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ABSTRACT

THE BIRTH CONTROL CLINIC, OUTPATIENT ABORTION
AND FAMILY PLANNING SERVICES?-
A DESIGN APPROACH
BY

Sonia Ruiz Stafko

The problem addressed in this project is to determine
the basic interior design elements, the size and interrela-
tionships of the interior spaces, for a highly specialized
structural facility--a combined outpatient abortion clinic
and family planning center. The Birth Control Clinic is a
hypothetical facility offering first trimester abortions
along with contraception and related family planning assis-
tance. The goal of the project is to demonstrate a design
approach adaptable to the requirements of either a public
or private facility offering such services.

The procedural steps followed in arriving at a solution
were: first, obtaining an understanding about the nature of
the activities to be accomodated by the facility; second,
analyzing existing facilities and charting the spatial re-

‘quirements for such activities; and third, adapting the

Sonia Ruiz Stafko
activities' spatial requirements to the needs of this parti-
cular facility.

These procedural steps culminated in a floor plan
illustrating the optimal utilization of interior space for I

the Birth Control Clinic.

THE BIRTH CONTROL CLINIC, OUTPATIENT ABORTION
AND FAMILY PLANNING SERVICES--

A DESIGN APPROACH

BY

Sonia Ruiz Stafko

A THESIS

Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree of

MASTER.OF ARTS

Department of Human Environment and Design

1975

C0pyright by
SONIA RUI Z STAFKO

1975

ii

II.

III.

IV.

V.

VI.

TABLE OF CONTENTS

INTRODUCTION . O O O O O O O O O O O O O
OBJECTIVE AND JUSTIFICATION -. . . . . .
REVIEW OF LITERATURE . . . . . .-. . . .

Contraception . . . . . . . . . . . .
Amrtion O O O O O O O O O O O O O O O

PROCEDURE 0 O O O O O O O O O O O O O 0

Birth Control Center Functions
Study of Existing Models . . .
Procedural Flow Chart . . . .
Capacity . . . . . ... . . . -

O O O O
O C . O
O O O O
O O O O

RESULTS--THE FLOOR PLAN . . . . . . . -

CONCLUS IONS O O O O O O O O O O O O O O

BIBLIOGRAPHY . . . . . . . . . . . . . . . . .

II.
III.

IV,

VI.
VII‘.

ILLUSTRATIONS AND CHARTS
WOrld Population Soars! . . . . . . . .

The Berkeley Aspirator . . . . . . . . .

Flow Chart A, Existing Family Planning Center.

Flow Chart B, Existing Abortion Clinic .2

Flow Chart C, The Birth Control Clinic .
Operating Room Scheduling Chart . ... .

Floor Plan for the Birth Control Clinic

iii

Page

13
24

24
30

44
52
60
62

ll
15
31
31
41
47
53

INTRODUCTION

In 1970 President Nixon established the Commission on
Population Growth and the American Future headed by John D.
Rockefeller III. The Commission warned that although the
birth rate in the United States has declined it must be
slowed still further. The report dealt with a range of
special problems but its most striking recommendations
concerned birth control:

A new federal law should be enacted to
help . . . set up population, sex and birth
control education programs.

State laws that restrict access to

contraceptive information and supplies

should be eliminated and such materials

should be available to minors.

Present laws restricting abortion should

be liberalized along the lines of the New

York state statute, which permits abortion

on request.

Of course the recommended legislation was never introduced.
A variety of-parochial state laws continued torestrict

women's ability to obtain contraceptives, information about

contraception, and abortion. The presidential commission's

1
P. 71.

Time Magazine, March 27, 1972, vol. 99, no. 13,

 

2

argument that ”all women have a moral right to freedom to
control their own fertility,"2 went unheeded by the legis-
lature due to perceived political antagonism to such reform.
However, as is‘often the case where an idea whose
time has come is ignored if not stifled by one branch of
our government, another will come to the rescue. In this
instance, it was the judiciary. By extending the Bill of.
Rights to include protection from state interference with a .
woman's right to decide whether or not she shall bear a
child, it invalidated state laws prohibiting her from
exercising that right. The Supreme Court decision of gang

Roe v. Henry Wade, decided January 22, 1973, held that the

 

Texas statute, and by implication all similar state statutes
proscribing abortion except for the purpose of saving a
mother's life, was an unconstitutional denial of an indivi-
dual's rights protected by the Ninth and Fourteenth Amend-
ments of the United States Constitution. 1
The Jane Roe decision was preceded by and in.part is

based upon Griswald v. Connecticut, a 1965 Supreme Court

 

decision invalidating as unconstitutionalstate laws
prohibiting the dissemination of contraceptive Or information
about contraceptives.

These two decisions have come at a time when the social
and economic climate increasingly demands that families plan

for their children. The accommodation of this demand in

 

21bid.

respect to both contraception and abortion, having been
recognized as a Constitutionally protected right and thus
legalthroughout the United States, can now be planned for by
public and private professionals in light of accepted medical
practices and public demands. Contraception and abortion need
no longer be associated with shame and danger. A relatively
new area of medical and social science is now accessible to
investigation and develOpment, and a demonstrated need of the
general public can and will now be accommodated. The subject
of this project is based on the premise that the role of
birth control in our society looms large in the near future.
It can be anticipated that the demand for such services will
increase, based on observations cf national and world demo-
graphic, social, and economic pressures. Recent public
opinion polls indicate increased recognition of these cir-
cumstances, and encourage speculation that well financed,
government-backed birth control programs such as those en-
visioned by the President's Commission may yet become a
reality.

Such services, be they publically or privately supplied,
will require facilities. Facilities need designing. This

project is a design approach for such a facility.

II

OBJECTIVE AND JUSTIFICATION

The objective of this project is to demonstrate an
approach to the interior design of a highly specialized
facility--an out-patient abortion clinic and family planning
center, hereafter entitled the Birth Control Clinic. The
objective is not to design the facility per se. Rather, it
is to illustrate the necessary first steps in formulating
such a design. The sum of these first steps should be an
understanding of the factors which determine the size and
interrelation of the interior spaces. The one interior
design element upon which all others rest is the determina-
tion of space. Before the architect begins to design his
structure, the spacial requirements of the human endeavor
enclosed within must be thoroughly examined and charted out.
The chartographer in this instance is the interior designer,
who supplies the architect with information necessary for him
to choose his course of construction. This project attempts
to illustrate such a chart, that is, a matching of a given
human endeavor with a structural arrangement that optimally
fulfills that endeavor's spacial requirements.

The justification for adopting the Birth Control

Clinic as the subject of this thesis is grounded in its

5

topicality. Only very recently has the subject of birth
'control in general, and abortion tharticular, emerged from
under the clOud of misinformation, taboo, and illegality. It
is also an area where interior design has not yet been given
the consideration it should, but where it soon shall.

Regardless of one's personal predilections, none will
deny that there is a demand for such services. Before
legalization, this demand was met in a largely haphazard,
dangerous, and socially destructive manner. In the 1960s,
maternal deaths caused by botched illegal abortions in the
United States averaged over three hundred a year. In 1973,
it has been estimated over 745,000 abortions were performed
in this country, and over 900,00 in 1974. Hewever, in 1973,
it was evident a good number of illegal abortions were still
being performed due to a lack of access to abortion facili-
ties in many areas; twenty-five of the fourty-seven abortidn
related deaths that year resulted from illegally performed
abortions.3

In Michigan there is a similar demonstrated demand.
In 1971, before the Egg decision and legalized abortion in
Michigan, and during the first full year of New York's
pioneering abortion statute, sixty-one percent of 262,807

reported New York abortions were performed on women from

3"The Abortion Trade," Detroit Free Press, February 4.
19 75, p. l-C.

out of state.4 It is estimated that a good ten percent of
that number came from Michigan, or as many as 15,000., The
present demand is estimated to be between 25,000 and 30,000
per year.5 It is also estimated that three or four abortion
clinics in the Detroit metropolitan area, along with two or
three outstate, each with a first trimester abortion (abortion
within the first twelve or so weeks of gestation) capacity
between twenty and twenty-five a day would adequately serve
Michigan's present needs.6
In summary, there is a demand, in Michigan, for
pregnancy termination services, and by logical implication,
for pregnancy prevention services. This demand is not
currently being met in an adequate fashion. The need for

adequate services, and for facilities to house them, is

imminent.

 

4"New York Abortions," Detroit Free Press, August 31,
1973' p. l-Co

SInterview, William Stien, Director, Planned
Parenthood, Inc., Detroit Chapter, March 5, 1974.

61bid.

III

REVIEW OF LITERATURE

The unique focus of this project--a design approach
for the spatial relationships of a birth control clinic
performing outpatient abortions and other family planning
services--prec1udes much drawing upon analysis and findings
of prior studies. Although much has been written on con-
traception and abortion, there appears to have been little
published concerning the design of facilities for these
services. Existing family planning services are universally
low on government priorities and are consequently under-
funded. They are sequestered in "available existing space,”
which is often inadequate to the proper function of the
service. Similarly, abortion clinics, being a relatively new
phenomenon in an area of Law and medicine that is rapidly
changing, heretofore have been only a functional part of
existing hospitals or at best an adequate remodeling job of a
building designed for some other purpose. Thus the author
has relied to.a large degree on interviews, analysis of
existing family planning and abortion facilities and analysis
of the functional aspects and personnel requirements of

such services as those offered in the Birth Control Clinic.

However, as stated, much has been written regarding the
functions of our proposed facilities. A general review of
these functional areas will be a beneficial background to
the designer.

The prevention of an unwanted birth may be affected at
two points: before conception by contraception, and after
conception by abortion. For obvious reasons, the former
is the more preferable of the two methods. But unfortunately
abortion plays, and will continue to play for the foreseeable
future, an important part in any comprehensive birth control
program. The following is a brief survey of general in-

formation on each of these two birth control methods.

Contraception

 

Methods

Home remedies commonly in use today include the
douche, withdrawal, and the "rhythm method." These are
considered 69%, 75% and 75% effective, respectively. Still
in wide use and available without prescription are spermi-
cidal foams and jellies (30% effective), condoms (86%
effective), and diaphragms (88% effective). Intrauterine
devices (IUD), the "pill," and sterilization which require
medical consultation and prescription, are 86%, 99% and

99.9% effective, respectively.7 At present, oral

 

7Sex, A Better Understanding (pamphlet), Community.
Sex Information and Education Service, P.O. Box 2858, Grand
Central Station, New York, New York 10017 (1971), pp. 72-74.

 

contraceptives account for approximately 25% of all contra—
ceptive practice in the United States, approximately eight
million as of 1967. "Although use . . . is highest among
young women with a college education, there is a general
consensus among clinicians that almost all women, including
those with a limited education, can be taught to take them
with reasonable consistency, and that this method of birth
control has proved acceptable to many couples who had been
unwilling . . . or unable to use (traditional 'methods)."8
The estimate of IUDs inserted in the United States
ranges between one and two million. Because of their small
expense, and lower risk of "patient failure" (cOnscientious and
consistent application by the patient is required for the
other popular methods), the IUD has become the mainstay of

many family planning programs abroad--most notably in India.9

History

Greeks, Romans and Islamic cultures all possessed

10

knOwledge of contraception through artificial means. But

the modern birth control movement--limited in the present
discussion to contraceptives-~begins with Thomas Malthus'

Essay on the Principle of POpulation. Malthus concluded that

 

 

8Christopher Tietze, Modern Methods of Birth Control:
An Evaluation, Basic Books Inc., 1969, p. 187.

9

 

Ibid.

10Norman'St. John—Stevas, Birth Control and Public
Policy, Center for the Study of Democratic Institutions,
P.O. Box 4068, Santa Barbara, California, 1960, p. 5.

10

pOpulation increases geometrically and that while technology
will increase food resources, technology will eventually be
left far behind; man is doomed to breed himself into perpe-
tual strife and famine. Even considering the current drop
in the national birth-rate, recent global projections bear

11'12 Although there are

out Malthus' gloomy predictions.
many complex variables to the overpopulation problem, papu-
lation growth figures demonstrate the urgency of the
situation (see Figure I, p. 11). The first doubling of
population since l750--an increase of 900 million--took 150
years, to 1900. The second doubling took 65 years, adding'.i
1,630 million peOple. The third doubling, adding over 3,000
million, is projected to take place before the turn of this
century--a period of under 35 years.13

While Malthus considered the momentum irreversible,
in 1822 (24 years after Malthus' Essay) Francis Place
pulished Illustrations and Proofs-of the Principle of Popu-
lation. Although Place essentially concurred with Malthus,

he was not as fatalistic. He suggested there was hope

through the use of contraception.

 

lanOS. Babies Absent." Detroit Free Press, October 23.
1974' p0 4-Co

12Katherine A. Kendall, Population Dynamics and Family
Planning, Council on Social Work Education, 345 E.—46Eh
Street, New York, New York 10017, 1970, p. 74.

13

 

Ibid.

FIGURE I.

World Population
in Millions

6000

5000

4000

3000

2000

1000

11

WORLD POPULATION GOES INTO ORBIT!

6,900,000,000
by A.D. 2000

 

 

 

 

)—
_ A.D. 1968
3, 356,000, 000 \{
A.D. 1650
500,000,000
Birth of
Christ, 250,000,000
L1—
eL ‘7 l ! 1 L1
500 1000 1500 2000

This chart is based on statistics from the Demographic
Yearbook issued by the United Nations Statistical Office and
Department of Economic and Social Affiars.

from’Familnylanning In An Exploding Population by

John A. O'Brien

(1968). p.'§T*

12

Birth control and Malthus' theories soon became a
popular topic of conversation among the educated, but by the
mid-18008 Victorian religious and political elements (in both
the United States and Britain) held sway. Religious edicts
against the use of contraceptives were passed along with.
legislation banning the sale, distribution, and dissemination
of information about contraceptives. Such laws spurred
Opposition and solidified the early birth control movement,
but only recently has the movement with the aid of the courts,
succeeded in overcoming most of these archaic laws.

In the light of changing attitudes within their
congregation and clergy, even the Catholic Church has
re-examined its position on the use of artificial means of
contraception:

The Second Vatican Council (1966) did not

speak directly to any . . . methods (of

contraception). . . . This is a different

stand-point than that taken under Pope Pius

XI some thirty years ago and his successor.

We can sense here a clear development in the

church. . . . It is advisable in such matters

to . . . approach a doctor who can take all

the varying circumstances into account and . . .

decide what is medically best.14

Between 1966 and 1968 the United States government
began to acknowledge the importance of family planning by
enacting legislation creating and supporting family planning

services. Federal family planning services were made

available for military personnel and dependents (through

 

14Herder and Herder, A New Catechism, (Imprimatur),
1971, p. 304.

 

13

the Department of Defense), for Neighborhood Health Centers
in low income areas (through the Office of Economic Oppor-
tunity), and for such civilian groups as American Indians
and Federal Employees (through HEW).15 A broader aspect of
federal involvement, again through HEW, is the provision of
funding to state and local government units who currently

operate most existing family planning services.16

Abortion

 

Methods

Abortion, performed by an experienced professional
is a relatively safe and simple procedure. In fact, today
it is four times safer for a woman to have an abortion than
to give birth; three times safer than a simple‘
tonsilectomy.17

Abortions can be divided into two types: those within
the first trimester of pregnancy where the two most common
methods are dilation and curettage and vacuum aspiration,
and those of later pregnancies where amniocentesis (saline

injection) or hysterotomy is normally required. The latter

procedures are much more serious operations and ascurrently

 

15Department of Health, Education, and Welfare, Family
Planning (pamphlet), U.S. Government Office, Washington, D.C.
p. 2. '

16

 

Ibid., p. 3.

17Garret Hardin, "Abortion and Human Dignity," The
Case for Legalized Abortion Now, Diablo Press, Berkley, Cali-

J

fornia 94717, 170, p. 72.

 

14

performed require access to the full range of emergency
medical service and inpatient facilities generally found
only in a hospital. However, new techniques in saline
abortions adopted from Eastern Europe show promise of
medically safe abortions for second trimester patients on

an outpatient basis.18

For the first trimester abortions,
vacuum aspiration is a newer and safer technique than the
old "D and C" (see Figure II, p. 15). Also developed in
Eastern Europe, it can be performed safely in a doctor's
office or clinic, requires little or no recuperation time,
and as opposed to the D and C requires only local
anesthetic.19
Most women report only minor discomfort during the
procedure, similar to the discomfort of menstrual cramps.
It has the advantage of simplicity of operation, less blood
loss, and greater speed and cleanliness. Vacuum aspiration,
when coupled with a vigorous educational program appears
the best suited for the outpatient Birth Control Clinic.
The procedure takes only a few minutes: first the doctor

opens the cervix with a series of gradually widening round

metal rods called dilators, then he inserts a hollow vacuum

 

18Benjamin E. Marbury, M.D., ”Anesthesia in Abortions;"
Legal Abortions in New York State: Medical, Legal, Nursing,
and Social Aspects (July l-December 30, 1970), MedicaI’
Department, Harper & Row, 1971.

19Thomas D. Kerenyi, M.D., "Outpatient Intra-amniotic
Injection of Hypertonic Saline;" Legal Abortions in New York
State: Medical, Legal, Nursing, and Social Aspects, Medical
Dept., Harper & Row, 1971, p. 111.

15

FIGURE II. THE BERKELEY ASPIRATOR

4 .r

 

 

16

tube (vacurette) through the cervix to the top of the uterus.
This tube is connected with the suction device, which will
gently pull away the uterine lining along with the fetus

and placenta, which is deposited into a transparent receptacle
which is placed outside of the vision of the patient. This
procedure remains the easiest, quickest, and least expensive

method. 2°

History

Historically, the practice of induced abortion did not
concern state or religious authorities. Abortion was
practiced by the Chinese as early as 2700 B.C. Aristotle
recommended abortion of all women having the prescribed
number of children or those over forty years old. During the.
days of the Roman Empire, induced abortion was widely
practiced among all classes of women. Curetting with a
varied assortment of instruments (scraping the fetus from
the uterine lining), douches of hot--often caustic--1iquids,
and more traditional methods such as vigorous exercise and

massages were employed with varying degrees of success.21

 

20Bernard N. Nathanson, M.D., "Suction, Curettage
for Elderly Abortion: Experience with 645 Cases;” Legal

Abortion in New York State: Medical, Le a1, Nursing, and
Social Aspects, Medical Dept., Harper 5 Row, I971, p. 36.

21Leslie Corsa Jr., "Abortion, Yesterday, Today, and
Tomorrow;".The Case for Legalized Abortion Now, Diablo
Press, Berkley California 94717] p. 1272

17

Even within the last century, permissible abortion has
been the rule rather than the exception in most non—western

22 This anomalie is usually

non-Christian societies.
attributed to the pervasive effects of Christian dogma on
the cultural values of western nations. Given the ideal of
asceticism, taboos built up around all matters "of the
flesh." Also, Hebrew attitudes regarding womans' servient
role in the society carried over into Christian beliefs.
However, the principal theological objection to abortion
stemmed from the doctrine of original sin; after much debate
from within the church it was decreed that the fetus pos--
sessed a soul from the very moment of conception. Therefore,
an aborted fetus "died unbaptised" and was thus doomed to
eternal damnation. It appears that induced abortions still
occurred, but canon law treated the act the same as murder.
Through the Renaissance era, to be caught usually meant a
sentence of death--un1ess, of course, one could afford to buy
an indulgence or pardon.23
deay unfortunately, vestiges of this dOgmatic

adversion to abortion remain imbedded in the Western culture.

But the Jane Roe decision and the trend in Western Europe

 

point to a new era where complete family planning, including

abortion, will be available to all. Many theologians are also

 

22Jerome E. Bates, Criminal Abortion, A Stud in
Medical Sociology, Chas. C. Thomas, PubliSher: Springfield,
Ill., 1964, p. 24.

23

 

 

Ibid., p. 20.

18

becoming more flexible in their approach to abortion; Paul
W. Rahmeier, chaplain at Dartmouth College, recently wrote:

If our intention is to promote reverenCe

for life, we should allow abortions in

situations where the termination of fetal

life would enhance human life. . . . Life

is present in the earliest union of repro-

ductive cells, but human life begins with

birth. . . . To prohibit abortions places

a premium on the quantity rather than the

quality of human life. . . 24

Until the 1973 Jane Roe decision, the majority of
American states still retained Nineteenth Century laws
requiring strict medical necessity before a doctor could
perform an abortion, i.e., the mother's life must have been
in danger. Typical of this genre was Michigan's abortion
statute, enacted 125 years before Roe invalidated it.

In 1967 Colorado became the first state to liberalize
their abortion statute. It was patterned after laws that
had been in effect for a decade or more in the Scandanavian
countries. It permitted abortion on humanitarian and eugenic
grounds (where a child would be born gravely deformed),
where pregnancy resulted from incest or criminal assault,
or where the birth would endanger the mother's physical or
mental health, and provided that abortions take place in

hospitals upon approval of three doctors.25 By January, 1969

 

24Paul W. Rahmeier,"Abortion and the Reverence for Lifefl
Christian Century Magazine, May 5, 1971, p. 558.

25Anthony Harden, Legal Abortion: The English
Experience, Pergamon Press Inc., Elmsford, New York, 1971,
p. 219.

 

19

North Carolina, California, Georgia, and Maryland followed
suit. Later that year New Mexico, Arkansas, Kansas, and
Oregon liberalized their abortion laws, and by May, 1970,
so did Alabama, Hawaii, and New York. All the new statutes
gave a large degree of discretion to the hospitals and
doctors.26
The new state statutes were of varying degrees of
liberalism and had different effects in their respective
states. In conservative Colorado, two years after the
enactment of the statute, hospitals concerned about their
reputations (and financial resources) had denied twelve
out of every thirteen abortion requests and had performed
a total of only 800--making barely a dentin the estimated
5,000 illegal abortions which took place there during the

27 At the other pole was California. With a

same period.
similarly worded law, in the first year of operation,
California hospital committees approved 91.9% of abortion

28 With the backing of California courts doctors

applicants.
had liberally interpreted the statute's requirement that
there be "substantial risk that continuance of the pregnancy
would gravely impair the physical or mental health of the
mother" (emphasis added).‘ This combined withthe fact '

that the statute had no residency requirement made California

 

ZGIbid.

27Ibid., p. 254.

28Ibid., p. 257.

20

the Mecca for women fronnthe Western half of the United States
who were seeking abortions.

The most liberal of the prejggg state abortion statutes
was enacted by New York in July 1970. New York Penal Law,
Section 125.05 states: ”An abortional act is justifiable
when committed upon a female with her consent by a duly
licensed physician . . . within 24 weeks from commencement

of her pregnancy."29

There are no restrictions on residency,
.age, or place of abortion. However, the State and city
health departments issued guidelines, and subsequently en-
forceable rules, for compliance with the new law. In October
1970 the New York City Department of Health enacted Article
42 to Title III of the city health code, perhaps the first
truly comprehensive code covering abortion clinics. It
specifies that pregnancies of duration longer than 12 weeks
or those involving medical, Surgical, gynecological, or
psychiatric conditions or complications during or after the

abortion, require inpatient facilities.30

The Article sets
forth the number, qualifications and duties of the staff, and
the physical requirements of the facility. The Article

also states that the abortion service shall have a social

unit and family planning information available to the patients.

 

, 29State Statutes, Abortion in New York State:
Medical, Legal, Nursing, and SociaI’Aspects (JuIy -
December 31, 1970), Medical Department, Harper & Row, 1971.

30Mary C. McLaughlin, "Abortion Standards, New York
City Board of Health;" Abortion in New York State: Medical,
Legal, Nursing, and Social Aspects, Medical Department,
Harper & Row, 1971.

 

 

 

 

 

 

 

 

 

 

. 4
.
.
4
..1
nu;
I
»
VITA

21

Immediately after the Egg decision in January, 1973, a
hodgepodge of abortion facilities Opened in Michigan. As of
1974, there were aboutiidozen first trimester outpatient
abortion facilities in the Detroit metropolitan area, plus
at least one each in Lansing, Grand Rapids, and Kalamazoo.

Of the twelve in Detroit, only three were tentatively :
approved by the 1973 National Organization for Women (NOW)
survey. Up to September of 1974, NOW was the only organie
zation investigating and rating abortion facilities in Michi-
gan. In September, as part of an award winning series of
articles exposing the disgraceful proceduresin and Conditions
of the abortion facilities in Metropolitan Detroit, the

Detroit Free Press rated only one of the twelve even

 

adequate.31 The articles disclosed many abuses and found
that a woman who goes to a Detroit area abortion clinic
could not be reasonably sure of getting a safe abortion at
a fair price:

She risks getting an abortion she doesn't
need (where there was no pregnancy). She
may be treated by a person who is not a doc-
tor. Her abortion may be performed under
unsanitary, unsafe conditions that increase
her chances of serious infection and
hemorrage. She cannot be certain that she
will receive counseling to deal with her
emotional problems and to arrange for an

 

31Delores Katz, "The ABortion Trade," Detroit Free
Press, September 8, 9, 10, and 11, 1974; SeptemberIUT
I971, p. 4-Ao

22

appropriate method of birth control. She
is preyed upon by referral agencies whose
only interest is the kickback they receive
from doctors.32

Largely in response to the furor created by the Free
Press articles, and within two weeks thereafter, a bill was
drafted and passed into law by the Michigan Legislature
which required the director of public health to establish a
system of licensing for "freestanding surgical outpatient
facilities," and to "promulgate rules . . . for the establish-
ment, maintenance, and operation of the facilities as shall
be necessary to accomplish the purposes of this act."33
Section 8 of the Act goes on to state:
After the effective date of this act, the
owner or governing body of a proposed free-
standing surgical outpatient facility shall
submit plans of a proposed facility to the
director for review and approval prior to the
initiation of any construction project. . . .
The review and approval shall assure that the
prOposed facility is designed and constructed
in accord with applicable rules.
As of spring, 1975, the Michigan Department of Public
Health (MDPH) has not yet enacted a final set of rules
defining the parameters within which an outpatient abortion

clinic must be designed, constructed, and Operated.. However,

even prior to the Roe decision, the Department of Public

 

32£§$§,, September 11, 1974, p. 3-A.

33Senate Bill 888, Reg. Session, 1974, Sections 1 and
6. The Bill was enacted and drafted as Public Act 1974,
no. 247, and made effective October 3, 1974. The Act is
statute number 331.461, et. seq., of Michigan Compiled Laws
Annotated.

23

Health, in anticipation of possible legalization of abortion
by referendum (defeated in the fall of 1972 election),
compiled Recommended Guidelines for Facilities Performing

Prggpancy Terminations. The MDPH Guidelines were published

 

 

in February 1973, and go into great detail defining the
various procedural and physical requirements for an optimal
facility. It may be safely anticipated that the forthcoming
Department of Health rules under the new statute may well be
less stringent than the guidelines, which in not having

the effect of law could be more idealistic in its approach.
Nonetheless, the guidelines, based upon the expertise of an
advisory committee composed of many well qualified individuals
and representatives, and upon the known experiences of other
states, together with other published materials, gives

an important indication of what rules a Michigan abortion
facility may soOn have to adhere to, and in any case, should

adhere to.

IV

PROCEDURE

Birth Control Center Functions

Our hypothetical facility, the Birth Control
Clinic, provides two general types of service, pregnancy
terminations and family planning assistance. There is reason
for combining these functions into one facility. They are
both directed toward and are essential aspects of one problem.
Although unwanted pregnancies could almost always be pre-
vented by the conscientious applicatiOn of any number of
proven contraceptive methods, according to one authority:

It is probably safe to say the biggest single

reason there is a market for abortions is

lack of education and/or lack of desire to

use contraceptive methods. Even with universal

counseling and readily available contraceptives,

abortions would still be required where a

diagnostic mistake has been made, e.g., where

the pregnancy was hidden by interference from

menOpause or drugs, or where there was rape

or incest, or where there is a serious de-

fective or deformed fetus.34

In any case, it is obvious that current methods of
education and dissemination of contraceptives are insuffi—

cient; all too often the desire to prevent pregnancy is

 

34Interview, Carol Parks, Administrator, Michigan
Clergy Counseling Service, August 14, 1973.

24

25

discovered only after conception, when only remedial measures
can help. In that latter instance, sound medical practice
requires the future welfare of the abortion patient be a part
of the procedure, e.g., that to the greatest extent possible,
she is advised on problems incidental and related to her
unwanted pregnancy, particularly contraceptive methods, to
insure that the relatively radical step of abortion will not
again be necessary. Both the New York City Health Code, a
statutory model on the subject of outpatient abortion
facilities, and the MDPH guidelines recognize the surgical
procedure cannot be undertaken without more: thorough
counseling is a vital addition to the surgical procedure.35

In reality, the weight given to each of these two

general functions:h1planning space allocations will be

 

35New York City Health Code, Section 42.29 requires
that "An abortion service shall have a social unit available
to serve its patients adequately." Section 42.31 (e) and
(f) state: "Interviewing and counseling by social service
staff shall be made available to patients before and
after abortions are performed. Family planning counseling
by such personnel as may be prescribed by the physician
in charge of the service shall be made available to patients
before and after abortions are performed." The Michigan
Department of Public Health Guidelines states, somewhat more
broadly on page 15, that "pregnancy termination clinics
should provide, through physicians, qualified nurses, social
workers, and/or specially trained and qualified counselOrs
for appropriate assistance and counseling for patients
as needed. The clinic should maintain liason with
community counseling, family planning, and other social and
health agencies to assure appropriate and adequate subse-
quent care of patients. Arrangements should be made for
the appropriate provision of contraceptives and/or supply,
preferably originating in the clinic, with apprOpriate
referral to other sources for any needed subsequent
attention."

 

26

determined by many factors, most of which regard the client's
needs, or perhaps, more accurately, the builder's motives and
the source and amount of his capital. A general assumption
might be made that a facility utilizing public funds, or
perhaps foundation money, will be more ”publicly" Oriented,
'or in this case, more apt to devote greater time and space
to counseling and the contraceptive aspects of family
planning, whereas a facility that is strictly privately
financed and operated, and is designed to be a profit-making
venture, will be "profit-oriented," and inclined to stress
the more remunerative surgery at the expense of counseling
and family planning services. Although the writer is inclined
to give more weight to the public service aspects of the
facility, it is recognized that the still politically
volatile nature of the services involved, especially
abOrtion, indicates a facility with such a service mix is
not likely to be publicly financed in the near future.
Secretary of Health, Education and Welfare (HEW) Frank
Carlucci, recently announced prOposed abortion restrictions
on federal funds heretofore available for abortions under
the medicaid program, which number up to 278,000 per year.
The proposed HEW rules are reported to have stated in part:
The services and supplies (must) include at
least physician's consultation, examination and
continuing supervision; necessary laboratory
examinations and tests, medically approved con-

traception through chemical, medical, or other
means; and surgical procedures for voluntary-

27

sterilization. . . . Not included under this

definition are abortions performed either for

therapeutic (for the life or health of the

mother) or non-therapeutic purposes.36
It is h0ped cooler heads will prevail and that comprehensive
public birth control programs including abortions will
some day soon be a reality.

Aside from the ethical considerations and enacted rules
and guidelines which mandate a portion of any facility offer-
ing abortions be dedicated to ancillary counseling, there is
also a strong possibility that a birth control clinic as
envisioned here, where each of the two birth control func-
tions complement the other, could advantageously be con—
structed as either a private facility or as a "hybrid" public-
private facility.

Some facilities such as the Twenty-Second Street
Planned Parenthood Center in New York City, financed by
government, private grants, donation, and fees, not only
perform first trimester abortions, but also provide
counseling on contraception, dispense contraceptives, and
provide a full range of services for all aspects of
pregnancy, genetics, infertility, venereal disease, and other

sex related matters. Presently up to ninety percent federal

matching funds are available for state supported facilities

 

36"HEW," Detroit Free Press, December 9, 1974, p. 2-B.

 

28

offering services and supplies related to family planning,
excluding abortion. This suggests a possible means of
combining the two functions, separately funded, into one
facility to the mutual advantage of the state and the
private investor.

In any case, the relative weight given to the two
types of birth control procedures in the Birth Control
Clinic shall be such that the design approach could be
adapted, hopefully, to either a public or an enlightened
private enterprise of a similar nature.

Aside from the general functions to be accommodated,
other "givens" will help narrow the scope of our hypothetical
problem to more workable dimensions._

First, having discussed some practical implications
regarding financing, we will hereby, be fiat, leave all
financing and budget problems behind. The design approach
will hOpefully be adjustable to variously financed projects
with the same of similar goals.

Second, for the purposes of this project, we will

restrict our attention to first trimester abortions. The

 

37Ibid. The Federal Social Service Act of 1972 £27
quires states to provide family planning services, as opposed
to allowing them discretion in the matter, if they wish to
receive federal money for other related social services.
This is due in part to the fact most states had previously
ignored the prior act's "recommendation," which in turn made
family planning assistance unavailable to the poor, who had
no alternative but to add to already over-burdened welfare
roles.

29

Supreme Court's Reg decision expressly prohibits state
interference with a citizen's ”fundamental right of privacy"
unless there isia "compelling state interest." In the light of
present medical knowledge, said the Court, this “compelling
state interest," is nonexistent before the second trimester
of pregnancy, "because of the now established fact . . . that
until the end of the first trimester, mortality in abortion
is less than mortality in normal childbirth." After the
first trimester, up to the point of viability of the fetus,
the state may impose regulation only "to the extent that
regulation reasonably relates to the preservation and pro-
tection of maternal health."

Furthermore, from a medical point of view, only first
trimester abortions may be consistently performed on an
ambulatory basis, thus allowing for an outpatient service,
one available to a greater number of patients at less cost.

The Michigan Department of Health Guidelines state, on

 

page 18,

Only uncomplicated first trimester preg-
nancies . . . can be safely terminated out-
side a hospital. All terminations beyond

the first trimester of pregnancy and all those
with a recognized potentially hazardous medi-
cal complications regardless of state of
gestation, should be performed on an inpatient
basis in a hospital.

Article 42 of the New York City Health Code similarly
restricts outpatient abortion services to first trimester

pregnancies.

 

30

Third, the abortion capacity of cnn: facility will also
be determined somewhat arbitrarily; it is to be fifteen
abortions per day. Based On an estimated 25,000 to 30,000
abortions per year in Michigan, a facility averaging
seventy-five abortions a week, or 3,900 abortions a year,
could service approximately one million people, or one-eighth
of the estimated Michigan demand.

Finally, we will locate our facility in Michigan not
only because of the demonstrated need, but because of the
fact that it is essential to establish a jurisdiction in
which the facility is to be built; the simple reason being
that every state, and many counties and municipalities, have
different laws and regulations which will have a direct

impact upon the direction of one's design program.

Study of Existing Models

 

The first step taken in the design approach for the
Birth Control Clinic, was to study the function-space
relationships in existing facilities. This entailed the
study of two separate types of facilities, family planning
centers and abortion clinics. In each case the patient flow,
the procedures, and the space used was charted out.

The family planning center, 701 North Logan Street,
Lansing, Michigan, was the model for Flow Chart A, entitled
"Existing Family Planning Center," Figure III, page 31. The
chart describes the facility, step by step, in three chrono-

logically concurrent parts: 1) patient flow, a word or

 

 

‘ '1 .:\ .‘l.f:!.9

~7-.'-" ‘.,‘ "hf:
. . . _

FIGURE II,

FLOW

CHART A

EXISTING FAMILY PLANNING CENTER

 

31

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PATIENT FLOW A ‘ 1 I F ‘ 5] Discharge
rriva Fi 1 out f Labora or tes Educatio . ' ‘ ' ~ "V447 ’
““rr1 1 orms t Y t5 n Interv1ew PhySical Examination 1 Consultant l, l l I I
Referral ' '
i i l i h __ I Social Worker , Nutritionist Publgfirggalth Matggggiefgildj
. Doctor . l
The "receiver": The patient fills The nurse The nurse or a The nurse Doctor performs; I II I
—gives patient general out forms, includ- draws blood volunteer lec- conducts an —pap smear test
information sheet and ing medical histo— sample and takes tures and pre- interview re. —pelvic exam The patient is re- The Social Worker The Nutrition- [The Public The Maternal-
necessary forms ry, laboratory blood pressure. sents material on medical history. —breast test ferred, as needed, counsels the ist advises Health Nurse Child
—Signs in patient and and nutritional contraception. —others as necessary to either the patient in the as needed on advises on Counselor
PROCEDURE aSSlgnS case no. and data forms. Social Worker,the areas of finance diet, eating misc. family offers assis—
flow no. Doctor makes out Public Health and personal habits, meal health pro- tance and
. A volunteer super— prescription in Nurse, or the problems of planning, blems, makes advice re.
The patient places a Vises. adjacent office while Maternal—Child sociological etc. referrals for child rearing

labeled urine specimen
on tray at desk.

patient dresses

 

Counsellor.

 

origin.

 

 

 

 

treatment if
needed, and

 

in general

 

 

is concerned
with public
health pro-

Patient goes to doctor
office to pick up
prescription and
proceeds to next

I step.
_ l . . . . I .
Ff I l I F NutritionisUs Any available Maternal-Child .
Classroom Laboratory Classroom ' 1 Interview office . Examination Room t————-Nurse Station Social Worker's 1 Office Office Health Office EX1t
. l i Office L—_

FIGURE IV, FLOW CHART B ‘
Pre-operation medi- I

l I | Post Operation instruction and
l ‘ Fill out forms [ ’ Laboratory tests ‘ cation and social _» Patient preparation r Recovery Period Family Planning Counselling

The volunteer takes
height and weight of
patient.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

   

Receiving area

! F

 

 

 

EXISTING ABORTION CLINIC

 

 

 

 

 

 

 

PATIENT FLOW Arrival The Operation Discharge

worker orientation.[ y}—F——[ a WW
I I I I I I l -

 

 

 

 

 

 

 

 

 

 

j

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

l .
p.
, . , Technician obtains: 1_ patient is coun- Nurse prepares I 1 A vaginal speculum is inserted. . 1. Patient is wheeled in 1. The patient is given a sheet Prior to leaving, the
The receiver hands The patient fills OUt —blood sample for gelled on pro- patient for the 2 A paracerVical block (anesthetic) IS in wheel chair. with post—operative instruc— patient passes by
forms to the in— the forms WBC hgb hema— ccdure operation: administered (1% lidocaine) 2. Patient lays in bed tions, which are orally sum- station in lobby/re—
coming patient. tocrit ahtibody 2_ Nurse administers —blood pressure 3 Ccrvic is dilated for 3 hrs. in case of marized by the distributing ceiving area where her
An appointment Attending staff member liter ’bloodtype 10 mg. diazepam is taken 4 The suction curette is inserted unknown complications staff member. The patient condition is certified
has already been answers any questions. and crossmatch tranquilizer. —patient is through the cervical os, and suction (required by statute). is then given a six dose as satisfactory and
made. rhogam tests 3, Patient changes positioned and equivalent to 25 mm. Hg. of pressure 3. After about 30 min. 1 supply ergovine (for cramps) Clinic's fee is
The forms will include: —urine specimen into hospital I draped. is applied. The gynecologist rotates the patient gets a and a four day supply of Collected.
PROCEDURE —personal QUEStiOHS SUCh for urinalysis gown. ___________ __J the curette around the uterine wall. snack. . tetracycline (to prevent
as name, address, age, and pregnancy 4 patient settles 5. 3 to 5 min. of suctioning is normally 4. Assuming no complica— infection).
and marital status. tests ' down prior to required to complete evacuation. tions, after the 3 hrs.
-medical questions re- ' operation. 6. Doctor carefully scrapes uterine the patient dresses 2. Contraceptives are the sub—
garding alergiesl men- lining with sharp curette to be sure and proceeds to the ject of a lecture by nurse,
strual history, obstet— ‘7 abortion is complete. next step. emphasis placed on the pa—
rical history and other F;;g;ggg;;g;g;:;gggéi— 7. The tissue is sent to Pathology. tient's responsibility to
medical problems. ~small waiting room L8. The Vital Signs are checked. 1 herself and others.
for steps 1 8 2 .
i -bathroom for step 3 ‘ I -
I —operation room fOr . V ___—J .
R00” Receiving area J—————[Patients' waiting room V}~——[*Laboratory 4J—_——— step 4 Operating room Operating Room ReCOVerY Room —— Counselling Area [ Ex1t

 

 

 

 

 

 

 

 

 

 

 

 

 

32

phrase description of each procedural step; 2) procedure,

 

a detailed description of the procedures that are performed
at that step; and 3) £923, a word or phrase description of
the space in which the aforementioned procedure takes place.
Reading from left to right, each step from arrival to dis-
charge is chronologically identified, described, and located
in a distinct space.

In addition to the charted infbrmation, some other
observations about the Lansing facility will assist in
assaying its applicability to our project.

The Lansing Family Planning Center isla typical public
contraceptive dissemination and information facility, with a
limited capacity for ancillary social service functions. It
employs at various times a coordinator, two doctors, four
nurses, a medical student, seventeen other staff members, and
Ithirty-five volunteers. The center is financed by the
federal government (approximately two-thirds) and Ingham
County (approximately one-third). Although open to all county
residents, the_location was selected for its close proximity.
to the Mbdel Cities neighborhood, where residethe highest
concentrations of low income families for whom public assis-
tance is required in obtaining family planning counseling
and centraceptives. The center is currently assisting about
6,000 pe0ple.- An average of fifty people visit the center

daily.

33

unfortunately, the Lansing facility has many spatial
deficiencies which become apparent both by general
observation and by interviews with staff members.- Some of
these deficiencies are enumerated in the following
paragraphs.

The Receiving area's main deficiency is in its lack of
privacy for patients transacting what is their very personal
business. This area includes a desk for the "receiver"
who answers initial questions and instructs the patient on the
order of procedures which will be followed through the center..
The patient hands in a labelled urine Specimen which has to
have been brought in from home for a laboratory analysis.
The seating for waiting patients is near the desk and every-
thing transpiring at the desk can be heard by anyone else
in the room. The adjacent area where two receptionists
receive phone calls and make appointments is also open;
private conversations are impossible. Further depersona-
lization is fostered in that the height and weight measure-
ments are also conducted in this same receiving area.

The classroom is set up for educational purposes, but
the absence of a room for filling out the requisite forms
has made it necessary to use this room for the latter
purpose to the exclusion of the former. The classroom also
serves as a waiting room for laboratory test results and

the subsequent interview.

34

The laboratory facilities are limited to pregnancy
tests. Blood samples, and cultures, and urine for complete
urinalysis, must be sent to another laboratory fOr testing.
This restricts both the scope and efficiency of the center's
services.

There are two interview offices for three interviewers.
Since again, privacy must be maintained, the odd interviewer
must look about for some unused yet relatively private
space in which to talk to the patient.

The patient next goes to one of four examination rooms,
assuming one is open; if not, she waits in a waiting room.
Only one examination room has an adjacent bathroom, which all
patients must use prior to examination. More and better
located bathrooms would be helpful.

There is one office for the doctors and one office
for all the social workers. Here again is a problem of
lack of privacy during consultations.

The clinic coordinator has an office, but because of
the interviewers' and social workers' lack of space, the
office is frequently used by the latter as well as by the
public health nurse who has no other space to work out of
when she is at the facility. The administrator needs her
own office.

The preceding paragraphs reflect on the use of the
individual rooms. Generally those problems noted are due

directly to lack of funds for the space required, which is a

35

situation plaguing most such facilities and is beyond the

scope of this paper. But to the extent these problems.are
due to poor use of the existing space, identifying them is
a useful means of determining a more apprOpriate plan fOr

the Birth Control Center.

It appears that little or no attention has been paid
to the planning of traffic patterns;fiImost existing facili-
ties. The criteria for what function takes place where,
appears not to be in its relation to the other functions but
rather depends solely on what space is available. In the
Lansing facility, as no doubt in others, this criteria
for relating space to function leads to ineffiCiency and
confusion along with a proportionate loss of a desirable aura
of professionalism and patient confidence. Thus our first
step is to analyze the functions of the facility in relation
to each other. Flow Chart A, based on the Lansing Family
Planning Center illustrates a method for such an analysis.

Flow Chart B, entitled "Existing/Abortion Clinic,"
Figure IV, page 31, is structured in afashion similar to
Flow Chart A. Reading from left to right, each step in the
first term abortion procedure is chronologically l) identi-
fied; 2) described in detail, and 3) located spatially as
the process takes place in an existing facility.

Obtainingauxadequate model for Flow Chart B presented
some difficulties for the writer. After discussing Detroit

area abortion clinics with informed pe0ple and after visiting

36

two area clinics,38 it became depressingly evident that

not only was the typical Michigan abortion facility physically
inadequate--generally a sparingly remodelled older building--
but the abortion procedures employed were themselves generally
open to much criticism, ethical and medical, as has been
discussed.39

Organizationally, the procedures might charitably be
termed informal and often resulted in confusion of both
staff and patient.

The principal catagorized procedural functions—-
receiving, administration, consultation, examination, surgery,
and recovery--were mixed and matched in various combinations,
both procedurally and spatially, resulting in varying degrees
of inefficiency and confusion. The common structural and
procedural focus more often than not appeared to be expe-
diency, to the derogation of many other and no less important
considerations.

Therefore, a more adequate model to draw upon was sought

and found in WOmen's Services, a New York facility.40 In

 

38$ummit Medical Center, 1400 w. McNichols, Detroit,
Michigan, visited April 1974; Women's Health Service, 16001
Grand River Avenue, Detroit, Michigan, visited April, 1974.

39See "Abortions, Assembly Line Style--The Abortion
Trade," Delores Katz, Detroit Free Press, Sept. 10, 1974, p. 3—A.
p. 3-A.

40Women's Services, 424 East 62nd Street, New York,
New York, visited, July, 1973.

 

37

operation since l97l, it is still a model facility of its
kind. Prior to the legalization of abortion in Michigan
persuant to the 1973 Roe decision, and for a good time
thereafter, this facility was the principal destination for
referrals from the-Michigan Clergy for Problem Pregnancy
counseling, the major non-profit Michigan abortion referral
41
agency.

Located in midtown Manhattan, Women's Services occupies

 

the first floor of a building which was completely gutted
and remodelled. It accommodates between twenty and twenty-
five first trimester vacuum aspiration abortions per day, and -*
incorporates progressive counseling. The procedures and flow
patterns of this facility are described in Flow Chart B,

and can be summed up as follows.

A large foyer, apart from the lounge area, contains a
receptionist--or receiver--who checks in the patient and
gives her the requisite forms to be filled out. Appointments
have been made in advance and proof of pregnancy obtained
prior to that day. The patient proceeds to an adjacent,
modern, well-lit and comfortable lounge area. It is large
enough to accommodate all patients and a reasonable number
of accompanying friends and relatives, and is divided up
into intimate groupings which allow for a welcome degree of

privacy for filling out of forms and waiting. The patient is

 

41Interview (Ibid.), Administrator, Michigan Clergy
Counseling.

 

38

then called into a small examination room where a blood
sample is taken, blood pressure is measured, and a urine
specimen is taken. An adjoining bathroom is provided for

the latter function. Afterwords, the patient returns to‘

the lounge area until a counselor is available, who then
takes her into a small counseling room.with space enough

for a desk and chair and privacy. The patient is intere
viewed, her medical history and other forms are reviewed, and

she is counseled on the entire abortion procedure to follow.

“WW—'1 2 u '-

She is then led to a small patient-only lounge area while

1......—

awaiting the actual surgery. When called, she proceeds into
a pre-operation room where she changes into a hospital gown.
Clothes and personal effects are put into a plastic bag
which is taken by the attendant to the post-operation
recovery area. Valuables have been left behind or with
friends or relatives in the waiting room. An adjacent
lavatory is available for any last minute needs. Mean-
while the laboratory tests have been made, and they and the
patient's medical history are reviewed by the doctor.

Having previously been given a mild oral sedative, the
patient proceeds into the operating room where she is given
a local anesthetic and then undergoes the operation. After-p
wards the doctor prescribes apprOpriate antibotics and other
medication and instruction as required. The patient is then
taken into the recovery room. If she feels too weak to walk,

she is taken by wheelchair. Each of the recovery rooms has

39

five to six beds with a nurse stationed inside each at a
desk. After three hours, if there are no complications, the
patient dresses and goes into a counseling area where she is
given instructions, post-operative care, and a brief lecture
on contraception. The patient is then released by the nurse,
and she goes to the office where the bill is paid.

The WOmen's Services facility is well designed, and
the spaces fit the function well by almost any criteria.
The one possible criticism of the facility stems not from
its design, but rather from the limited purposes for the
design. It was set up to serve transient patients, many if
not most from out of state, as opposedtx>serving a particular
community. The whole procedure is one day, and the
operating rooms are underutilized because the doctors are
unable to commence operating until after the paperwork and

42 Furthermore,

test results of the first patient are ready.
the one-shot surgical procedure, though well handled, cannot
adequately address the broader aspects of the patient's
problems. This requires family planning counseling on a
continuous basis.

Having thus charted out existing procedures for the two

separate facilities, as well as pointing out their respective

 

42Since the author's visit to New York in July, 1973,
the New York City Health Code has been amended to require
an interval of not less than two days between initial
examination and the termination of pregnancy.

mam xhfifl
L
c
I

....g-

 

40

deficiencies, there remained only to adopt these procedures
to the Birth Control Clinic, which combines both of the

functions.

Procedural Flow Chart

The existing procedures for family planning assistance
and for abortion as illustrated by Flow Charts A and B are
overlapping in many respects, including much of the same
administration, paperwork, explanations, and laboratory
tests, and the birth control counseling and education itself.
The proposed Birth Control Clinic, by advantageously combining
the two functions in one facility, eliminates much duplication.
in furtherance of a common goal: efficient, comprehensive,
and personal birth control services.

Flow Chart C, Figure V on page 41, shdws in graphic
form.how the two existing facility types could be combined
into one facility. The proposed Birth Control Clinic
procedures are charted room by room. The patient flow is
divided into family planning and those elements common to the
abortion procedure, and the surgical and recovery elements
of the abortion procedure which are organizationally, medi-
cally, and ethically better accommodated apart from and on a
day subsequent to the examination and the other procedural
elements. The two day abortion procedure allows for better
scheduling and utilization of the abortion facilities; it

provides time for all recommended tests to be completed and

41

FIGURE V, FLOW CHART C

THE BIRTH CONTROL CLINIC

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

’_' 1
Family Planning & . —_~———-————~—— I Examination Room Social Worker's office
. _____ s Laborator ’ '-——"— ————
1 Day One Abortion IntLerew Room i Classroom | y
I
ROOM Receiving Area EXIT
I f i C’—
, - Pre—O ratio Room .
——~——Day TWO Abortion pe n } Operation Room i Recovery Area
Patient signs in, Patients are inter- All patients are Aituggtiinfiiine spe— Nurse goes over med. Patients receiving
receives case no. Viewed as to given brief lecture cimen (bathroom history of patient public asSistance
and all necessary reason for visit; and presentation adjacent if neces— and prepares record are required to ‘
forms; . on birth control sary) for complete for doctor; report;
- - SerVices and proce— in general and. urinalaysis & preg. Doctor performs- Social worker coun—
Patient fills out dures are explained; contraception in test -general physical sels and advises
baSIC information— ' ' particular; written —have b100d sample examination on ancillary pro—
al forms and medi- FinanCial arrangements information/pamph- taken (tests made _ a sm ar blems of at' t
cal history; and are discussed; lets available; will depend on -ge§viceexamination- p ien .
_ Ad . . t t' f Pati t whether abortion '
Waits as necessary minis ra ive orms en 5 use as atient) ,
I reviewed & filed. lounge between —geasure height & Dogggiogii:igfbes as
procedures. weight '
PROCEDURE —measure b100d pres. Nurse refers to soc.
wkr. or outside
__~____________~___ , _ . . , agency as required
k . Patient is pOSitioned Patient rests in
BlOOd pressure ta en, on the table and bed for minimum
. . . prepared by nurse; of 3 hrs. of
Oral seditive given; observation by
. . Doctor administers nurse;
Patient disrobes & local anesthetic;
dons gown; goes to After 30 min. light
lavatory as neces— Doctor performs snack offered
sary; abortion by vacuum (forestalls nausea);
. d . _ asperation.
Counseling an in Additional counseling
structions by nurse on contraception as

as reqUired. needed.

 

 

 

 

 

 

 

 

 

     

42

properly analyzed prior to the Operation, it allows the
impulsive patient additional time to recondider, and creates
an ambience more in keeping with our stated community service
~~vice "abortion mill"--goals. Beneath and connected to each
specified room is an itemized’and self-explanatory list of
the procedures taking place therein. The following para-
graphs outline the Birth Control Clinic procedures from.the
point of view of a typical patient. L

When a patient comes to the Birth Control Clinic for
contraceptive or other family planning services apart from
pregnancy termination, she will enter the receiving area,
sign in, receive the appropriate forms, and then fill out
the forms. The receiving area includes an adjoining waiting
area. The patient is then taken by her interviewer into an
interviewing room where she will be advised of the services
available, sign her medical releaseif required, and arrange
for payment of services, e.g., medicaid. Any questions or
problems of a general nature she may have at that point can
be resolved. She then proceeds to a classroom where general
birth control instruction will be given. The classroom can
also serve as a patients' lounge for waiting as necessary.
The patient then proceeds to the laboratory where she is
given the necessary tests. Next, a nurse interviews the
patient and takes a complete medical history, and afterwards
accompanies the patient to the examination room. She then

is given an interval pelvic examination and has a pap smear

43

taken by the doctor. The physician will then issue appro-
priate perscriptions. If the patient is in need of social
service assistance, as determined at her initial interview,
she will be referred to a social worker. If no referral
subsequent to examination is required, or if so, after
completing that conference, the patient may proceed to the
exit and have her prescription filled and pay her fee at
the reception desk.

When a patient comes to the Birth Control Clinic for
an abortion, the procedure will be, of course, more complex.
The procedure will be divided into two days; the Day One
procedures will generally be the same as those for non—abor-
tion patients, with the actual operation on Day Two.

Day One: Patient arrives at the receiving area and
follows the procedures as outlined for non-abortion patients.
Although the procedures are essentially the same for all
patients on the initial visit, abortion patients will fill
out additional medical forms and undergo additional labora-
tory tests including a white blood cell count, hemoglobin,
hematocrit, pregnancy determination, complete urinalysis,
blood typing, antibody titer, and cross match rhogham when
necessary. Also recommended are tests for rubella, gonorrhea,

and sickle cell (for blacks).43

 

43MDPH Guidelines, pp. 23-24, and 28. Title 111,
New York City Health Code, Section 42.31 (d).

 

44

Day Two: The patient checks in with the receptionist,
and follows the second day schedule as described in Flow
Chart Three; it is limited to the actual abortion procedure

and recovery.

Capacity
After having charted out the Birth Control Clinic

procedures and the several spaces in Which they take place,

it is necessary to make an analysis of its prOposed capacity,
i.e., to determine the size and number of such spaces. To
this point, the only definite figure established is the number
of abortions to be performed each dayé-fifteen. Although
another point of reference, such as total physician time
available or the budget might serve as well, the capacity,
based on the number of abortions per day, will be our starting
point. The entire Day Two procedure for abortions (see Flow 5
Chart C, Figure V, page 41) should take approximately

four hours and ten minutes. The preoperation procedure
wherein the patient receives an oral Sedative (usually
valium), disrobes, goes to the lavatory, and has her blood
pressure taken, requires thirty minutes, which is also about
the same amount of time required for the sedative to take
effect. The same preoperative space will serve fdr two

or three patients at a time, which will allow for some

mutually beneficial discussion and support.

 

45

The total time required for the procedures in the
Operating room is approximately twenty minutes. First a
nurse will position, prepare, and drape the patient, then a
local anesthetic, generally a paracervical block, is
administered by the doctor. Within a minute, the patient is
sufficiently anesthesized. It takes another minute or so.
for the cervix to be dilated and the suction currettee to
be inserted. Three to five minutes of suction is normally
required for evaction. A sharp surette is often carefully
used after the suction to insure abortion iscomplete. The
aborted tissue is removed to laboratory for pathological
examination, and the patient's vital signs are checked
before she is taken to the recovery room. The doctor
prescribes the necessary antibiotics and other medications.

Although most patients are without pain and might
safely leave shortly after the Operation, the standard
medical and legal requirement is that she be closely Observed
for a minimum of three hours before she is released.44
Patients are encouraged to have light snacks, which helps
to forestall fainting, nausea, headaches, as well as being
necessary nourishment for patients kept for over three hours
of observation. Clothes are withheld to discourage

patients from leaving prior to their dismissal.

 

44MDPH Guidelines, p. 34; New York City Health Code,
Section 42.33 (f).

 

46

Thus adding thirty minutes preoperation, twenty minutes
operation, and three hours recovery, we get three hours and
fifty minutes. To this is added twenty minutes slack time
for scheduling difficulties and movement between spaces, for
a total of four hours and ten minutes. 'Assuming the clinic
is open approximately eight hours a day, with one hour off
for lunch, the maximum daily patient capacity will be eight
per Operating room per day as illustrated by the Operating
Room Scheduling chart, Figure VI, page 47.

The Operating room is the one space in which only one
patient at a time can be accommodated during the abortion t“
procedure and therefore, is easiest to quantify: for fifteen
abortions per day, we will need at least two operating rooms
with a capacity of eight abortions per day each.45

The preoperation room will be provided for all Day Two
abortion patients. By referring to its function as stated
(see Figure V, page 41), it can be seen that the maximum of
two or three patients at that stage of the abortion procedure
could easily and conveniently be accommodated in one Space.

Recovery rooms are quantified not only by reference to

the three hours requirement, but also by other existing legal

 

45The complication rate for first trimester abortions
under appropriate clinical conditions has been found in one
survey to be 11.7 per 1,000 abortions, or about one percent,
and each complication is estimated to require an additional
amount of time equal to the abortion itself;"An Operational
and Planning Staffing Model for First and Second Trimester
Abortion Servicesfl'Mark D. Mandel, M.P.A. American Journal
of Public Health, V01. 64, NO. 8, Auguest, I573, p. 760.

47

FIGURE VI. OPERATING ROOM SCHEDULING CHART
Time

10 ll 12 1 2 f 3

l l

|

r

snuariea
\D

...;

 

 

 

 

 

 

— 1 — — —

 

 

 

— _ — ‘

 

 

— — ‘ —

 

 

 

 

 

 

Pre-Operation--30 min.

%%%Z% Operation--20 min.

Recovery--3 hrs.

M
K:

Slack Time

48

standards. The MDPH guidelines provide that the maximum
number of bed patients per room should be four.‘ Thus allowing
for some time Overlap, there should be bed space for each
of the sixteen patients, which requires a total of four
recovery rooms.

Determining the number of spaces for the Family Planning
and Day One abortion procedures is more difficult than for
the Day Two abortion procedures. These procedures are much
more flexible and thus less predictable and are not

ammenable to precise documentation. Each patient will have

 

her own set Of circumstances and needs. However, some he,
statistical information is available regarding staffing
requirements, and hence spacial requirements, for facilities
having a service mix similar to the Birth Control Clinic.
The following procedural time requirements for each abortion
patient have been calculated based upon a 1973 New York City
Hospital Study.46

Reception, interview, and
financial investigation 75 minutes

Medical History 25 minutes

Review Of Medical History and
Physical examination 25~minutes

Social Service (seventy-five
percent Of all patients re-
quested abortions and sixty-
five percent of those were
referred to social service) 70 minutes

 

46Ibid., pp. 756, 759.

49

Assuming a similar patient population as with the New
York survey, a lS-abortion-per-day clinic will require for
the abortion patients alone, even given the staggered
scheduling indicated in Figure VI, page 47, a minimum of
three interviewing spaces, three social service spaces, two
spaces for the taking of medical histories, and two examining
rooms, plus the requisite laboratory facilities. The New F”“
York City Hospital Study found that seventy-five percent of
all their patients requested abortions, even though a full

range of family planning, counseling, and perscription was

 

available. Assuming a similar ratio for our facility, we

need a minimum total of four interviewing rooms plus two
similarly structured medical history rooms, two examining
rooms, and four social service spaces. In addition class-
rooms, Offering flexibility for educational and waiting spaces,
are provided to allow further adaptability of the clinic

to a family planning program, can realistically only be
determined once the patient population needs and demands
become established.

To this point, we have discussed capacity principally
from the perspective of the patient. Of course, the staff's
needs must also be considered. The New York Study was done
in order to establish the staff requirements for such a
facility. The study was based on statistics cOmpiled over
22 month period from fourteen New York City general care

hospitals Offering abortion and related care services and

50

accounting for 13.3% of all of New York's abortions. The
study converted these statistics into a staffing model which
indicated the number of full time personnel required for the
Operation of a facility offering first trimester abortions
and ancillary family planning services. By liberally inter—
polating the results Of that study into our hypothetical
facility, we can establish, in approximate figures, our
personnel requirements. Categorized by function, they are

as follows:

Administration
Administrator 1
Clerical (including Interviewers) 11

Medical Screening

Physicians 1
Professional Nurses (R.N.s) 2
Licensed Practical Nurse (L.P.N.) 1
Family Planning Counselors 2
Social WOrkers 4
Procedure (Day Two abortion)
Physicians 2
R.N.s 2
L.P.N.s 2
Ward Coverage (Recovery)
R.N. l
L.PON. 1
Laboratory Technicians 4
Housekeeping and Maintenance 2

TOTAL V 36

51

This staffing model cannot, of course, be rigidly
interpreted since its application would depend on many
variables not ascertained or ascertainable in our hypothetical,
including: the general physical condition and the education
of the patient pOpulation, their needs for social service
assistance, the availability of part-time or non-shift
employees, and the mix of task assumption by employees,

e.g., the amount Of clerical functions performed by nurses

or the amount of family planning counseling done by clerical
interviewers, which is a difficult thing to measure in
existing facilities much less hypothetical ones. Nonethe-
less, the model gives a reasonable basis for gauging the
number of personnel required to staff the Birth Control
Clinic and thereby is a means for determining the number

and size Of the remaining spaces in the facility, particu-
larly the staff lounge and the administrative area.

To this point in the project we have discussed the
functions of the facility, the procedural flow of the

functions, and the capacity or size Of the facility.

V

RESULTS--THE FLOOR PLAN

The floor plan is the culmination Of the interior
designer's initial research efforts, which should include
investigation Of the primary design ingredients of function,
movement and capacity.

Figure VII, page 53, is the floor plan for the Birth
Control Clinic. The most notable feature is the separation
of the abortion Day One and family planning services from
abortion Day Two. This spatial arrangement is not only to
provide a better flow pattern, but is also designed for
traffic control and sanitation purposes.

The reader may wish to refer again to Figure V, page
41, the Birth Control Clinic Flow Chart, regarding the
precise procedures taking place in each space and the
relation of each space to the others functionally.

The flow path for each of the two functions are
represented on the floor plan by arrows, broken arrows for
abortion Day Two and solid arrows for abortion Day One
and family planning. Thus, in the latter instance the
patient proceeds from the receiving area to an interview
room to a classroom to the laboratory to a nurse's Office

to the examining room and, as necessary to a social worker's

52

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FIGURE VII. FLOOR PLAN FOR THE BIRTH CONTROL CLINIC I:2:35'1:"gwgssis'ance’ Abortion Dav o...
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54

Office and back to the receiving area. In the former
instance, the patient proceeds from the receiving area to
the pre-Operation room to the Operating room to the recovery
area and then back to the receiving area.

Other spaces appear in the floor plan that are not
represented in Flow Chart C, they being ancillary, albeit
essential, to the primary functions. Administrative spaces
are located in the center of the facility, close to the
reception counter and the interviewing-counselling area.
Also close by are the doctors' offices and the employees'
lounge. Adjoining the two Operating rooms are a scrub room
and a work area. Also provided are a supply and storage
room, and abundant lavatories.

The following is a brief room by room description
of the floor plan.

The receptionist's counter is situated by both doors
and is therefore convenient and in a position to monitor
traffic. The counter is located somewhat apart from the
waiting area to allow for privacy.

The waiting area has a seating arrangement broken
up into several groupings which fosters an ambience of
privacy and comfort. Each grouping has end tables con-
veniently placed within and near it. A space is provided
for vending machines and tables and chairs; lavatories are
located off this part of the waiting area. The size of the

waiting area should be sufficient to accommodate not only

55

the patients, but also a reasonable number of friends and
relatives of the patients.

Upon being paged, the patient will enter the hallway
off the waiting area, turn left and then immediately right,
accompanied by her interviewer, and proceed up the center
passageway, and then depending on the purpose of her visit,
will either turn left to the pre-Operation room or turn right
into the interview area. The hallways are all six feet
wide (except for one emergency exit) to provide sufficient
room for the traffic and for the carts, wheelchairs and the
occasional stretcher. We will first follow the flow path
of the abortion Day One-family planning patient.

The four interview rooms are small and sparsely
furnished with a desk and two chairs, one for the interviewer
and one for the patient. The interview rooms and the ad-
jacent nurses"and family planning counselors' rooms are
comprised of movable partitions, which are sufficient
to provide the required aura of privacy but which also allow
for maximum flexibility in utilizing the entire space.

The classrooms are designed to be flexible from the
beginning. They can be used for educational activities such
as lectures, discussion groups and movies, for a waiting
area for patients, and for other activities as required.
Both are furnished with large tables, chairs and cabinets.
The family planning counselors have separate offices

adjacent to the interviewing rooms.

 

_ ' m.
'I
D"
o

56

Immediately to the left of the classrooms are the
doctors' Offices. These utilize partitions and provide
an area for the physicians to complete paperwork and keep
personal records. These spaces are located between the
principal work areas of the physicians.

Adjacent to the classrooms is the laboratory.» It is
sufficiently large to provide working space for the four
technicians and for the patient or two with whom they may
be working. In addition, the laboratOry has space to store
all the Clinic's drugs and medicines, including refrigerated
medicines and plasma, and for a variety of medical equip-
ment. Such equipment would include a centrifuge, a micro-
scOpe or two with space for slides and petri dish cultures,
and an autoclave for the sterilization of instruments.

A lavatory is conveniently situated for patients to secure
urine specimens.

From the laboratory the patient would if necessary
return to a classroom until called by a nurse, who would
then take the patient into a nurses' office, make a
thorough investigation of the patient's medical history,
and then accompany the patient across the hall to an
examination room.

The examination rooms are large enough to allow ample
working room for the doctor and his assisting nurse. The
space is furnished with a gynecological examination table,

a stool, a chair and a cabinet for medicines and instruments.

57

Along one wall is a work counter with storage cabinets below
and a sink (pedal operated) at one end.

Across the hall from Umzreception area and sharing a
common wall with the interview rooms and nurses' offices
are the social workers' offices. Unlike the former, the
social workers' spaces have fixed walls and are securable
due to the fact the social workers would be keeping some of
their records in their Offices. Otherwise, these spaces
are identical to the cubicles above.

After leaving the social worker, or the examination
room, as apprOpriate, the patient would then exit by the
reception counter where she could pick up her prescription
if any and pay her bill.

Proceeding up the central hallway again, we first
come to the administrative offices on the left. Five desks
with ample typing and work space are provided for the
clerical staff. A separate Office is provided for the
administrator.

Continuing back up the central hallway and turning
left (through swinging doors) we come to the pre-Operation
room. The pre-op area contains a lavatory and a dressing
room, and is furnished with several comfortable chairs and
end tables.

The operating rooms are each furnished with an

operating table, a stool and a cabinet. Additional space

58

is provided for the vacuum aspirator and for emergency
equipment such as oxygen tanks.

Between the two operating rooms are two smaller spaces.
The scrub room provides space for the physicians to don their
gowns and wash up prior to and after each Operation. Behind
the scrub room is a small work area for the temporary storage
of supplies and used instruments and tissue to be taken
to the Laboratory for examination. Soiled drape cloths
and disposable paper products would be put into covered
receptacles which would be emptied frequently and taken
to the maintenance-utility room.and the outside dumper,
respectively.

The maintenance and utility room is an area for the
storage of brooms, mOps and other items required to maintain
the prOper sanitary conditions of the clinic. It also
provides space for the temporary storage of soiled linen
and if necessary non-organic disposables to be disposed.

The supply room is a space for the storage of clean
paper products and linen, administrative supplies, and any
other items of a non-medicinal nature for which such storage
may be required. The supply room is conveniently located
by a door where supplies can be delivered. 4

The exit at this end of the facility is also conve-
nient to the Operation and recovery rooms so that in the

event a patient has complications of a serious nature she can

 

59

be easily taken out of the clinic and transported to a full
service in-patient hospital.

The recovery area is composed of four recovery rooms
centered around a nurses' station and food preparation space.
The nurses' station is located so as to allow easy access
to the patients' recovery rooms; it has a work counter for
the completion of the necessary charts and records and has
space for a sink and refrigerator. The food area might
also have a refrigerator and sink along with a stove or
hot plate and a microwave oven. Each Of the recovery rooms
has four standard hospital beds, two cabinets, and one chair,
and is provided with its own lavatory with shower.

The staff lounge contains a kitchen area with refri-
gerator and stove, and ample counter space for food prepa-
ration and the inevitable coffee bar. Although furnishings
would be a matter of some flexibility, two tables with four
chairseach and a large sofa. should be sufficient for the
staff's breaks and lunch requirements. Lavatories are
provided for the staff.

The patient would proceed, after being released from
the recovery area, to the reception desk where she would

pay her bill prior to departing.

VI

CONCLUSION

In conclusion, this project has attempted to demonstrate
an approach to the design of a particular facility, The Birth
Control Clinic. The goal of the design approach was the
formulation of a floor plan. Certain assumptions were re- .
quired to narrow the hypothetical facility to workable
dimensions, however research and planning are the essential
ingredients of not only this but all floor plans.

The floor plan, although the beginning of any given
construction project,is or should be the end result of
considerable effort on the part of the interior designer.

The steps involved in formulating the floor plan for this
facility, and suggested for the formulation of any floor
plan, include: obtaining an understanding of the nature

of the activities to be accommodated by the proposed facili-
ty; constructing flow charts which spatially segmentize

the procedural elements of those activities; adapting those
flow charts to the particular needs Of your project; and

establishing the capacity of the facility.

60

61

Following this design approach, especially when dealing
with a highly specialized facility, should result in a
floor plan that prOperly apportions and relates interior

spaces to meet the actual needs Of the client.

BIBLIOGRAPHY

"Abortion Trade, The." Detroit Free Press. February 4, 1975,
p. l-C.’

Bates, Jerome E. Criminal Abortion, A Study in Medical
Sociolo . Springfield, Illinois: Charles C. Thomas,
PEBlisher. 1964.

Corsa, Leslie, Jr. "Abortion, Yesterday, TOday, and
Tomorrow." The Case for Legalized Abortion Now.
Berkley, California: Diablo Press. 1975}

Harden, Anthony. Legal Abortion: L293 English Egperience.
Elmsford, New York: Pergamon Press Inc. 1 71.

Hardin, Garrett.r "Abortion and Human Dignity." The
Case for Legalized Abortion Now. Berkley, California:
Diablo Press, 1970.

Health, Education, and Welfare, Department of. Family
Planning. U.S. Government Printing Office, washington
D.C., n.d.

"HEW." Detroit Free Press. December 9, 1974, p. 2-B.

 

Katz, Delores. "Abortions, Assembly Line Style-~The
Abortion Trade." Detroit Free Press. September 10,
1974' p. 3-Ao

Kendall, Katherine A. Populgtion Dynamics and Family Plannigg.
New York: Council on Social Work EducatiOh. 1970.

Kereny, Thomas D., M.D. "Outpatient Intra-amniotic Injection
of Hypertonic Saline." Legal Abortions in New York
State: Medical, Leggl, Nursing, and Social Aspects.
New York: Harper & Row, MedicaIODepartment. 1971.

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