N.S.
      Safety learning laboratory for neonatal and maternal care. understanding the heterogeneity of labor and delivery units: using design thinking methodology to assess environmental factors that contribute to safety in childbirth.
      ]. The main focus was that the spaces needed to be flexible to change according to requirements; the usability of the space was reported to be more important than the size of room [
      • Hammond A.D.
      • Foureur M.
      • Homer C.S.E.
      The hardware and software implications of hospital birth room design: a midwifery perspective.
      ,
      • Hammond A.
      • Homer C.S.E.
      • Foureur M.
      Friendliness, functionality and freedom: Design characteristics that support midwifery practice in the hospital setting.
      ]. One study also discussed the importance of flexible space in the whole unit to ensure spaces were adaptable for birthing as a contingency/overflow during peak times [
      • Plough A.
      • Polzin-Rosenberg D.
      • Galvin G.
      • Shao A.
      • Sullivan B.
      • Henrich N.
      • et al.
      An exploratory study of the relationship between facility design and the provision of childbirth care.
      ]. There were incidences reported where the design of equipment or facilities impacted on the way midwives could complete their tasks, in some cases resulting in risky workarounds [
      • Hammond A.D.
      • Foureur M.
      • Homer C.S.E.
      The hardware and software implications of hospital birth room design: a midwifery perspective.
      ]. Neonatal resuscitation equipment also needs to be considered in the design to ensure that it is easily accessible when needed, does not block other equipment, and has space for multiple clinicians to perform complex neonatal resuscitation [
      • Sherman J.P.
      • Hedli L.C.
      • Kristensen-Cabrera A.I.
      • Lipman S.S.
      • Schwandt D.
      • Lee H.C.
      • Sie L.
      • Halamek L.P.
      • Austin N.S.
      Safety learning laboratory for neonatal and maternal care. understanding the heterogeneity of labor and delivery units: using design thinking methodology to assess environmental factors that contribute to safety in childbirth.
      ].
      Lack of storage was highlighted as limiting the functionality of the space for both women and midwives [
      • Hammond A.D.
      • Foureur M.
      • Homer C.S.E.
      The hardware and software implications of hospital birth room design: a midwifery perspective.
      ,
      • Hammond A.
      • Homer C.S.E.
      • Foureur M.
      Friendliness, functionality and freedom: Design characteristics that support midwifery practice in the hospital setting.
      ,
      • Symon A.
      • Paul J.
      • Butchart M.
      • et al.
      Maternity unit design study part 2: perceptions of space and layout.
      ]. Midwives felt there should be better designed storage that was more easily accessible for women and midwives [
      • Hammond A.D.
      • Foureur M.
      • Homer C.S.E.
      The hardware and software implications of hospital birth room design: a midwifery perspective.
      ,
      • Symon A.
      • Paul J.
      • Butchart M.
      • et al.
      Maternity unit design study part 2: perceptions of space and layout.
      ]. Some women found lack of storage distressing as they worried people may trip over their bags [
      • Symon A.
      • Paul J.
      • Butchart M.
      • et al.
      Maternity unit design study part 2: perceptions of space and layout.
      ]. Reorganisation of storage and accessibility of clinical equipment to be more human-centred was noted as a factor which may improve staff workflow [
      • Sherman J.P.
      • Hedli L.C.
      • Kristensen-Cabrera A.I.
      • Lipman S.S.
      • Schwandt D.
      • Lee H.C.
      • Sie L.
      • Halamek L.P.
      • Austin N.S.
      Safety learning laboratory for neonatal and maternal care. understanding the heterogeneity of labor and delivery units: using design thinking methodology to assess environmental factors that contribute to safety in childbirth.
      ].
      Shin et al. and Sherman et al. produced design and human factors recommendations for birth environments [
      • Sherman J.P.
      • Hedli L.C.
      • Kristensen-Cabrera A.I.
      • Lipman S.S.
      • Schwandt D.
      • Lee H.C.
      • Sie L.
      • Halamek L.P.
      • Austin N.S.
      Safety learning laboratory for neonatal and maternal care. understanding the heterogeneity of labor and delivery units: using design thinking methodology to assess environmental factors that contribute to safety in childbirth.
      ,
      • Shin J.H.
      • Maxwell L.E.
      • Eschelman P.
      Hospital birthing room design: a study of mothers’ perception of hominess.
      ]. This included providing comfortable, spacious, light spaces to enable the woman and her family to have private, supportive areas within labour wards [
      • Shin J.H.
      • Maxwell L.E.
      • Eschelman P.
      Hospital birthing room design: a study of mothers’ perception of hominess.
      ]. Privacy was important for sensitive discussions with women without being overheard, and also for clinicians to have private space to discuss cases [
      • Sherman J.P.
      • Hedli L.C.
      • Kristensen-Cabrera A.I.
      • Lipman S.S.
      • Schwandt D.
      • Lee H.C.
      • Sie L.
      • Halamek L.P.
      • Austin N.S.
      Safety learning laboratory for neonatal and maternal care. understanding the heterogeneity of labor and delivery units: using design thinking methodology to assess environmental factors that contribute to safety in childbirth.
      ]. Labour rooms should have transition spaces to enable women to feel less exposed and have time to prepare for visitors [
      • Shin J.H.
      • Maxwell L.E.
      • Eschelman P.
      Hospital birthing room design: a study of mothers’ perception of hominess.
      ]. Natural light was important to women but windows should not result in women feeling over-exposed [
      • Lyndon A.
      • Malana J.
      • Hedli L.C.
      • Sherman J.
      • Lee H.C.
      Thematic analysis of women’s perspectives on the meaning of safety during hospital-based birth.
      ], blinds or curtains can help enhance women’s feelings of homeliness and control of the room [
      • Shin J.H.
      • Maxwell L.E.
      • Eschelman P.
      Hospital birthing room design: a study of mothers’ perception of hominess.
      ].

      Discussion

      Current guidance recommends that women with straightforward pregnancies are offered a choice of birth setting (e.g. home, midwifery-led unit, obstetric-led unit) [

      NHS England. Better Births: Improving outcomes of maternity services in England – A Five Year Forward View for maternity care. 2016. 〈https://www.england.nhs.uk/publication/better-births-improving-outcomes-of-maternity-services-in-england-a-five-year-forward-view-for-maternity-care/〉 (accessed Dec 2021).

      ]. However, for women with more complex pregnancies with medical conditions or in situations where there is increased risk for the woman or baby during labour, an obstetric-led unit is recommended [

      National Institute for Health and Care Excellence (NICE). Intrapartum care for healthy women and babies. Clinical guideline [CG190] 2014, updated 2017.

      ]. Obstetric units tend to have an emphasis on safety and facilitating the use of interventions, in contrast to environments that are explicitly designed to complement birth physiology and enhance the quality of care such as midwifery-led units. We believe this to be the first systematic review of birth environments which focusses beyond women with straightforward pregnancies and midwife-led settings.
      The synthesised findings highlight that the flexibility, space and comfort of the environment may help facilitate staff to assist women with comfortable positions and ultimately straightforward birth. This is in line with other research which shows that more comfortable environments (midwifery-led units) are associated with decreased use of analgesia and clinical intervention during labour, as well as increased likelihood of spontaneous vaginal birth, breastfeeding at six-to-eight weeks and very positive views of care [
      • Hodnett E.D.
      • Downe S.
      • Walsh D.
      Alternative versus conventional institutional settings for birth.
      ]. Birthing pools and aids (such as floor mats, or bean bags) were highly valued by women to support birthing, as was the ability to mobilise. However, many women may not have access to these, particularly in obstetric-led settings or if they are restricted by widely used continuous electronic fetal monitoring equipment and/or oxytocin infusions. The introduction of remote telemetry (wireless monitoring), which is recommended to be offered to all women requiring continuous fetal monitoring [

      National Institute for Health and Care Excellence (NICE). Intrapartum care for healthy women and babies. Clinical guideline [CG190] 2014, updated 2017.

      ], offers women more freedom to mobilise and birth rooms need to adapt to these technological changes. This is a good example of where the safety and quality of care can be equally facilitated by appropriate technological solutions.
      Having a comfortable and homely space was another major theme in this review. Fannin describes these home-like settings within the hospital unit as a ‘hybrid space’ highlighting the conflicting priorities of safety, control and family [
      • Fannin M.
      Domesticating birth in the hospital: “family‐centered” birth and the emergence of “homelike” birthing rooms.
      ]. Adjustable lighting can help a space feel more relaxing whilst also facilitating the lighting required for medical assessments. Alcoves, such as window seats, can provide flexible spaces and make the room feel more homely. Comfortable and adaptable furniture could help support women and their partners through long labours. Storage for both personal possessions and equipment could help to prevent rooms becoming too cluttered, promoting flexibility. Well-designed rooms may feel more spacious than larger rooms. Women have reported feeling disappointed when they are transferred from a midwifery-led unit to a hospital labour ward, having to adjust from a more relaxed and homely environment to one which felt clinical and confining [
      • Larkin P.
      • Biggerstaff D.L.
      Disconnection: exploring transfer from midwifery-led to consultant-led care a phenomenological study of women’s views.
      ]. A modified ‘ambient’ labour room pilot trial also seemed to prompt positive reactions in women with straightforward pregnancies and reduce the amount of time spent in bed [
      • Hodnett E.D.
      • Stremler R.
      • Weston J.A.
      • et al.
      Re‐conceptualizing the hospital labor room: the PLACE (pregnant and laboring in an ambient clinical environment) pilot trial.
      ].
      Women preferred a private space where they could control who enters the room and be out of sight of other people. This is in line with previous research reporting that modern hospital birth spaces provide high levels of surveillance of the birthing woman, which serve to reassure the maternity care providers, but can result in women feeling stressed and reduce women’s sense of control [
      • Stenglin M.
      • Foureur M.
      Designing out the fear cascade to increase the likelihood of normal birth.
      ]. This may also be a particular issue for obstetric-led settings as women who gave birth in midwifery-led birth centres reported greater feelings of dignity, confidentiality and social considerations compared to those receiving obstetric-led care in hospital [
      • Hitzert M.
      • Hermus M.A.A.
      • Scheerhagen M.
      • et al.
      Experiences of women who planned birth in a birth centre compared to alternative planned places of birth. Results of the Dutch Birth Centre Study.
      ]. Transition spaces (e.g. partition wall) in doorways may help to achieve this. Large openable exterior windows were preferred by women to help provide natural light and ventilation, but full-length windows may make women feel exposed. Women also preferred rooms to be insulated from noise and particularly did not want to be overheard or hear other women giving birth.
      In birth environments there are different, and sometimes conflicting, priorities of women, partners, midwives and doctors. The systems in which midwives practice can create tensions between the provision of woman-centred midwifery philosophy of care and negotiating the dominant medicalised model of care [
      • Larkin P.
      • Biggerstaff D.L.
      Disconnection: exploring transfer from midwifery-led to consultant-led care a phenomenological study of women’s views.
      ]. This conflict has come through strongly in our review findings, particularly with regard to the bed dominating the room (and often placed in the centre therefore limiting flexible space). It is sometimes unclear who has control of the space, and the review suggests that midwives may fear reprimand for adapting the room. While spaces need to be supportive for women, they need to work well for medical emergencies; lack of storage, space, layout, and clutter poses a risk in emergency situations. The review shows that room design may affect the care given by midwives, particularly if they need to spend time adapting the room or leaving the room to write notes. Workplace conditions can be challenging for midwives, with a lack of control over environmental factors, including noise. Clearly, working in an uncomfortable environment has implications for health and wellbeing, and may affect staff performance potentially influencing safety of care [
      • Al Horr Y.
      • Arif M.
      • Katafygiotou M.
      • Mazroei A.
      • Kaushil A.
      • Elsarrag E.
      Impact of indoor environmental quality on occupant well-being and comfort: A review of the literature.
      ,
      • Wang X.
      • Carol D.
      • Menassa C.
      • Kamat V.
      Investigating the effect of indoor thermal environment on occupants’ mental workload and task performance using electroencephalogram.
      ]. Midwives also reported needing to get into positions to assist births which were uncomfortable or not well supported by the physical environment, improved design is recommended to ameliorate this [

      Health and Safety Executive. Manual handling risks to midwives associated with birthing pools: literature review and incident analysis. 2018. 〈http://www.hse.gov.uk/research/rrpdf/rr1132.pdf〉 (accessed Dec 2021).

      ].
      With innovative design, many of the environmental changes to birth rooms can be made to improve the birthing experience of all women, irrespective of risk status [
      • Jenkinson B.
      • Josey N.
      • Kruske S.
      BirthSpace: an evidence-based guide to birth environment design.
      ]. The Birth Unit Design Spatial Evaluation Tool provides a theoretical framework identifying four domains for the optimal birth environment: the Fear Cascade, Facility, Support and Aesthetics [
      • Foureur M.J.
      • Leap N.
      • Davis D.L.
      • Forbes I.F.
      • Homer C.E.
      Developing the birth unit design spatial evaluation tool (BUDSET) in Australia: a qualitative study.
      ]. However, the spatial design of labour and delivery units varies greatly and best practices for unit design are undefined [
      • Austin N.
      • Kristensen-Cabrera A.
      • Sherman J.
      • Schwandt D.
      • McDonald A.
      • Hedli L.
      • et al.
      Analyzing the heterogeneity of labor and delivery units: A quantitative analysis of space and design.
      ]. Creating a gold standard for labour rooms and units requires both an analysis of the physical space, clinical outcomes and maternal level of care. A human factors approach may provide an appropriate framework to investigate this, given the complexity of factors and users involved [
      • Reiling J.
      Safe design of healthcare facilities.
      ]. Human factors led design standards may be useful for units that are being newly constructed, remodelled, or retrofitted. All users of the space (including women, families, clinicians and facilities staff) should be actively involved in the design process to maximize safety, efficiency, and experience of care.

      Limitations

      Screening by title was completed by one researcher, however this was based on topic relevance rather than the specific inclusion criteria (completed by two researchers), so it is unlikely that relevant papers were excluded due to this. The review was limited to OECD countries to enable greater comparability between health systems and socio-economic contexts, particularly as this review informed new guidance for intrapartum care. However, this review will remain relevant to the many countries that have similar maternity systems to the UK. The studies exploring women’s views were less rich than those exploring midwives’ views, as they were based mainly on survey data, therefore this may affect the findings. Although most of the included papers were rated as high or medium quality, some were rated as low quality due to methodological and reporting concerns. In addition to this, we were unable to identify any ‘gold standard’ randomised controlled trials which assessed birth environments for women with complex pregnancies, however, there are some ongoing trials [
      • Berg M.
      • Goldkuhl L.
      • Nilsson C.
      • et al.
      Room4Birth - the effect of an adaptable birthing room on labour and birth outcomes for nulliparous women at term with spontaneous labour start: study protocol for a randomised controlled superiority trial in Sweden.
      ,
      • Lorentzen I.
      • Andersen C.S.
      • Jensen H.S.
      • et al.
      Study protocol for a randomised trial evaluating the effect of a “birth environment room” versus a standard labour room on birth outcomes and the birth experience.
      ]. As this systematic review was focussed on women with complex pregnancies, papers were excluded if they focussed solely on women with straightforward pregnancies or associated settings. However, the included papers may have had a mix of low- and high-risk women or settings and in some cases data could not be differentiated between these during analysis.

      Conclusions

      Women, their families, midwives, and doctors have different requirements from birth environments and these must all be considered. Environments for women with complex pregnancies need to be multi-functional so that they have the space to both support women to use birthing aids and mobilise, but also have the facilities for medical emergencies. This can be achieved through innovative design of equipment, furniture, and storage solutions. A sense of privacy and control in the space is important, particularly for women, but also to help midwives feel comfortable to support women as they would like to. There is a need for more high-quality research investigating birth environments for women with complex pregnancies and those supporting them, particularly in terms of: (i) in-depth qualitative data of women’s experiences, and (ii) the design requirements for different users of the space.

      Funding

      The Royal College of Midwives, UK.

      Conflicts of interest

      None.

      Acknowledgments

      This work was supported by the Royal College of Midwives (RCM) UK and the Nottingham Maternity Research Network PPI group.

      Appendix A. Supplementary material

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