Summary

Evidence shows that “physiological” births, powered by the innate abilities of the body, benefit the mother and baby, and reduce the potential harm posed by medical interventions like epidurals and caesarian sections. Despite this, the rates of physiological birth continue to decline in Ireland.

To address this, midwife Sinead Thompson developed the Labour Hopscotch Framework (LHF), which gives women and their partners a series of simple steps to support a physiological birth. A team of researchers at UCD and the National Maternity hospital have now evaluated the LHF, finding that it is an effective tool for promoting shared, inclusive decision-making during childbirth.

On the back of these findings, the LHF has been rolled out nationally by the Department of Health, and it has been included in national standards for antenatal education, empowering women and their birth partners, and improving health outcomes for mother and child.

Research description

The Labour Hopscotch Framework (LHF) was designed by Sinead Thompson, a Community Midwife at the National Maternity Hospital, in response to growing concerns by senior midwifery management about rising rates of medical intervention during childbirth. At the time, the national rate of caesarean section was 31.2% from a total of 61,655 births. The LHF offers women and their partners a series of practical, 20-minute steps to take to support a so-called “physiological birth”, powered by the innate abilities of the woman and foetus, without resorting to medical interventions like epidurals and caesarean sections.

When medically necessary, caesarean sections can save the lives of mothers and babies, but they can cause significant complications. Physiological births reduce interventions and improve women's experiences of childbirth, by offering choices such as hydrotherapy, massage, acupuncture, increased physical activity, active birth strategies, and changes in birthing position. Physiological birth is also associated with earlier initiation of breastfeeding.

The LHF is a visual birthing tool, laid out like the childhood game hopscotch. The steps it suggests include things like sitting on a stool while being massaged and keeping mobile by walking sideways on a flight of stairs.

To evaluate the effectiveness of the LHF, a team of researchers from UCD and the National Maternity Hospital conducted a research project based around a survey of 809 women and 759 partners, as well as a focus group of 8 midwives. They studied the experiences that women and their partners had with the LHF, the different factors that lead to women to using it, and the extent to which the LHF influences rates of epidurals.

40% of women reported that the LHF had influenced their decision-making about pain relief during childbirth. The epidural rates were much lower among women who engaged with the LHF (38.5%) compared to the overall hospital epidural rate (57%).

90% of women reported that the steps of the LHF helped them to feel very or somewhat confident to cope with labour. The researchers also found a significant association was found between how physically active a woman is during labour and the mode of birth taken. Of the 641 women who identified this physical activity as being the most beneficial step in the LHF, 78% had a normal birth, while 14% had a forceps or vacuum birth, and just 8.7% had a caesarean section.

Birth partners supported the use of the LHF, with 79% recommending that it should be used by women during childbirth. Midwives also suggested that the LHF inspired women to take initiatives and play an active role in their birthing experience.

As Lead Midwife in the National Women and Infants Programme we endorse this framework and we have seen the benefits and are now rolling it out across the 19 maternity units.

—Angela Dunne, Director of Midwifery, National Women and Infants Health Programme

Research impact

Through the Labour Hopscotch Framework, midwives and users of maternity services benefit from greater autonomy, wider access to childbirth-related choices, and more opportunities for shared decision-making. Ultimately, it is improving health outcomes for tens of thousands of women and the babies.

Social and policy impact

In 2019, members of the team presented their project findings – including the benefits and impacts of the LHF – to the Department of Health, after which the Department supported a national rollout of the Framework through the National Women’s Infant Programme. The team also engaged with midwives, presenting the LHF at a national midwives’ conference in February 2020 and at the Trinity Health and Education International Research Conference in March of the same year.

As a result, midwives, service users and allied health professionals have reported that implementing the LHF has resulted in positive change: women are more proactive during childbirth, using steps of the LHF with coaching from their birth partner or midwives, enhancing confidence and nurturing their relationships.

Health impact

Despite strong evidence of how a physiological birth benefits mother the baby, as well as the potential harm posed by unnecessary obstetric intervention, the rates of physiological birth continue to decline in the general population. Responding to this, the LHF was designed as “a midwifery package of care with a philosophy embedded in the inherent normality of childbirth and the natural ability of women to achieve it”.

The use of the LHF has changed how women, their birth partners and maternity care professionals and policymakers think about and experience physiological childbirth and pain relief in Ireland. The LHF has improved rates of physiological childbirth, supported partner participation, and improved the psychological wellbeing and physical health of women.

As one mother said, after using the LHF: “I was surprised at my own ability to do this and felt such a huge sense of achievement. I was able to see first-hand how effective both hypnobirthing and labour hopscotch were for progressing labour and birth.”

Educational impact

Based on the team’s research findings, the conceptual thinking and clinical skills associated with the LHF have been embedded into the undergraduate and postgraduate midwifery curriculum in UCD and transferred into clinical practice. During 2020 and 2021, members of the team ran educational training and workshops on the LHF in 10 of Ireland’s 19 maternity units, and in De Montfort University, Leicester, UK.

In 2020, the Health Service Executive also included the LHF in the national standards for Antenatal Education in Ireland, meaning all antenatal educators in the country will teach Labour Hopscotch, and it will be included in their nationally approved curriculum of training. Students of midwifery, practising midwives and services users have all benefited from a greater understanding about the steps to take for a physiological birth, and the benefits of doing so.

Cultural impact

Active Management of Labour (AML) refers to a philosophy of care embedded in the culture of the National Maternity Hospital. This philosophy is based around accurate diagnosis of labour, diagnosis and treatment of abnormal contractions that interfere with the progress of labour, peer review, and audit. And it aims to ensure the baby is optimally positioned for easy descent and manoeuvring through the pelvis.

While the AML is successful in supporting positive outcomes for both the mother and infant, it has been criticised for limiting opportunities for shared decision-making for women in labour. Since its inception, the LHF has been integrated as a complementary approach in the National Maternity Hospital, supporting AML and women to feel more confident about the decisions they make during their labour, and contributing to a cultural shift in approaches to childbirth.

This concept has caught the imagination of midwives and mothers and is being adopted in all 19 maternity units across Ireland. It is becoming a very vital tool in empowering women and midwives.

—Mary Brosnan, Director of Midwifery and Nursing, National Maternity Hospital