Queen Elizabeth Central Hospital Maternity Complex Reconfiguration by Priya Badri

ARCHITECTURE OF MATERNAL HEALTHCARE QUEEN ELIZABETH CENTRAL HOSPITAL BLANTYRE, MALAWI

PRIYA BADRI

DESIGN 10: Global Design Studio Professor Chrisopher Harnish Thomas Jefferson University College of Architecture & the Built Environment

Malawi Public Health Infrastructure Queen Elizabeth Central Hospital: Maternity Complex Reconfiguration by Priya Badri Project presented to the Faculty of the Department of Architecture College of Architecture and the Built Environment Thomas Jefferson University In partial fulfillment of the requirements for the degree of BACHELOR OF ARCHITECTURE Arch-508 / Design 10: Research and Design Faculty: Associate Professor Chris Harnish Philadelphia, Pennsylvania

CONTENTS 01 - PROJECT OVERVIEW introduction intentions & methodology background 02 - PROGRAM STUDIES program & user group studies site study initial program proposals 03 - PROJECT PROPOSAL masterplans circulation green spaces & nodes spatial adjacencies 04 - PROJECT CONCLUSIONS

01 - PROJECT OVERVIEW

QUEEN ELIZABETH CENTRAL HOSPITAL

INTRODUCTION: Queen Elizabeth Central Hospital requests a reconfiguration for optimal user and healthcare worker comfort, circulation efficiency and access to optimal outdoor conditions. Requirements include expanding building size by 25% to accomodate medical college and increase space for staff, patients & administration. This project focuses on the design and future developments of the Queen Elizabeth Central Hospital’s maternity facility. Loccated in Blantyre, Malawi. The main goals to the improvement of this facility will focus on: • Staff / Healthcare provider spatial efficiency • Patient care & comfort • Improved access to exterior space Sub-Saharan maternity hospitals for expectant mothers and families as well as for general women’s health require spaces that improve user experience spatially and thermally for healthcare staff as well as patients.

Why is maternal healthcare so important? • Critical to maintaining proper spaces and services to ensure good health for expectant mothers. • Reduce maternal and neonatal mortality rates • Reduce the impact of existing or developing health conditions like hypertension, diabeties or other heart based conditions for both mothers and babies • Provide necessary services to ensure health of newborns and mother after delivery

QUEEN ELIZABETH CENTRAL HOSPITAL ANTENATAL SERVICES: According to the guidelines developed by the World Health Organization, antenatal services must have the same level of care and service as postnatal. The following interventions and developments are critical to a positive pregnancy experience: A. Nutritional Care B. Maternal & Fetal Assessment C. Preventative Measures D. Care for Physiological Symptoms E. Health System Interventions (for improvement of service and care) According to a study done by VM Lema et al, Maternal Mortality specifically at QECH details the main causes for maternal death are due to conditions such as sepsis, hemmorhages, and eclampsia. INTRAPARTUM CARE & SERVICES: Monitoring the mother and child during the 3 different stages of labor as well as postpartum is essential to proper guidelines and routines for a successful and healthy birth. WHO recommends a series of interventions that should be ready at hand in the case that something goes awry. With each level of labour into the process towards delivery, it is imperitive for mothers to be cared for with consistent monitoring and care.

QUEEN ELIZABETH CENTRAL HOSPITAL Intrapartum care is one of the most important parts during the pregnancy and childbirth process. Without proper care and necessary spaces, it creates grounds for dangerous territory for both mother and child. During each of the stages of labour, programmatic spaces must be adjacent to facilities equipped with necessary services in case of emergencies. Constant screening and consistent checkups are a must for expectant mothers in labour. POSTNATAL CARE & SERVICES Postnatal care must be equipped to handle all different levels of risk that may occur during post partum. It is absolutely essential that a woman giving birth must be provided a space that nurtures her own health as well as her newborn while maintaining dignity and privacy. Spaces must encourage positive feelings that provide comfort and dignity for expectant mothers to reduce any sense of anxiety or fear for the birth giving process. Sanitary requirements are of utmost importance for the well being of the newborn and especially the mothers as their bodies are weakest and immunocompromised at the moment they give birth Mothers should be monitored consistently and for intensive care cases, space should be provided for staff efficiency as well as familial & guardian space. Post partum / post natal experiences should also aim to create safe spaces for new mothers and family members to be educated on the effects of pregnancy for their own care. Educational spaces can provide the mothers and familes the knowledge they need to move foward post pregnancy as well.

QUEEN ELIZABETH CENTRAL HOSPITAL RESEARCH QUESTION: How can the existing maternity hospital at Queen Elizabeth Central Hospital be redesigned and configured spatially and through improved building performance to promote staff spatial efficiency while building user comfort, dignity and privacy and create a pleasant, clean and sustainable environment throughout the facility? INTENTIONS: • Increase the efficiency between spaces for better traffic flow for users • Develop larger spaces to provide room for better technological equipment necessary for best care • Compose program for ease of access for incoming patients as well as emergency care • Develop a better work environment for the staff and healthcare providers • Provide shelters for family members aside from just the patients • Utilize green space between program groups as areas of relief • Use natural, locally sourced materials to develop a thermally comfortable space for both patients and staff workers • Improve daylighting and ventilation through wall and roof assemblies to better air flow, light and air quality. • Incorporate materials that promote better sanitary conditions

METHODOLOGY: • Establish findings through research • Programmatic analysis of existing maternity complex in QECH • Qualitative interviews with stakeholders and other contributing individuals to understand medical and academic perspective of maternity hospital experiences and necessities. • Evaluate site and develop iterations for site specific goals and necessities based on user experience.

02 - PROGRAM STUDIES

PROGRAM & USER GROUP STUDY

This initial exercise allowed for a program study to investigate spatial adjacencies and hierarchy of spaces. After further investigation, this allowed for a more intensive understanding of the user groups, the spaces within each program and the proximity between each program group. It identified the major components that would comprise the final organization of the Queen Elizabeth Central Hospital Maternity Complex with regards to outpatient services and inpatient care and treatment. This initial study allowed for a further understanding of each of the spaces and created the major components. After meeting with stakeholders, each space was further defined by use and user groups.

EXISTING PROGRAM AREA: 12,245 m2 PROPOSED PROGRAM AREA: 16,327 m2

OUTPATIENT

EMERGENCY

Prenatal Care Exam Stations patients.

DIAGNOSTIC SERVICES

Sluice Room Private 3m x 3m screening stations for incoming short term

Emergency Care Spaces -

Family Planning - Classroom in flex spaces to educate women and family members about pregnancy and post natal experience

Triaging Area -

Individual screening spaces for private patient/doctor consultations. Both a general screening area & procedural screening space

Emergency One Stop Station -

screening & testing for women experiencing sexual abuse

Laboratories

Operating Theatres (4)

Gynecology Screening -

PROGRAM & USER GROUP STUDY

Screening Services 5 Trauma bays upon arrival in emergency care

services along with 20 emergency care beds. Adjacent to operating theatres.

Pharmacy

Rooms set in order to determine course of action for incoming expectant patient. Access to emergency rooms, Operating Rooms and triage into inpatient services

Additional Screening Rooms -

attached to small diagnostics room in

connection with outpatient services and emergency screening

INPATIENT

ADMIN & EDUCATION

Labor & Delivery Ward

Neonatal Intensive Care Unit (NICU)

Postnatal Ward -

General Ward - Recovery

General Recovery Ward

Triaging Area

General Ward - Nurseries- Separate Nurseries in proximity to general maternity

High Dependency Unit (HDU)

ward & MICU

Grievance Room -

Maternity Intensive Care Unit (MICU)

wives to childbirth.

Intrapartum Care -

Nurses Stations

Based on W.H.O. Guidelines: Should first and foremost be

woman centric and individualized. Could mean for more individualized spaces or rooms allotted to expecting mothers.

Necessary for women & families who have lost their children or

Lecture Halls - For both students and patients alike, lecture halls can be used as flex spaces for chilcare classes pre and post pregnancy. Can also host lectures and lessons Classroom Laboratories - these are simple classrooms that can be and shifted to accomodate a laboratory setting should it be necessary

reorganized

Student Study Space Administration Offices -

for both faculty members and healthcare workers - includes administrative and faculty offices with two flex conference rooms

ENTRA

PROGRAM & USER GROUP STUDY

RECEPTIO

FAMILY ROOMS

Initial program studies allowed an understanding of how spaces were to be aligned and developed schematically.

GUARDIAN SHELTER (DAYTIME)

PRIVATE EXAM ROOMS

PRIV. ADMIN OFFICES

ADMINISTRATIVE OFFICE

FACULTY STAFF LOUNGE

FAM. PLANNING RECOVERY WARD CRS

ENTRANCE

RECEPTION DESK

GENERAL: NURSERIES

ADMISSIONS

PATIENT WAITING ROOM

NURSE’S STATION

ENTRANCE

EDUCATION/ UNIVERSITY

RECEPTION DESK

SANITATION STATION RECORD COLLECTION ROOM

PATIENT WAITING ROOM

PRIV SCREENING RMS

PRIV. ADMIN OFFICES EMERGENCY ENTRANCE

FAM. PLANNING MULTIPURPOSE SPACE TRIAGE SPACE

FAMILY PLANNING

OPERATING THEATRES

CONSULTATION RMS

FAM. PLANNING CRS

PRENATAL CARE OBSTERICS

LECTURE HALLS

LABORATORIES

SLUICE ROOM

EMERGENCY CARE

SANITATION STATION

FAMILY PLANNING CLASSROOM LABORATORIES

NURSE’S STATION GYNECOLOGY SCREENING RMS (XRAYS/ULTRASND)

ENTRANCE

RI SK

AR EA

EARLY SCREENING SERVICES

AR TP EA AT I E HC OU NT AR TP P EA AT RO SE RV HC IEN AD VID I PR T S ER CES M OV ER S IN VI ID AD C /S ER ES M TU S IN DI DE /S AG TU A NT DD N DI D S/ EN OS AD AG I T FA TS IO TI DI NO M /F NA CS TI ST AM ILY ON IC L ILY AL S & SE & SE RV RV IC IC ES ES

PRIV. EXAM ROOMS

RI S ED

CONSULTATION RMS

PRIV. ADMIN OFFICES

OUTDOOR PATIO STUDY SPACE

NEONATAL INTENSIVE CARE UNIT (NICU)

PRIV SCREENING RMS

HIGH DEPENDENCY UNIT (HDU) PRIV. EXAM ROOMS

CLASSROOM SPACES

MATERNITY INTENSIVE CARE UNIT (MICU)

Each user group must be complementary to each other in regards to program adjacencies

GENERAL

DELIVERY/LABOR

Outpatient Inpatient Emergency Diagnostics Adminsitration Academics/Education

GRIEVANCE ROOM

CONFERENCE RMS

This focues on 6 main user & program groups: • • • • • •

OUTDOOR SPACE (CLOTHING/ WASHING/GUARDIAN)

PROGRAM & USER GROUP STUDY ENTRANCE ENTRANCE

The outpatient flow focuses on the specifics of the outpatient services provided by the maternity department:

RECEPTION DESK

ADMISSIONS

PATIENT WAITING ROOM

PRIV SCREENING RMS

FAM. PLANNING CRS

FAM. PLANNING MULTIPURPOSE SPACE

PRENATAL CARE OBSTERICS

LABORATORIES

PRIV. ADMIN OFFICES

CONSULTATION RMS

GYNECOLOGY

PRIV. ADMIN OFFICES

CONSULTATION RMS

SCREENING RMS (XRAYS/ULTRASND) PRIV. EXAM ROOMS

RI S

NURSE’S STATION

AR TP EA AT HC IEN PR T S ER O VI AD VID ER CES M S IN /S TU D DE AD IAG NT DI NO S/ TI ST FA ON IC M ILY AL S & SE RV IC ES

AR TP EA AT HC IEN PR T S ER O VI AD VID ER CES M S IN /S TU D DE AD IAG NT N DI O S/ TI ST FA ON IC M ILY S AL & SE RV IC ES

EARLY SCREENING SERVICES

PRENATAL CARE OBSTERICS

FAMILY PLANNING

The outpatient flow primarily focuses on the reproductive health services provided by the department. The primary user groups includes short term patients, heathcare staff, and administrators specific to outpatient needs.

ADMISSIONS

PATIENT WAITING ROOM

Access to: • Emergency care units • One Stop Stations • Educational Spaces - Family Planning and Reproductive Education • Labs and screening services for regular monitoring • Outdoor spaces (Areas of relief)

RECEPTION DESK

PATIENT WAITING ROOM

GYNECOLOGY

PRIV. EXAM ROOMS

EARLY SCREENING SERVICES

PROGRAM & USER GROUP STUDY FAMILY ROOMS

GUARDIAN SHELTER (DAYTIME)

OUTDOOR SPACE (CLOTHING/ WASHING/GUARDIAN)

GRIEVANCE ROOM ENTRANCE

PRIVATE EXAM ROOMS

Inpatient flow focuses on the specifics of the inpatient services provided by the maternity department:

PATIENT WAITING AREA

Access to: • Emergency care units • Recovery spaces • Delivery rooms • Labor Unit • Operating Theatres • Intensive care units for mothers and newborns • Labs and screening services for regular monitoring • Outdoor spaces for laundry/green space

GENERAL RECOVERY WARD

PRIV SCREENING RMS

GENERAL: NURSERIES NURSE’S STATION

SANITATION STATION

TRIAGE SPACE

MATERNITY INTENSIVE CARE UNIT (MICU)

OPERATING THEATRES FAM. PLANNING MULTIPURPOSE SPACE

PRIV. ADMIN OFFICES

EMERGENCY CARE

CONSULTATION RMS SLUICE ROOM

SANITATION STATION NURSE’S STATION

AR TP EA AT HC IEN T PR SE O RV AD VID I ER CES M S IN /S TU D DE AD IAG NT DI NO S/ TI ST FA ON IC M ILY AL S & SE RV IC ES

ENTRANCE

AR EA RI SK AR TP EA AT HC IEN PR T S ER O VI AD VID ER CES M S IN /S TU D DE AD IAG NT DI NO S/ TI ST FA ON IC M ILY AL S & SE RV IC ES

RI SK

GYNECOLOGY

PRIV. EXAM ROOMS

EARLY SCREENING SERVICES

SCREENING RMS (XRAYS/ULTRASND)

PRENATAL CARE OBSTERICS

TRIAGE SPACE FAMILY PLANNING

EMERGENCY ENTRANCE

PATIENT WAITING ROOM

NEONATAL INTENSIVE CARE UNIT (NICU) FAM. PLANNING CRS

PRIV SCREENING RMS

LABORATORIES

ADMISSIONS

DELIVERY/LABOR UNIT

HIGH DEPENDENCY UNIT (HDU)

The inpatient flow has more specific necessities on the spatial adjacencies required between emergency services and inpatient care. This includes proximity between wards and recovery units to labor and delivery in adjacency to the operating theatres and other spaces that might be required for easier means of access.

RECEPTION DESK

PATIENT WAITING ROOM

SITE STUDY

Main Road Traffic (Indirect access to hospital) Primary Traffic Circulation Pathway for thru hospital traffic

Emergency Services Traffic Circle

Sun path - coming from southeastern perspective

Foliage Covering Sound Barrier Prevailing Wind patterns - breeze can promote cross ventilation

SITE STUDY

Exterior Conditions

Interior Conditions

INITIAL PROPOSALS PROPOSAL 1: L Scheme

ADMIN OFFIC

OUTPATIENT

PROPOSAL 2: Single Level Double Courtyard

GUARDIAN & VIS ITOR QUARTERS

OUTPATIENT

INPATIENT

MEDICAL COLLEGE MATERNITY EMERGENCY SERVICES

• • • • • •

Uses vertical and horizonatal system to create linear circulation pathways Private sectors to each program unit Lines outer edge with public based program groups. L-Shaped Program overlayed along major inpatient/outpatient access points. Minimal outdoor relief (courtyard spaces) Primary focus is ciruclation

• Uses central courtyard scheme along primarily public based programs. • Combines Outpatient and Medical College Access to secondary level • Emergency, diagnostics & inpatient services are all groups together into one singular contextual spot. • Public based program (admin) lines the main perimeter of Maternity campus. • Larger courtyard along inner edge joining double story outpatient services, medical college, guardian space & inpatient services.

INITIAL PROPOSALS PROPOSAL 3: Second Story Overlap

• Second story layover major connecting program groups: inpatient, emergency, diagnositics, outpatient & medical college. • Two inner courtyards - administration/outpatient courtyard & inpatient//guardian extended space • Two main areas as central circulation points • Combines inner set of program groups to create

PROPOSAL 4: Outer Edge Perimeter

• Two tier system of outer perimeter with access to interior. • Patient systems access through outer edge (specifically for visitors & guardians) • Inner circulation route connected through two main courtyard areas with 3 entry/exit points. • second story levels connected through inner structure to main inpatient components (inpatient units & emergency services). • Form is responsive to edge conditions of site perimeter

03 - PROJECT PROPOSAL

MASTER PLAN - LEVEL I 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17.

Outpatient - General One Stop Station Outpatient - Procedural Emergency Room - equipped w/ trauma bays & emergency bed spaces Inpatient Triaging Operating Theatres HDU, ICU, NICU Nursery High Risk Delivery Antenatal Open Ward Low Risk Delivery Spaces Postnatal Nursery - General Kangaroo Care Postnatal Open Ward Postnatal Open Ward Postnatal Open Ward Grievance Rooms Pharmacy Laboratory & Screening Space

The final masterplan shows a site responsive perimeter layout of the proposed maternity complex. This aims to keep the outpatient sector towards the outer edge of the site while maintaining a compact perimeter along the interior of the site. This is to house the emergency and inpatient units and services. The plan is designed to create series of spaces that follow the specific sequence of events from prenatal care, antenatal, intrapartum care and postnatal care. Increasing the amount of pathways will also create multiple pockets of circulation to increase flow of traffic and efficiency of workers and patients.

2 1 17

4 15

11 12 7 5

8 10 9

MASTER PLAN - LEVEL II 1. 2. 3. 4. 5. 6. 7. 8.

Multiuse - Lecture Hall w Student Lounge Academic Classsroom Spaces Admin/Staff Office Rooms Conference Rooms / Flex Classroom Flex Lounge Space Admin/Staff Office Rooms Staff Lounge w/ Kitchen Outdoor Second Story Patio

Attached atop the inpatient corridor is the faculty, healthcare staff and administration spaces. These have been kep specifically adjacent and above the inpatient units for ease of access for doctors, nurses, healthcare workers and medical students with each of their own spaces aside from the high functioning environment of the hospital sector on the first level. This space is equipped with rooms specific to classrooms, office spaces, lounges for both students, staff and administrators with access to a larger lecture hall providing room for outpatients as well, looking to start families.

5 3

7 2 1

TRAFFIC & PEDESTRIAN EXTERNAL CIRCULATION The primary external circulation allows for the traffic flow to be split between inpatient allows for trafic flow to be split between inpatient and outpatient access. Keeping the emergency locations adjacent to one another would provide ease of access for emergency vehicles while directing outpatients to different sectors based on varying needs. Alternate traffic flow pattern - side access to outpatient sector of complex

Main traffic flow circle - can be configured to provide ease of access for emergency and inpatient entry

Connection for traffic route between both emergency centers - Maternity Emergency & General Emergency

Sheltered Roof Overhang - primary circulation route connection between all circulation paths Exterior Traffic Flow Guardians, Low Risk Patients - Easier Traffic Flow

Side road access to outpatient sector of complex

Clerestory windows - stack ventilation & additional daylighting from above.

Exterior seating & waiting spaces - guardians, patients etc.

ELEVATION 1 - A: ENTRY FACADE

Low risk emergency entrance - patient friendly (walkthrough)

Ambulance entry point straight to trauma bays/triage

Inpatient entry directly into triaging unit

Exterior shelter space One Stop Post

Interior Courtyard Space - used by staff & patients alike

SECTION 1 - A: ENTRY SPACE INTO COURTYARD

Surgery Suites - directly across from high risk delivery & adjacent to emergency

High Risk Delivery adjacent to antenatal open ward & direct access from triage & surgery

Antenatal Open Ward - rest space for women prior to going into labor - reserved for patients from distances

PRIMARY ENTRY POINTS FOR PATIENTS CIRCULATION CORRIDORS - STAFF CIRCULATION CORRIDORS - PATIENTS

The primary circulation routes allow the influx of patients to enter the complex through the outer perimeter. This is outlined in red, defining each of the patient entry points. The staff circulation outlined in blue, follows the pattern in line within the complex’s roof overhang system, more specifically on the inside to create a separation of circulation flow and keeping the staff to the interior of the complex. The patient/guardian circulation created and shown in maroon primarily operates around the exterior edge of the maternity complex. Part of this circulation path additionally creates a connection between patients and staff in adjacency to the nurseries.

PRIMARY CIRCULATION ROUTES

The staff and administrative components located on the second level of the complex can be accessed through a stariwell located towards the interior of the of the main courtyard.. This is meant to restrict access specifically for the students, staff workers and administration. After speaking with Dr. Luis Gadama, the decision to develop these additional spaces to provide ease of access to facilities for these specific user groups. It creates an extra level of privacy on behalf of the adminstration and educational units to create a dividing element for the academics and adminstration. While the bottom level keeps a level of transparency in program use and organization, this upper level aims to maintain a sense of privacy, keeping official business separate from the high intensity environments.

PRIMARY CIRCULATION ROUTES

The primary adjacencies aim to focus on the relationships between the emergency, triage and inpatient servicing units. The main emergency room is equipped with 5 total trauma bays with direct proximity to the surgery and operating theatre units. For lower level emergency services, an access point into inpatient triage is provided allowing the maternity/ midwifery led department to lead the women based on their respective needs and birthing plans. The emergency rooms are also adjacent to the high risk patients in need of special care for their birthing plans. The low risk delivery and antenatal ward allow room for expectant mothers to have a space prior to giving birth in order to prepare for the process of labor and delivery.

TRIAGE TO INTRAPARTUM CARE

G TIN RA ES E OP ATR E TH

TRIAGING UNIT/ INPATIENT ENTRY

ISK H R RY G I E H LIV DE

NA TE AN RD WA

O AL

RIS

IV EL

The postnatal sector of the maternity complex is composed of the nurseries, grievance rooms and three sets of postnatal service rooms which are in close proximity to the general nurseries as well as the green spaces. This gives ease of access to the new mothers both in the general open wards as well as the kangaroo mother care units if mothers need time to rest. In addition to proximinty between the inpatient postnatal open wards and nurseries, these open wards have a close adjacency to three separate green spaces each with different ranges of privacy. Having proximity with these spaces promote quicker healing and recovery as well as providing spaces for guardians to reside when not within the open wards attending to their loved one.

POSTNATAL ADJACENCIES TO GREEN SPACE & NURSERIES

Each of these green spaces provide central points of relief from the interior environment and the circulation pathways. The primary location for these green spaces include the central courtyard space as well as two smaller, more private courtyard areas. This allows for the three tiers of privacy and space needed for the patients as well as staff and healthcare workers. In addition to acting as areas of relief, these nodes also provide opportunity for proper air ventilation between each of the program units, mainly delivery/ labor suite and each of the postnatal units. Daylighting would also be an improved factor for some of these areas in the inpatient sector as well as the outpatient clinics opposite the large main courtyard.

GREEN SPACE NODES

ELEVATION 2-A - INTERIOR COURTYARD

Private garden adjacent grieving space - privacy barrierfrom main circulation

Upper level staff lounge w/ office & kitchen space. Open to second floor patio w/ clerestory windows for circulation

GREEN SPACE NODES

Postnatal Open Ward (Kangaroo Mother Care) open to two separate green spaces on either side of postnatal unit

Exterior sheltered walkway bordering green spaces - providing shelter & circulation pathways

Secondary green space, adjacent to delivery & postnatal. Access for guardians & patients - away from staff work circulation

CONCLUSIONS Through the course of this investigation in maternal care and infrastructure, this provided an opportunity to develop a baseline schematic design that aims to provide a solution towards a healthier, safer and nurturing environment for expectant mothers in Malawi. Through mulitiple iterations and planning exercises, this project developed a large lower level scheme that increased spatial efficiency between each of the program units as well as providing a healthier space for all the users of this space. It aims to provide services for each tier of maternity and reproductive health for women in Malawi, giving each the equal opportunity towards the care that is necessary and deserved. This deign aims to promote and inclusive space that connects all the level of maternal healthcare while looking to achieve safety, efficiency, cleanliness and a positive user experience throughout the process of conception, birth and life after delivery of newborns.

BIBLIOGRAPHY Dr. Luis Gadama - Maternity Hospital Head @ QECH Dr. Zayithwa Fabiano - Doctor @ QECH Dr. Meghan Gannon - Researcher & Doctor @ Jefferson University Kayla Holston - Researcher @ Jefferson University AID (2014). Rwinkwavu Neonatal Intensive Care Unit. https://www.architectureindevelopment.org/project.php?id=518. Azuma, K., Yanagi, U., Kagi, N. (2020). Environmental Factors involved in SARS- CoV-2 Transmission: Effect and Role of Indoor Environmental Quality in the Strategy for COVID-19 Infection Control. https://link.springer.com/article/10.1186/s12199-020-00904-2#citeas. Block, India (2018). Dezeen. Maternity Facility in Rural Uganda is Entirely Self Sustaining https://www.dezeen.com/2018/08/23/maternity-facility-hks-architects-self-sustaining-kachumbala-uganda-architecture/ Build Health International (2017). African Birthing Center Prototype. https://www.buildhealthinternational.org/project/african-birthing-center-prototype/ Center for Disease Control and Prevention (2019).COVID-19 in Non-US Healthcare Settings.www.cdc.gov/coronavirus/2019-ncov/hcp/non-us-settings/overview/index.html. Centers for Disease Control and Prevention (2020). Scientific Brief: SARS-CoV-2 and Potential Airborne Transmission. https://www.cdc.gov/coronavirus/2019-ncov/more/scientific-brief-sars-cov-2.html Changole, J. Bandawe, C. Makanani, B. Nkanaunena, K. Taulo, F. Malunga, E. George Kafulafula, G. (2010) Patients’ Satisfaction With Reproductive Health Services At Gogo Chatinkha Maternity Unit, Queen Elizabeth Central Hospital, Blantyre, Malawi. https://pubmed.ncbi.nlm.nih.gov/21618840/. International Health Facility Guidelines (2017). Maternity Unit - Health Facility Briefing & Design. https://healthfacilityguidelines.com/ViewPDF/ViewIndexPDF/iHFG_part_b_maternity_unit Khaki, J.J. Sithole, L. (2019) Factors Associated With The Utilization Of Postnatal Care Services Among Malawian Women. https://pubmed.ncbi.nlm.nih.gov/31143390/. Kim, E. T. (2019) The Role Of Health Facilities In Women’s Use Of Maternal And Newborn Postnatal Care In Malawi. https://bmcpregnancychildbirth.biomedcentral.com/articles/10.1186/s12884-019-2534-x. Kyei-Nimakoh, M., Carolan-Olah, M., and McCann, T. (2017). Access Barriers to Obstetric Care at Health Facilities in Sub-Saharan Africa- A Systematic Review. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5461715/ Mass Design Group (2013). Rwinkwavu Hospital Master Plan 2014-2034. Nilsson, C. Wijk, H. Glund, L. H. Sjo¨blom, H. Eva Hessman, E. Berg, M. (2020) Effects Of Birthing Room Design On Maternal and Neonatal Outcomes: A Systematic Review. https://journals.sagepub.com/doi/full/10.1177/1937586720903689. Qian Long, Tavares Madede, Saara Parkkali, Leonardo Chavane, Johanne Sundby & Elina Hemminki (2017). Maternity Care System in Maputo, Mozambique: Plans and Practice? https://www.tandfonline.com/doi/full/10.1080/2 331205X.2017.1412138 Setola, N. Naldi, E. Cocina, G.G. Bodil Eide, L. Iannuzzi, L. Daly, D. (2019) The Impact Of The Physical Environment On Intrapartum Maternity Care: Identification Of Eight Crucial Building Spaces. https://journals.sagepub.com/doi/10.1177/1937586719826058. World Health Organization (2017). WHO Recommendations on Antenatal Care For a Positive Pregnancy Experience. https://www.who.int/publications/i/item/9789241549912 World Health Organization (2018). WHO Recommendations: Intrapartum Care For Positive Childbirth Experience. https://apps.who.int/iris/bitstream/handle/10665/260178/9789241550215-eng.pdf;jsessionid=3C521072F0F7BF932F8F2DC7A78BE1F3?sequence=1