British Journal of Obstetrics and Gynaecology

February 1986, Vol. 93, pp. 182-187

The use of a birthroom: a randomized controlled trial

comparing delivery with that in the labour ward
M. G. CHAPMAN Lecturer, M. JONES Nursing OfJicer, J . E. SPRING S. H . O.*,
M. DE SWIET Consultant Physician & G . V. P. CHAMBERLAIN Consultant
Obstetrician* *, Queen Charlottes Maternity Hospital, London W6
Summary. A randomized controlled trial of two environments for
delivery was conducted at Queen Charlottes Maternity Hospital. A
total of 253 parous women expecting to have a labour ward delivery
were invited to participate in the trial but only 148 agreed. These women
were randomly allocated t o be delivered either with standard labour
small bedroom
ward management ( n = 72) or in the birthroom-a
decorated in a homely manner, without facilities for epidural analgesia
or electronic fetal monitoring ( n = 76). Eleven women in the birthroom
group and 10 in the labour ward group withdrew from the trial before
labour and four were transferred from the birthroom t o the labour ward
when in labour. A questionnaire sent in the postnatal period to the
women who completed the trial was returned by 80%. In the birthroom
group there was significantly (i) decreased admission-to-delivery interval (ii) less analgesia (iii) more freedom of movement (iv) less suturing
(v) increased rooming-in. No difference was found in the assessment of
difficulty of labour nor in the method of subsequent infant feeding.
The move to lessen the regimentation of labour
is growing. One option has been for a return to
home delivery; another has been the provision
of a birthroom (Kerner & Bailey Ferris 1978)
where a home-like bedroom is provided within
the environs of a maternity unit. Widespread
enthusiasm in the United States has led to many
units adopting these facilities (Dobbs & Kirkwood 1981). Their value has not been proven.
Subjects and methods
A birthroom was constructed close to the fully
equipped labour ward. Wallpaper, carpet, cur-

Correspondence: M. G. Chapman, Senior Lecturer,

Guys Hospital Medical School, London SE1.
* Now Lecturer at Guys Hospital Medical School,
London SE1.
* * Now Professor at St. Georges Hospital Medical
School, London SW17.

182

tains and a modern timber bedroom suite furnished the room. The bed was a single divan, and
a beanbag and a comfortable lounge chair were
available. A washbasin was the only feature of
difference from most standard bedrooms. Any
relevant medical equipment was stored out of
sight but was readily available.
Selection of women

All the women considered were multiparous

who had had normal previous pregnancies and
deliveries. All were under the care of the Queen
Charlottes Maternity Hospital community midwives; all had asked for early discharge and lived
within 5 miles of the hospital. Prior to
acceptance, women were made aware that
neither epidural analgesia nor continuous electronic fetal heart rate monitoring would be available in the birthroom. The randomization
procedure was explained and all suitable women
were then offered by 30 weeks gestation the

The use of a birthroom

Table 1. Distribution by parity in the study groups

weights and the frequency of the many events of

labour, delivery and puerperium in the two
groups.

Parity
Study group

183

Total

>3

46

21

76

Labour ward 46

16

10

72

Results
Birthroom

Acceptance

opportunity to participate in the project. When

they had agreed to enter, a random envelope
selection was made. After this the woman was
allocated either a standard labour ward delivery
or a birthroom delivery. Any reasons for refusal
to join the trial were noted.

Of the 253 women asked to participate, 148

(59%) accepted. The main reasons for refusal
were (i) the desire for epidural analgesia (86) or
preference for continuous fetal monitoring (13).
Even after careful explanation before entry to
the study, two women withdrew later since they
had decided that they wished to have epidural
analgesia.

Management

Study population

The antenatal care of all the women in this study

was no different from that of others admitted to
the hospital. Withdrawal from the trial occurred
if the woman was considered to be unsuitable for
birthroom delivery, either on medical or social
grounds.
On admission in labour, the women were
directed to the previously selected delivery site.
The same group of community midwives cared
for the women, in either place. Records of the
events of labour and delivery were made on a
specially designed form. Postnatal events, the
method of infant feeding and complications
were noted. A detailed sociological questionnaire to assess the birth experience was sent to
the mothers at 6-8 weeks postpartum. Of those
who completed the trial, 45 (83%) of the birthroom group and 45 (76%) of the labour ward
group replied.

Randomization successfully provided two

groups who were well matched for parity (Table
l ) , social class and age (birthroom group mean
28.5 years; labour-ward group mean 29.7 years),
subsequent birthweights and gestation at birth
(Table 2).
Withdrawals

Twenty-two women in the birthroom group

were withdrawn, 11of them before labour. The
reasons were: request for epidural analgesia,
intrauterine growth retardation, post-maturity,
pre-eclampsia, transverse lie, and antepartum
haemorrhage (Table 3). After admission in
labour, seven women were kept in the labour
ward. Two were incorrectly directed in the early
hours of the morning by the labour ward staff.
Fever, meconium-stained amniotic fluid and
preterm labour accounted for the remainder.
Four women were transferred in labour from the
birthroom for reasons shown in Table 3.
A total of 10 women in the labour ward group
were withdrawn (Table 4) from the study in the
antenatal period. Reasons were breech presen-

Statistical analysis

Mann-Whitney U-tests were used to compare

labour length, admission-to-delivery intervals,
and x2 tests were applied to compare birth-

Table 2. Mean birthweight and gestational age at delivery in the two study groups

Mean birthweight (kg) at these weeks gestation

Study group

37

38

39

40

41

42

3 4 0 (3)
2.74 (6)

2.95 (8)
3-27 (6)

3.39 (23)
3.36 (23)

3.49 (31)
3.55 (23)

3.51 (10)
3.70 (9)

4.01 (1)
3.78 (4)

~~

Birthroom
Labour ward

Number of women is shown in parenthesis

184

M . G. Chapman etal.

Table 3. Reasons for withdrawal from project in 76

women allocated a birthroom delivery

Reason for withdrawal

Gestation
Number (weeks)

Before reaching birthroom

Before labour
Epidural requested
Growth retardation
Post maturity (induced)
Pre-eclampsia
Transverse lie
Antepartum haemorrhage
In labour
Admitted to labour ward
Fever
Meconium stained amniotic
fluid
Preterm labour

27,36
37,37,38

3
1
1
1

41,41,42

Transferred from birthroom in labour

Forceps (oocipito-posterior)
Meconium stained amniotic
fluid
Epidural requested
Prolonged first stage of labour
Total

2
3

35
37
32

39,40
40

1
3

39
34,36

41

1
1

39
40

40

22

tation (3), twins (l),moved from our area (2),

antepartum haemorrhage ( l ) ,induction for preeclampsia (2) and poor social circumstances preventing early discharge (1).Three other women
were withdrawn in labour, they had caesarean
sections, one for cord prolapse at artificial rupture of membranes and two for failure to progress. The number of withdrawals was
statistically greater in the birthroom group
(P<O.Ol), than in the labour ward group.

From the questionnaire, the position adopted

in labour had a similar distribution in both
groups. However, only 8% ( n = 4) of the birthroom group, compared with 24% ( n = 11) of the
labour ward group felt that freedom of movement was not sufficient during labour (P<0.05).

Delivery
Among the women still in the trial when in
labour, there was one forceps delivery. There
were three caesarean sections, all in the labour
ward group. Among those withdrawn before
labour there were four further caesarean sections: three in the birthroom group and one in
the labour ward group.
Perineal injury was similar in each group.
However, suturing for episiotomy or tears was
less common in the birthroom group (P<0.05).
The tendency was for episiotomy to be less frequent, although statistical significance was not
reached (Table 7).

Postnatal
Postnatal problems in either mother or baby
were not different between the groups. All the
women thought the postnatal period was satisfactory. From the postnatal questionnaire more
birthroom mothers had their infant rooming-in
all the time compared with labour ward mothers
(R0.01) (Table 8).
Time in hospital was similar in both groups
with mean length of stay being 3-5days (range
Table 4. Reasons for withdrawal from project in 72
women allocated for labour ward delivery

Labour

Reason for withdrawal

The women were asked to complete a linear

analogue rating scale of difficulty of this delivery
compared with the last delivery. N o difference
was shown between the two groups. The frequency distribution of scores is shown in Fig. 1.
A significantly higher number of women used
no analgesia in the birthroom group. Epidural
analgesia was used ,by six women in the labour
ward group (Table 5).
Length of labour was not significantly different between the two groups. However,
admission to delivery intervals were shorter in
the birthroom subjects (PC0.05) (Table 6).

Before labour
Breech
Twins
Antepartum haemorrhage
Moved outside area
Unsuitable for early discharge
Pre-eclampsia (induced)
During labour*
Cord prolapse
Failure to progress
Total

* All required caesarean section.

Gestation
Number (weeks)

2
1
2

36,37,36
30
38
32.34
32
38,41

1
2

42
39,40

1
1

13

The use of a birthroom

30

native to the hospital labour ward where

clinically unattractive rooms, monitors and doctors are said to produce fear and anxiety with a
resultant unrewarding birth experience. No
properly conducted trial has been mounted to
assess its value. We have endeavoured to carry
out such a study in a highly selected and, we
assumed, motivated group of women, i.e. those
with previous normal labours and who were
being cared for by the community midwives and
their general practitioners.
Our first surprise was the lack of willingness of
our women to participate; only 59% of those
asked wished to join in. With a previous happy
experience of epidural analgesia and electronic
monitoring, many wished these to be available
and thus declined our offer to join the trial.
However, those that were recruited did seem
to have advantages if they were selected for the
birthroom. No bias should have occurred once
the delivery site was selected. This is demonstrated by the fact that two women were mistakenly kept in the labour ward. The antenatal
and labour care in both groups was provided by
the same staff, i.e. the community midwives.
The birthroom group had a significantly shorter
time in labour after admission than did the
labour ward group and fewer of them used analgesia. In part this was due to the use of epidural
analgesia in six women. This is interesting in that
these women had happily entered the trial with
the understanding that they may have drawn the
birthroom and not had this service available.
Only one woman in the birthroom ultimately
requested an epidural in labour. She was transferred to the labour ward but, in fact, was
delivered before the epidural was inserted.
Fewer women needed sutures for perineal injury
in the birthroom group despite the finding of no
significant difference in the rates of episiotomy
or tears. This suggests that the extent of injury
was less severe in the birthroom group, although
it is possible that the medical staff and midwives

E 25
C

g 20

2 15
Q

f 10

5
0

Easier

185

More difficult
Degree of difficulty

Fig. 1. Histogram of linear analogue responses comparing the degree of difficulty of this labour and
delivery with previous experience. (0)
Labour ward;
(0)
birthroom.

&8). There was no difference in feeding

methods chosen between the groups either at
discharge from the community midwivescare or
from the follow-up questionnaire; 85% of each
group breast fed.
When asked whether the experience of birth
had any effect on their relationship with this
baby compared with previous births, 24 birthroom mothers were positive it had, compared
with only 11 labour ward mothers (P<O-Ol).For
future pregnancies, 91% of those delivered in
the birthroom wished a similar environment and
two were uncertain. Only five of the labour ward
group wished to repeat a labour room delivery
while 29 requested a birthroom delivery. Ten of
this group were uncertain.

Discussion
Obstetricians are accused of interventionist
medicine of unproven value in their mangement
of the pregnant woman. However, many of the
measures which natural childbirth groups would
advocate are also untested. Thus to alter any
policy of childbirth managment, it is essential
that it receive critical assessment before widespread acceptance on a wave of biased
enthusiasm.
The birthroom has been mooted as an alterTable 5. Analgesia used in the two study groups
~~

~~

~~~

Study group

Nil

Nitrous oxide

Pethidine

Epidural

Exclusions

Total

Birthroom
Labour ward

31*
17*

19*
27*

4
9

O* *
6**

22
13

76

* P<O.Ol; * * P<0.02.

(xz calculated after exclusion of withdrawals).

12

186

M . G . Chapman etal.

Table 6. Length of labour and admission-to-delivery

intervals in the two study groups (women completing

move about compared with those in the labour

ward group. Once in a labour ward room there is
a tendency for women to feel confined t o their
hospital labour and delivery bed.
In terms of bonding, a process thought to b e
fostered by an enjoyable and rewarding birth
experience, the evidence we have suggests there
may be a slightly better outcome in the birthroom group. Breastfeeding occurred in 85% of
mothers in each group and was continuing at the
same level at &8 weeks. However, a higher
rooming-in rate and a more positive attitude to
the baby were recorded by the birthroom group.
Although it is difficult to quantitate bonding,
these crude measures are perhaps an indication
of a beneficial effect of the birthroom.
A n important test of satisfaction is to ask
where the women would prefer to have their
next baby. The birthroom group were virtually
unanimous in wanting a further birthroom
delivery. The labour ward group were certainly
less enthusiastic about their place of delivery. Of
the five women who wanted to have a further
labour ward delivery, three had had an epidural.
We have shown that a birthroom is a facility
that many women would appreciate as an alternative to a clinical labour ward for delivery. We
have been able to demonstrate certain possible
advantages, such as shorter admissionto-delivery intervals, less analgesia, less suturing
and possibly better bonding. However, the room
must be sited where rapid and safe transfer to a
fully equipped labour ward is possible. O u r
series and those of others suggest a transfer rate
of 1525%. A larger study is necessary t o assess
the true safety of this alternative birth
environment.

the trial)
Study group

Length of
labour

Admission-todelivery interval

Birthroom
Labour ward

5.1 (3.0-8.9)
5.3 (2.5-11.4)

2.5 (0~&10.7)*

1.9 (0.7-5.5)*

* R0.05.

Results are means with range in parenthesis.

were less inclined to suture minor lacerations in
the birthroom.
The rate of withdrawal from the study, once
labour had begun, was greater in the birthroom
group than in the labour ward group. This was
due to the transfer rate in labour; 7% of women
had to be moved from the birthroom to the
labour ward. This, however, is still a low rate.
Even when combined with those women who
were transferred direct to the labour ward on
admission for obstetric reasons, the number is
not high (17%) and compares favourably with
other studies (Faison et al. 1980; Dejong et al.
1981; Bennetts & Lubic 1982). However, these
latter trials included both primigravid women as
well as multipara which may explain our lower
transfer rate.
The women who participated expressed
general satisfaction with their birth experience,
equally whether in the labour ward o r in the
birthroom. The distribution of the results of the
linear analogue ratings of the difficulty of the
labour were no different between the groups.
However, more women in the birthroom group
felt they had their desired degree of freedom to
Table 7. Perineal injuries in the two study groups
Study group

Nil

1st degree tear

2nd degree tear

Episiotomy

Suturing

Birthroom
Labour ward

12
13

23
19

9
8

10
19

26*
39*

Table 8. The time spent with baby rooming-in in early postnatal period in the two study groups
~

Study group

All the time

Birthroom
Labour ward

~~~~

Most of of the time

Part of of the time

Very little

19*

24

7*

30

2
7

0
1

The use of a birthroom

Acknowledgments

We would like to thank the Community Midwives who undertook the study with such
enthusiasm and the Board of Governors,
Q.C.M.H. for their generous financial support
to refurbish the birthroom.

References
Bennetts, A. B. & Lubic, R. W. (1982)The free standing birth centre: Lancet i, 378-380.
Dejong, R. N., Kirkwood, K. S . & Camachocarr, K.

187

(1981) An out-of-hospital birth centre using University referral. Obstet Gynecol58, 703-707.
Dobbs, K. B. & Kirkwood, K. S. (1981) Alternative
birth rooms and birth options. Obstet Gynecol58,
626-630.
Faison, S. B., Pisani, B. J., Douglas, R. G., Cranch,
G. S. & Lubic, R. W. (1979) The childbearing
centre: An alternative birth setting. Obstet
Gynecol54,527-532.
Kerner, J. & Bailey Ferris, C. (1978) An alternative
birth centre in a community teaching hospital.
Obstet GynecolSl, 371-373.
Received 13 December 1984
Accepted 8 May 1985