Vaissnavi Shukl
We wrapped up the season a few weeks ago, but when I saw Kim Holden’s article on my LinkedIn feed, I knew I had to speak to her. Strangely enough we had connected over two years ago when she had written us a lovely note after listening to one of our episodes from season one. Kim’s change of careers has been unconventional. And if I may say so, very courageous. She was a founder, managing principal and architect on shore architects and decided to become a doula after 20 years of working as an architect with the support of the Graham Foundation. For advanced studies in the fine arts. We speak about her new practice doula by design, and how she helps people during pregnancy labour, birth and postpartum.

I am Vaissnavi Shukl and this is Architecture Off-Centre, a podcast where we discuss contemporary discourses that shape the built environment, but do not necessarily occupy the centrestage in our daily lives. We speak to radical designers, thinkers and change makers who are deeply engaged in redefining the way we live and interact with the world around us.

Kim will begin with a question that I’m sure you get asked a lot. I’ll start with that as well. So we all know at least those of us who’ve lived in North America or even just generally are enthusiastic, excited about the world of contemporary modern architecture. I think everybody knows about shock. And you were one of the founding members and a partner there. Talk to me about deciding to pivot from an architect from an architectural design to becoming a doula

Kim Holden
Thank you for having me. First of all, happy to be here. So it was a combination of factors. As I was growing shop, I was also growing my family and the births of both of my daughters five years apart, were completely transformative. For me, I had a circle of support that included a midwife, a doula, my sister, my husband, and I chose a sort of alternate model of care, which was a birth Centre in a hospital in New York City, and I came out of both experiences with my mind blown in terms of how I felt. On the other side, I felt like a superhero. I felt like I could do anything and when, in reflecting on those experiences, I kept going back to the environment that I was in and by environment, I mean, not just the four walls and what was in them, but the support that I received from the people around me, going into perience, having been educated by my doula and my midwife, having a dignified experience in both cases, feeling safe, feeling protected, feeling respected, and it really stuck with me. So as I continued on in my life and my professional life, and in my life, I kept returning to those experiences during periods of challenge and just thinking if I could do that I could do anything. So it really stuck with me and then around 2016 When a lot was going on in the world with politics, the election, and I was, you know, we’d grown the firm to over 225 people. There was a lot involved in that. And I was at a point in my life where I really felt that I wanted to make a difference in some way for women, for girls, and I felt that I wasn’t able to do that in my current role. So there were a variety of factors. I ended up leaving the firm and giving myself some time to figure out next steps. Not really sure what I was going to do next. I kept going back to this list of criteria that I had. One was having my own business because I always had my own business. Another one was being having the flexibility to co parent. My daughter’s I was divorced at that point and advocating for women and girls. And so I kept going back to that and I thought, well, perhaps midwifery but I was not at a place in my life where I was ready to go back to school for many years. And I landed on a doula. And I thought that there was a lot of opportunity to expand the notion of what a doula could do. And I saw an opportunity to somehow incorporate design into my role as a doula. So I saw an opportunity for greater advocacy, I saw an opportunity essentially, to create a platform for this intersection of design and birth. I wasn’t sure how I was going to do it, but I just once the light bulb went off, I just went all in and did the training. I came up with my brand. I set up my website and then I just had my shingle and I started getting clients. And so it was important to me and the trajectory was first I needed to learn everything I could about birth, about supporting women, birthing people in birth, about what kind of impact that I have and how can I use not only my design skills, but my management skills to help excuse me to help people have better experiences. So from that point, you know, I just it just kept expanding and kept growing and it was those real life experiences. It is those real life experiences with people in the birth space, that were critical to me having an understanding of the impact of design and environment can have I was

Vaissnavi Shukl
just going to ask it’s a very simple question, but I never thought about it before. What is What do you think is the basic difference between a midwife and

Kim Holden
a doula the primary differences that doula does not provide any medical care whatsoever? A midwife is a professional and a doula is not a doula is trained to provide physical emotional educational support, and we are hands on physically, but there’s no medical intervention at all. So we don’t do pelvic exams. We don’t do assessments on you know, where the baby is, you know, lying in the woman’s belly. So it’s a non medical professional versus a midwife who’s a medical professional.

Vaissnavi Shukl
So this ties into my second question, what is the role of a doula during a childbirth and then if you can talk about how you’ve tried to integrate your architectural background or your management skills from being at shop into your practice right now?

Kim Holden
It’s a great question. So a doula is someone who empowers and advocates for birthing families, a birthing person and birthing partner provides educational resources, a lot of what a doula does is prenatal support that became clear during COVID Right, so I had to prepare my clients for any possible scenario, birth wise, postpartum wise, but also pandemic wise. So I had clients who were showing up at the hospital, and partners may not be allowed to go up because they were showing signs of COVID. So how do you prepare people for that? And really, it’s advocating for your client but also helping the client advocate for themselves to have a positive, dignified experience. So that’s primarily what it what a doula is. And doula provides non judgmental support. So I meet my clients where they’re at, you know, if someone comes to me and says, I want to have a scheduled C section, I say, Okay, let’s talk about that. You know, what does that mean? What are the pros and cons? And in thinking about, you know, what kind of doula I want it to be. There’s a whole spectrum of doulas, there are people who who are much more, you know, spiritual per se, versus people who are more kind of pragmatic, and I really do use my my management skills, both to educate my clients, and also in terms of how I work so for instance, there’s a lot of how do I navigate this medicalized system that that is the obstetrics system or the medicalized birth system in the United States. How do I manage that? So a lot of it is how do I prepare? How do I read the room, manage what’s happening in the room? How do I advocate for myself? How do I educate on what the steps are going to be? How do I foresee what the steps are going to be? Isn’t that’s all project, that’s all that’s all project management. So listening is a skill, a huge skill, you know for me, and I listened to my clients, I listened to what their practitioner or their care provider has to say, I listened to what’s happening in the room during the birth, and then postpartum. There could be a lot going on whether it’s trouble with breastfeeding, signs of postpartum depression, and then listening to what’s happening, and helping my client support that they need whether it’s a pelvic floor therapist, a lactation counsellor, cranial sacral therapist, and connecting those connecting those people to each other, and kind of streamlining the process because when you’re postpartum and you’re sleep deprived, and you know, you’d like fluids coming out everywhere. The last thing you need to be doing is googling a specialist, you know, so I’m there to help support and give people three or four suggestions and why this person would work for you. Here’s their contact. information. So yeah, I would say that’s, those are the project management skills.

Vaissnavi Shukl
And what about what about the design aspect of it because on your website, you have a nice section, we’re talking about environments. Can you talk a little bit about those environments? Sure.

Kim Holden
environment means different things to different people and feeling safe during labour and birth is different for everybody. Under thinking about having my clients think about in advance what they are meant to be like, do they want to have a lot of daylight? Do they want to be in a dark quiet space? Do they want to be wills feeling safe? mean that they are, you know, monitored? Having continuous monitoring? So monitoring of the contractions, monitoring of the babies of the baby, or will that create more stress? Who do you want to have in the room? Do you want to have your mother there? Do you want to have your mother in law there? Do you want to wear your own clothing or do you want to put on the hospital gown? What kind of sense do you like to have? Do you like lavender oil or does that make you feel nauseous? What kind of touch to like, do you like having, you know some people you know, they don’t want to have their feet touched? And going through all of this in advance. You know, how can we how can we transform the hospital room? I guess, to like, you know, meeting the environment where it’s at meeting the birthing person where they’re at. How can you transform that room? Right, can you put twinkle lights up? Do you want to? If so, like what kind of music do you want and also talking about you never know who your nurses are going to be in sort of hit or miss you can have someone who’s, who comes in at the other end of their shift. Who knows what’s happened that day? They can be grumpy, how do you navigate that? You know, always introduce yourself and you know, sometimes they sometimes providers are so harried or hassled, they come in there and even say with their name, their container name and so, you know, in the same way that you go into a business meeting and you feel a lot of stress in the room, how can you defuse that stress that’s also part of environment, which prefer birthing at home where you have your, you know, your dog or your cat there and you have your kitchen there and you can get up and have a snack or you can, you know, take a bath. So, talking about these things in advance and also the relationship between the birthing person and their partner. That partner doesn’t know birth very well, but they know their partner better than anyone. So talking about in real life situations, outside of birth, how does your parent support you? you know, is it you know, making you laugh is or does that annoy you? is it you know, stroking your hair? so talking about these kinds of things, in event, all part of environment. and educating my clients on the importance of that. So, so that’s sort of, you know, credit, working with what you have. And it’s also, it’s also, you know, moving forward, how can we change Hospital. to be more geared towards labour and birth. I mean, it’s well known that having a quiet, calm environment, a non institutional environment is what’s helpful. So that’s sort of like the next that’s like the bigger picture of you know, what can we do? What can I do? Yeah,

Vaissnavi Shukl
and that’s that’s something I definitely want to touch upon because in our in a previous discussion you did mention the similarities in standards between hospitals and and birthing centres. I mean, considering your experience as an architect, how do you think these these things boiled down to a guidelines like the tick marks that you need to have? How do you think those impact the environment or water conducive birthing centre could be and I was just wondering if you’ve encountered any said any specific situations where you think specific Medicaid modifications to these environments could have benefited the client or particular community or I don’t know. Yes.

Kim Holden
So the standards of what I meant by the standards are similar in birth. centres and hospitals are actually not. What I meant to say was that the barriers to opening more birth centres are that way because birth centres are often held to the same standards as hospitals, when the reality is the model of care of a birth centre is completely antithetical to the model of care provided in a hospital for birthing people. So yeah, so So birth centres, just as sort of a general concept. They support birth as a normal life event, not something to be managed or medically managed, percentage promote self care, family engagement, and support the mother baby dyad. So the mother baby as a unit, you know, they’ve been a unit for you know, nine plus months and really the first, the first hours after birth, but the first days, the first weeks and the first three months, we call the fourth trimester, and the environment that you want to create for the baby needs to be very, should be very similar to the environment that was in the womb. So how do we do that birth centres and midwives and doulas support that the model of care includes respecting human dignity of the mother and the baby and the family. Percentage respect cultural diversity at birth centres focused on education and promotion of health for families. It’s a community approach. It’s a societal approach, and it’s really about supporting if you support the mother, the baby, the birthing partner, you’re also supporting the family. You’re also supporting the community and you’re also supporting the society so that is, that’s the crux of how birth centres view care. The problem comes when and regulations are different in every state. The problem happens when someone wants to open a birth centre and they’re held to the same standards at the hospital. So they are held to a certain certificate of need is this onerous process that people who want to open a birth centre need to go through it can take up to 10 years to become profitable for a birth centre and that’s just not sustainable. The profits in the hospitals often come from the interventions that happen, right so and birth centre model cares that you need you need limited medical intervention, so therefore there’s less to build for, right. So you have an epidural, you bill for the epidural you’re given Pitocin which is synthetic oxytocin, which is the hormone labour, you can build for that C section. Bill a lot more than for vaginal birth. So licencing require requirements require that a percentage must be led by a physician in certain cases, and in many cases, physicians are not trained in the midwifery led model of care or the birth centre model of care. Some regulations require that a birth Centre has to have special neonatal equipment to manage conditions that are outside of a birth centre scope. So in a birth centre if there’s a problem with the baby, immediately the mother and the baby are transferred to the hospital. However, with birth centre bursts, because of the care that’s provided, the incidence of Neo natal issues is lessened than it is in a hospital. So there you’re less likely to have an issue with the infant where an infant needs to go to the ICU than in the hospital. There are less complications in a birth centre, so less likely to lead to maternal mortality, less likely to lead to the mother having to have medical intervention adventures or just by being in a birth centre, and reducing the risk for all of those things. Yet regulations often require that those are on site which is antithetical to what a birth centre is. Often licencing requirements require a separate nursery, which is required in a hospital. Again, totally antithetical to the midwifery model of care where you keep the mother and the baby together. You allow that skin to skin and the family together, the beds are larger so that the partner can crawl into bed either during labour or afterwards if the family is all together and the family has that chance to bond. So those are just a couple of examples. Acknowledging that there’s a complete lack of understanding when it comes to regular regulations. And requirements for birth centres because birth centre is like the opposite of a hospital. So that was sort of what it meant and I didn’t articulate it well, but standards are very different. But yet hospital standards are often applied to birth centres in order for a birth centre to

Vaissnavi Shukl
open something that really I think stood out was the fact that you mentioned the size of the bed and the fact that the partner can get in and you have the baby and you know, kind of create a little cocoon. This is also something that well now three years ago in the first season, when he spoke to Chris who is a midwife, and she also spoke about this space specific thing, which is about the size of the bed and how that is very different from the one that you would have in a hospital. And just the whole ergonomics of where because she’s, she’s not she’s not an architect, but you know, I asked you to do a thought exercise what would like an ideal birth centre centre kind of looked like and and he mentioned in like a very nuanced fashion all these little things about what if somebody wants a pool of water to give birth to what if you want to have ropes hanging by the ceiling? What if you want a specific kind of lighting and very, very similar to the observations? You may and I think it’s very interesting, you know, because of course, she’s a midwife, and you work as a doula and very similar observations.

Kim Holden
Yes, that is one thing I didn’t mention and I should have a part of, you know, what is necessarily needed is birth is all of these. I hesitate to word that you use the word tool, that’s not what it is, but, but birth ball, yoga ball, silks that hang from the ceiling so that you can use gravity to help the baby get down, you know, which should be in a labour room, because that’s really what helps the last thing you want is to be lying. Horizontal on the bed and not having the ability to move. So, you know, in hospital rooms is the centre of the bed. And ideally, that should not be the case, you know, you should walk in and it should be more like, you know, a yoga studio, honestly. So, and sort of going back to sort of the crux of the difference between a hospital labour delivery room and a birth centre room is that a hospital labour delivery room is designed for the convenience of the practitioner, whereas a birth centre room is designed for the convenience of the birthing person, right. So you know, giving birth in your back is really for the convenience of the practitioner. It’s like the last position that you shouldn’t be in giving birth, because you’re not allowing the sacrum which is the bottom of your spine to have flexion which is required for the baby to rotate and navigate and find the path of least resistance out. You’re fighting against gravity, you know, as you’re pushing, so, you know, just that right there. You know, yes, the bed should be bigger, but really the bed shouldn’t be the central focus of the room.

Vaissnavi Shukl
And I want to reflect a little bit on the current state of politics. In the country and how a person’s born sport bearing capacity or not has become a focus on national nationwide debates. And these are often looked at as like cement oriented issues. I was wondering if you can talk a little bit about I don’t know how we can view the establishment of birthing centres as a societal concern rather than just solely like a woman’s issue. I mean, to the extent that just while we’re talking about this, have you seen I’m sure you’ve seen Have you seen pieces of a woman? Yeah. The the Oscar nominated movie. Somebody wants something for the movie, right? And I think it gets into really specific details of of the whole episode and navigating the legal system and blah, blah, blah, blah, blah. But what do you think about all of this?

Kim Holden
So when I first heard about that movie, I was excited because I thought oh, this is about a home birth. And then I sort of became dismayed after I watched it because the whole movie is based on it’s more fear mongering. Right? There are very many things in that movie that were unrealistic in terms of how that birth was handled, and it’s giving people the wrong and pressure at wrong impression of what a home birth can be. So it sort of did the opposite had the opposite effect of what I was sort of hoping for. But there is this culture of fear. Surrounding birth people are afraid of birth. I think that’s because we haven’t grown up with birth. We haven’t grown up thinking of that as a normal process. And media portrays it inaccurately for the most part, and then also portrays it as something to be afraid of, you know, there’s a lot of work to be done on that front. So, you know, creating awareness is a huge part of what I do. And I’m always shocked at how little people know when they come to me about birth, people are usually afraid, they you know, they, what they know, they’ve seen on TV, and so I think creating awareness about the process of birth, and how your body is designed to give birth. And granted that is not the case. For everybody, but understanding that and that at the anatomical physiological, physiological, physiological aspects of birth, the role that hormone plays hormones play when you learn about that. You’re like, that is so cool. Like, oh my gosh, how amazing that you know, the uterus is contracting and doing this and, you know, why are you what’s the cervix doing and why and why is movement important and why is change of position important once you learn that? And you understand that the light bulb goes off, right? So I think starting to read awareness, but then also, you know, birth should not be a for profit industry, because the minute you make an a for profit industry, there’s no distance. There’s no disincentive to add these interventions to create a chronology of birth because the more you intervene, the more money the hospital makes. The other thing to consider is that is the postpartum period, which I often find that I’m working with clients, it’s so hard for people to see past the birth are so focused on the pregnancy and the birth, very little attention is given to postpartum. What’s the postpartum plan? What what’s real is what are the realistic aspects of postpartum that gets into you know, these issues of lack of parental leave here in the United States, lack of acknowledgement of the healing that is required after birth I mean, you’ve grown a human being for nine months plus, given birth to that human being, your uterus is is reducing from the size of a watermelon back to the size of plum. The area of your uterus where the placenta was, is you have a wound the size of a dinner plate, in your in your uterus, if that was outside your body and people saw it. I think there would be a lot more care and attention paid to the healing that birthing person has to do. So that’s why there’s bleeding because as the uterus contracts, and reduces to the to the size of the African power plant, every time that happens, it’s like a scab being healed. So you know, Scab will bleed and then it will scab over it will bleed. So that’s what that’s leading us. So, you know, if, in this country, women were given support after birth, they were given someone to help do everything except for feeding the baby and healing. So that’s what I tell my clients to jobs in that postpartum period and that is to heal your body and to nourish your baby, whether that’s breastfeeding or bottle feed, whatever it is, those should be your two jobs. Everything else should be done by other people in your life. It should be a community effort, and sadly, it’s not and there’s so many people who have to go back to work, because there’s no family leave. There are people who don’t have family living around them or if they do, they don’t necessarily want them to come and leads to a higher rate of postpartum depression, to stress in a partnership stress in a marriage because the partner needs to have support too. So you’re you know, if you if you get the family, the new family off on a good footing, that just builds a foundation for the rest of the growth of that family, for the rest of the transformation of that woman into a mother and the partner into the partner, father, and ever and that’s just not happening. So there’s a really weak foundation often and that just stays with you, which is say nothing about the trauma that many women experienced during birth, it stays with them forever. So you know, for me, a positive birth experience is not about whether you’ve had your dream birth or whether you’ve had exactly what your birth plan was supposed to be. It’s not about vaginal versus C section. It’s about having a dignified experience where you feel that you’re the birth didn’t have to you that you were an actual birth, you understood what was happening. You had a voice in the decisions that were being made. You are treated with respect and dignity. That is a positive birth experience. So you know, preparation, having a doula and having a supportive team in a supportive environment is what leads to a positive birth experience. So supporting the new family and doing everything we can to support women in childbirth, that leads to stronger community and ultimately a stronger society. So creating an awareness of that. Creating an awareness of how this affects not just the birthing person but the partner and then the family is critical to understanding why the birth model centre model of care is important. I

Vaissnavi Shukl
am not familiar with the process. I haven’t seen anybody close to me go through the process. I mean, physically, like witnessing but a lot of I guess most of our exposure to the thing is through the movies and as you said the movies kind of portrayed in a very different to hear about this from your perspective, kind of just because they interesting never knew I mean, at least your allergies for the size of the bone and stuff I had, I had no idea.

Kim Holden
Right and what and you know, you know and why, why is that and that’s the norm. You know, one other example is in the movies, the woman’s water breaks, like bending over and pain and rushing to the hospital. That rarely happens. The water will breaks and it’s it can take 2448 hours for contractions. To start and labour. And so, you know, hospitals tend to try to speed it along. And that’s also antithetical, but the expectation is my waters gonna break oh my gosh, I have to rush to the hospital. So you have to sort of undo the learning as a doula to you know, normalise. What birth is normalised the length of time it can often take normalise that your water breaking doesn’t automatically lead to contractions right away, of unlearning, that has to do has to be done before learning what it really is and demystifying the process.

Vaissnavi Shukl
Do you think that are enough? Again, using the word tools out there for people to demystify things or to kind of make it simpler or odd? It’s just one learn as they go.

Kim Holden
It’s good question. There’s so much information out there. There’s so much information and it can seem overwhelming. So the benefit of having someone like a doula to guide you through is to be able to customise the information flow for you. You know, people are busy, too. They don’t have time to weed through. It’s overwhelming and I think some people are like, I’m just going to do what my doctor says I’m just going to defer because this is too overwhelming and I’m busy and I’m you know, having dropped in New York and I’m what I do think that if we started true education early and by education, I mean, just talking about what birth is and using using actual anatomical terms, rather than in that in a rather than, you know, get a baby baby kids and not using the real word. So, you know, that’s the start. What are you freedom? There’s, you know, starting early, I think is one way of creating awareness. And I do think since COVID There is a greater awareness of choice of environment that a greater awareness of what doulas are and the benefits that a doula can provide, because the pandemic and zoom and virtual platforms made the information and the doulas more accessible and maternal mortality. There’s more discussion about the crisis. There have been articles not just in women’s magazines, but Wall Street Journal and you know, business publications and the New York Times and Fortune magazine. So there is more conversation about it, which I think is a good thing.

Vaissnavi Shukl
I think now truly the season has come full circle, because somewhere in the middle of the season, we’ve spoken to an artist about that, and she spoke about how we should openly discuss that, even with kids and now I think we just come full circle about how we should openly talk about birth with kids and it’s just really about talking about these things. So as we wrap up, what’s what’s next for you? Big architecture years. Now you’re working as a doula, where do you see yourself going from here?

Kim Holden
It’s a good question. I just kind of keep on building on what I’m doing. So I taught on architecture studio last semester at Yale, where the topic was the intersection of birth and design and the impact that environment has on birth outcomes experiences, disparities and mortality. It was a groundbreaking studio, one of the first of its kind, so I would like to teach more. I’d like to lecture more about the topic and continue to meet people who are also trying to do the same thing. There are those that were out there and we’re slowly finding each other and brainstorming about how to create more awareness, whether that’s through exhibitions or symposiums and for me personally, I know and the people who are in my colleagues know how important environment is, I mean, we know it will improve experiences, outcomes, you know, racial disparity and mortality. The next step is how do we affect change? Right How do we combat the system? How do we do with the insurance companies and you know, these huge hospital systems whose priorities are yes, you know, healthy baby healthy mom, but there’s so much more to it. There’s so much more to it, so that you know how do we how do we do that? so that’s also my focus, trying to figure out how to make these changes and that’s what I’m also focusing on to well,

Vaissnavi Shukl
thank you so much for your time for sharing your work and for being so honest and open about this

Kim Holden
personality. I’m so I’m so happy that you contacted me and I’m so happy and grateful to you for asking these questions and for helping to give a platform for these issues. It’s. so important. I mean, it’s so critical. And I’m so passionate about this. And when I first made this change, I wasn’t sure if I was going in the right direction. But the more I do and the more I speak about it, the more people are convinced that yes, I am going in the right direction, and it’s so critical for the future of our society. So thank you so much for having me. Especially thanks to IoT tower, the research and

Vaissnavi Shukl
Special thanks to Ayushi Thakur for the research and design support, and Kahaan Shah for the background score. For guests and topic suggestions, you can get in touch with us through instagram or our website through our website archoffcentre.com, both of which are ‘archoffcentre’. And thank you for listening.