 keynote speaker, Professor Marilyn Thoreau is from the University of Technology in Sydney, specifically the Centre for Midwifery, Child and Family Health. She teaches undergrad and post-grad Midwifery students and supervises students undertaking the honours, masters and PhDs and she's published in over a hundred journals, book chapters, edited books, particularly an amazing book called Birth Territory and Midwifery Guardianship. Marilyn's been a Midwifery clinician, academic and researcher for three decades working in Australia, New Zealand and in Denmark. Her PhD was one of the earliest randomized control trials of continuity of midwifery care conducted in Australia and now it's part of the Cochrane Systematic Review on Midwifery-led models of care, demonstrating conclusively that midwives and babies benefit if they have opportunities to get to know their midwife caregivers. And for the past five years Marilyn's research has focused on the impact of the birth environment on the neurophysiology of laboring and birthing women and on their supporters and care providers and this is the topic of this morning's presentation. So join me in welcoming Marilyn. Thank you Marilyn. Thank you Deb and happy international day of the midwife to midwives everywhere. Can you hear me alright is the first question? Looks like it's happening. Good. Thank you. I feel very privileged to be part of this amazing community of midwives to make a difference in the lives of millions of women and their families every day. I'm sitting here on the land of the Gadigal people of the Eora Nation. So you can see we're spread across Australia far and wide as well as the rest of the world. I'm very pleased to be part of the virtual conference to share some of the ideas we've been exploring for the past five years around how the space in which women give birth and where midwives work might influence what happens and in particular to explore the prevailing emotion of fear that many of us feel about birth and I want to explore a little bit about where does that feeling come from? How does the space that we are working in make a difference to that feeling and what can we do about it using the concept of design? I've got multiple things happening here in front of me and I'm trying to get the technology to work properly so forgive me if I'm coming about here a bit to do that. Okay so what we're going to do is fundamentally explore three questions. First of all I want you to consider the spaces in which you work be that at home or in birth centres or in hospitals and here are the questions is the space in which you work a sanctuary or what we might call a surveillance space and just what does that mean? Does the space in which you work create feelings of trust and safety or feelings of insecurity mistrust and fear in you and in the women for whom you care and finally just what do we mean by that and what can we do about designing out this concept, this idea, this feeling of fear. One of the people who's had something to say about design was Steve Jopes who's the co-founder of the Apple company. He said this, most people's vocabulary design means the veneer it's interior decorating just the fabric of the curtains or sofa in fact nothing could be further from the meaning of design. Design is not just what something looks like and feels like although they are critical. The most important thing is that design is how it works. I'm going to come back to that again. First of all I want to take you on a small journey of the imagination. I want you to imagine for a moment you're a brand new midwife it's your first day at your job in a new hospital you've never been in it before or you're a woman having her first baby excited about the prospect of becoming a mother and holding your baby in your arms very soon. You've been allocated a room so you open the door and you walk in. I want you to focus on the thoughts that might be appearing in your mind. Focus on how this space is making you feel what might be happening as you move around the room and look at what's in there. Now the spaces in which you work of course might be very differently set up with more or less of what that room contains. It might look like any of these rooms. What messages or images do these rooms bring to mind? What's common for them all? Many years ago a group of us put together what we called the safe satisfying birth hypothetical model to see if we could pull together what was understood at that time about that the elements that made up an environment a space in which a woman could experience a safe and satisfying birth. A lot of it was based on the work of an architect that we'd met many years before called Bianca Lappori and in order to design spaces that she thought would best meet the needs of women in labour she followed women at home. See what it was like in environments where women weren't constrained by what was around them but in their own environment and what she discovered was that at home women seldom give birth in the bedroom but more often in their sitting room where they select an empty and protected area never exposing themselves at the centre of the scene. The birth room to house women in hospitals is clearly a bedroom and it's not the cozy private nest that women create at home but a stage on which the woman becomes a spectacle under constant surveillance and control. So the place of birth matters and here's a list of the kinds of places where birth occurs at home free-standing birth centres alongside birth centres and in hospitals either tertiary secondary or indeed primary hospitals and the UK place of birth study which was published in 2011 in the British Medical Journal looked at maternal and perinatal outcomes by planned place of birth for healthy women with low risk pregnancies. It's called the birth place in England it's a national prospective cohort study and they produced reams and reams of wonderful data revealing that where the women birthed made a difference to the kinds of outcomes they had and the kinds of interventions they experienced during labour and birth. I'm not going to show you the reams of tables what I want to show you is the way a journalist from the BBC reconstructed some of that material to show you very clearly why he came up with the conclusion that home birth might be the best option for many babies. What James Gallagher did was to extract the data from those tables to reproduce this table divided by home free-standing with unit alongside unit and obstetric unit to demonstrate what was the experience of mothers and babies. These data are rates per 1,000 babies or 1,000 mothers going into labour so for similarly risk women serious medical problems in their babies occurred at the same rate from home to hospital with a slightly lower rate in alongside midwifery units but normal vaginal birth occurred more per thousand births at home of course than it did in the obstetric unit. Physiology was less at home compared to the obstetric unit so there in birth was far less for women who started their labour at home compared to those in the obstetric unit and instrumental births have a similar pattern so clearly intervention rates alter depending on how complex the unit is and home is where you experience the least amount of intervention for the same rate of wellness in babies so I think his conclusion looked pretty reasonable on the basis of that data. The place of birth matters just why what is it about those different places of birth that might be making a difference to the outcomes so let's explore just a couple of those places home birth center and hospital and this woman is experiencing birth at home and every home is entirely different in terms of its physical layout and construction the aesthetics the temperature the smells the sounds the light the colors the people who are with you your culture and of course the element of fear at home during the course of labour women can move freely from one space to another moving from laying down on a bed if they want with other people if they want they can be making food in a very domestic part being part of the domestic and intimate daily life or they can retreat into into themselves through immersion in a bath or pool in order to focus inwardly there are many ways at home that the woman can be in that space this is a birth center the this is one of the woman who took part in our a particular piece of research where we followed women during labor and birth in various locations it's the middle of the night so the photographs are quite dark because the soft subdued lighting there are mats on the floor where the woman's mother has made her a nest to rest in the sister is sitting by her on the couch asleep almost because it's the middle of the night at one stage the mother got up off the floor and said she needed to lean against the wall the mattress happened to be leaning against the wall itself so she leaned against it I was interested to find that this is clearly a movement that other women make during labor because on the Royal College of Midwives normal birth campaign website there are illustrations to suggest the kinds of movements activities that might be possible for women and I found they similarly had drawn a picture of a woman standing and leaning against the wall but this woman in the birth center who ultimately had a straightforward normal birth there was no sense of fear she labored for 15 hours she resisted any suggestions of interventions to speed up her labor or to receive analgesia so in the birth center she achieved the same kind of outcome as the woman at the home birth these are another three women from our research very generous people who agreed to have us in their filming them during the labor so they could see how they interacted with this with the space and with the people they shared the space with they all experienced the vaginal birth with healthy babies and how different or how similar are their birth spaces to each other and how are these spaces different from those of the birth center or home think about how does the hospital space enable the woman to be herself to move as she wishes and to do what she wants and what is the pervasive sense of safety security or fear in this kind of a space what's common and how do they differ and I've made a list of some of the commonalities and the differences in all of these spaces they certainly look and smell different and in their level of familiarity and homeliness they may differ on which women can access which locations what models of care are on offer what are the levels of surveillance or sanctuary and we're going to explain that a little more they differ on how autonomous are the clinicians who work with them what access is there to drugs or interventions or more complex levels of care they differ on what are the cultures of care who has the power in that place and then there are unknown unknowns that we don't even know about yet that they may differ on so basically how do we make sense of this and here we go how can we make sense of this the place of birth is quite complex and all of these characteristics may interact in known and unknown ways so there are three questions that we need to consider what is it about the place of birth that makes a difference if we can find out what it is can we design more of it is it simply the physical nature of it remember Steve Job said it's not just what it looks like and feels like there's something about how it works that is the key element how it works is clearly influenced by what it looks like and feels like and what this in what this implies what you are meant to do in this room and in hospitals we mostly work in rooms that are to a larger or a lesser extent versions of this kind of a space it's probably fairly easy to see that this kind of space might make possible different feelings and therefore different kinds of birth outcomes it's a beautiful new birth centre in Toronto in Canada very few of us will ever have the possibility to rebuild our hospitals to look like this so let's explore some theoretical ideas that might provide some principles we could use in our existing unit to design what we have to work differently Kathleen Faye developed this idea of places for birth as either surveillance rooms or sanctuaries and I'm sure you don't need to which kinds of rooms might be preferred by women and why the ideas of surveillance and sanctuary are also multifaceted and complex ideas and it's not as clearly differentiated as you might imagine for instance is this woman also experiencing surveillance or sanctuary I met a wonderful person called Marie Stengland many years ago and Marie is a linguist a social linguist and she worked in the area of semiotics or what are the meanings of objects and spaces and Marie produced this concept of binding that I think helps us understand even more about what we mean by a surveillance space or a sanctuary where women might feel safe and secure or unsafe and afraid the concept of binding talks about the way spaces close in on us or open up around us spaces that close in around us in a particular way feel comfortable make us feel secure and are the basis of what is a sanctum spaces that are too close too tight around us or who or which are much too open with too little enclosure actually make us feel quite insecure and these are the characteristics of surveillance spaces have a look a little more what Marie's theory suggests to us is the reason why many women want to gravitate towards a birthfall or bath during labor if you think about it in terms of okay we're just taking a minute to try and fix the the problem here we won't be in a moment if my microphones back on again now can you hear me did yeah we all seem to lose sound then so we'll just get your screen back to where you're up to and carry on Marilyn maybe a minute just taking a minute to get the PowerPoint back up to where I was you might be able to take this opportunity to stand up almost there okay while we're working on getting the presentation back okay might take a minute we're just having to search for the slides perhaps I see in the comments Marilyn people were really enamored with the idea of the sanctuary or surveillance and I see that you're just starting to unpack that now which is fascinating yeah I mean certainly thinking about women in Australian hospitals in particular all want to be able to have access to order immersion during labor and indeed often end up giving birth in the bath to the point where in New South Wales the state that I'm located in the government has made a mandate that every birth unit must provide women with the opportunity for water immersion during labor which is pretty unusual and Marie Stingland's concepts of binding kind of give us an understanding of why that might be there we are so we're back to why a woman might want to get into a bath or indeed stand under a shower and basically when we and we have with Robin Maude in New Zealand I interviewed numbers of women about why they got into the bath during labor basically what they said was well it's a place where no one else can touch me it's a private space it's an enclosed space where I feel much more secure and safe so this idea of binding gives us an idea why women might want to get into the bath or indeed stand under a shower because they know that other people aren't going to get under there with them and get wet they're certainly not going to get in the bath with them all although obviously partners sometimes do at the woman's invitation so using this idea of bonding suggests or suggests why this might be important for women I want you to look at this space and think about in terms of the bindness or unboundness of this space it's a newly renovated birth unit previously the unit that they were in had no outside windows and the spaces were quite enclosed and cave-like how would women feel in this space and where does it fit on the the bound or unbound spectrum and I think you'll agree with me it's beautiful from an architectural point of view wouldn't you love to be sitting there having a lunch looking out at that wonderful view but for a woman in labor this space is experienced as incredibly unbound and an unbound space feels unsafe so what's happening in practice is the blinds are kept closed the entire time and the woman is not gazing out at the view because she feels exposed and vulnerable and under surveillance in this kind of space about two bound spaces again in interviewing women and women for instance who are connected to a CTG machine and many of them for the entire length of their labor and most of our units can't afford to have telemetry monitoring so the woman is strapped to the machine and therefore marooned on her bed or in a chair unable to move and she certainly feels trapped and potentially too bound and this idea of not being able to move freely evokes feelings of insecurity and fear and apprehension so again thinking about how do we design out fear in our spaces how many women are we keeping attached to CTG monitors so Marie's theory about binding came up with the kind of idea that makes a sanctum is one that is optimally bound and optimally unbound because again there are times during labor where there's an ebb and flow where the woman wants to interact differently with people where she wants to move or be or lay or stand or sit or talk and so we have to be able to think about how the design spaces that can accommodate this ebb and flow one of the places that I'm aware of is in fact in Denmark and in this space the designers have thought very carefully about how do you accommodate the ebb and flow of labor or they may have it done it accidentally but this is what's happened this unit is certainly not at a beach what you're looking at is a projection of a beach on the walls plain white walls of this birth unit and it's done by a very simple piece of equipment that's located on the ceiling it's a little projector and on the table you can see a small little computer screen or iPad screen and the woman and the family in the space can actually dial up what kind of an environment they would like to be in an open unbound space like this one or at a different time in a labor she might want to feel that she's in a more bound enclosing and secure kind of space and in fact I can imagine you could put in all sorts of images that might be even more personal for the woman in the room that would make her feel secure and bound or at times when she wanted to be open and engaged with other people you could have an image of a much more open vista this equipment is not expensive I've been in my local Apple shop and I can purchase the projector to do this for around two hundred dollars so at least in the developed world where we are relatively affluent we could all afford to do this kind of thing in our Birkin challenges of course we need to have walls which are plain and unobstructed by other sorts of equipment and paraphernalia in the space so let's have a look more carefully at what's happening at a neurophysiological level the limbic system there that little yellow kind of horseshoe shape in the middle of the brain on the right is hardwired to translate emotions to keep us safe and surveillance activates very core of this limbic system the amygdala it stimulates the release of all sorts of neuro hormones that have to do with flight fight and freeze but in particular adrenaline and those of you you know me know I bang on about this stuff all the time that we need to know what's going on neurophysiologically with women in labor not just would be a uterus because if a woman is afraid fearful stressed feels like she's under constant surveillance and her amygdala activates this process she will produce adrenaline in particular but also nor adrenaline which has a slightly different effect let's focus on adrenaline adrenaline when it increases it disrupts the production of oxytocin and it interferes with the rhythmic contractions of the uterus either making them irregular or making them slow down to the point where uterine inertia is diagnosed on the other hand increases in adrenaline divert blood away from the trunk of the body into the muscles of the arms and the legs for fast running away or fighting and into the brain for thinking about how to get out of this fearful situation so in fact it constricts the blood vessels to the abdomen decreases uterine blood flow which then decreases potential perfusion and fetal oxygenation leading to fetal distress so whilst we haven't done experiments on women to actually see that this happens they have been experiments done on animals and it can demo we can demonstrate in laboring primates in particular you can induce both uterine inertia and fetal distress by making the animal feel afraid so what can we do if we can't change that space as many of us can't we can actually use the human body to simulate that experience because the very first sense of shelter we might have is that of being in your mother's arms so that we can make spaces that are comforting or protective in that same way by being in someone's arms and again the Royal College of Midwives normal birth campaign website has wonderful cartoon illustrations which show exactly how you can make bound spaces for women in places where you can't modify the environment and here are just some of them these enveloping arms help the woman to feel that she's in a bound secure safe space and you can do it in all sorts of ways with the woman sitting on the birth ball with the woman squatting in between her partner's knees she can get into the bathtub and it doesn't have to be a deep immersion pool although that's ideal but in this even in this kind of a little space the woman is not going to be having anybody else getting in there with her so she may get that sense of security and a private space for these kinds of places even using inanimate objects like the chair which the woman woman can in billop also gives her a sense of being bound and more secure so there's much more that we can talk about but we don't have time today these are just a small snippet of the kind of ideas that we've been exploring about how do you optimize birth physiology basically we need an optimal birth environment that might be optimally bound for women but we also need relationship-based care because the two together help initiate the amazing neurophysiological calm and connect system that ensures that the woman has optimal oxytocin to help her lay the progress it lowers her blood pressure her heart rate increases her pain threshold and normal birth is more likely if a woman has straightforward normal birth then she is more her baby is more likely to have its own neurophysiological system initiated in an optimal way there are many many studies that I could talk about we've also looked at the impact of these kinds of places on midwives themselves and Athena Hammond is one person who's produced several papers in this area and this paper is also from Deb Davis and Caroline Homer recently looking at how does place a birth impact on the flights what Athena has concluded is that the current design of many hospital birth rooms challenges the provision of effective midwifery practice and changes the design and the aesthetics of birth rooms may engender safer more comfortable and more effective midwifery practice because if midwives are working in environments where their brain is affected it shuts down their prefrontal cortex and makes their amygdala fire up so that they are fearful and in the fight fly for freeze moment I think we might call it a day there that's the end of my presentation thank you and I'm very happy to receive question what a lovely joyous family photo to finish on there Marilyn thank you so much we'll open the floor to question so if you can raise your hand if you want to ask a question and we can give you the mic alternatively you can type it in in the chat box we did have one question just while people are getting ready to put their hands up Marilyn from somebody in the chat box I think it was rain from Western Australia and it might have been the Danish birth room and we wanted to know the name of the equipment he might have been referring to the projection or the room itself the projection equipment I think if you just go into any one of these techno shops it's it's it's a projector that can project it has a little projection apparatus that has four outlets so it will do 360 degree projection they're very simple pieces of machinery I don't know exactly what their name of them Rita thank you and I think the the images that were projected were specifically made for that purpose from memory yes yeah I think they are scenes of a forest in Denmark seems of a beach somewhere in Denmark and they have other amazing things that were going so and they also had the sound of the lapping water and I think the one that they particularly have was purchased from the Phillips company and it costs many many many thousands of dollars but I discovered it is possible to set it up in a much less sophisticated way and a much less expensive way thank you I'm just scrolling down does anybody want to take the mic and ask a question or make a comment I can see Eva Wilding made a question what study was it that showed the security of home birth there is a paper by Bianca Lepore and it's called trying to think of it now it's in a journal called about children's spaces I've lost I've lost it now did I can't think of what it's called but you'll find it referred to in our paper on safe satisfying birth so have a look there and you'll find the paper oh yeah so someone's also mentioned making an allergy with newborns and how they need that close nesting kind of approach rather than something unbounded yeah absolutely you certainly wouldn't leave a newborn laying out in the open and watch what it was doing you want to cuddle them close and help them feel secure in that bound way so absolutely the same sense I think what I really appreciate a Marilyn was that you you drew on some great new theoretical insights I love the idea of the bounded and the unbounded but you brought it down to a level of practice so there's great practice tips really for people how they can kind of understand this theory and what they can do I mean any sort of environment because not everybody can have a home birth and many women are birthing in hospitals which are environments that we can't change immediately but you gave us some great ideas for what we can do just to help women feel more secure in in the worst of environments really yeah and one of the challenges is that in Australia I know for sure and it happens in most developed countries that many many millions of dollars are being spent every year on renovating or rebuilding birth units and unless midwives get to talk to architects and designers who are part of the teams putting these together then they will build or renovate birth units like the illustration I showed you of the one with the blue couch and the blue bed and all the beautiful windows in it it looks great if its purpose is other than for women during labor and birth you have to help them understand what it is that women during labor and birth knee in order to make the room work so designers about how it works not just what it looks like or feels like in Australia there are several units that are using these design principles and have used them to establish their birth units debut work in some in Canberra I do yes we've got a beautiful birth center in Canberra and that is really a sanctuary I think but I was going to comment as well when people are asking about the redevelopment and involving other people that it's really hard work to get the midwifery perspective and some of this theory and understanding through isn't it to architects and the powers that be when a new hospital or a new unit is being developed I don't know if you want to comment on that I think you had a lot of experience with that. Yeah it is challenging and certainly all of these possibilities are filtered through budgets ultimately but if we can get some principles in the mind of the people who are designing them then they will interpret them in various ways but if the principles are strong and hopefully that you know these ideas of binding will be embraced within the principles. Next week I'm about to start work with in New South Wales the part of the health department that writes the health facility guidelines for how you build amongst other things like birth units in hospitals and we have been consulted in years past and parts of our work is included in them but now there's a whole redevelopment of these facility guidelines about to happen. These facility guidelines influence what happens in the building of all maternity facilities in Australia and in New Zealand as well depending on which companies get to build them and often they're Australian related companies that are building all over the Australasia region. I also work with a private architecture firm on their health facility guidelines and they build facilities throughout Southeast Asia, parts of America and India and their health facility guidelines pretty much match what is done in the New South Wales health guidelines so that's one way of trying to influence what happens. Hopefully we've put in an abstract at ICM for actually running a workshop for midwives in what do you need to know to sit at the table in order to influence the design of the birth unit in your place. So hopefully our abstract might get accepted and we can run a workshop. Thank you. Tracy, the issue of smells which I think is really important and the role of essential oils. Yep, absolutely critical. I mean your olfactory nerves are connected directly and deeply into the brain and smells trigger memories and if you've had a health care experience with the smells you're likely to encounter in a hospital with disinfectants and cleaning agents and things that might be associated with painful procedures you're not even aware of that what will be triggered in your brain when you walk into a birth room. And I spoke just yesterday to a group of new midwives, new student midwives first year about to start their clinical placements and they've walked into these units and they say wow it smells like disinfectant and kind of the metallic smell of blood is in the air and it's terrifying for them. So yep, aromatherapy is a critical part of setting the environment. Thank you. And maybe just the last point a good one to finish on was Anna was asking how she can follow your work Marilyn. Certainly through our publications Anna and if you just Google my name I'm somewhere in some people's papers but we're hopefully going to be able to write a new book that pulls all of this together because it's a critical topic we have to get it right. We can't be wasting money on rebuilding units that aren't fit for purpose and the purpose is helping women to have a straightforward normal birth and we keep building units that look like modified operating theatres with material all around them that women are very well aware is going to be used on them and in them. So it's quite a frightening prospect. So hopefully in the future a book but certainly in our publications currently. Thank you Marilyn. Okay I'll bring it to a close right on time. I want to thank you Marilyn for years and years of dedicated work and the most fascinating work particularly in this area it's just given midwifery and so much. So thank you for that and thank you for sharing it so generously as you very often do with this audience and more. So join me everybody in thanking Marilyn. You can do a virtual, there's a virtual clap happening. Thank you. Thank you everybody and happy international midwifery day. You too. You too. Thank you. Okay everybody just bear with us now we'll be doing a changeover. We have about ten minutes to get ourselves set up so it's time to stretch your legs. Just delivered me a coffee into my office which I'm going for you.