Implementation of uniform information on fetal movement in a Norwegian population reduced delayed reporting of decreased fetal movement and stillbirths in primiparous women - a clinical quality improvement

Evaluating the reach and impact of Still Six Lives: A national stillbirth public awareness campaign in Australia

BACKGROUND

The Still Six Lives campaign aimed to increase awareness of stillbirth among Australian women and educate people about three modifiable behaviours that pregnant women could take to reduce the risk of stillbirth. The campaign used earned media, digital advertising and social media.

AIM

The aim of this study is to evaluate the impact of the campaign on Australian women's awareness of stillbirth, and knowledge of the three modifiable behaviours.

METHODS

The study collected process evaluation data about campaign implementation from digital platforms. The impact evaluation comprised of two components: a three-wave community survey of Australian women aged 18-50 years old, and a pre-post cross-sectional maternity service survey of pregnant women.

RESULTS

The campaign gained significant reach, including 2,974,375 completed video views and 910,000 impressions via social media influencers. The community surveys had 1502 participants at baseline, 1517 mid-campaign and 1598 post-campaign. Participants were slightly more likely to have encountered messages about stillbirth after the campaign (aOR 1.30, 95% CI 1.09-1.55). There were increases in awareness of each behaviour after the campaign: be aware of baby's movements (aOR 1.26, 95% CI 1.08-1.47), quit smoking (aOR 1.27, 95% CI 1.10-1.47) and going-to-sleep on side (aOR 1.55, 95% CI 1.32-1.82). The antenatal clinic survey had 296 participants at baseline and 178 post-campaign. Post-campaign, there was an increased likelihood that women were aware of side-sleeping (aOR 3.11, 95% CI 1.74-5.56).

CONCLUSIONS

The national campaign demonstrated some evidence of change in awareness of three modifiable behaviours that can reduce the risk of stillbirth.

A systematic review of behaviour change techniques used in the context of stillbirth prevention

BACKGROUND

Stillbirth is one of the most devastating pregnancy outcomes that families can experience. Previous research has associated a wide range of risk factors with stillbirth, including maternal behaviours such as substance use, sleep position and attendance and engagement with antenatal care. Hence, some preventive efforts have been focused on tackling the behavioural risk factors for stillbirth. This study aimed to identify the Behaviour Change Techniques (BCTs) used in behaviour change interventions tacking behavioural risk factors for stillbirth such as substance use, sleep position, unattendance to antenatal care and weight management.

STUDY DESIGN

A systematic review of the literature was conducted in June 2021 and updated in November 2022 in five databases: CINHAL, Psyhinfo, SociIndex, PubMed and Web of Science. Studies published in high-income countries describing interventions designed in the context of stillbirth prevention, reporting stillbirth rates and changes in behaviour were eligible for inclusion. BCTs were identified using the Behaviour Change Technique Taxonomy v1.

RESULTS

Nine interventions were included in this review identified in 16 different publications. Of these, 4 interventions focused on more than one behaviour (smoking, monitoring fetal movements, sleep position, care-seeking behaviours), one focused on smoking, three on monitoring fetal movements and one on sleep position. Twenty-seven BCTs were identified across all interventions. The most commonly used was "Information about health consequences" (n = 7/9) followed by "Adding objects to the environment" (n = 6/9). One of the interventions included in this review has not been assessed for efficacy yet, of the remaining eight, three showed results in the reduction of stillbirth rates. and four interventions produced behaviour change (smoking reductions, increased knowledge, reduced supine sleeping time).

CONCLUSIONS

Our findings suggest that interventions designed to date have limited effects on the rates of stillbirth and utilise a limited number of BCTs which are mostly focused on information provision. Further research is necessary to design evidence base behaviour change interventions with a greater focus to tackle all the other factors influencing behaviour change during pregnancy (e.g.: social influence, environmental barriers).

Fetal Movement Counting in Prolonged Pregnancies: The COMPTAMAF Prospective Randomized Trial

In prolonged pregnancies, the risks of neonatal morbidity and mortality are increased. The aim of this trial was to assess the benefits of maternal information about fetal movement (FM) counting on neonatal outcomes in prolonged pregnancy. It was a prospective, single center, randomized, open-label study conducted from October 2019 to March 2022. Intention-to-treat analyses were performed on 278 patients randomized into two 1:1 groups (control group and FM counting group). The primary outcome was a composite score of neonatal morbidity (presence of two of the following items: fetal heart rate abnormality at delivery, Apgar score of <7 at 5 min, umbilical cord arterial pH of <7.20, and acute respiratory distress with mutation in neonatal intensive care unit). There was no significant difference between the two groups in the rate of neonatal morbidity (14.0% in the FM counting group versus 22.9% in the standard information group; p = 0.063; OR 0.55, 95% CI 0.29−1.0). In this study, fetal movement counting for women in prolonged pregnancy failed to demonstrate a significant reduction in adverse neonatal outcomes.

Knowing your audience: Investigating stillbirth knowledge and perceptions in the general population to inform future public health campaigns

BACKGROUND

The prevalence of stillbirth in many high income countries like Australia has remained unchanged for over 30 years. The 2018 Australian government Senate Select Committee on Stillbirth Research and Education highlighted the need for a public health campaign to encourage public conversations and increase awareness. However, there is little evidence about the community's knowledge and perceptions towards pregnancy and stillbirth, nor their aspirations for a public health campaign.

AIMS

To assess the general knowledge, perceptions, myths and attitudes towards stillbirth to inform future public health campaigns.

METHODS

Australian participants (n = 344; predominately women n = 294 (85.5%)) were recruited via Facebook.com. They completed a cross-sectional online survey designed to assess their knowledge of pregnancy and stillbirth, with additional questions on socio-demographic characteristics.

RESULTS

Stillbirth knowledge and awareness of incidence was low in this sample. Prominent myths, such as baby runs out of room in the uterus (n = 112, 33%) and baby slows down when preparing for labour (n = 24, 27%) were endorsed. Only 25% (n = 85) knew the prevalence of stillbirth in Australia (six per day). Almost two-thirds (n = 205; 62%) agreed that there needs to be a public health campaign, however one in five (n = 65; 20%) were concerned that talking about stillbirth with pregnant women may cause them to worry.

DISCUSSION AND CONCLUSION

Our findings reinforce the need for a targeted campaign, which educates the general population about the definition and prevalence of stillbirth, stillbirth risks and modifiable health behaviours. Appropriate messaging should target pregnant women during antenatal care as well as their support and care systems (family, friends, and care providers).

Fetal movement counting is associated with the reduction of delayed maternal reaction after perceiving decreased fetal movements: a prospective study

Maternal perception of decreased fetal movement is associated with adverse perinatal outcomes. Although there have been several studies on interventions related to the fetal movements count, most focused on adverse perinatal outcomes, and little is known about the impact of the fetal movement count on maternal behavior after the perception of decreased fetal movement. We investigated the impact of the daily fetal movement count on maternal behavior after the perception of decreased fetal movement and on the stillbirth rate in this prospective population-based study. Pregnant women in Shiga prefecture of Japan were asked to count the time of 10 fetal movements from 34 weeks of gestation. We analyzed 101 stillbirths after the intervention compared to 121 stillbirths before the intervention. In multivariable analysis, maternal delayed visit to a health care provider after the perception of decreased fetal movement significantly reduced after the intervention (aOR 0.31, 95% CI 0.11–0.83). Our regional stillbirth rates in the pre-intervention and post-intervention periods were 3.06 and 2.70 per 1000 births, respectively. Informing pregnant women about the fetal movement count was associated with a reduction in delayed maternal reaction after the perception of decreased fetal movement, which might reduce stillbirths.

Evaluation of Movements Matter: A social media and hospital-based campaign aimed at raising awareness of decreased fetal movements

BACKGROUND

The Movements Matter campaign aimed to raise awareness of decreased fetal movements (DFM) among pregnant women and inform clinicians of best practice management.

AIM

To conduct a process evaluation of campaign implementation, and an impact evaluation of the campaign's effects on knowledge and experiences of pregnant women, and attitudes and practices of clinicians in relation to DFM.

METHODS

This study used a cross-sectional before-after design. Pregnant women and clinicians were sampled at five hospitals. Women were surveyed about their knowledge of DFM, and actions to take if they noticed DFM. Clinicians were asked about their current practices and attitudes about informing women about DFM. Logistic regression was used to calculate campaign effects on outcome measures.

RESULTS

The Movements Matter campaign reached 653 262 people on social media, as well as being covered on news media and popular women's websites. The evaluation surveyed 1142 pregnant women pre-campaign and 473 post-campaign, and 372 clinicians pre-campaign and 149 post-campaign. Following the campaign, women were more likely to be aware that babies should move the same amount in late pregnancy (adjusted odds ratio (aOR) 1.81, 95% CI 1.43-2.27), and were more likely to contact their health service immediately if their baby was moving less (aOR 1.52, 95% CI 1.22-1.91). Clinicians were 2.84 times more likely to recommend women should come in for assessment if they experience DFM (95% CI 1.35-5.97).

CONCLUSIONS

This evaluation has shown that a campaign using social media and in-hospital education materials led to some increases in knowledge about fetal movements among pregnant women.

Lactobacillus plantarum IS-10506 promotes renal tubular regeneration in pyelonephritic rats

Lactobacillus plantarum IS-10506 is a novel probiotic isolated from Indonesian traditional fermented buffalo milk dadih. Probiotics are clinically proven to be effective in accelerating recovery after urinary tract infection (UTI) and in decreasing recurrent UTI in children with or without structural disorders of the urinary tract. This study aimed to investigate the role of the probiotic L. plantarum IS-10506 in activating and regenerating renal epithelial stem cells in pyelonephritic rats. Fifty-five 20-weeks-old male Sprague-Dawley rats were randomised into control, lipopolysaccharide (LPS) and treatment (LPS and probiotic) groups. Pyelonephritis was induced with Escherichia coli ATCC 25922 LPS administered via a urethral catheter on the first experimental day to the LPS and treatment groups. Microencapsulated L. plantarum IS-10506 was orally administered once daily for up to 14 days to the treatment group. On days 3, 5, 7, 10 and 14, five rats per group were sacrificed and their kidneys were immunohistochemically analysed for production of interleukin (IL)-10, lipocalin-2 and Ki-67 in the renal tubular cells. IL-10 production was upregulated starting from day 3 through day 14 in the treatment group (P<0.05) compared with that in the control and LPS groups. Moreover, treatment with the probiotic led to increased activation of renal tubular stem cell, as indicated by a higher lipocalin-2 production, and further proliferation of renal tubular stem cells was documented by a higher Ki-67 production. Taken together, these results indicate that the anti-inflammatory probiotic L. plantarum IS-10506 improves renal injury in pyelonephritic rats by activating endogenous renal tubular stem cells to proliferate into mature renal tubular epithelial cells.

My Baby's Movements: a stepped wedge cluster randomised controlled trial to raise maternal awareness of fetal movements during pregnancy study protocol

Background

Stillbirth is a devastating pregnancy outcome that has a profound and lasting impact on women and families. Globally, there are over 2.6 million stillbirths annually and progress in reducing these deaths has been slow. Maternal perception of decreased fetal movements (DFM) is strongly associated with stillbirth. However, maternal awareness of DFM and clinical management of women reporting DFM is often suboptimal. The My Baby’s Movements trial aims to evaluate an intervention package for maternity services including a mobile phone application for women and clinician education (MBM intervention) in reducing late gestation stillbirth rates.

Methods/design

This is a stepped wedge cluster randomised controlled trial with sequential introduction of the MBM intervention to 8 groups of 3–5 hospitals at four-monthly intervals over 3 years.

The target population is women with a singleton pregnancy, without lethal fetal abnormality, attending for antenatal care and clinicians providing maternity care at 26 maternity services in Australia and New Zealand. The primary outcome is stillbirth from 28 weeks’ gestation. Secondary outcomes address: a) neonatal morbidity and mortality; b) maternal psychosocial outcomes and health-seeking behaviour; c) health services utilisation; d) women’s and clinicians’ knowledge of fetal movements; and e) cost. 256,700 births (average of 3170 per hospital) will detect a 30% reduction in stillbirth rates from 3/1000 births to 2/1000 births, assuming a significance level of 5%. Analysis will utilise generalised linear mixed models.

Discussion

Maternal perception of DFM is a marker of an at-risk pregnancy and commonly precedes a stillbirth. MBM offers a simple, inexpensive resource to reduce the number of stillborn babies, and families suffering the distressing consequences of such a loss. This large pragmatic trial will provide evidence on benefits and potential harms of raising awareness of DFM using a mobile phone app.

Trial registration

ACTRN12614000291684. Registered 19 March 2014.

Version

Protocol Version 6.1, February 2018.

Maternally perceived fetal movement patterns: The influence of body mass index

BACKGROUND

Maternal reports of decreased fetal movements are associated with adverse pregnancy outcome, but there are conflicting data about perception of fetal movements in women with obesity.

AIM

To compare perceived fetal movements in women with obesity (body mass index [BMI] ≥30 kg/m²) and women with normal BMI (<25 kg/m²).

MATERIAL AND METHODS

Data from two separate pregnancy studies were used for this analysis; the Healthy Mums and Babies (HUMBA) trial, which recruited women with obesity and the Multicentre Stillbirth Study (MCSS), which recruited women from a general obstetric population. Fetal movement data were collected using identical interviewer-administered questionnaire in each study. We compared fetal movement strength, frequency and pattern between HUMBA and MCSS women with obesity and MCSS women with normal BMI.

RESULTS

Participants were 233 women with obesity and 149 with normal BMI. Mean (SD) gestation at interview was similar between groups (36.9 [2.2] vs 36.6 [0.9], P = 0.06). Perceived fetal movement strength and frequency did not differ between groups. In both women with obesity and normal BMI, a diurnal fetal movement pattern was present, with the majority reporting strong or moderate movements in the evening (88.7% vs 99.3%) and at night-time (92.1% vs 93.1%). Women with obesity, were more likely to report strong fetal movements when hungry (29.1% vs 17.7%, P = 0.001) and quiet fetal movements after eating (47.4% vs 32.0%, P = 0.001).

CONCLUSIONS

In women with obesity compared to normal BMI, strength and frequency of fetal movements were similar, although patterns were altered in relation to maternal meals.

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.

Effect of the use of a national information brochure about fetal movements on patient delay

BACKGROUND

Perinatal audits in the Netherlands showed that stillbirth was nearly always preceded by a period of reduced fetal movements. Patient or caregiver delay was identified as a substandard care factor.

AIM

To determine whether the use of a new information brochure for pregnant women on fetal movements results in less patient delay in contacting their maternity caregiver.

METHODS

A pre- and post-survey cohort study in the Netherlands, including 140 women in maternity care with a singleton pregnancy, expecting their first child. All participating women filled out a baseline questionnaire, Cambridge Worry Scale and pre-test questionnaire at the gestational age of 22-24 weeks. Subsequently, the intervention group received a newly developed information brochure on fetal movements. At a gestational age of 28 weeks, all women received the post-test questionnaire. Multiple regression analyses were used.

FINDINGS

Per-protocol analysis showed less patient delay in the intervention group compared to the control group (Odds Ratio 0.43; 95% Confidence Interval 0.17-0.86, p=0.02). A significant linear relation was observed between reading the information brochure and an increase of knowledge about fetal movements (B=1.2, 95% Confidence Interval 1.0-1.4, p<0.001). Maternal concerns did not affect patient delay to report reduced fetal movements.

CONCLUSION

Use of an information brochure regarding fetal movements has the potential to reduce patient delay and increase knowledge about reduced fetal movements. A national survey to determine the effect of an information brochure about reduced fetal movements on patient delay and stillbirth rates is needed.

Fetal movement frequency and the effect of associated perinatal factors: Multicenter study

BACKGROUND

Decreased fetal movements are associated with adverse perinatal outcomes, including stillbirth. Delayed maternal visits to a health care provider after perceiving decreased fetal movements are frequently observed in stillbirths. Informing pregnant women of the normal range of fetal movement frequency is essential in their earlier visits in order to prevent stillbirth.

AIM

To investigate the fetal movement frequency in late pregnancy and the effects of associated perinatal factors.

METHODS

This prospective multicenter study was conducted in 20 obstetric facilities in our region of Japan. A total of 2337 pregnant women were asked to record the time it took to perceive 10 fetal movements by the modified 'count to 10' method every day from 34weeks of gestation until delivery.

FINDINGS

The 90th percentile of the time for the maternal perception of 10 fetal movements was 18-29min, with a gradually increasing trend toward the end of pregnancy. The numbers of both pregnant women giving birth after 39weeks' gestation and infants with a birth weight exceeding 3000g were significantly higher in mothers who took ≥30min to count 10 fetal movements than in those who took <30min.

CONCLUSION

The maternal perception time of fetal movements shows a gradually increasing trend within 30min for 10 fetal movements by the modified 'count to 10' method. Informing pregnant women of the normal range of the fetal movement count time will help improve the maternal recognition of decreased fetal movements, which might prevent fetal death in late pregnancy.

Effect of the fetal movement count on maternal-fetal attachment

AIM

This study aimed to determine the effect of fetal movement counting on maternal-fetal attachment.

METHODS

This study was a randomized controlled trial, conducted with experimental and control groups, each including 55 pregnant women from six family health centers in the Malatya Province, located in the east of Turkey. The data were collected by using a Personal Information Form and the Maternal Antenatal Attachment Scale. Training for fetal movement counting was provided to the experimental group. The pre- and posttraining maternal-fetal attachment levels of the experimental group (fetal movements that were regularly counted for 4 weeks) and the control group (continual routine monitoring) were compared.

RESULTS

In the pretraining pretest, no difference was found between the maternal-fetal attachment scores of the experimental and the control groups, whereas the maternal-fetal attachment score of the experimental group was found to be higher than that of the control group in the post-test that was applied 4 weeks later.

CONCLUSION

This research indicated that fetal movement counting positively affected maternal-fetal attachment.

Understanding the associations and significance of fetal movements in overweight or obese pregnant women: a systematic review

INTRODUCTION

Presentation with decreased fetal movement (DFM) is associated with fetal growth restriction and stillbirth. Some studies report that DFM is frequent among overweight or obese mothers. We aimed to determine the significance and associations of fetal movements in women of increased body size.

MATERIAL AND METHODS

This systematic review was conducted in accordance with the PRISMA statement and the protocol was registered with PROSPERO (CRD42016046352). Major databases were explored from inception to September 2017, using a predefined search strategy. We restricted inclusion to studies published in English and considered studies of any design that compared fetal movements in women of increased and normal body size. Two authors independently extracted data and assessed quality.

RESULTS

We included 23 publications from 19 observational studies; data were extracted from 10 studies. Increased maternal body size was not associated with altered perception of fetal movement (four studies, 95 women, very low-quality evidence), but was associated with increased presentation for DFM (two cohort studies, 20 588 women, OR 1.56, 95% CI 1.27-1.92: three case-control studies, 3445 women, OR 1.32, 95% CI 1.12-1.54; low-quality evidence). Among women with DFM, increased maternal body size was associated with increased risk of stillbirth and fetal growth restriction (one study, 2168 women, very low-quality evidence).

CONCLUSIONS

This systematic review identified limited evidence that women with increased body size are more likely to present with DFM but do not have impaired perception of fetal movements. In women with DFM, increased body size is associated with worse pregnancy outcome, including stillbirth.

Can promoting awareness of fetal movements and focusing interventions reduce fetal mortality? A stepped-wedge cluster randomised trial (AFFIRM)

BACKGROUND

In 2013, the stillbirth rate in the UK was 4.2 per 1000 live births, ranking 24th out of 49 high-income countries, with an annual rate of reduction of only 1.4% per year. The majority of stillbirths occur in normally formed infants, with (retrospective) evidence of placental insufficiency the most common clinical finding. Maternal perception of reduced fetal movements (RFM) is associated with placental insufficiency and increased risk of subsequent stillbirth.This study will test the hypothesis that the introduction of a package of care to increase women's awareness of the need for prompt reporting of RFM and standardised management to identify fetal compromise with timely delivery in confirmed cases, will reduce the rate of stillbirth. Following the introduction of a similar intervention in Norway the odds of stillbirth fell by 30%, but the efficacy of this intervention (and possible adverse effects and implications for service delivery) has not been tested in a randomised trial.

METHODS

We describe a stepped-wedge cluster trial design, in which participating hospitals in the UK and Ireland will be randomised to the timing of introduction of the care package. Outcomes (including the primary outcome of stillbirth) will be derived from detailed routinely collected maternity data, allowing us to robustly test our hypothesis. The degree of implementation of the intervention will be assessed in each site. A nested qualitative study will examine the acceptability of the intervention to women and healthcare providers and identify process issues including barriers to implementation.

ETHICS AND DISSEMINATION

Ethical approval was obtained from the Scotland A Research Ethics Committee (Ref 13/SS/0001) and from Research and Development offices in participating maternity units. The study started in February 2014 and delivery of the intervention completed in December 2016. Results of the study will be submitted for publication in peer-reviewed journals and disseminated to local investigating sites to inform education and care of women presenting with RFM.

TRIAL REGISTRATION NUMBER

www.clinicaltrials.gov NCT01777022.

VERSION

Protocol Version 4.2, 3 February 2017.

Causes and temporal changes in nationally collected stillbirth audit data in high-resource settings

Few high-income countries have an active national programme of stillbirth audit. From the three national programmes identified (UK, New Zealand, and the Netherlands) steady declines in annual stillbirth rates have been observed over the audit period between 1993 and 2014. Unexplained stillbirth remains the largest group in the classification of stillbirths, with a decline in intrapartum-related stillbirths, which could represent improvements in intrapartum care. All three national audits of stillbirths suggest that up to half of all reviewed stillbirths have elements of care that failed to follow standards and guidance. Variation in the classification of stillbirth, cause of death and frequency of risk factor groups limit our ability to draw meaningful conclusions as to the true scale of the burden and the changing epidemiology of stillbirths in high-income countries. International standardization of these would facilitate direct comparisons between countries. The observed declines in stillbirth rates over the period of perinatal audit, a possible consequence of recommendations for improved antenatal care, should serve to incentivise other countries to implement similar audit programmes.

Excessively delayed maternal reaction after their perception of decreased fetal movements in stillbirths: Population-based study in Japan

BACKGROUND

Fetal movement is the most common method to evaluate fetal well-being. Furthermore, maternal perception of decreased fetal movements is associated with perinatal demise. Previously, we showed that perception of decreased fetal movements was the most common reason for mothers visiting the outpatient department among those who had stillbirths in our region. Further investigation of stillbirths with decreased fetal movements is essential to find a possible way of preventing stillbirth.

AIM

To investigate maternal reaction time after their perceiving decreased fetal movements among stillbirths in our region of Japan.

METHODS

This is a population-based study of stillbirths in Shiga Prefecture, Japan conducted from 2007 to 2011. We sent a questionnaire to each obstetrician who had submitted the stillbirth certificate. We reviewed and evaluated the questionnaires returned from the obstetricians.

FINDINGS

There were 66 cases (35%) with decreased fetal movements among 188 stillbirths in Shiga during the study period. The number of maternal visits to outpatient department after perception of decreased fetal movements within 24h was only seven (11%) among 64 stillbirths diagnosed at outpatient department.

CONCLUSION

We conclude that delayed maternal visit after perceiving decreased fetal movements is frequently observed in stillbirths. Promoting more thorough maternal education on fetal movements, including emphasizing earlier visitation after perceiving decreased fetal movements, may prevent stillbirths.

The effect of mobile application interventions on influencing healthy maternal behaviour and improving perinatal health outcomes: a systematic review protocol

BACKGROUND

Perinatal morbidity and mortality remain significant public health issues globally, with enduring impact on the health and well-being of women and their families. Pregnant women who adopt, practice and maintain healthy behaviours can potentially improve the health of themselves and their babies. Mobile applications are an increasingly popular mode of accessing, storing and sharing health information among pregnant women. The main objective of this review is to evaluate the effects of mobile application interventions during pregnancy on maternal behaviour and associated maternal and infant outcomes.

METHODS

This review will include randomised and non-randomised studies which tested use of mobile applications designed to improve either maternal knowledge or behaviours to address known risk factors associated with adverse perinatal health outcomes. This review will include studies which included pregnant women and/or women during birth. The search strategy will utilise a combination of keywords and MeSH terms. Literature databases such as PubMed, Embase, The Cochrane Library, CINAHL and WHO Global Health Library will be searched. Two reviewers will independently screen retrieved citations to determine if they meet inclusion criteria. Studies will be selected that provide information about interventions commenced in early pregnancy, late pregnancy or labour. Comparisons to be made include mobile applications versus interventions relying on paper-based or text-messaging-based communication; interpersonal communication such as face-to-face or telephone conversation; and no intervention or standard care. Quality assessment of included randomised studies will utilise established guidelines provided in the Cochrane Handbook for Systematic Reviews of Interventions. Quality assessment of non-randomised studies will be based on the Risk of Bias in Non-randomised Studies-of Interventions (ROBINS-I) assessment tool. Quality of the evidence will be evaluated using the Grades of Recommendation, Assessment, Development and Evaluation (GRADE) approach. Separate comparisons and analyses for primary and secondary outcomes will be performed. Results of the review will be reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

DISCUSSION

This systematic review will identify and synthesize evidence about the effect of interventions delivered through mobile applications on influencing maternal behaviour and improving perinatal health outcomes.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42016037344 .

The effect of foetal movement counting on maternal anxiety: A randomised, controlled trial

This study assessed the effect of foetal movement counting on maternal anxiety. In a randomised, controlled trial, 208 primigravida women with a singleton pregnancy were allocated either to perform daily foetal movement counting (n100) from 28 weeks ’ gestation or to follow standard Iranian antenatal care (n108). Maternal anxiety was measured by Spielberger State-Trait Anxiety Inventory. Statistical analysis was performed by SPSS (16.0). There was no significant difference in mean state and trait anxiety scores at 28 weeks ’ gestation; the difference was significant at 37 weeks ’ gestation in state anxiety score between the intervention and control groups (35.34 9.98 vs. 38.25 9.63, respectively, P0.001). A significant difference was found in mean trait anxiety score at 37 weeks ’ gestation between the two groups (35.88 8.19 vs. 39.15 9.25, respectively, P 0.008). Women who performed foetal movement counting from 28 to 37 weeks ’ gestation reported less anxiety compared with those in control group.

Fetal movements: What are we telling women?

PROBLEM

Information that women receive about the importance of monitoring fetal movements and what to do if there are changes is inconsistent and may not be evidence based.

BACKGROUND

This paper reports a summary of the kind of messages a group of South Australian midwives (n=72) currently give pregnant women.

METHODS

Comment data from two questions in a larger survey asking (1) what information midwives routinely provide to women about fetal movements and (2) their practice regarding advice they give to women reporting reduced fetal movements. Data were analysed using summative content analysis.

FINDINGS

Four main recurring words and phrases were identified. With respect to information midwives give all women about monitoring fetal movements, recurring words were "10", "normal", "kick charts" and "when to contact" their care-provider. Recurrent words and phrases arising from answers to the second question about advice midwives give to women reporting reduced fetal movement were "ask questions," "suggest fluids," "monitor at home and call back" or "come in for assessment".

DISCUSSION

These findings suggest that a group of South Australian midwives are providing pregnant women with inconsistent information, often in conflict with best practice evidence.

CONCLUSION

As giving correct, evidence based information about what to do in the event of an episode of reduced fetal movement may be a matter of life or death for the unborn baby it is important that midwives use existing guidelines in order to deliver consistent information which is based on current evidence to women in their care.

To be taken seriously and receive rapid and adequate care - Womens' requests when they consult health care for reduced fetal movements

BACKGROUND

decreased fetal movement is a reason for women to seek health care in late pregnancy.

OBJECTIVE

to examine what pregnant women who present with decreased fetal movements want to communicate to health care professionals and to other women in the same situation.

DESIGN

a qualitative descriptive study.

SETTING AND PARTICIPANTS

questionnaires were distributed in all seven labour wards in Stockholm from 1 January to 31 December 2014 to women who consulted care due to decreased fetal movements. In total, 3555 questionnaires were completed of which 1 000 were included in this study. The women's responses to the open ended question: "Is there something you want to communicate to health care professionals who take care of women with decreased fetal movement or to women who experience decreased fetal movements?", were analysed with manifest content analysis.

FINDING

three categories were revealed about requests to health care professionals: Pay attention to the woman and take her seriously, Rapid and adequate care and Improved information on fetal movements. Regarding what the women want to communicate to other pregnant women, four categories were revealed: Contact health care for check-up, Pay attention to fetal movement, Recommended source of information and Practical advice.

CONCLUSION

pregnant women who consult health care due to decreased fetal movements want to be taken seriously and receive rapid and adequate care with the health of the infant as the primary priority. The women requested uniform information about decreased fetal movements. They wished to convey to others in the same situation the importance of consulting care once too often rather than one time too few.

The Effects of Fetal Movement Counting on Pregnancy Outcomes

INTRODUCTION

Counting fetal movements may lead to timely assess fetal health and prevent the adverse effects of pregnancy.

AIM

The aim of this study was to determine the effect of fetal movement counting on pregnancy outcomes.

MATERIALS AND METHODS

In a randomized controlled trial, 208 women with singleton pregnancy were randomly divided into two groups of fetal movement counting and control. Pregnancy outcomes were compared between the two groups. Data were analysed with SPSS and p<0.05 was considered significant.

RESULTS

There was no significant difference in the mean maternal concern (p=0.36), admission to hospital due to the decreased fetal movements (p=0.99), birth weight (p=0.21), Apgar score (p=0.51), the mean of gestational age at the time of decreased fetal movements (p=0.49) and mode of delivery (p=0.69) between the two groups. There were no cases of premature labour, intrauterine growth retardation and fetal death in the two groups.

CONCLUSION

Pregnancy outcome was similar in the two groups of fetal movement counting and control. Further studies are needed to evaluate the effect of fetal movement counting on the major outcomes of pregnancy such as intrauterine fetal death.

[Maternal knowledge of fetal movements in late pregnancy]

OBJECTIVES

Evaluate knowledge of patients with late pregnancy on active foetal movements.

PATIENTS AND METHOD

This prospective study has been carried out with volontary patients during the 41-week of gestation term consultation, with a questionnaire, at the obstetric gynecology departments of St-Etienne Hospital (CHU), Clermont-Ferrand Hospital (CHU), Roanne Hospital (CH) and Firminy Hospital (CH), from July 22nd, 2013 to September 14th, 2014.

RESULTS

Few patients (17%) have been seen urgently by an obstetrician or a midwife in case of a decrease of the active foetal movements. Most patients (73.6%) wait 24hours to consult. More than 50% of women have not been informed on this topic before the birth. However, 86.84% of the patients are interested in being informed when they see their doctor. The easiest way would be to count the active foetal movements 3 times a day on a short period.

CONCLUSION

There is still a lack of information on the active foetal movements. It remains a difficult topic because its definition is still subjective and the information has no protocol.

Wavelet principal component analysis of fetal movement counting data preceding hospital examinations due to decreased fetal movement: a prospective cohort study

Background

Fetal movement (FM) counting is a simple and widely used method of assessing fetal well-being. However, little is known about what women perceive as decreased fetal movement (DFM) and how maternally perceived DFM is reflected in FM charts.

Methods

We analyzed FM counting data from 148 DFM events occurring in 137 pregnancies. The women counted FM daily from pregnancy week 24 until birth using a modified count-to-ten procedure. Common temporal patterns for the two weeks preceding hospital examination due to DFM were extracted from the FM charts using wavelet principal component analysis; a statistical methodology particularly developed for modeling temporal data with sudden changes, i.e. spikes that are frequently found in FM data. The association of the extracted temporal patterns with fetal complications was assessed by including the individuals’ scores on the wavelet principal components as explanatory variables in multivariable logistic regression analyses for two outcome measures: (i) complications identified during DFM-related consultations (n = 148) and (ii) fetal compromise at the time of consultation (including relevant information about birth outcome and placental pathology). The latter outcome variable was restricted to the DFM events occurring within 21 days before birth (n = 76).

Results

Analyzing the 148 and 76 DFM events, the first three main temporal FM counting patterns explained 87.2% and 87.4%, respectively, of all temporal variation in the FM charts. These three temporal patterns represented overall counting times, sudden spikes around the time of DFM events, and an inverted U-shaped pattern, explaining 75.3%, 8.6%, and 3.3% and 72.5%, 9.6%, and 5.3% of variation in the total cohort and subsample, respectively. Neither of the temporal patterns was significantly associated with the two outcome measures.

Conclusions

Acknowledging that sudden, large changes in fetal activity may be underreported in FM charts, our study showed that the temporal FM counting patterns in the two weeks preceding DFM-related consultation contributed little to identify clinically important changes in perceived FM. It thus provides insufficient information for giving detailed advice to women on when to contact health care providers. The importance of qualitative features of maternally perceived DFM should be further explored.

Placental pathology in pregnancies with maternally perceived decreased fetal movement--a population-based nested case-cohort study

Background

Decreased fetal movements (DFM) are associated with fetal growth restriction and stillbirth, presumably linked through an underlying placental dysfunction. Yet, the role of placental pathology has received limited attention in DFM studies. Our main objective was to explore whether maternal perceptions of DFM were associated with placental pathology in pregnancies recruited from a low-risk total population.

Methods/Principal Findings

Placentas from 129 DFM and 191 non-DFM pregnancies were examined according to standardized macro- and microscopic protocols. DFM was defined as any maternal complaint of DFM leading to a hospital examination. Morphological findings were timed and graded according to their estimated onset and clinical importance, and classified in line with a newly constructed Norwegian classification system for reporting placental pathology. With our population-based approach we were unable to link DFM to an overall measure of all forms of placental pathology (OR 1.3, 95% CI 0.8–2.2, p = 0.249). However, placental pathology leading to imminent delivery could be a competing risk for DFM, making separate subgroup analyses more appropriate. Our study suggests a link between DFM and macroscopic placental pathology related to maternal, uteroplacental vessels, i.e. infarctions, placental lesions (intraplacental hematomas) and abruptions. Although not statistically significant separately, a compound measure showed a significant association with DFM (OR 2.4, 95%CI 1.1–5.0, p = 0.023). This association was strengthened when we accounted for relevant temporal aspects. More subtle microscopic materno-placental ischemic changes outside the areas of localized pathology showed no association with DFM (OR 0.5, 95%CI 0.2–1.4, p = 0.203). There was a strong association between placental pathology and neonatal complications (OR 2.9, 95% CI 1.6–5.1, p<0.001).

Conclusions

In our population-based study we were generally unable to link maternally perceived DFM to placental pathology. Some associations were seen for subgroups.

Fetal movement counting--maternal concern and experiences: a multicenter, randomized, controlled trial

BACKGROUND

Fetal movement counting may improve timely identification of decreased fetal activity and thereby contribute to prevent adverse pregnancy outcomes, but it may also contribute to maternal concern. This study aimed to test whether fetal movement counting increased maternal concern.

METHODS

In a multicenter, controlled trial 1,013 women with a singleton pregnancy were randomly assigned either to perform daily fetal movement counting from pregnancy week 28 or to follow standard Norwegian antenatal care where fetal movement counting is not encouraged. The primary outcome was maternal concern, measured by the Cambridge Worry Scale. Analysis was by intention-to-treat.

RESULTS

The means and SDs on Cambridge Worry Scale scores were 0.77 (0.55) and 0.90 (0.62) for the intervention and the control groups, respectively, a mean difference between the groups of 0.14 (95% CI: 0.06-0.21, p<0.001). Decreased fetal activity was of concern to 433 women once or more during pregnancy, 45 and 42 percent in the intervention and control groups, respectively (relative risk=1.1, 95% CI: 0.9-1.2). Seventy-nine percent of the women responded favorably to the use of counting charts.

CONCLUSIONS

Women who performed fetal movement counting in the third trimester reported less concern than those in the control group. The frequency of maternal report of concern about decreased fetal activity was similar between the groups. Most women considered the use of a counting chart to be positive.

Fetal movement counting improved identification of fetal growth restriction and perinatal outcomes--a multi-centre, randomized, controlled trial

Background

Fetal movement counting is a method used by the mother to quantify her baby's movements, and may prevent adverse pregnancy outcome by a timely evaluation of fetal health when the woman reports decreased fetal movements. We aimed to assess effects of fetal movement counting on identification of fetal pathology and pregnancy outcome.

Methodology

In a multicentre, randomized, controlled trial, 1076 pregnant women with singleton pregnancies from an unselected population were assigned to either perform fetal movement counting from gestational week 28, or to receive standard antenatal care not including fetal movement counting (controls). Women were recruited from nine Norwegian hospitals during September 2007 through November 2009. Main outcome was a compound measure of fetal pathology and adverse pregnancy outcomes. Analysis was performed by intention-to-treat.

Principal Findings

The frequency of the main outcome was equal in the groups; 63 of 433 (11.6%) in the intervention group, versus 53 of 532 (10.7%) in the control group [RR: 1.1 95% CI 0.7–1.5)]. The growth-restricted fetuses were more often identified prior to birth in the intervention group than in the control group; 20 of 23 fetuses (87.0%) versus 12 of 20 fetuses (60.0%), respectively, [RR: 1.5 (95% CI 1.0–2.1)]. In the intervention group two babies (0.4%) had Apgar scores <4 at 1 minute, versus 12 (2.3%) in the control group [RR: 0.2 (95% CI 0.04–0.7)]. The frequency of consultations for decreased fetal movement was 71 (13.1%) and 57 (10.7%) in the intervention and control groups, respectively [RR: 1.2 (95% CI 0.9–1.7)]. The frequency of interventions was similar in the groups.

Conclusions

Maternal ability to detect clinically important changes in fetal activity seemed to be improved by fetal movement counting; there was an increased identification of fetal growth restriction and improved perinatal outcome, without inducing more consultations or obstetric interventions.

Trial Registration

ClinicalTrials.govNCT00513942

Fetal movement counting--effects on maternal-fetal attachment: a multicenter randomized controlled trial

BACKGROUND

  Women presenting with decreased fetal movement have an increased risk of adverse pregnancy outcomes. Fetal movement counting may be associated with improvement in maternal-fetal attachment, which in turn, improves pregnancy outcome and postnatal mother-infant attachment. The study aim was to test whether maternal-fetal attachment differed between groups of mothers who systematically performed fetal movement counting and mothers who followed standard antenatal care where routine fetal movement counting was discouraged.

METHODS

  In a multicenter, randomized trial, 1,123 women were assigned to either systematic fetal movement counting from pregnancy week 28 or to standard antenatal care. This study sample included primarily white, cohabiting, nonsmoking, and relatively well-educated women. The outcome measure was maternal-fetal attachment, measured by using the Prenatal Attachment Inventory. Analysis was by intention-to-treat.

RESULTS

  No difference was found between the groups in the scores on prenatal attachment; the means and standard deviations were 59.54 (9.39) and 59.34 (9.75) [corrected] for the intervention and the control groups, respectively (p = 0.747). The mean difference between the groups was 0.20 (95% CI: -1.02-1.42) [corrected].

CONCLUSIONS

  Fetal movement counting in the third trimester does not stimulate antenatal maternal-fetal attachment. This result differs from a previous study where fetal movement counting improved maternal-fetal attachment. Further research with a focus on possible mediating factors such as levels of stress, concern, and other psychological factors is required.

Screening and triage of intrauterine growth restriction (IUGR) in general population and high risk pregnancies: a systematic review with a focus on reduction of IUGR related stillbirths

BACKGROUND

There is a strong association between stillbirth and fetal growth restriction. Early detection and management of IUGR can lead to reduce related morbidity and mortality. In this paper we have reviewed effectiveness of fetal movement monitoring and Doppler velocimetry for the detection and surveillance of high risk pregnancies and the effect of this on prevention of stillbirths. We have also reviewed effect of maternal body mass index (BMI) screening, symphysial-fundal height measurement and targeted ultrasound in detection and triage of IUGR in the community.

METHODS

We systematically reviewed all published literature to identify studies related to our interventions. We searched PubMed, Cochrane Library, and all World Health Organization Regional Databases and included publications in any language. Quality of available evidence was assessed using GRADE criteria. Recommendations were made for the Lives Saved Tool (LiST) based on rules developed by the Child Health Epidemiology Group. Given the paucity of evidence related to the effect of detection and management of IUGR on stillbirths, we undertook Delphi based evaluation from experts in the field.

RESULTS

There was insufficient evidence to recommend against or in favor of routine use of fetal movement monitoring for fetal well being. (1) Detection and triage of IUGR with the help of (1a) maternal BMI screening, (1b) symphysial-fundal height measurement and (1c) targeted ultrasound can be an effective method of reducing IUGR related perinatal morbidity and mortality. Pooled results from sixteen studies shows that Doppler velocimetry of umbilical and fetal arteries in 'high risk' pregnancies, coupled with the appropriate intervention, can reduce perinatal mortality by 29 % [RR 0.71, 95 % CI 0.52-0.98]. Pooled results for impact on stillbirth showed a reduction of 35 % [RR 0.65, 95 % CI 0.41-1.04]; however, the results did not reach the conventional limits of statistical significance. This intervention could be potentially recommended for high income settings or middle income countries with improving rates and standards of facility based care. Based on the Delphi, a combination of screening with maternal BMI, Symphysis fundal height and targeted ultrasound followed by the appropriate management could potentially reduce antepartum and intrapartum stillbirth by 20% respectively. This estimate is presently being recommended for inclusion in the LiST.

CONCLUSION

There is insufficient evidence to recommend in favor or against fetal movement counting for routine use for testing fetal well being. Doppler velocimetry of umbilical and fetal arteries and appropriate intervention is associated with 29 % (95 % CI 2% to 48 %) reduction in perinatal mortality. Expert opinion suggests that detection and management of IUGR with the help of maternal BMI, symphysial-fundal height measurement and targeted ultrasound could be effective in reducing IUGR related stillbirths by 20%.

Fetal movements in the third trimester--Important information about wellbeing of the fetus

It can be quite natural for pregnant women to believe that a decrease in the frequency of fetal movements at the end of pregnancy is normal if they have been so informed. There is also probably scope for interpretation concerning what is to be regarded as a decrease in the number of movements. Non-evidence-based information that a decrease in fetal movements is normal during the third trimester poses a threat to the unborn baby's life. If the mother does not react to a decrease in frequency and if she waits too long before contacting healthcare professionals, the window of opportunity to save the baby's life may be closed.