Amie Shao: Designing Birth Spaces That Change Outcomes

What if maternal health outcomes are shaped by design decisions? In this episode of Play with Matches, Amie Shao, Principal and Senior Director at Model of Architecture Serving Society (MASS), explores how architecture and the built environment influence maternal care, health equity, and patient outcomes. Through projects spanning Malawi to Boston, she explains why birth spaces impact trust, dignity, and whether families seek care at all.

This conversation reframes healthcare design in the AEC industry as a critical factor in access, outcomes, and equity.

Model of Architecture Serving Society (MASS) | Show Transcript

Think you’d make a great guest on Play with Matches? We’d love to hear from you. 

UpSpring is a strategic PR, marketing, and growth partner for firms and product companies shaping the built environment. For more than 17 years, the agency has helped architecture, design, development, and building product brands turn expertise into market authority.

Learn more about UpSpring: Website | LinkedIn | Instagram

Transcript

SPEAKER_00 0:00

What if some of the most consequential design decisions in architecture have nothing to do with aesthetics? They happen in the spaces where life begins. Every year, millions of families experience birth in environments built to deliver clinical care, but rarely designed with emotional, cultural, and human realities of birth in mind. And emerging research is revealing something the design community can no longer ignore. The built environment does more than support medicine. It quietly influences whether people feel welcome, whether they remain connected to care, and whether health systems deliver on the outcomes they promise. This is the story of an architectural practice that treats design not as a luxury, but as essential infrastructure. A model that challenges the traditional business of architecture by asking a different question. Where can design have the greatest impact? Welcome to Play with Matches, the podcast igniting bold ideas and redefining what's possible in architecture and design. I'm your host, Tiffany Rampey, CEO of Upspring, a strategic PR and marketing partner to brands a built environment. In each episode of Interview the Distributors are contained at the intersection of creativity and business. Today, we're joined by Amy Shell, principal at Mass Design Group and leader of their maternal and newborn health design lab. Her work spans projects from Malawi to Boston and explores how the environment surrounding childbirth can shape health outcomes, restore dignity, and challenge the design industry to rethink architecture's role in public health. Let's start at the moment that changed how Amy understood the power of architecture.

SPEAKER_01 1:44

One of my first projects with Mass was a tuberculosis hospital in Haiti. And that really changed how I understood the role of architecture. I saw how space could directly cause harm, how poor layouts and poor ventilation could contribute to drug-resistant infections for both the patients and the staff. But I also saw how buildings would heal. In the hospital that we designed, we focused on light and air and dignity, creating courtyards, creating shaded outdoor spaces and places where patients could safely gather. Our primary goal, of course, was infection control, but the drugs used to treat multidrug resistant TB can have really severe mental health side effects, including deep depression. And I remember that staff later told us that suicide attempts stopped after the new hospital opened and that they directly attributed some of those changes to the environment. And that was a real turning point for me. It really made clear that architecture isn't neutral. Living in places like Haiti, Rwanda, and Liberia did expose me to realities that reshaped how I think about power and access and design and who systems are built for. And along the way, I was fortunate to work at a lot of scales from national infrastructure policy and design standards with government partners to hands-on work with artisans on interiors and project design. Over time, those experiences began to converge around birth because birth sits at this intersection of health and gender and equity and systems failure in a really visible way. And when those systems fail, women and newborns are often the first to suffer. There was also this moment when my personal and professional worlds collided. I'd spent the first decade of my career working in healthcare, but when I was pregnant with twins, I developed a complication and I ended up being hospitalized at seven months. My babies were born prematurely, and we spent the next month in the NICU. And I really vividly remember that my first experience of motherhood wasn't holding my babies in my arms as I'd imagined. It was reaching through the holes of a plastic incubator to try and touch their chests and under the blue glow of this phototherapy machine. And my husband and I would search for chairs to pull close so we could sit with them for a few hours because we knew that holding babies skin to skin improves outcomes. But I remember looking around the room and noticing that a lot of the other babies lay alone. Their parents lived too far away, and the space just wasn't designed to welcome families beyond short visits. And after weeks of that routine, I realized that as grateful as we were for access to some of the best care of the world in Boston, the space itself was telling a different story. It was engineered to save lives. It was engineered to be a workspace, but it wasn't necessarily designed to honor life. Then years later in Malawi, I was assessing a health facility when I heard this sobbing and I watched a mother collapse to the floor. And her baby had just died from the same condition that mine had survived. And the hospital didn't have the equipment to treat this really preventable death. And the reason they didn't have that equipment was because they didn't have a designated space or the right space for newborn care. And unlike me, she didn't get to bring her baby home. In the US, nine out of ten premature babies survive. And in many other parts of the world, like Africa, that number was flipped. And that contrast made it really impossible for me to not focus my work on maternal newborn health.

SPEAKER_00 5:33

Moments like that make it impossible to treat design as a neutral backdrop to care. They force a harder question. If the environment shapes whether people seek care, trust it, or survive it, why isn't space treated as an essential infrastructure? That question started to shape the work that came next.

SPEAKER_01 5:53

During the pandemic, we began working with the Gates Foundation and the Institute for Healthcare Improvement on a human-centered design toolkit for respectful maternal newborn care in low and middle-income countries. And one of the first places we worked was Ethiopia, where there's a really strong push to increase facility-based birth. And as part of that work, we spent a lot of time doing deep engagement and listening to mothers and family members and healthcare providers. And I remember in this one facility being shocked to learn that because they had no running water, women were expected to clean up their blood after birth using their own clothing. And not only was that just shocking and terrible from an infection control standpoint, but even more than that, it just felt like a really fundamental breach of human dignity. And it raised a really obvious question of if you're trying to increase facility-based births, why would anyone choose to give birth in a place like that? And at the same time, we learned other important things there. Things like privacy and space for family and a sense of belonging weren't things that necessarily came across as innovations, but they can make a huge difference between trauma and trust. And things like culture is an incredible driver. For example, in Ethiopia, families told us that having space for traditional coffee ceremonies mattered even more than access to emergency transport as an indicator of whether people would go to facilities for care. So we began integrating coffee ceremonies into maternity facilities to encourage families to come and to stay during that critical postpartum period. And I think it's worth calling out that this isn't just an issue abroad. In the US, for example, we also see people avoiding hospitals because birth spaces feel cold or rushed or unsafe, especially for black and indigenous families. And that contradiction is a global one that we need to address. We know how to save lives, but we don't always design places or spaces that honor them. And that realization made it really clear to me that safe and dignified birth spaces are not a luxury. In places like the US, the vast majority of birthing people give birth in hospitals, which are really meant to be like high acuity care spaces. But birth doesn't always require a medical intervention. I think around maybe 15% of births do need one, but 85% of them don't. And so there's this mismatch where you have people going to a really intensive care environment for something that could be treated as a kind of natural human process. In places like Ethiopia, I would say that relationship is flipped. When you have too many people delivering at home that don't necessarily have the endenatal care to get screened when there are complications or higher risk, or they live too far away from health facilities to get there safely in time, that's when you see a lot of preventable deaths and bad outcomes happening because people don't get the professional care they need.

SPEAKER_00 9:07

Seeing those patterns play out makes it clear that improving one project at a time won't solve the problem. The deeper challenge is creating a way of practicing architecture that allows design to reach the places where it can change outcomes the most.

SPEAKER_01 9:48

Structuring mass as a nonprofit allows us to start with a different question. How can design have the greatest impact rather than what fits within a traditional fee or a timeline? And that shift lets us invest in research and relationships and long-term outcomes, not just deliverables. So we can work in some places where the need is high and resources limited, and we can take risks on ideas that wouldn't make sense in a typical model. Because we operate through a hybrid approach, we're able to do great design work for aligned partners, but we can also invest philanthropic dollars into areas that are chronically underfunded. And our design labs grew out of that. Each lab tries to take insights from individual projects and transform those into kind of broader movements for change, addressing systemic challenges that shape community well-being beyond individual buildings. And at its core, that nonprofit model lets us stay focused on impact so that we can try to use design as a tool to improve lives. Recognizing that the built environment is a powerful lever across these domains.

SPEAKER_00 11:07

That philosophy doesn't live on paper. It shows up in mass groups projects themselves. Some of the clearest lessons came from the work in Malawi, where the question wasn't just how to expand access to care, but how to create a place where mothers would actually want to come and stay.

SPEAKER_01 11:25

So Mraternity Waiting Village is a place where pregnant women, especially those who are higher risk, can stay in the final weeks of their pregnancy really close to skilled care, so they don't have to travel long distances while on labor. And in a country like Malawi, where geography and transportation can make access to health facilities incredibly different, that proximity can be life-saving. Back in 2010, Malawi had one of the highest maternal mortality rates in the world. And so in response, the government launched this effort to build maternity waiting homes nationwide. And we were invited to help design one of those homes near a hospital in Kasungu. But after visiting some of the kind of existing standard maternity waiting home facilities, we really quickly realized that the challenge wasn't just access, it was also experience. And some of those existing facilities were dark, crowded, hot dormitories with really poor sanitation and no space for the family members or companions that these mothers were showing up with. So the question shifted to not just how we can get women closer to care, but how we can create a place where mothers actually want to come and to stay. So if this is meant to be a place for waiting, how do you turn waiting into something that isn't a waste, but something that is empowering and productive? And if it's meant to function as a home, what does that mean? How do you actually make it feel like one? So rather than continue with a single dorm-style building, we designed smaller residential groupings clustered around courtyards, really inspired by the way that villages Malawi are traditionally organized. So we had spaces for companions, for cooking, for gathering, for education. And it was really important that those weren't extras. They were essential to whether women could feel safe and respected and willing to remain there. And after it opened, it became clear that women's experiences were really fundamentally different. And that is when we understood the design wasn't just about improving comfort, but also influencing trust. So we called ours a maternity waiting village because we tried to expand the design to really consider deeply what home actually means. But the concept of a maternity waiting home isn't just relevant in places like Malawi or Africa. They are already in other, many other continents. And we see many of the same challenges in real parts of the US, especially for native and indigenous communities where hospitals have closed and there are long distances to care and access to culturally respectable birth spaces are limited. So the idea of maternity waiting, meaning creating places that support families before birth, not just when they have a medical emergency, but in an attempt to prevent one from happening, has real potential in many of these contexts too. But it's not exactly about copying a model from one place to another, but more about kind of the same thread or the same principles, which are proximity to care and dignity and cultural grounding and space for family and community.

SPEAKER_00 14:46

But stories like that raise an important question. If design can reshape how care is experienced, can it also be measured?

SPEAKER_01 14:55

Evidence is really important. It was key for us to conduct really robust academic post-occupancy research because we needed to demonstrate to ourselves and the funders whether there was evidence about design actually making a difference. So working with partners at UNC Malawi and the Academy of Architecture for Health, we did a peer-reviewed study to compare our improved maternity-weighting village design to the standard government prototype. We surveyed 600 women about privacy and sanitation, safety, comfort. And I remember being really struck by the results that the new improved design scored much higher across nearly every category from toilets and showers, companion spaces, sleeping areas, safety and overall comfort. But perhaps the most important thing was why those things mattered. Satisfaction wasn't higher because there was a change in the actual medicine. It was higher because the space expanded what care could be in. When women feel safe and respected and supported, they're more likely to seek care and stay connected to the health system and stay there until they're ready for birth. So that's why measuring dignity and satisfaction is really important. If a space is technically capable of saving lives, but women don't go and they don't stay, then it's not succeeding. So experience isn't a kind of soft or nice-to-have metric. It's really foundational to access and impact. And then on a personal note, I remember actually trying to wrap up that research and evaluation work while I was in the hospital during my own pregnancy, trying to get that work done before I went on maternity leave. And I remember sitting in my hospital bed looking at photos of the women gathered in those courtyards in Malawi, cooking and singing and preparing for motherhood together, and feeling this really a strange mix of gratitude for the amazing care that I had in the hospital I was sitting in Boston, but also longing for what they had. And I had access to incredible world-class care, but I was also alone.

SPEAKER_00 17:12

Results like these make it difficult to treat design as a secondary factor in care. The real question becomes: how lessons from a single project begin shaping the systems that determine what gets built.

SPEAKER_01 17:24

Projects like the Maternity Waiting Village were really formative because we could see the impact. Women arriving, coming more, staying longer, feeling safer. But over time we realized as we kept on doing other projects and other places, that we were applying similar lessons again and again to different projects, to different contexts and countries. And we realized that we needed to expand our thinking from individual partners and projects to systems. So we started asking how these insights can travel, how can we reach governments and funders and health system leaders who are in the end the people who are shaping what gets built? So the Institute for Healthcare Improvement, IHI, actually approached us to partner on delivering more. This is implementing partner that works across a lot of different geographies. And they were investing in staffing and equipment and care practices and many low resource settings, but they kept running into the same barrier, which was space. The facilities were often working against these attempts to improve quality of care rather than supporting it. And all too often those spaces were designed without engaging the clinicians or the people that they're meant to serve. So Delivery More grew out of that gap. It's a human-centered design toolkit that provides a clear process and roadmap and planning tools, as well as based design principles that try to translate evidence-based maternal and newborn care models into environments that support how care should happen. So just to give you a couple examples, one of the things that a lot of governments and funders are trying to do is called zero separation mother-baby care, keeping mothers and babies together in the NICU rather than separate. There's all of this evidence that shows how that leads to better outcomes, faster discharge. There are other models like group antenatal care. And that is often not only more efficient from a clinical perspective, but allows mothers to hear advice from more experienced mothers that funders and governments don't always have a clear visual or space guideline for how to create the space to support those models. So that's what we've been trying to do. And before delivery more space was largely an afterthought in maternal health because clinical guidelines rarely dig deeply into whether the physical environment can make quality care possible. But delivery more was about making the case for space and giving health systems a way to act on it and to demand greater rigor and specificity around how those spaces need to support high quality of care, what the practices should be that are emerging and proven, and also how to align it with the contextual and specific needs of people and places. So we've applied it in places like Ethiopia and Bangladesh and Kenya. And now we're focused on a second phase of global dissemination, working with funders and ministries of health to try and shine a light on infrastructure as a core determinant of maternal and newborn health outcomes. And ultimately that shift has been from proving that design matters to building the conditions for it to be possible to scale and matter at scale.

SPEAKER_00 20:53

Thinking about maternal health at a systems level inevitably brings the conversation home. Because inequities in care and the role spaces play in them don't stop at national borders.

SPEAKER_01 21:05

The Neighborhood Brist Center in Roxbury, a neighborhood of Boston, has felt like a really full circle moment in a lot of ways. It's a community, like many other communities, that have been excluded from safe and culturally affirming maternity care despite being a city with world-class hospitals. Roxbury is a historically black neighborhood that has faced generations of disinvestment and many forms of inequity. And in Massachusetts, as in other places, blackbirthing people are significantly more likely to experience maternal death than their white counterparts, even when you control for income and education. So much of what we've learned through our global maternal and newborn health work has shaped how we approach this topic. Home. And for NBC, the biggest through line was the importance of a truly human-centered process. From the beginning, the design was guided by really deep engagement with birthing families and midwives and staff. And we were constantly trying to ask how we could support safe care flows while also centering trust and culture and community and making sure to design for dignity and not just compliance. I remember being surprised about how transferable some of those principles were. The context is different, but the values are the same. Listening deeply, letting clinicians lead, creating spaces that feel really culturally grounded and affirming. The inequities show up differently in the US, particularly along racial lines, but the role of space in either reinforcing harm or supporting justice or trust is just as real. There was also a second lesson from our global work that we were also able to pull in, which was the importance of engaging policy and standards beyond individual buildings. Many low and middle-income countries, national infrastructure guidelines often overlook the spatial conditions that are needed for quality care. They're not specific or rigorous enough. But in the US, we sometimes see the opposite problem that facility regulations can be so restrictive that they can actually undermine the kind of care that's needed or make it kind of operationally challenging. So Mass and the Neighborhood Birth Center work together to try and shift that landscape. And last year, in 2025, the Massachusetts Department of Public Health approved a really big overhaul of statewide birth center facility regulations to bring them into closer alignment with midwifery-led care. And that shift was amazing and matters because infrastructure standards do quietly determine what kinds of care are even possible. And when space requirements don't match the care models, they create barriers that can disproportionately affect community-based providers. And for me, this reinforced that advancing racial and reproductive justice means working at a lot of levels, not just designing better spaces with partners, but trying to change the rules that shape and govern what those spaces can be.

SPEAKER_00 24:30

Projects like the Neighborhood Birth Center show what's possible when design, care, and policy start aligning. But they also signal something bigger. Meaningful change begins when the broader system starts moving together.

SPEAKER_01 24:44

What gives me real optimism right now is that we're starting to see momentum where different parts of the system are starting to move together in isolation. And over the past couple years, I've seen midwives pour over floor plans and give really precise and deep feedback on how the spaces need to work to support care and have been so generous with their time. I've met funders and health system leaders who are deeply committed to improving the lives of mothers and babies and to scale models like zero separation, not as pilots, but as hopefully someday standard practice. And I've seen one by one a growing community of champions advocate for care that's not just safe but respectful and culturally grounded. And what's amazing is to see that shift happen holistically. The Beginnings Fund is working with ministries of health across several countries to try to work on all those puzzle pieces, the workforce development, equipment, commodities, care model, systems. And we're being pulled in as the infrastructure partners. This is an opportunity for us to take that delivering more work to the next level. Now we have the chance to partner directly with ministries of health to shift from guidance to implementation. So we'll be improving and upgrading facilities, working together to build capacity, and in some places, expanding or deepening infrastructure standards. So this work is really going to be about pairing design with policy and training and evidence so that improvements don't stay small or isolated. This is a real opportunity to think about what long-term momentum and systems change can look like when these different governments and funders are aligning around what mothers and newborns need and when the focus is shifting from trying to prove what's possible to putting these ideas into practice at scale.

SPEAKER_00 26:54

Momentum like this suggests the system may finally be starting to shift, but it also invites a deeper reflection about the assumptions that have shaped design for decades, who gets centered in the process, whose voices shape the brief, and whose needs are too often treated as optional.

SPEAKER_01 27:11

I think a really important question is who the work actually serves and who is left out, especially in the process. And if we were really honest about that, it could change a lot. It would change what we choose to build, where we choose to work, and how we define success. We might stop measuring value by only budget size or speed or aesthetics and start to ask whether our work expands access and dignity and trust, especially for people who are usually excluded from design decisions. I do want to say that I don't mean to exclude beauty from the equation. Beauty is actually a really important part of that equation to get people to come to build trust, to build spaces that are ingrained in the places and the communities that they're trying to serve. Answering that question honestly also requires us to look at power and who gets to set or create the brief, whose expertise counts, who's included in the process, and whose needs are overlooked or treated as negotiable. And if we took that really seriously, I think we'd see a shift away from designing for communities and towards designing with them and how that can change outcomes. My path led me to maternal newborn health specifically, but I think some of the questions that it raises are universal. What does it mean to design spaces for care, not just in the medical sense, but in the most kind of human and expansive sense of the word? Because care shows up in how people feel safe and seen. And when designers consider how their work can enable care for people and communities and dignity, it can reshape how we think about the role of space in creating value and impact.

SPEAKER_00 29:07

Amy's work makes something difficult to ignore. If space can influence whether someone seeks care, stays, or walk away, then design isn't operating at the edges of these systems. It's shaping them. At Mass Design Group, that idea shows up in real decisions, choosing projects based on need, not visibility, investing in research and relationships that don't always fit within a typical timeline, and defining success by whether people feel supported, respected, and able to access care in the first place. It raises a question that's hard to shake. What would change if we approached every project with that same level of responsibility? Because at the end of the day, this isn't just about healthcare. It's about how we define the role of design in shaping people's lives. And as this conversation makes clear, good design isn't extra. It's essential. Thank you for joining us for this episode of Play with Matches. We hope this conversation inspires you to push a little further, imagine a little bigger, and keep igniting the ideas that move our industry forward. To hear more conversations like this one, follow Play with Matches wherever you get your podcasts. You can find show notes and full transcripts at WeareUpspring.com. Play with Matches is part of the Surround Podcast Network. This show is produced by Upspring, an award-winning strategic PR marketing partner with more than 17 years of experience supporting architecture firms, design practices, and product manufacturers shaping the built environment. A huge thank you to our guests, to our audio editing team at Make A Scene Productions, and to the Upsprinkers who helped make this episode possible. Brittany Lloyd, Eleanor Ling, and Marcus McDermott. Thanks so much for listening. Until next time.