Fetal movements: What are we telling women?

Midwives' and obstetricians' practice, perspectives and experiences in relation to altered fetal movement: A focused ethnographic study

BACKGROUND

Reducing avoidable stillbirth is a global priority. The stillbirth rate in England compares unfavourably to that of some other high-income countries. Poorly-managed episodes of altered fetal movement have been highlighted as a key contributor to avoidable stillbirth, and strategies introduced in England in 2016 to reduce perinatal mortality included recommendations for the management of reduced fetal movement. Despite a downward trend in stillbirth rates across the UK, the effects of policies promoting awareness of fetal movement remain uncertain.

OBJECTIVE

To provide in-depth knowledge of how practice and clinical guidance relating to altered fetal movement are perceived, enacted and experienced by midwives and obstetricians, and explore the relationship between recommended fetal movement care and actual fetal movement care.

DESIGN

A focused ethnographic approach comprising over 180 h of observation, 15 interviews, and document analysis was used to explore practice at two contrasting UK maternity units.

SETTINGS

Antenatal services at two UK maternity units, one in the Midlands and one in the North of England.

PARTICIPANTS

Thirty-six midwives, obstetricians and sonographers and 40 pregnant women participated in the study across 52 observed care episodes and relevant unit activity. Twelve midwives and three obstetricians additionally participated in formal semi-structured interviews.

METHODS

Fieldnotes, interview transcripts, policy documents, maternity notes and clinical guidelines were analysed using a modified constant comparison method to identify important themes.

RESULTS

fetal movement practice was mostly consistent and in line with guideline recommendations. Notwithstanding, most midwives and obstetricians had concerns about this area of care, including challenges in diagnosis, conflicting evidence about activity, heightened maternal anxiety, and high rates of monitoring and intervention in otherwise low-risk pregnancies. To address these issues, midwives spent considerable time reassuring women through information and regular monitoring, and coaching them to perceive fetal movement more accurately.

CONCLUSIONS

Practice relating to altered fetal movement might be more uniform than in the past. However, a heightened focus on fetal movement is associated by some midwives and obstetricians with potential harms, including increased anxiety in pregnancy, and high rates of monitoring and intervention in pregnancies where there are no 'objective concerns'. Challenges in diagnosing a significant change in fetal movement with accuracy might mean that interventions and resources are not being directed towards those pregnancies most at risk. More research is needed to determine how healthcare professionals can engage in conversations about fetal movement and stillbirth to support safe outcomes and positive experiences in pregnancy and birth.

REGISTRATION

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TWEETABLE ABSTRACT

Midwives and obstetricians take #reducedfetalmovement seriously but worry this 'unreliable' symptom increases anxiety, monitoring and intervention in many 'low risk' pregnancies.

Pregnancy, birth and neonatal outcomes associated with reduced fetal movements: A systematic review and meta-analysis of non-randomised studies

PROBLEM

Maternal perception of reduced fetal movements (RFM) is identified as an important alarm signal for possible risk of impending adverse perinatal outcomes.

BACKGROUND

Perinatal outcomes associated with RFM are increasingly being investigated in non-randomised studies with several associated outcomes, including stillbirth, preterm birth, fetal growth restriction and neonatal death being reported. Findings from studies, however, are conflicting.

AIM

To synthesise the findings of published studies regarding pregnancy, birth and neonatal outcomes in women who presented with RFM.

METHODS

PubMed, EMBASE, CINAHL complete, Maternity and Infant Care, PsycINFO, and Science Citation Index databases were searched up to 8th July 2021 and updated again on 8th September 2022. Non-randomised studies involving pregnant women ≥24 weeks' gestation, who presented with a primary complaint of RFM compared to women who did not present with RFM were included. Data were meta-analysed using a random-effects model and presented as Odds Ratios (OR) or Standard Mean Differences (SMD) with 95% Confidence Intervals (CI).

FINDINGS

Thirty-nine studies were included. Women with RFM had increased odds of stillbirth (OR 3.44, 95% CI 2.02-5.88) and small for gestational age (OR 1.37, 95% CI 1.16-1.61) when compared with women who did not have RFM. Associations were also found for induction of labor, instrumental birth and caesarean section but not for preterm birth (OR 0.92, 95% CI 0.71-1.19) or neonatal death (OR 0.99; 95% CI 0.52-1.90).

CONCLUSION

This review revealed that RFM is associated with increased odds of stillbirth, small for gestational age, induction of labor, instrumental birth and caesarean section but not preterm birth or neonatal death.

Fetal movements: A framework for antenatal conversations

BACKGROUND

Presentations for decreased fetal movements comprise a significant proportion of acute antenatal assessments. Decreased fetal movements are associated with increased likelihood of adverse pregnancy outcomes including stillbirth. Consensus-based guidelines recommend pregnant women routinely receive information about fetal movements, but practice is inconsistent, and the information shared is frequently not evidence-based. There are also knowledge gaps about the assessment and management of fetal movement concerns. Women have indicated that they would like more accurate information about what to expect regarding fetal movements.

DISCUSSION

Historically, fetal movement information has focussed on movement counts. This is problematic, as the number of fetal movements perceived varies widely between pregnant women, and no set number of movements has been established as a reliable indicator of fetal wellbeing. Of late, maternity care providers have also advised women to observe their baby's movement pattern, and promptly present if they notice a change. However, normal fetal movement patterns are rarely defined. Recently, a body of research has emerged relating to maternal perception of fetal movement features such as strength, presence of hiccups, and diurnal pattern as indicators of fetal wellbeing in addition to frequency.

CONCLUSION

Sharing comprehensive and gestation-appropriate information about fetal movements may be more satisfying for women, empowering women to identify for themselves when their baby is doing well, and importantly when additional assessment is needed. We propose a conversational approach to fetal movement information sharing, focusing on fetal movement strength, frequency, circadian pattern, and changes with normal fetal development, tailored to the individual.

Assessing fetal movements in pregnancy: A qualitative evidence synthesis of women's views, perspectives and experiences

Background

Raising awareness of the importance of fetal movements (FMs) and advising women on the appropriate action to take if they experience reduced FMs, is important for minimising or avoiding adverse perinatal outcomes. To gain insight and understanding of women’s perspectives of assessing FMs in pregnancy, we conducted a qualitative evidence synthesis.

Methods

A qualitative evidence synthesis using thematic synthesis was conducted. Studies were eligible if they included pregnant women who were at least 20 weeks gestation and reported qualitative data from women on assessing FMs in pregnancy. MEDLINE, CINAHL, EMBASE, PsycINFO and Social Science Citation Index, from inception to July 2020, were searched. The methodological quality of included studies was assessed by at least two reviewers using an Evidence for Policy and Practice Information (EPPI)-Centre quality assessment tool. Data synthesis, using the Thomas and Harden framework, involved line by line coding of extracted data, establishing descriptive themes, and determining analytical themes. Confidence in the findings was assessed using GRADE CER-Qual.

Results

Nine studies, involving 2193 women, were included in the review. The methodological quality of the studies was overall generally high. The synthesis revealed three dominant themes, and seven sub-themes that reflected women’s perspectives of assessing FMs in pregnancy. These were; 1) How women engage with FMs, with subthemes of informal engagement, formal engagement, and strategies to stimulate FMs; 2) ‘ … like a feather inside my belly’ - articulating and describing FMs, with sub-themes of sensations associated with FMs and timing and frequency of FMs; and 3) FMs and help/health seeking, with sub-themes of information sources and interacting with healthcare professionals. Confidence in the findings was either high or moderate, although two findings were rated low confidence and one very low.

Conclusion

This qualitative evidence synthesis reveals that women informally engage with FMs during pregnancy. Women commonly adopt strategies to stimulate FMs when concerned. The use of the internet was a common source of obtaining information regarding FMs. Women require better support when contacting healthcare professionals about FMs. As only three of the nine included studies were exclusively qualitative in design, further qualitative studies exploring women’s perspective of assessing FMs in pregnancy are required.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-021-03667-y.

Midwives' experiences of using the Mindfetalness method when talking with pregnant women about fetal movements

BACKGROUND

Information given to pregnant women about fetal movements is important in maternity care and decreased fetal movements is associated with fetal growth restriction and stillbirth. The fetal movement pattern is different for every fetus and women perceive different types of movements. Mindfetalness is a self-assessment method for a woman to use to become familiar with her unborn baby's fetal movement pattern.

AIM

We aimed to explore midwives' perceptions about informing pregnant women about fetal movements and their experiences of working with Mindfetalness in their daily work.

METHODS

A web-questionnaire was distributed to midwives who participated in a randomized controlled trial evaluating Mindfetalness, a method for the observation of fetal movements. In total, 67 maternity clinics in Stockholm, Sweden, were randomized to Mindfetalness or routine care. Of the 144 midwives working in maternity clinics randomized to Mindfetalness, 80% answered the questionnaire.

FINDINGS

The midwives thought that the leaflet about Mindfetalness was supportive in their work when informing women about fetal movements and the majority wanted to continue to distribute the leaflet when the trial ended. The midwives also expressed that the study increased their own knowledge about fetal movements. Women embraced the information about Mindfetalness positively and appreciated the written material. The midwives thought that talking about fetal movements in maternity care is an important but challenging task.

CONCLUSION

Mindfetalness is a useful tool to use in maternity clinics when informing pregnant women about fetal movements. The written information was appreciated by both pregnant women and midwives.

'InUTERO': The effectiveness of an educational half day stillbirth awareness workshop for maternity care providers

BACKGROUND

There is a disconnect between what maternity care providers consider should be done and what they actually do with respect to talking with their pregnant clients about reducing their risk of stillbirth. This suggests that they would benefit from receiving up-to-date knowledge about stillbirth, alongside education that provides them with strategies for talking about stillbirth with pregnant women.

OBJECTIVES

To gain an understanding of maternity care provider (obstetricians and midwives) knowledge of stillbirth and determine whether delivering a half day workshop improves knowledge and results in intention to change practice.

DESIGN

A pre-post intervention study.

SETTING

Maternity care providers (Obstetricians, Midwives) working in the northern areas of Tasmania, Australia were asked, via questionnaire, about their knowledge of stillbirth both before and after attending a half-day workshop.

PARTICIPANTS

Maternity care providers (n = 51) attended the workshop and 30 (59%) completed both the pre-workshop and post-workshop surveys.

METHODS

A four hour interactive workshop grounded in understanding the stillbirth experience. Participants were given up-to-date information about stillbirth risks and current prevention research as well as provided with an actionable step wise approach to talking about stillbirth prevention in pregnancy.

RESULTS

Stillbirth knowledge scores (total of 8-points) significantly increased following the workshop (pre: mean = 2.9 ± 1.5; post: mean = 4.7 ± 1.4 points, t ₂₉ = 7.9, <0.001). Before the workshop, only 20% of participants responded that they "always" or usually" discussed the possibility stillbirth occurring with pregnant women in their care whereas, after the workshop, nearly all (88%) indicated that they planned to "always" discuss stillbirth with their pregnant clients.

CONCLUSIONS

Attending a stillbirth awareness for prevention education workshop resulted in significant knowledge improvement and self-reported intention to change practice in a group of Australian maternity care providers. While these results are promising, further study is needed to determine the presence and extent of actual practice change following such education.

A diurnal fetal movement pattern: Findings from a cross-sectional study of maternally perceived fetal movements in the third trimester of pregnancy

BACKGROUND AND OBJECTIVES

Encouraging awareness of fetal movements is a common strategy used to prevent stillbirths. Information provided to pregnant women about fetal movements is inconsistent perhaps due to limited knowledge about normal fetal movement patterns in healthy pregnancies. We aimed to describe maternally perceived fetal movement strength, frequency, and pattern in late pregnancy in women with subsequent normal outcomes.

METHODS

Participants were ≥28 weeks' gestation, with a non-anomalous, singleton pregnancy who had been randomly selected from hospital booking lists and had consented to participate. Fetal movement data was gathered during pregnancy via a questionnaire administered face-to-face by research midwives. Participants remained eligible for the study if they subsequently gave birth to a live, appropriate-for-gestational-age baby at ≥37 weeks.

RESULTS

Participants were 274 women, with normal pregnancy outcomes. The majority (59.3%, n = 162) of women reported during antenatal interview that the strength of fetal movements had increased in the preceding two weeks. Strong fetal movements were felt by most women in the evening (72.8%, n = 195) and at night-time including bedtime (74.5%, n = 199). The perception of fetal hiccups was also reported by most women (78.8%). Women were more likely to perceive moderate or strong fetal movements when sitting quietly compared with other activities such as having a cold drink or eating.

CONCLUSIONS

Our data support informing women in the third trimester that as pregnancy advances it is normal to perceive increasingly strong movement, episodes of movements that are more vigorous than usual, fetal hiccups, and a diurnal pattern involving strong fetal movement in the evening. This information may help pregnant women to better characterise normal fetal movement and appropriately seek review when concerned about fetal movements. Care providers should be responsive to concerns about decreased fetal movements in the evening, as this is unusual.

Breaking through the silence in antenatal care: Fetal movement and stillbirth education

BACKGROUND

Fetal movements are a key indicator of fetal health. Research has established significant correlations between altered fetal activity and stillbirth. However, women are generally unaware of this relationship. Providing pregnant women with information about the importance of fetal movements could improve stillbirth rates. However, there are no consistent fetal movements awareness messages globally for pregnant women.

AIMS

This study aimed to explore the antenatal care experiences of Australian mothers who had recently had a live birth to determine their knowledge of fetal movements, the nature and source of that information.

METHODS

An online survey method was used for 428 women who had a live birth and received antenatal care in Australia. Women's knowledge of fetal movements, stillbirth risk, and the sources of this knowledge was explored.

FINDINGS

A large proportion of participants (84.6%; n=362) stated they had been informed by health care professionals of the importance of fetal movements during pregnancy. Open-ended responses indicate that fetal movements messages are often myth based. Awareness that stillbirth occurs was high (95.2%; n=398), although, 65% (n=272) were unable to identify the current incidence of stillbirth in Australia.

CONCLUSION

Women who received antenatal care have high-awareness of fetal movements, but the information they received was inconsistent. Participants knew stillbirth occurred but did not generally indicate they had obtained that knowledge from health care professionals. We recommend a consistent approach to fetal movements messaging throughout pregnancy which focuses on stillbirth prevention.

Deferred and referred deliveries contribute to stillbirths in the Indian state of Bihar: results from a population-based survey of all births

BACKGROUND

The India Newborn Action Plan (INAP) aims for < 10 stillbirths per 1000 births by 2030. A population-based understanding of risk factors for stillbirths compared with live births that could assist with reduction of stillbirths is not readily available for the Indian population.

METHODS

Detailed interviews were conducted in a representative sample of all births between January and December 2016 from 182,486 households (96.2% participation) in 1657 clusters in the Indian state of Bihar. A stillbirth was defined as foetal death with gestation period of ≥ 7 months wherein the foetus did not show any sign of life. The association of stillbirth was investigated with a variety of risk factors among all births using a hierarchical logistic regression model approach.

RESULTS

A total of 23,940 births including 338 stillbirths were identified giving the state stillbirth rate (SBR) of 15.4 (95% CI 13.2-17.9) per 1000 births, with no difference in SBR by sex. Antepartum and intrapartum SBR was 5.6 (95% CI 4.3-7.2) and 4.5 (95% CI 3.3-6.1) per 1000 births, respectively. Detailed interview was available for 20,152 (84.2% participation) births including 275 stillbirths (81.4% participation). In the final regression model, significantly higher odds of stillbirth were documented for deliveries with gestation period of ≤ 8 months (OR 11.36, 95% CI 8.13-15.88), for first born (OR 5.79, 95% CI 4.06-8.26), deferred deliveries wherein a woman was sent back home and asked to come later for delivery by a health provider (OR 5.51, 95% CI 2.81-10.78), and in those with forceful push/pull during the delivery by the health provider (OR 4.85, 95% CI 3.39-6.95). The other significant risk factors were maternal age ≥ 30 years (OR 3.20, 95% CI 1.52-6.74), pregnancies with multiple foetuses (OR 2.82, 95% CI 1.49-5.33), breech presentation of the baby (OR 2.70, 95% CI 1.75-4.18), and births in private facilities (OR 1.75, 95% CI 1.19-2.56) and home (OR 2.60, 95% CI 1.87-3.62). Varied risk factors were associated with antepartum and intrapartum stillbirths. Birth weight was available only for 40 (14.5%) stillborns. Among the facility deliveries, the women who were referred from one facility to another for delivery had significantly high odds of stillbirth (OR 3.32, 95% CI 2.03-5.43).

CONCLUSIONS

We found an increased risk of stillbirths in deferred and referred deliveries in addition to demographic and clinical risk factors for antepartum and intrapartum stillbirths, highlighting aspects of health care that need attention in addition to improving skills of health providers to reduce stillbirths. The INAP could utilise these findings to further strengthen its approach to meet the stillbirth reduction target by 2030.

Tertiary education regarding stillbirth for student midwives: The tears 4 SMS project

PROBLEM

Undergraduate education for midwives in the area of stillbirth may be lacking.

BACKGROUND

When a baby dies the families are usually cared for, at some stage in their pregnancy or birth journey, by midwives, however, midwives may not be adequately prepared to care for them.

AIM

The aim of this study was to investigate the current content of stillbirth education in undergraduate midwifery curricula in Australia.

METHODS

Nineteen midwifery program leaders from each of the Australian Universities that deliver undergraduate midwifery education were invited to respond to an online survey regarding content related to stillbirth risk, prevention and/or bereavement care. There were 10 complete surveys. Quantitative survey data were analysed and described using percentages, and data from the free text comments collected verbatim.

FINDINGS

Responses indicated that there is a diverse inclusion of material relating to the topic of stillbirth, with different approaches to teaching the content and the amount of time devoted to the topic is relatively small.

DISCUSSION

This small study in scoping curricula from participating Australian Universities indicated that more could be done to strengthen stillbirth related content. Stillbirth is a complex issue and therefore it is important for midwives to understand not only bereavement care but also the physiological underpinnings of issues that could be an antecedent cause or precursor for stillbirth.

CONCLUSION

There is room to improve and standardise appropriate stillbirth curriculum nationally. It is imperative that midwives are able to provide sensitive and knowledgeable care to all women and their families.

Stillbirth is associated with perceived alterations in fetal activity - findings from an international case control study

Background

Stillbirth after 28 weeks gestation affects between 1.3–8.8 per 1000 births in high-income countries. The majority of stillbirths in this setting occur in women without established risk factors. Identification of risk factors which could be identified and managed in pregnancy is a priority in stillbirth prevention research. This study aimed to evaluate women’s experiences of fetal movements and how these relate to stillbirth.

Methods

An international internet-based case–control study of women who had a stillbirth ≥28 weeks’ gestation within 30 days prior to completing the survey (n = 153) and women with an ongoing pregnancy or a live born child (n = 480). The online questionnaire was developed with parent stakeholder organizations using a mixture of categorical and open–ended responses and Likert scales. Univariate and multiple logistic regression was used to determine crude (unadjusted) and adjusted odds ratios (aOR) with 95% confidence intervals (CI). Summative content analysis was used to analyse free text responses.

Results

Women whose pregnancy ended in stillbirth were less likely to check fetal movements (aOR 0.54, 95% CI 0.35–0.83) and were less likely to be told to do so by a health professional (aOR 0.55, 95% CI 0.36–0.86). Pregnancies ending in stillbirth were more frequently associated with significant abnormalities in fetal movements in the preceding two weeks; this included a significant reduction in fetal activity (aOR 14.1, 95% CI 7.27–27.45) or sudden single episode of excessive fetal activity (aOR 4.30, 95% CI 2.25–8.24). Cases described their perception of changes in fetal activity differently to healthy controls e.g. vigorous activity was described as “frantic”, “wild” or “crazy” compared to “powerful” or “strong”.

Conclusions

Alterations in fetal activity are associated with increased risk of stillbirth. Pregnant women should be educated about awareness of fetal activity and reporting abnormal activity to health professionals.

Electronic supplementary material

The online version of this article (10.1186/s12884-017-1555-6) contains supplementary material, which is available to authorized users.

"Better safe than sorry"-Reasons for consulting care due to decreased fetal movements

BACKGROUND

Experience of reduced fetal movements is a common reason for consulting health care in late pregnancy. There is an association between reduced fetal movements and stillbirth.

AIM

To explore why women decide to consult health care due to reduced fetal movements at a specific point in time and investigate reasons for delaying a consultation.

METHODS

A questionnaire was distributed at all birth clinics in Stockholm during 2014, to women seeking care due to reduced fetal movements. In total, 3555 questionnaires were collected, 960 were included in this study. The open-ended question; "Why, specifically, do you come to the clinic today?" was analyzed using content analysis as well as the complementary question "Are there any reasons why you did not come to the clinic earlier?"

RESULTS

Five categories were revealed: Reaching dead line, Receiving advice from health care professionals, Undergoing unmanageable worry, Contributing external factors and Not wanting to jeopardize the health of the baby. Many women stated that they decided to consult care when some time with reduced fetal movements had passed. The most common reason for not consulting care earlier was that it was a new experience. Some women stated that they did not want to feel that they were annoying, or be perceived as excessively worried. Not wanting to burden health care unnecessarily was a reason for prehospital delay.

CONCLUSION

Worry about the baby is the crucial reason for consulting care as well as the time which has passed since the women first experienced decreased fetal movements.