Tackling Maternal, Infant Health Disparities Through Healthcare Design

The Centers for Disease Control and Prevention report that Black women have a pregnancy-related mortality rate more than three times higher than that of white women. Related data show that infant mortality rates in the U.S. follow a similar unsettling trend. These stark maternal and infant health disparities indicate broader underlying social and economic inequities embedded in our culture.

Given that social and environmental factors such as neighborhood quality, healthcare access, and community resources contribute significantly to health outcomes, architects must critically examine how healthcare built environments can be designed to better support maternal and infant well-being for women and children of all races and ethnicities.

Additionally, it’s important to consider that, sometimes, the best practices used to design for one community may not hold when designing for another. For healthcare design to be equitable, designers need to balance generalized planning and design recommendations with contextual insights from the communities they serve, recognizing that these may not always align.

Social inequities that drive health disparities

The stark disparities in maternal and infant health outcomes are deeply rooted in social inequities that permeate our healthcare infrastructure. As such, healthcare built environment factors may contribute to discrimination within the healthcare system and further complicate maternal and infant health. Healthcare designers must recognize these issues and strive to create nuanced spaces that address the needs of diverse patient populations.

In healthcare design, health equity is sometimes equated with access to care. For example, building a hospital or clinic within a community may enhance residents’ access to care through closer proximity.

However, research tells us that proximity is only one of numerous factors—many beyond the realm of facility design—that affect care access. Within the realm of design, it’s not enough just to build this space. Rather, the goal should be to create a culturally sensitive facility that is not only conveniently located but also designed to reflect a community’s values and meet the diverse needs of its residents.

Difference between equal and equitable

Designing with health equity in mind requires a fundamental understanding of the difference between equality and equity. While equality involves treating everyone the same, equity focuses on providing individuals with the specific resources and opportunities they need to achieve similar health outcomes.

In the context of maternal and infant healthcare, this means recognizing and addressing the unique circumstances and challenges faced by each patient, such as education level, language preference, pre-existing or chronic health conditions, poverty, and structural racism and sexism.

Healthcare design can play a role in enhancing health equity. Design should focus on patient dignity and privacy, support patient- and family-centered care, and accommodate individuals with diverse needs, including those with physical disabilities, limited mobility, or sensory impairments.

Materials and design practices that contribute to a healthy indoor environment, such as good air quality, natural light, and noise control, are essential, too. Furthermore, healthcare design should consider the entire patient journey, from home and back. This includes ensuring that transportation options and parking facilities are accessible and convenient for all users.

It’s also important to consider who is included in the planning and design process, and how to measure design outcomes. Reaching out to the community for input and feedback is essential, but how we solicit that information affects what we hear.

How do we ensure that we gain feedback from people who are representative of the whole community? Is enough incentive provided for someone to miss time from work? Can we provide childcare, adequate transportation or easy access to technology, and translation services? A welcoming space that feels inclusive and judgment free? If not, we may not have the right people in the room.

But when those discussions are ready to happen, it’s important to listen deeply to what these individuals share about their experiences and needs, setting aside personal assumptions, and making sure those insights influence the facility goals and design process.

How unconscious bias impacts design and process

Unconscious bias, or implicit bias, refers to the negative attitudes or prejudices individuals hold unconsciously against specific social groups. This bias can subtly influence various aspects of life, including the design and planning of hospitals and healthcare environments.

While buildings do not possess biases, how they are designed, planned, and utilized can reflect and perpetuate social inequalities—a concept known as spatial (in)justice.

Political geographer Edward Soja defined spatial justice as the “fair and equitable distribution in space of socially valued resources and opportunities to use them.” This concept emphasizes the importance of representation and acknowledgment of a range of users within a given space.

The underrepresentation of people of color in design professions may contribute to the perspectives and needs of communities being overlooked in the design process, which can lead to healthcare facilities that do not adequately serve or reflect the cultural preferences and sensitivities of minority communities.

Historically, underprivileged communities have suffered from a lack of investment in critical infrastructure, including hospitals and healthcare facilities, contributing to disparities in care access. Even when facilities are established in lower-income or minority communities, their design often mirrors predominant cultural or industry standards rather than the actual needs of the communities they serve.

Choosing the right design strategies

Evidence-based design (EBD) strategies, which are intended to improve healthcare outcomes, may not always be appropriately applied in these contexts due to significant knowledge gaps in the literature and in understanding of how best to implement the principles.

For example, the use of single-family rooms in the neonatal intensive care unit (NICU) at Parkland Memorial Hospital in Dallas hypothesized various patient benefits based on EBD best practices at the time. These benefits included greater parental presence and involvement in the care of their infants, including more opportunities for skin-to-skin contact and breast feeding, which can help reduce stress levels and lead to higher satisfaction with their child’s care due to the private, quiet environment.

The single-family rooms were also expected to help control infections by reducing exposure to others.

While these NICU rooms provided some families the privacy and care they were seeking, they also presented challenges and disadvantages for others, such as:

• Isolation: Not all parents are able to spend extended periods in the hospital, limiting the potential parental involvement benefits of single-family rooms for infants.
• Reduced Peer Support: Parents, and single mothers in particular, may have fewer opportunities to interact with other families experiencing a similar situation, limiting social support, connection, and shared experiences.
• Staff Challenges: Physical separation can make it harder for staff to communicate with families and each other. A larger unit layout can increase staff travel distances, and single-family rooms reduce staff visibility of patients compared to open-bay NICU designs.

At Parkland, a public safety-net hospital, not all patients come with their own social support network or resources to benefit from single-family rooms in the NICU.

Additionally, the 2020 article, “Single family room neonatal intensive care unit design: Do patient outcomes actually change?” published in Journal of Perinatology, found no significant changes in infant length of stay, time to first oral feeding, or incidence of sepsis due to the single-family room NICU design.

These findings emphasize a need for careful examination when implementing specific design strategies and the importance of distinct patient populations.

Delivering inclusive, supportive healthcare environments

There is no one formula to achieve equity in healthcare design. While sustainability rating systems are evolving to incorporate social equity into their schemes, the manner and degree to which systems engage equity concerns varies widely.

Three key dimensions of equity are as follows: Recognitional equity involves consideration and recognition of community context and history. Procedural equity pertains to affected groups’ involvement and influence on the decision-making process. Distributional equity attends to how potential benefits and harms or risks of a program or project are allocated.

For example, fostering engagement and understanding with community members may support recognitional equity, involving community members in decisions supports procedural equity, and careful consideration of siting, access, and cultural sensitivity may affect distributional equity.

Based on an analysis in the 2023 article, “Social equity in sustainability certification systems for the built environment: Understanding concepts, value, and practice implications,” published in Environmental Research Infrastructure and Sustainability, there is no guarantee that following one prescribed process or achieving points for a certification will lead to real-world equitable outcomes.

Importance of community input

While broadly generalized EBD strategies can provide helpful direction as well, they may not be optimal for all groups or communities. When designing healthcare environments, context is key. To meet the needs of all patients, especially in the realm of maternal and infant health, design teams must engage deeply with the communities being served, including credible and representative community-scale research where possible.

A prime example of this approach was a series of focus groups and workshops with recent mothers at the Texas Health Resources Center for Women in Denton, Texas, which provided designers with invaluable insights into patients’ needs and preferences and allowed them to understand what these mothers wanted in their maternal experience.

This community engagement revealed the value of privacy and comfort in the birth process to support family bonding, a strong need to feel fully supported rather than judged, and a positive influence of intuitive adjacencies and clear wayfinding. These findings were integral to development of patient pathways, birth spaces, and interactions with staff.

Historically, women, particularly women of color, have been underrepresented in the design process, with a male perspective often being the default. Such a lack of inclusion can result in healthcare environments that do not fully meet the needs of all women.

To address this issue, it is crucial for project teams to include team members with local knowledge of community needs and to improve representation, recruitment, and development within the industry. Equally important is engaging communities in the design process to ensure that projects reflect their values and meet their needs.

Fostering trust through partnerships

While community engagement can help foster a wider representation of voices in the design process, several barriers can also hinder community engagement, including lack of trust in the healthcare system and environment, past negative experiences, resource and power imbalances, misaligned incentives and goals, lack of familiarity, community capacity, funding, time, and language or cultural barriers.

Overcoming these challenges requires a long-term commitment and a concerted effort to build trust and foster meaningful partnerships.

As healthcare providers and systems strive to provide culturally appropriate care, designers must also re-evaluate their own practices.

Creating inclusive and responsive environments that support the health and well-being of mothers and infants through the lens of equity means listening to our communities about their needs and setting aside assumptions about what works best.

Francesqca Jimenez, M.S., is a senior social scientist at HDR (Seattle) and can be reached [email protected]. Melissa Templeton, Ph.D., is a senior research coordinator at HDR (New York) and can be reached at [email protected]. Jeri Brittin, Ph.D., is director of social and behavioral sciences at HDR (Boise, Idaho) and can be reached at [email protected].

HCD Expo Preview: For more on this topic, the authors will be speaking in the panel session “E64 – Equal Is Not Always Equitable: Understanding Equity in Maternal and Infant Health and the Implications for Healthcare Planning,” at the HCD conference + Expo, Oct. 5-8 in Indianapolis. For conference and registration details, visit hcdexpo.com.