Background
Methods
Inclusion criteria
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Participants: Pregnant women (at the time of participating in a study) of any parity or risk status who have reached gestational age of at least 20 weeks;
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Exposure: Expression of views, perceptions or experiences of assessing FMs during pregnancy. These expressions could be drawn from maternal subjective assessments or reports related to awareness of FMs, or from more structured methods of monitoring such as the use of ‘kick’ charts, or technical aids;
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Outcomes: Inductive dominant themes representative of women’s views, experiences, and perceptions of assessing FMs in pregnancy;
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Study type: Studies providing qualitative data of women’s perspectives of FMs in pregnancy. Qualitative studies of any design were eligible. Studies of mixed methods design, where qualitative data could be extracted separately, were included. Survey designs with open-ended questions that provided qualitative data were also considered for inclusion.
Search strategy
Quality assessment
Data extraction and synthesis
Assessment of confidence in the review findings; GRADE-CERQual
Results
Search and selection
Description of included studies
Reference | Aim | Year study conducted | Description of participants | Description of setting | Data collection method | Data analysis method |
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Akselsson 2017 [28] | To explore women’s attitudes, experiences and compliance concerning the practice of Mindfetalness in late pregnancy | 15 Feb −7 Jul 2016 | 104 women, 17–42 years of age, 28–32 weeks of pregnancy | Three maternity clinics in Stockholm, Sweden | Midwife administered questionnaire | Qualitative manifest content analysis |
To explore normal fetal activity in the third trimester as perceived by pregnant women themselves | Not stated | 19 low-risk nulliparous women, 19–34 years and ≥ 28 week’s gestation | Five community-based midwifery practices in a provincial city in the North Island of New Zealand | Interviews conducted in the third trimester at two time-points; 28–32 weeks and 37–41 weeks | Qualitative content analysis | |
Draper 1986 [31] | To report on the views of women on filling in fetal movement charts during pregnancy | 1982 and 1983 | 132 women, 27–37 weeks gestation | Community antenatal clinic in Cambridge | Interviews and postal questionnaire | Not stated |
To examine how women, who consulted health care due to RFM, describe how the baby had moved less or differently, and to explore why women decide to consult health care due to RFM and investigate reasons for delaying a consultation | Jan-Dec 2014 | 960 women of median age 32 years and ≥ 28 week’s gestation | Seven delivery wards in Stockholm, Sweden | Questionnaire with open-ended response options | Modified content analysis | |
McArdle 2015 [34] | To investigate sources pregnant women used to acquire information about FMs and their preferences for receiving this information | Dec 2011-Mar 2012 | 526 women of mean age 30.5 years and ≥ 32 week’s gestation | Antenatal clinic of a large metropolitan maternity hospital, Australia | Questionnaire with open-ended questions | Content analysis |
Pollock 2020 [35] | To explore the ANC experiences of Australian mothers who had recently had a live birth to determine their knowledge of FMs | May-Oct 2017. | 391 women, > 18 years of age who had given birth to a live baby within the last ten years | Australia | Online survey with open ended questions | Summative content analysis |
Rådestad & Lindgren 2012 [36] | To explore women’s perceptions of FMs in full-term pregnancy | 2011 | 40 women, 23–40 years old, between 37 + 2 and 41 + 5 week’s gestation | One antenatal clinic in the capital of Sweden | Interviews | Thematic analysis |
Raynes-Greenow, 2013 [37] | To examine maternal perception of normal FMs, and to describe FM advice in a routine antenatal care setting | Not stated | 156 women ≥28 weeks gestation of mean age 32 years | A major metropolitan tertiary referral hospital in Sydney, Australia | Self-administered questionnaire with open-ended questions | Thematic analysis |
Smyth 2016 [38] | To explore what triggers women to access health care after experiencing RFM and conversely what stops them | Aug 2012-Feb 2013 | 21 women of mean age 27 years, and gestation at time of RFM 32 weeks | Large teaching hospital in the North-West of England | Semi-structured interviews | Framework analysis |
Quality assessment
Author and year | Quality criteriaa met | A: Aims and objectives clearly reported B: Context of the research adequately described C: Sample and sampling methods described D: Data collection methods described E: Data analysis methods adequately described F: Reliable data collection tools established G: Valid data collection tools H: Reliable data analysis I: Valid of the data analysis J: Appropriate data collection methods used to allow for expression of views K: Used the appropriate methods for ensuring the analysis was grounded in the views L: Actively involved the participants in the design and conduct of the study |
Akselsson 2017 [28] | A, B, D, E, K | |
A, B, C, D, E, F, G, H, I, J, K | ||
Draper 1986 [31] | B, F, G | |
A, B, C, D, E, F, G, H, I, K | ||
McArdle 2015 [34] | A, B, C, D, E, F, G, H, I | |
Pollock 2020 [35] | A, B, C, D, E, G, H, I | |
Rådestad & Lindgren 2012 [36] | A, B, C, D, E, F, G, H, J, K | |
Raynes-Greenow 2013 [37] | A, B, C, D, E, F, G, H, I, K | |
Smyth 2016 [38] | A, B, C, D, E, F, G, H, I, J, K |
Findings
How women engage with FMs | Articulating and describing FMs | FMs and help/health seeking | |||||
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Informal engagement with FMs | Formal engagement with FMs | Strategies to stimulate FMs | Sensations associated with FMs | Timing and frequency of FMs | Information sources | Interactions withHCPs | |
Akselsson 2017 [28] | ✓ | ✓ | |||||
Bradford & Maude 2014 [29] | ✓ | ✓ | ✓ | ||||
Bradford & Maude 2018 [30] | ✓ | ✓ | ✓ | ✓ | ✓ | ||
Draper 1986 [31] | ✓ | ✓ | ✓ | ✓ | |||
Linde 2016 [32] | ✓ | ✓ | ✓ | ||||
Linde 2017 [33] | ✓ | ✓ | ✓ | ✓ | |||
McArdle 2015 [34] | ✓ | ✓ | |||||
Pollock 2020 [35] | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ |
Rådestad & Lindgren 2012 [36] | ✓ | ✓ | |||||
Raynes-Greenow 2013 [37] | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | |
Smyth 2016 [38] | ✓ | ✓ | ✓ | ✓ |
Theme 1: how women engage with FMs
Informal engagement with FMs
and, referring to feeling hungry, one woman describes how her baby gets ‘ … ..really wriggly and really squirmy’ but ‘feels a lot more comfortable after I’ve eaten’ ([29], p.4).‘I lie on my back instead of on the side, otherwise the baby protests because she/he doesn’t like the side ([29], p.3).‘ … she gets very excited before dinner time’ ([30], p.4).
Women also reported struggling to identify a pattern which made FM monitoring more difficult and interfered with women relaying information about FMs to clinicians. Expressed expectations of frequency and quantity of FMs also varied, ranging from a few times each day, to four per hour or at least 10 per hour. Women’s narratives also highlighted uncertainty around what they should expect of FMs;‘The baby has not moved at the times that she had moved earlier, following the pattern that she had previously … ..the movements felt weaker the past two days compared to before’ ([32], p.4).
Women subconsciously engaged with and monitored FMs from the beginning of their pregnancy. Some experienced doubt and uncertainty when attempting to identify first movements, finding it difficult to distinguish between actual FMs and other sensations, until a pattern or more consistent sensations became established;‘I would like to know the normal number of movements for babies of different gestations’ ([34], p.575).
For women, identifying their first FMs made their pregnancy and baby feel real, although initial sensations could be ‘a little unpleasant’ ([36], p.114). Informal monitoring of FMs also acted as a mechanism of communication between the mother and her baby [28‐30]. Women became more aware of the baby ‘as an individual’ and felt more ‘connected’; when FMs were visible and palpable, this experience of FMs could then be shared with family members; ‘my husband is also with me and listens, he has his hands on my tummy during this time’ ([28], p.4).‘It was just one little tiny movement and I wasn’t sure if it was, but then movements after that felt the same’ ([30], p.289).
Formal engagement with FMs
In contrast, women also felt that monitoring their babies’ FMs formally was very important so as ‘to gain an understanding over time of what is ‘normal’ for you and your baby’ ([34], p.33). These women were happy to complete a FM chart, and did not view it as an inconvenience [31]. Formal FM monitoring provided women with reassurances that their babies were kicking and that this meant that their baby was well. Some women stated that they felt more confident and less worried about FMs when a method of formally assessing them was used. This was especially so for women using Mindfetalness, where the characteristics of FMs, such as intensity and pattern, are noted;‘would have preferred to have been told to notice and report changes in her baby’s movements’ ([31], p.336).
‘I practice the method more when I get worried about fetal movements. Now, I’m not as worried as before” ([28], p.4)
Strategies to stimulate FMs
‘ … ..try to encourage movements, stand up, move around, have a sugar, citrus drink. If still no movements/reduced movements, go to hospital’ ([35], p, 81).
Theme 2: ‘ … like a feather inside my belly’ – articulating and describing FMs
Sensations associated with FMs
Women’s descriptions of FMs changed as pregnancy progressed. Descriptions of FMs at the start of the third trimester were varied [29, 30, 36, 37], with women describing more specific limb movements that were sometimes visible on the skin;‘ … it felt so jerky and I couldn’t imagine what it was doing, but now I have got used to feeling that way’ ([36], p.114).
These limb movements were described as ‘punchy’, with whole body movements described using a variety of terms from ‘smooth’ or soft ‘wriggling’ and ‘tapping’ movements to stronger ‘kicking’ or ‘swooping’ movements [30, 37]. As the baby reached term, women described movements as becoming less varied, slower, and stronger [29, 30, 36, 37];‘you can sometimes see the actual skin moving. I can’t tell what it is; like an elbow, knee or foot, but just seeing the skin move’ ([30], p.290)
Women interpreted these slower, stronger and altered FMs as the baby having less space as the end of pregnancy approached ‘as the baby gets bigger’ and ‘has less room to move’ ([37], p.5) although there appeared to be some confusion amongst women as to expectations of FMs towards term; ‘Close to birth … ..movements will less a bit’ [35] and ‘slow down’ because there is ‘less room’ [35, 37] versus ‘movements should not slow down towards the end of pregnancy even if the baby has less room’ ([35], p.5).‘like a film in slow motion … there is a lot of power, but everything is going slowly, gliding along. I imagine a wrestling match, maybe in slow motion. You see lots of power, but things move slowly’ ([36], p.114)
Timing and frequency of FMs
‘I haven't felt any kicking for about 12 hours’ ([32], p.3).‘When the activity had decreased and had not gone in the right direction after 2 days’ ([33], p.378).
Theme 3: FMs and help/health seeking
Information sources
Women also indicated a desire for specific information about monitoring FMs, such as information on movement counts/types/changes and when to seek advice [34, 35, 37]; although a preference for more general information about health and wellbeing rather than information that was specific to FMs only was also expressed ‘so as not to distress or cause too much anxiety’ ([35], p.82).‘a hand-out to read throughout pregnancy, so we can refresh our cloudy heads’ ([34], p.57).
Interacting with healthcare professionals
Reasons for contacting healthcare professionals due to a decrease or change in FMs included a defined period of time had passed with decreased or altered movement, although this varied from a few hours to a number of days, if the worry became unmanageable, when women experienced a fear of fetal loss, and when strategies to stimulate movements were unsuccessful [33, 34, 38]. Barriers to contacting healthcare professionals were mostly related to doubts or fears of being perceived in a particular way. Concerns experienced by women included fears that they would not be taken seriously, not listened to, or that they may be viewed as ‘hysterical’, ‘overly anxious’, or ‘being a hypochondriac’ [35, 37, 38] with fears often based on previous negative interactions;‘ … as long as she moved then I consider that to be okay. I think if it’s been a couple of days and they’ve not moved or a full day then it’s something to worry about’ ([38], p.3).
Other barriers to contacting healthcare professionals included feelings of uneasiness that they were taking up the healthcare professionals time unnecessarily and concerns that they would be induced or be perceived as trying to get induced [33, 35, 38]. Contrary to this, healthcare professionals were explicit on what to do should women experience reduced or altered FMs and women responded actively to this advice;‘I was made to feel uneducated and overly anxious, and at times I agonised whether to take my concerns to the professionals or just ‘Dr, Google’ … to save face and stress’ ([35], p.80).
Advice from healthcare professionals on monitoring FMs and on what to do if they were concerned about FMs varied. This ranged from making contact with a healthcare provider if there was any reduction or change in FMs, not to worry as long as there were some FMs everyday regardless of quantity, specific advice on expected frequency and quantity of FMs, and little or no advice at all [32, 34, 37, 38];‘My midwife at antenatal care has told me clearly that I should call the birth clinic if I experience decreased fetal movements’ ([33], p.378).‘It was the midwife when I saw her … ..and straight away she was like, you need to ring triage, we need to get it checked out. So that what prompted me to call in’ ([38], p.5)
“During visits I have only been asked if the baby has moved – I reply yes and the conversation ends’ ([34], p.57).
Confidence in the review’s findings – CERQual
Finding | Contributing reports | Methodological limitations | Coherence | Adequacy | Relevance | Overall Confidence |
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Analytical theme: How women engage with FMs | ||||||
Women identified perceived factors that impact FMs such as; mother’s position, time of day, and mother’s hunger/eating patterns | 28–30,37 | No or very minor concerns | Minor concerns | Minor concerns | Moderate concerns | Moderate |
Women associated FMs with health; regular, individualised patterns of FMs were viewed as reassuring and altered patterns as a cause for concern | 31–33,34,35 | No or very minor concerns | No or very minor concerns | Minor concerns | Moderate concerns | High |
Informal monitoring of FMs acted as a mechanism of communication between mother and baby | 28–30 | No or very minor concerns | No or very minor concerns | Minor concerns | Minor concerns | High |
Formal engagement with and assessment of FMs can cause worry and anxiety, but was also considered important, providing reassurances that the baby was well | 28,31,35 | Serious concerns | Moderate concerns | Moderate concerns | Minor concerns | Very Low |
When women were experiencing reduced or altered FMs, they adopted a variety of strategies to elicit movement | 30,32-34,37,38 | No or very minor concerns | No or very minor concerns | Moderate concerns | Moderate concerns | Moderate |
Analytical theme: Articulating and describing fetal movements | ||||||
Women’s descriptions and sensations of FMs differed at different gestational ages with changes in FMs noted as pregnancy progressed | 29–30,35–37 | No or very minor concerns | Minor concerns | Minor concerns | Minor concerns | High |
Women’s expectation of the timing of first FMs and the frequency they experienced FMs throughout the day were varied | 29,30,35,37 | Minor concerns | No or very minor concerns | Moderate concerns | Moderate concerns | Low |
Women commonly experienced increased FMs in the evening and before mealtimes | 30,31 | Moderate concerns | No or very minor concerns | Moderate concerns | Minor concerns | Low |
Women associated unusual or changed FMs with changes in frequency or absence of FMs, or changes in the sensation of FMs | 32,33,37 | No or very minor concerns | No or very minor concerns | Moderate concerns | Moderate concerns | Moderate |
Analytical theme: Fetal movements and help/health seeking | ||||||
Women accessed multiple information sources on FMs including; healthcare professionals, antenatal classes, books, the internet, and family and friends | 30,34,35,37,38 | No or very minor concerns | No or very minor concerns | Minor concerns | Minor concerns | High |
There were preferences towards receiving FM information particularly in the format of printed documentation such as a pamphlet or hand-out, although preferences for the types of information were mixed | 34,35,37 | No or very minor concerns | Minor concerns | Minor concerns | Moderate concerns | Moderate |
The internet was a common source of information often ahead of consulting a healthcare professional | 34,35,37,38 | No or very minor concerns | No or very minor concerns | Minor concerns | Moderate concerns | High |
A decrease in FM was generally perceived as a cause for concern that warranted help from a healthcare professional | 30,31,33,35,37,38 | No or very minor concerns | Minor concerns | Moderate concerns | Minor concerns | Moderate |
Reasons for contacting healthcare professionals due to a decrease or change in FMs included; if a defined period of time had passed, if the worry became unmanageable, fear of fetal loss, unsuccessful strategies to stimulate FMs | 33,34,38 | No or very minor concerns | No or very minor concerns | Minor concerns | Minor concerns | High |
Barriers to contacting healthcare professionals were mostly related to doubt or fear of being perceived a particular way, not being listened to, wasting healthcare professionals’ time | 33,35,37,38 | No or very minor concerns | Minor concerns | Moderate concerns | Minor concerns | High |
The advice offered by healthcare professionals to women on monitoring FMs and on what to do if they were concerned about FMs varied | 32–34,37,38 | No or very minor concerns | No or very minor concerns | Moderate concerns | Moderate concerns | Moderate |