Women's attitudes, experiences and compliance concerning the use of Mindfetalness- a method for systematic observation of fetal movements in late pregnancy

Are reduced fetal movements "merely" a maternal perception or truly a reflection of umbilical cord complications? A clinical trial

OBJECTIVE

To characterize obstetric outcomes and the association with umbilical cord (UC) complications among women complaining of reduced fetal movements (RFMs).

METHODS

This retrospective cohort compared women with a perception of RFMs within 2 weeks prior to delivery with women who reported no changes in fetal movements in terms of maternal characteristics and neonatal outcomes. A primary outcome of UC complications at delivery was defined. Multivariable regression analysis was performed to identify independent associations with RFMs and UC complications.

RESULTS

In all, 46 103 women were included, 2591 (5.6%) of whom reported RFMs and 43 512 (94.4%) in the control group. Compared with controls, the RFM group was more likely to be nulliparous (42.6% vs 32.2%, P < 0.001), smokers (6.4% vs 5.4%, P = 0.029), or obese (body mass index >30) (16.4% vs 11.6%, P < 0.001). They were also more likely to have an anterior placenta (56.2% vs 51.8%, P < 0.001) and poly/oligohydramnios (0.7% vs 0.4%, P = 0.015 and 3.6% vs 2.1%, P < 0.001, respectively). Induction of labor was more common in the RFM group (33.9% vs 19.7%, P < 0.001), as well as meconium (16.8% vs 15.0%, P = 0.026) and vacuum extractions (10.1% vs 8.0%, P < 0.001). Higher rates of stillbirth and the severe composite neonatal outcome were observed in the RFM group (1.5% vs 0.2%, P < 0.001 and 0.6% vs 0.3%, P = 0.010, respectively). The RFM group was characterized by higher rates of triple nuchal cord (P = 0.015), UC around body or neck (32.2% vs 29.6%, P = 0.010), and true knot (2.3% vs 1.4%, P = 0.002). Multivariable logistic regression found RFMs to be independently associated with triple nuchal cord and with a true cord knot. A sub-analysis including only cases of stillbirth (n = 127) revealed even higher rates of UC complications: 7% of all stillbirths presented with a true cord knot (20% true knots were found in stillbirths preceded by RFMs vs 6.1% in stillbirth cases without RFMs). Additionally, 33.8% of all stillbirths presented with nuchal cord (40% preceded by RFMs vs 33.3% without RFMs).

CONCLUSIONS

RFMs are associated with increased risk of UC complications observed at delivery, as well as increased risk of stillbirth and neonatal adverse outcomes.

Epidural use among women with spontaneous onset of labour - an observational study using data from a cluster-randomised controlled trial

OBJECTIVE

To investigate whether the proportion of pregnant women who use epidural analgesia during birth differed between women registered at a maternity clinic randomised to Mindfetalness or to routine care.

DESIGN

An observational study including women born in Sweden with singleton pregnancies, with spontaneous onset of labour from 32 weeks' gestation. Data used from a cluster-randomised controlled trial applying the intention-to-treat principle in 67 maternity clinics where women were randomised to Mindfetalness or to routine care. ClinicalTrials.gov (NCT02865759).

INTERVENTIONS

Midwives were instructed to distribute a leaflet about Mindfetalness to pregnant women at 25 weeks' gestation. Mindfetalness is a self-assessment method for the woman to use to become familiar with the unborn baby's fetal movement pattern. When practising the method in third trimester, the women are instructed to daily lie down on their side, when the baby is awake, and focus on the movements' intensity, character and frequency (but not to count each movement).

FINDINGS

Of the 18 501 women with spontaneous onset of labour, 47 percent used epidural during birth. Epidural was used to a lower extent among women registered at a maternity clinic randomised to Mindfetalness than women in the routine-care group (46.2% versus 47.8%, RR 0.97, CI 0.94-1.00, p= 0.04). Epidural was more common among primiparous women, women younger than 35 years, those with educational levels below university, with BMI ≥25 and with a history of receiving psychiatric care or psychological treatment for mental illness.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

Pregnant women who were informed about a self-assessment method, with the aim of becoming familiar with the unborn baby's fetal movement pattern, used epidural to a lower extent than women who were not informed about the method. Future studies are needed to investigate and understand the association between Mindfetalness and the reduced usage of epidural during birth.

Country of birth, educational level and other predictors of seeking care due to decreased fetal movements: an observational study in Sweden using data from a cluster-randomised controlled trial

OBJECTIVES

To identify predictors of seeking care for decreased fetal movements and assess whether care-seeking behaviour is influenced by Mindfetalness.

DESIGN

Observational study with data from a cluster-randomised controlled trial.

SETTING

67 maternity clinics and 6 obstetrical clinics in Sweden.

PARTICIPANTS

All pregnant women with a singleton pregnancy who contacted the obstetrical clinic due to decreased fetal movements from 32 weeks' gestation of 39 865 women.

METHODS

Data were collected from a cluster-randomised controlled trial where maternity clinics were randomised to Mindfetalness or routine care. Mindfetalness is a self-assessment method for women to use daily to become familiar with the unborn baby's fetal movement pattern.

OUTCOME MEASURES

Predictors for contacting healthcare due to decreased fetal movements.

RESULTS

Overall, 5.2% (n=2059) of women contacted healthcare due to decreased fetal movements, among which 1287 women (62.5%) were registered at a maternity clinic randomised to Mindfetalness and 772 women (37.5%) were randomised to routine care. Predictors for contacting healthcare due to decreased fetal movements were age, country of birth, educational level, parity, prolonged pregnancy and previous psychiatric care (p<0.001). The main differences were seen among women born in Africa as compared with Swedish-born women (2% vs 6%, relative risk (RR) 0.34, 95% CI 0.25 to 0.44) and among women with low educational level compared with women with university-level education (2% vs 5.4%, RR 0.36, 95% CI 0.19 to 0.62). Introducing Mindfetalness in maternity care increased the number of women seeking care due to decreased fetal movements overall.

CONCLUSION

Women with country of birth outside Sweden and low educational level sought care for decreased fetal movements to a lesser extent compared with women born in Sweden and those with university degrees. Future research could explore whether pregnancy outcomes can be improved by motivating women in these groups to contact healthcare if they feel a decreased strength or frequency of fetal movements.

TRIAL REGISTRATION NUMBER

NCT02865759.

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.

Pregnancy outcomes among women born in Somalia and Sweden giving birth in the Stockholm area - a population-based study

Background

Studies report that women born in some African countries, after migrating to the Nordic countries, have worse pregnancy outcomes than women born in the receiving countries. With the aim of identifying unmet needs among Somali-born women, we here study this subgroup.

Objective

We compared pregnancy outcomes among women born in Somalia to women born in Sweden. Further, we investigated whether the proactive maternal observation of fetal movements has effects on birth outcomes among women born in Somalia.

Methods

In Stockholm, half of the maternity clinics were randomized to intervention, in which midwives were instructed to be proactive towards women by promoting daily self-monitoring of fetal movements. Data for 623 women born in Somalia and 26 485 born in Sweden were collected from a population-based register.

Results

An Apgar score below 7 (with stillbirth counting as 0) at 5 minutes was more frequent in babies of women born in Somalia as compared to babies of women born in Sweden (RR 2.17, 95% CI 1.25–3.77). Babies born small for gestational age were more common among women born in Somalia (RR 2.22, CI 1.88–2.61), as were babies born after 41 + 6 gestational weeks (RR 1.65, CI 1.29–2.12). Somali-born women less often contacted obstetric care for decreased fetal movements than did Swedish-born women (RR 0.19, CI 0.08–0.36). The differences between women born in Somalia and women born in Sweden were somewhat lower (not statistically significant) among women allocated to proactivity as compared to the Routine-care group.

Conclusions

A higher risk of a negative outcome for mother and baby is seen among women born in Somalia compared to women born in Sweden. We suggest it may be worthwhile to investigate whether a Somali-adapted intervention with proactivity concerning self-monitoring of fetal movements may improve pregnancy outcomes in this migrant population.

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.

A decrease in cesarean sections and labor inductions among Swedish women by awareness of fetal movements with the Mindfetalness method

Background

Maternal perception of decreased fetal movements is commonly used to assess fetal well-being. However, there are different opinions on whether healthcare professionals should encourage maternal observation of fetal movements, as researchers claim that raising awareness increases unnecessary interventions, without improving perinatal health. We aimed to investigate whether cesarean sections and labor induction increase by raising women’s awareness of fetal movements through Mindfetalness. Further, we aimed to study perinatal health after implementing Mindfetalness in maternity care.

Methods

In a cluster randomized controlled trial, 67 maternity clinics were allocated to Mindfetalness or routine care. In the Mindfetalness group, midwives distributed a leaflet telling the women to focus on the character, strength and frequency of the fetal movements without counting each movement. The instruction was to do so for 15 min daily when the fetus was awake, from gestational week 28 until birth. In this sub-group analysis, we targeted women born in Sweden giving birth from 32 weeks’ gestation. We applied the intention-to-treat principle.

Results

The Mindfetalness group included 13,029 women and the Routine-care group 13,456 women. Women randomized to Mindfetalness had less cesarean sections (18.4% vs. 20.0%, RR 0.92, CI 0.87–0.97) and labor inductions (19.2% vs. 20.3%, RR 0.95, CI 0.90–0.99) compared to the women in the Routine-care group. Less babies were born small for gestational age (8.5% vs. 9.3%, RR 0.91, CI 0.85–0.99) in the Mindfetalness group. Women in the Mindfetalness group contacted healthcare due to decreased fetal movements to a higher extent than women in the Routine care group (7.8% vs. 4.3%, RR 1.79, CI 1.62–1.97). The differences remain after adjustment for potential confounders.

Conclusions

Raising awareness about fetal movements through Mindfetalness decreased the rate of cesarean sections, labor inductions and small-for-gestational age babies.

Trial registration

ClinicalTrials.gov (NCT02865759). Registered 12 August 2016, www.clinicaltrials.gov.

Mindfetalness to increase women's awareness of fetal movements and pregnancy outcomes: a cluster-randomised controlled trial including 39 865 women

OBJECTIVE

To examine whether a method for raising women's awareness of fetal movements, Mindfetalness, can affect pregnancy outcomes.

DESIGN

Cluster-randomised controlled trial.

SETTING

Sixty-seven maternity clinics in Stockholm, Sweden.

POPULATION

Women with singleton pregnancy with birth from 32 weeks' gestation.

METHODS

Women registered at a clinic randomised to Mindfetalness were assigned to receive a leaflet about Mindfetalness (n = 19 639) in comparison with routine care (n = 20 226). Data were collected from a population-based register.

MAIN OUTCOME MEASURES

Apgar score <7 at 5 minutes after birth, visit to healthcare due to decrease in fetal movements. Other outcomes: Apgar score <4 at 5 minutes after birth, small-for-gestational-age and mode of delivery.

RESULTS

No difference (1.1 versus 1.1%, relative risk [RR] 1.0; 95% CI 0.8-1.2) was found between the Mindfetalness group and the Routine care group for a 5-minute Apgar score <7. Women in the Mindfetalness group contacted healthcare more often due to decreased fetal movements (6.6 versus 3.8%, RR 1.72; 95% CI 1.57-1.87). Mindfetalness was associated with a reduction of babies born small-for-gestational-age (RR 0.95, 95% CI 0.90-1.00), babies born after gestational week 41⁺⁶ (RR 0.91, 95% CI 0.83-0.98) and caesarean sections (19.0 versus 20.0%, RR 0.95; 95% CI 0.91-0.99).

CONCLUSIONS

Mindfetalness did not reduce the number of babies born with an Apgar score <7. However, Mindfetalness was associated with the health benefits of decreased incidence of caesarean section and fewer children born small-for-gestational-age.

TWEETABLE ABSTRACT

Introducing Mindfetalness in maternity care decreased caesarean sections but had no effect on the occurrence of Apgar scores <7.

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.