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“Better safe than sorry”—Reasons for consulting care due to decreased fetal movements
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Women and Birth xxx (2016) xxx–xxx
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Women and Birth journal homepage: www.elsevier.com/locate/wombi
Original Research - Qualitative
“Better safe than sorry”—Reasons for consulting care due to decreased fetal movements Anders Lindea,b , Ingela Rådestadb , Karin Petterssona , Linn Hagelbergb , Susanne Georgssona,b,* a b
Department of Clinical Science, Intervention and Technology, CLINTEC, Karolinska Institutet, Stockholm, Sweden Sophiahemmet University, Stockholm, Sweden
A R T I C L E I N F O
A B S T R A C T
Article history: Received 22 August 2016 Received in revised form 24 November 2016 Accepted 13 February 2017 Available online xxx
Background: Experience of reduced fetal movements is a common reason for consulting health care in late pregnancy. There is an association between reduced fetal movements and stillbirth. Aim: To explore why women decide to consult health care due to reduced fetal movements at a specific point in time and investigate reasons for delaying a consultation. Methods: A questionnaire was distributed at all birth clinics in Stockholm during 2014, to women seeking care due to reduced fetal movements. In total, 3555 questionnaires were collected, 960 were included in this study. The open-ended question; “Why, specifically, do you come to the clinic today?” was analyzed using content analysis as well as the complementary question “Are there any reasons why you did not come to the clinic earlier?” Results: Five categories were revealed: Reaching dead line, Receiving advice from health care professionals, Undergoing unmanageable worry, Contributing external factors and Not wanting to jeopardize the health of the baby. Many women stated that they decided to consult care when some time with reduced fetal movements had passed. The most common reason for not consulting care earlier was that it was a new experience. Some women stated that they did not want to feel that they were annoying, or be perceived as excessively worried. Not wanting to burden health care unnecessarily was a reason for prehospital delay. Conclusion: Worry about the baby is the crucial reason for consulting care as well as the time which has passed since the women first experienced decreased fetal movements. © 2017 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.
Keywords: Decreased fetal movements Reduced fetal movements Pregnancy Worry Care
Statement of significance
Problem or issue There is an association between reduced fetal movements and stillbirth and it is important to avoid delaying a consultation when the woman experience reduced fetal movements. It is unknown why women decide to consult care at a specific time point. What is already known Experience of reduced fetal movements is a common reason for consulting health care in late pregnancy.
* Corresponding author. E-mail address: [email protected] (S. Georgsson).
What this paper adds Worry about the baby is the crucial reason for consulting care as well as the time which has passed since the women first experienced decreased fetal movements. Not wanting to burden health care unnecessarily was a reason for ‘pre-hospital’ delay.
1. Introduction Worry about reduced fetal movements is common, and increases with advanced gestational age. Half of all pregnant women worry about reduced fetal movements some time during pregnancy.1 Further, women’s experience of decreased fetal movements is a common reason for consulting acute care during pregnancy.2,3 In the third trimester, four to sixteen percent consult health care due to reduced fetal movements.4 A review by Hijazi and East5 shows that about seven percent of all pregnant women consult health care at
http://dx.doi.org/10.1016/j.wombi.2017.02.007 1871-5192/© 2017 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: A. Linde, et al., “Better safe than sorry”—Reasons for consulting care due to decreased fetal movements, Women Birth (2017), http://dx.doi.org/10.1016/j.wombi.2017.02.007
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some time due to worry about reduced fetal movements. In most cases these are uncomplicated pregnancies with a viable fetus. Reduced fetal activity may appear normal in a healthy fetus and is not necessarily a threat to the health of the fetus.5 However, a reduction of the frequency and power in the fetal movements may be a sign of a compromised fetus. About half of the women who suffer a stillbirth report reduced fetal movements in the days before the baby died.5,6,7 According to guidelines from the Royal College of Obstetricians and Gynecologists, RCOG,6 the recommendation is not to wait but to consult care services promptly in order to confirm the well-being of the baby. A study by Tveit et al.3 showed that pregnant women waited before consulting care when they experienced reduced fetal movements. One third of the women waited until the fetal movements ceased and one quarter waited another 24 h after the movements had disappeared. When the women received information about reduced fetal movements the delay before consulting care decreased. Further, the same study showed that when the clinic complied with uniform information and clear guidelines about fetal movements, the number of stillbirths was reduced by almost 50%. Women receive disparate information from different caregivers about the normal frequency of fetal movements,1,3,6 and are not offered evidence-based advice.8 An Australian prospective study included 526 women, of whom two thirds stated that they received information about normal fetal movements from health care professionals. Women who expected their first child had received information to a greater extent compared to women who already had children. Barely 80% stated that they had received the information from a midwife and 40% from an obstetrician. Slightly more than half of the women stated that they had searched for information on the internet. The women expressed a wish for more extensive information from health care professionals including written information early in pregnancy.9 In a Norwegian study from 2008, the relation between information to pregnant women about fetal movement, the awareness and worry about the fetal movements, and outcome of the pregnancy were explored. In this study 99.9% of the women stated that it was important to experience fetal movements every day, and almost all, 99%, regarded fetal movements as an indicator of a healthy baby. Further, the women described the great responsibility they felt about the well-being of their unborn child. The study found a relation between low awareness of fetal activity and an increased risk to give birth to a baby small for gestational age (SGA).1 The importance of information, awareness of fetal movements and what to do if the movements decrease or cease, is emphasized by the Royal College of Obstetricians and Gynecologists.6 Decreased fetal movements are associated with worry among pregnant women. Lack of guidelines and disparate information may lead to uncertainty for the pregnant woman. The aim of this study was to explore why women decide to consult care due to reduced fetal movements at a specific point in time, as well as to investigate reasons for delaying a consultation. 2. Methods 2.1. Methodology Malterud’s method of analyzing qualitative data in several steps was used with the first question. This qualitative content analysis is a systematic condensation of the text.10 2.2. Sampling and setting Pregnant women who consulted care due to reduced fetal movements during January–December 2014 at one of the seven birth clinics in Stockholm, Sweden were requested to fill in the
questionnaire. The questionnaire was distributed by the health care professionals at the birth clinics after obtaining informed consent. Before asking the woman about participation all women had a CTG or ultrasound examination to verify a healthy fetus. The inclusion criteria were: women in gestational week 28 + 0 or above who could read and write at least one of the following languages: Swedish, English, Spanish, Sorani, Farsi, Arabic or Somali. Only Swedish and English answers were included in this study because the authors only master these languages. Further, only singleton pregnancies were included. In total, 3555 questionnaires were completed, of which 3058 fulfilled the inclusion criteria. In this study 960 women’s answers were included in the analysis which is an extensive but reasonable number, giving a broad representation of the material. The first 80 completed questionnaires every month during the data collection period were selected. The selection was spread to avoid the results being affected by the season or the work load on the birth clinics. The responses of the 960 selected women who answered the first question, “Why, specifically, do you come to the clinic today?” as well as those of the 872 women who answered the attendant question, “Are there any reasons why you don’t come to the clinic earlier?” The characteristics of the participants are presented in Table 1. The mean age of the women was 31.6 years and the median age was 32 years (range 16–50). Most of the women were native Swedes, a quarter were born in another country. Slightly more than half of the women were in gestational week 37 or later. The majority, 67%, had a college or university level of education (Table 1). 2.3. Data collection This study was based on two multiple choice and open ended questions included in a 22-item questionnaire. 2.4. Data analysis The answers to this question ranged from several sentences to a few words. The first step entailed a careful reading and re-reading
Table 1 Sociodemographic characteristics. Native country N = 959
N (%)
Sweden Nordic countries (not Sweden) Europe (not the Nordic countries) Asia South America USA/Canada Africa Australia/New Zealand Other
727 (76) 14 (2) 68 (7) 96 (10) 19 (2) 1 (0.1) 31 (3) 2 (0.2) 1 (0.1)
Age N = 960 Mean (Md) <19 20–24 25–29 30–34 >35
31.6 (32) 3 (0.3) 80 (8.3) 260 (27) 340 (35) 277 (29)
Gestational week N = 960 28–32 33–37 >37
133 (14) 335 (35) 492 (51)
Education N = 958 Elementary school High school College or university 1–3 years College or university >3 years
29 (3) 286 (30) 203 (21) 440 (46)
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of the whole material. Preliminary themes were crystallized after the second reading. The text was then divided into units – parts of the text which describe the content.10 The material consisted of many short quotations, which were used as one unit. The units were sorted separately into different themes and categories. In total, 152 answers were excluded in the cases where the women did not answer the question, i.e. did not state the reason for consulting care at the specific time. Further, the units were sorted into codes and preliminary themes. Subheadings were revealed, clusters with units were given preliminary names, and codes showed up as themes. After codes had been developed into themes they were merged, depending on similarities, into final categories.10 The complementary analysis of the second, attendant question was similar but the answers to that question were shorter and much more straightforward. The answers most often consisted of one unit and were sorted directly into categories. The analysis of the reasons for not having contacted care for a check-up earlier was made to identify possible obstacles to consulting care that were not stated in the first question. Responses to the second question are not quoted since they were short, close to the category and do not require confirmation. The analysis was performed manually by the author LH, in a close collaboration with SG. To ensure the validity, both LH and SG read the quotations and during the whole process the analysis was confirmed. In case of disagreement, all four authors discussed the analysis until consent was reached. Data was managed confidentially. The answers were coded and were not possible to identified or connect to each individual. The study was approved by the Regional Ethical Review Board in Stockholm: DNR: 2013/1077-31/3. 3. Findings The results for the question, ‘Why specifically do you come to the clinic today’, will be presented in themes and categories which have been revealed during the analysis. The determination of the point in time when the woman chose to consult care was divided into categories. Several themes constitute a category. The category is used as a heading, and the different themes are presented as subheadings. In total, five categories were revealed: Reaching deadline, Receving dvice from health care professionals, Undergoing unmanageable worry, Contributing external factors and Not wantin to jeopardize the health of the baby (Table 2). A synthesis of the statements divided into categories will be presented for the accompanying question, i.e. why the women did not contact care earlier.
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3.1. Reasons for contacting care at a specific point in time 3.1.1. Reaching dead line That a certain amount of time had passed, a dead line had been reached, was the most common reason for contacting health care at a specific point in time. The time limit for experiencing decreased fetal movement ranged from a few hours to several days before contacting health care. Several women reported fewer or ceased movements during the same day as enough reason to contact care services. “Because I have not felt movements during the past 15,17 hours” “Less activity just today” Others reported that the fetal movements had decreased or had become different over several days but the time for how long they had experienced this had reached a climax and that it was time to check what was happening. “Because it has been going on for two days now” “The movements have been different for three days” Some women described how they first waited but when there was no difference and no improvement they contacted care. “Believed that the movements would improve” “When the activity decreased and had not gone in the right direction after two days again” 3.1.2. Receiving advice from health care professionals Of a total of 808 women, 289 stated that they have been advised to contact health care for a check-up. The women had usually received this advice from a midwife, antenatal care or the birth clinic. “Because my midwife told me” In some cases it was the midwife who made the appointment at the birth clinic for a check-up. This action was often taken after the women had visited the antenatal clinic or had called their midwife and reported decreased fetal movements. “Was at the midwife who called and made the appointment for me” Indirect advice was also a factor, i.e. when the midwife on a previous occasion had informed the women how to handle decreased fetal movements and when they should contact health care. “My midwife at antenatal care has told me clearly that I should call the birth clinic if I experience decreased fetal movements.” 3.1.3. Undergoing unmanageable worry Worry was a common reason for contacting care due to decreased fetal movements at a specific point in time. The feeling of worry combined with the experience of reduced fetal movements determined when the woman contacted health care. “Now I am starting to get worried”
Table 2 Reasons to contact care at a specific point of time. Categories
Themes
N = 808 (100%) N (%)*
Reached deadline
Days have passed Movements decreased or ceased today Advice from different care instance The bounds for worry is reached Worry Physical symptoms No reaction on stimuli Better safe than sorry
211 (26) 137 (17) 280 (35) 140 (17) 56 (7) 102 (13) 21 (3) 18 (12)
Advice from health care professionals Unmanageable worry External factors Did not want to jeopardize the health of the baby *
The quotes may appear in more than one category and theme.
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An increased and ultimately, unmanageable worry sometimes led to the decision to contact care at the specific point in time. “The worry became too great” “I couldn’t stop thinking of it, which made it even worse” The worry was continuously centered on the decreased, different or ceased fetal movements. Some women described the worry as an indicator that something was wrong and wanted to have a check-up to confirm that the baby was healthy. Decreased fetal movements seem to be interpreted as a threat to the baby’s health. A few women mentioned they were worried that it would be too late to contact care, which can be interpreted as a fear that the baby would die. “Worry that it would be too late to contact care” Other women described how the worry disturbed them in their daily life and it was therefore necessary to act. Some reported that they could not get rid of the thoughts about the baby moving less. “The worry escalated. Decided that it was time to check instead of walking around being worried” 3.1.4. Contributing external factors In this category the reason to contact care at a specific point in time was an external occurrence. The fact that there was a physical symptom in combination with decreased fetal movements led to the decision to contact care. Examples of physical symptoms related to pregnancy were: bleeding, contractions or rupture of membranes. “Because I have had strong contractions during the night” “Because there was vaginal bleeding and considerably fewer movements” Other symptoms mentioned were: headache, dizziness, loss of vision, nausea, hypertension, rash, itch, proteinuria, back pain, an infection or cold, in combination with decreased fetal movements. A few even mentioned symptoms of hepatosis, liver test results and lack of sleep. “due to hypertension, decreased fetal movements” Some women contacted care when it was not possible to stimulate the baby to move. The most common ways to try to stimulate fetal movements were to push the tummy or to drink cold and sugary drinks. “I did not feel any movements during the morning despite pushing at my tummy and intake of sugary drinks” 3.1.5. Not wanting to jeopardize the health of the baby Some expressed that it was better to be safe than sorry and check the baby’s health rather too often than risking the health of the baby.
“Better to check once too often” “think it is better to check an extra time” The women sometimes explained that they already knew that they should contact care when experiencing reduced fetal movements. One woman stated that she had received information from her sister, but most of the women did not mention where they had received the information. “I have read a lot about reduced fetal movements and the importance of trusting one’s instinct.” “I have heard that one should contact care if it suddenly feels different” “Know that one should go for a check-up if you feel the baby less often or it feels different” 3.2. Reasons for delaying a consultation Of the 960 women, 88 did not answer the question and 227 women responded “No”. The results are presented in Table 3. The most common reason for not having consulted care earlier was that decreased fetal movement was a new experience. Several women stated that they wanted to wait because they thought it was a coincidence that the movements had decreased and that they waited for the baby to move again. Some women stated that they did not want to burden the health care service unnecessarily, that they felt excessively worried, stupid and ridiculous. Further, some women had not contacted care earlier because they had still felt movements, although fewer. Few women referred to practical problems such as: having children at home, no car and that it was too late in the evening or night. Also, a few women felt reassured due to the baby kicking when the tummy was stimulated in various ways. 4. Discussion The amount of time that had elapsed, together with the feeling of having waited long enough with the experience of decreased or different fetal movements were crucial in determining the point in time when the women consulted care. Advice from health care, most commonly from the midwife, to come for a check-up, and increasing worry about the health of the fetus were additional factors which determined the point in time for taking action. Various physical symptoms also affected the decision to consult care. Restraining factors were that the experience of decreased fetal movements was new to the woman and that she believed that it was temporary. Even a feeling of not wanting to burden the health care services unnecessarily or being considered too annoying and overly worried, led to hesitation to go to hospital for a check-up.
Table 3 Reasons for not contacting care earlier. Statements N = 872
N (%)
No reason Not been like this before Thought it was temporary – waited Did not want to burden/contact care services unnecessarily. Did not want be annoying, feel stupid, seem ridiculous Not been worried before Still some movements Believed it was normal with decreased fetal movements Recommended to wait by the midwife at the antenatal care unit Waiting for antenatal care visit Consulted care before and had a check-up Practical problems such as siblings, no car, weekend, too late at night Insecure, did not trust oneself Stimulation which led to increased fetal movements
227 (26) 130 (15) 89 (10) 69 (8) 68 (8) 55 (6) 20 (2) 20 (2) 15 (2) 14 (2) 14 (2) 10 (1) 7 (1)
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4.1. Reaching deadline The most common reason to contact care was that a certain amount of time had passed. Although the length of time varied, many women reported having experienced that too long a time had passed and that they wanted reassurance that everything was alright with the baby. The definition of too long may be affected by the information and recommendations the women receive about fetal movements and when they are supposed to consult care. Pregnant women do not receive information about what is regarded as normal fetal movements.1,3,6 Disparate and sometimes even inaccurate information about fetal movements and varying advice about when an examination is appropriate may delay the check-up of the fetus. In a study by Tveit et al.,3 one third of the women waited until the movements had ceased before consulting care. A quarter of the women waited 24 h or more after the movements had ceased. This is in line with the results of the present study. Many women reported having waited for several days. The risk for a negative outcome increases with a delayed contact with health care.11 If the fetal movements have ceased, research shows that intrauterine fetal death increases up to eight times if more than one day passes before the examination. Cardiotocography (CTG) and an ultrasound examination within two hours are recommended if the woman experiences no fetal movements at all. If she experiences decreased fetal movement the recommendation is to perform these examinations within twelve hours.12 When women wait before consulting care due to decreased or absent fetal movements, as many women did in the present study, the recommended examinations are impossible to perform within the recommended timeframe. Consequently, the risk for a negative pregnancy outcome and intrauterine fetal death increases. In a study by Erlandsson et al.13 women’s premonitions about something being wrong with the baby were explored before they were informed (after an ultrasound examination) that their unborn child was dead. Some of the women said that they had postponed contacting care because they were afraid of being regarded as too worried or hysterical by the care givers. None of the women in the present study stated that they were afraid to be regarded as excessively worried or hysterical. However, in the analysis of obstacles, women reported feeling that they did not want to burden care unnecessarily or to be regarded as troublesome. Further, compared to the study of women who lost their child, few expressed that they did not want to feel stupid. A possible explanation for this is that they may have stronger self-esteem; they are not prepared to compromise the health of their unborn child. All women in the present study had a fetus assessed as healthy after the examination at the hospital. Conversely, low selfesteem may be a risk factor for intrauterine fetal death. 4.2. Receiving advice from health care professionals The second most stated reason for contacting care at a specific point in time was advice from health care professionals. The women had often been in contact with a midwife working in antenatal care or at the birth clinic. Indirect advice, i.e. previous information about when one should contact healthcare was also reported. In a study by McArdle et al.,9 the women stated that they preferred to receive information from a midwife. In the same study the women requested more written information about fetal movements. In the Guide for Caregivers given out by Stockholm County,14 caregivers are recommended to send women who experience decreased fetal movements to a birth clinic at a hospital immediately. Further, the recommendations include that all women in around gestational week 25 should be asked about fetal movements. They should also be informed about the
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importance of contacting a birth clinic as soon as possible if the fetal movements decrease or cease. Midwives are exhorted to actively ask about fetal movements at every check-up from gestational week 25, and to document all deviations in the medical record. In the present study, some women mentioned that it was the previous information from the midwife which determined the point in time when they contacted care. High levels of confidence in the midwife may explain why more than one third of the women stated that it was this advice that was crucial in determining the point in time when they consulted care. A further explanation for contacting the midwife at a specific point in time may be a need to receive advice from an expert before contacting the hospital. The woman may not trust her own ability to decide when she is supposed to consult care or may be afraid of being dismissed if the decision has not been made in consultation with health care professionals. The reason why so many women needed advice from their midwife may indicate that the previous information they have received has been insufficient for making an informed choice. In the study by McArdle et al.,9 only 67% stated that they had received information about fetal movements and what to expect during pregnancy. According to a study by Saastad et al.,11 women who had received information about fetal movements consulted care earlier than those who had not received information. The same study demonstrated a decrease of intrauterine fetal death. Information and advice from the midwife seem to have a significant role regarding the point in time the woman consults care. 4.3. Undergoing unmanageable worry Worry was an important factor in deciding when to contact care. Some women reported that they contacted care when the worry increased. The recommendations are not to wait until the next day before contacting care and checking on the baby’s health.6 According to Bayrampour et al.15 pregnancy is associated with some worry and motivates behavior that favors the fetus. Worry is considered as a facilitator during the pregnancy, protecting the baby from harmful behavior. This may be one of the reasons why many of the women in the present study describe worry as an indicator that something is wrong and therefore crucial regarding the point in time for contacting care. According to Malm et al.,16 the reason to consult care due to decreased fetal movements was increased worry. In the present study, the women described how they had reached the limit of their worry. Bayrampour et al.15 describe that worry may cause a dysfunction and make it difficult to concentrate in daily life, which may have been the case in the present study. Only one woman expressed that she contacted care due to her worried partner. However, the women often expressed themselves in terms of “we” not “I”, which may be interpreted that the decision to contact care was not taken alone. That the decision was not made according to one person’s subjective opinion may strengthen the feeling of having made the right decision. 4.4. Contributing external factors Some women stated that they tried to stimulate the fetus to move by drinking cold, sweet drinks or by pushing their belly. When these strategies did not work they contacted care and decided to go to the birth clinic. Some studies show increased fetal movements when the maternal blood glucose is increased but there are also studies with contradictory results.6 Sometimes the decision when to contact care was determined by a physical symptom, such as bleeding or stomach pain in addition to the decreased fetal movements. The opposite also occurred; that a physical symptom was already present and when the fetal
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movements decreased the women contacted care. The physical symptoms may have been regarded as more objective and therefore facilitated making the decision. An alternative explanation is that women had knowledge about some physical symptoms being an indication that the fetus is not healthy. 4.5. Not wanting to jeopardize the health of the baby An intuitive feeling that something was wrong was given by the women as a reason for contacting care at a specific point in time, which should be met with respect and be encouraged. In a study by Malm et al.,16 which explored women’s experiences in the period before being informed of their baby’s intrauterine death, the category, “the feeling that something was wrong” revealed that the women were aware of a growing feeling that something was wrong. Some of the women stated that they knew it was important to contact care due to decreased fetal movements but that this knowledge had not come from health care professionals. One can assume that women had searched for information themselves. Common sources of information about fetal movements are: the internet, one’s own mother, other family members or friends, articles, books, prophylaxis courses, doulas and brochures.9 The pregnant woman should receive the information necessary to make an informed decision about when she is supposed to contact care from the midwife in antenatal care. 4.6. Strengths and limitations A large number of all women who contacted care due to decreased fetal movements during a one-year period in Stockholm was included in the study. It is not known if all women who fulfilled the inclusion criteria were asked to participate in the study. How many women declined to participate, and if the individuals among the drop-outs differ from those in the study group is unclear. The fact that only English and Swedish-speaking women were selected for analysis may have affected the results. Those speaking other languages may have related differently to decreased fetal movements. Some may have come from another socio-economic background, some may have been influenced by another culture and may have chosen to contact care at different points in time. 5. Conclusions Worry about the baby is the crucial reason for consulting care as well as the amount of time that has elapsed since the first experience of decreased fetal movements. Obstacles were that the experience of decreased fetal movements was new to the woman, who believed it to be a temporary decrease. Prehospital delay was due to not wanting to burden the health care service unnecessarily.
Pregnant women are supposed to receive clear information about how to recognize the normal pattern of movements of the unborn baby, and at what point in time they are should consult care due to decreased fetal movements. The midwife has a crucial role regarding counseling and imparting basic information about fetal movements to the pregnant women. National guidelines about information regarding fetal movements may be a support both for health care professionals and pregnant women. Conflict of interest The authors declare that they have no conflict of interest. References 1. Saastad E, Ahlborg T, Frøen F. Low maternal awareness of fetal movement is associated with small for gestational age infants. Am Coll Nurse-Midwives 2008;53(4):345–52. 2. Nowlan NC. Biomechanics of fetal movement. Eur Cells Mater 2015;29:1–21. 3. Tveit JVH, Saastad E, Stray-Pedersen B, Børdahl PE, Flenady V, Fretts R, et al. Reduction of late stillbirth with the introduction of fetal movement information and guidelines—a clinical quality improvement. BMC Pregnancy Childbirth 2009;9. 4. Frøen JF. A kick from within: fetal movement counting and the cancelled progress in antenatal care. J Perinat Med 2004;32:13–24. 5. Hijazi ZR, East CE. Factors affecting maternal perception of fetal movement. Obstet Gynecol Surv 2009;64(7):489–97. 6. RCOG. Green-top guideline No. 57: reduced fetal movements. London: Royal College of Obstetricians and Gynaecologists (2011). http://www.rcog.org.uk/ womens-health/clinical-guidance/reduced-fetal-movementsgreen-top-57 (Accessed 24 November 2017). 7. Linde A, Pettersson K, Rådestad I. Women’s experiences of fetal movements before the confirmation of fetal death; contractions misinterpreted as fetal movement. Birth Issues Perinat Care 2015;42(2):189–94. 8. Warland J, Glover P. Fetal movements: what are we telling women? Women Birth 2017;30(1):23–8. 9. McArdle A, Flenady V, Toohill J, Gamble J, Creedy D. How pregnant women learn about foetal movements: sources and preferences for information. Women Birth 2015;28(1):54–9. 10. Malterud K. Kvalitativa metoder i medicinsk forskning: En introduktion (3. uppl.). Lund : Studentlitteratur AB. Malterud, K., 2014. [In Swedish]. 11. Saastad E, Tveit JVH, Flenady V, Stray-Pedersen B, Fretts RC, Børdahl PE, et al. 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. BMC Res Notes 20103(2). 12. Tveit JVH, Saastad E, Stray-Pedersen B, Børdahl PE, Frøen JF. Concerns for decreased fetal movements in uncomplicated pregnancies—increased risk of fetal growth restriction and stillbirth among women being overweight, advanced age or smoking. J Matern-Fetal Neonat Med 2010;23(10):1129–35. 13. Erlandsson K, Lindgren H, Davidsson-Bremborg A, Rådestad I. Women’s premonitions prior to the death of their baby in utero and how they deal with the feeling that their baby may be unwell. Acta Obstet Gynecol Scand 2012;91 (1):28–33. 14. Guide for caregivers. Stockholm County. www.vardgivarguiden.se, Minskade fosterrörelser. [In Swedish]. 15. Bayrampour H, Ali E, McNeil DA, Benzies K, McaQueen G, Tough S. Pregnancyrelated anxiety: a concept analysis. Int J Nurs Stud 2015;55:115–30. 16. Malm MC, Lindgren H, Rådestad I. Losing contact with one’s unborn baby— mothers’ experiences prior to receiving news that their baby has died in utero. Omega: J Death Dying 2011;62(4):353–67.
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Women and Birth xxx (2016) xxx–xxx
Contents lists available at ScienceDirect
Women and Birth journal homepage: www.elsevier.com/locate/wombi
Original Research - Qualitative
“Better safe than sorry”—Reasons for consulting care due to decreased fetal movements Anders Lindea,b , Ingela Rådestadb , Karin Petterssona , Linn Hagelbergb , Susanne Georgssona,b,* a b
Department of Clinical Science, Intervention and Technology, CLINTEC, Karolinska Institutet, Stockholm, Sweden Sophiahemmet University, Stockholm, Sweden
A R T I C L E I N F O
A B S T R A C T
Article history: Received 22 August 2016 Received in revised form 24 November 2016 Accepted 13 February 2017 Available online xxx
Background: Experience of reduced fetal movements is a common reason for consulting health care in late pregnancy. There is an association between reduced fetal movements and stillbirth. Aim: To explore why women decide to consult health care due to reduced fetal movements at a specific point in time and investigate reasons for delaying a consultation. Methods: A questionnaire was distributed at all birth clinics in Stockholm during 2014, to women seeking care due to reduced fetal movements. In total, 3555 questionnaires were collected, 960 were included in this study. The open-ended question; “Why, specifically, do you come to the clinic today?” was analyzed using content analysis as well as the complementary question “Are there any reasons why you did not come to the clinic earlier?” Results: Five categories were revealed: Reaching dead line, Receiving advice from health care professionals, Undergoing unmanageable worry, Contributing external factors and Not wanting to jeopardize the health of the baby. Many women stated that they decided to consult care when some time with reduced fetal movements had passed. The most common reason for not consulting care earlier was that it was a new experience. Some women stated that they did not want to feel that they were annoying, or be perceived as excessively worried. Not wanting to burden health care unnecessarily was a reason for prehospital delay. Conclusion: Worry about the baby is the crucial reason for consulting care as well as the time which has passed since the women first experienced decreased fetal movements. © 2017 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.
Keywords: Decreased fetal movements Reduced fetal movements Pregnancy Worry Care
Statement of significance
Problem or issue There is an association between reduced fetal movements and stillbirth and it is important to avoid delaying a consultation when the woman experience reduced fetal movements. It is unknown why women decide to consult care at a specific time point. What is already known Experience of reduced fetal movements is a common reason for consulting health care in late pregnancy.
* Corresponding author. E-mail address: [email protected] (S. Georgsson).
What this paper adds Worry about the baby is the crucial reason for consulting care as well as the time which has passed since the women first experienced decreased fetal movements. Not wanting to burden health care unnecessarily was a reason for ‘pre-hospital’ delay.
1. Introduction Worry about reduced fetal movements is common, and increases with advanced gestational age. Half of all pregnant women worry about reduced fetal movements some time during pregnancy.1 Further, women’s experience of decreased fetal movements is a common reason for consulting acute care during pregnancy.2,3 In the third trimester, four to sixteen percent consult health care due to reduced fetal movements.4 A review by Hijazi and East5 shows that about seven percent of all pregnant women consult health care at
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Please cite this article in press as: A. Linde, et al., “Better safe than sorry”—Reasons for consulting care due to decreased fetal movements, Women Birth (2017), http://dx.doi.org/10.1016/j.wombi.2017.02.007
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some time due to worry about reduced fetal movements. In most cases these are uncomplicated pregnancies with a viable fetus. Reduced fetal activity may appear normal in a healthy fetus and is not necessarily a threat to the health of the fetus.5 However, a reduction of the frequency and power in the fetal movements may be a sign of a compromised fetus. About half of the women who suffer a stillbirth report reduced fetal movements in the days before the baby died.5,6,7 According to guidelines from the Royal College of Obstetricians and Gynecologists, RCOG,6 the recommendation is not to wait but to consult care services promptly in order to confirm the well-being of the baby. A study by Tveit et al.3 showed that pregnant women waited before consulting care when they experienced reduced fetal movements. One third of the women waited until the fetal movements ceased and one quarter waited another 24 h after the movements had disappeared. When the women received information about reduced fetal movements the delay before consulting care decreased. Further, the same study showed that when the clinic complied with uniform information and clear guidelines about fetal movements, the number of stillbirths was reduced by almost 50%. Women receive disparate information from different caregivers about the normal frequency of fetal movements,1,3,6 and are not offered evidence-based advice.8 An Australian prospective study included 526 women, of whom two thirds stated that they received information about normal fetal movements from health care professionals. Women who expected their first child had received information to a greater extent compared to women who already had children. Barely 80% stated that they had received the information from a midwife and 40% from an obstetrician. Slightly more than half of the women stated that they had searched for information on the internet. The women expressed a wish for more extensive information from health care professionals including written information early in pregnancy.9 In a Norwegian study from 2008, the relation between information to pregnant women about fetal movement, the awareness and worry about the fetal movements, and outcome of the pregnancy were explored. In this study 99.9% of the women stated that it was important to experience fetal movements every day, and almost all, 99%, regarded fetal movements as an indicator of a healthy baby. Further, the women described the great responsibility they felt about the well-being of their unborn child. The study found a relation between low awareness of fetal activity and an increased risk to give birth to a baby small for gestational age (SGA).1 The importance of information, awareness of fetal movements and what to do if the movements decrease or cease, is emphasized by the Royal College of Obstetricians and Gynecologists.6 Decreased fetal movements are associated with worry among pregnant women. Lack of guidelines and disparate information may lead to uncertainty for the pregnant woman. The aim of this study was to explore why women decide to consult care due to reduced fetal movements at a specific point in time, as well as to investigate reasons for delaying a consultation. 2. Methods 2.1. Methodology Malterud’s method of analyzing qualitative data in several steps was used with the first question. This qualitative content analysis is a systematic condensation of the text.10 2.2. Sampling and setting Pregnant women who consulted care due to reduced fetal movements during January–December 2014 at one of the seven birth clinics in Stockholm, Sweden were requested to fill in the
questionnaire. The questionnaire was distributed by the health care professionals at the birth clinics after obtaining informed consent. Before asking the woman about participation all women had a CTG or ultrasound examination to verify a healthy fetus. The inclusion criteria were: women in gestational week 28 + 0 or above who could read and write at least one of the following languages: Swedish, English, Spanish, Sorani, Farsi, Arabic or Somali. Only Swedish and English answers were included in this study because the authors only master these languages. Further, only singleton pregnancies were included. In total, 3555 questionnaires were completed, of which 3058 fulfilled the inclusion criteria. In this study 960 women’s answers were included in the analysis which is an extensive but reasonable number, giving a broad representation of the material. The first 80 completed questionnaires every month during the data collection period were selected. The selection was spread to avoid the results being affected by the season or the work load on the birth clinics. The responses of the 960 selected women who answered the first question, “Why, specifically, do you come to the clinic today?” as well as those of the 872 women who answered the attendant question, “Are there any reasons why you don’t come to the clinic earlier?” The characteristics of the participants are presented in Table 1. The mean age of the women was 31.6 years and the median age was 32 years (range 16–50). Most of the women were native Swedes, a quarter were born in another country. Slightly more than half of the women were in gestational week 37 or later. The majority, 67%, had a college or university level of education (Table 1). 2.3. Data collection This study was based on two multiple choice and open ended questions included in a 22-item questionnaire. 2.4. Data analysis The answers to this question ranged from several sentences to a few words. The first step entailed a careful reading and re-reading
Table 1 Sociodemographic characteristics. Native country N = 959
N (%)
Sweden Nordic countries (not Sweden) Europe (not the Nordic countries) Asia South America USA/Canada Africa Australia/New Zealand Other
727 (76) 14 (2) 68 (7) 96 (10) 19 (2) 1 (0.1) 31 (3) 2 (0.2) 1 (0.1)
Age N = 960 Mean (Md) <19 20–24 25–29 30–34 >35
31.6 (32) 3 (0.3) 80 (8.3) 260 (27) 340 (35) 277 (29)
Gestational week N = 960 28–32 33–37 >37
133 (14) 335 (35) 492 (51)
Education N = 958 Elementary school High school College or university 1–3 years College or university >3 years
29 (3) 286 (30) 203 (21) 440 (46)
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of the whole material. Preliminary themes were crystallized after the second reading. The text was then divided into units – parts of the text which describe the content.10 The material consisted of many short quotations, which were used as one unit. The units were sorted separately into different themes and categories. In total, 152 answers were excluded in the cases where the women did not answer the question, i.e. did not state the reason for consulting care at the specific time. Further, the units were sorted into codes and preliminary themes. Subheadings were revealed, clusters with units were given preliminary names, and codes showed up as themes. After codes had been developed into themes they were merged, depending on similarities, into final categories.10 The complementary analysis of the second, attendant question was similar but the answers to that question were shorter and much more straightforward. The answers most often consisted of one unit and were sorted directly into categories. The analysis of the reasons for not having contacted care for a check-up earlier was made to identify possible obstacles to consulting care that were not stated in the first question. Responses to the second question are not quoted since they were short, close to the category and do not require confirmation. The analysis was performed manually by the author LH, in a close collaboration with SG. To ensure the validity, both LH and SG read the quotations and during the whole process the analysis was confirmed. In case of disagreement, all four authors discussed the analysis until consent was reached. Data was managed confidentially. The answers were coded and were not possible to identified or connect to each individual. The study was approved by the Regional Ethical Review Board in Stockholm: DNR: 2013/1077-31/3. 3. Findings The results for the question, ‘Why specifically do you come to the clinic today’, will be presented in themes and categories which have been revealed during the analysis. The determination of the point in time when the woman chose to consult care was divided into categories. Several themes constitute a category. The category is used as a heading, and the different themes are presented as subheadings. In total, five categories were revealed: Reaching deadline, Receving dvice from health care professionals, Undergoing unmanageable worry, Contributing external factors and Not wantin to jeopardize the health of the baby (Table 2). A synthesis of the statements divided into categories will be presented for the accompanying question, i.e. why the women did not contact care earlier.
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3.1. Reasons for contacting care at a specific point in time 3.1.1. Reaching dead line That a certain amount of time had passed, a dead line had been reached, was the most common reason for contacting health care at a specific point in time. The time limit for experiencing decreased fetal movement ranged from a few hours to several days before contacting health care. Several women reported fewer or ceased movements during the same day as enough reason to contact care services. “Because I have not felt movements during the past 15,17 hours” “Less activity just today” Others reported that the fetal movements had decreased or had become different over several days but the time for how long they had experienced this had reached a climax and that it was time to check what was happening. “Because it has been going on for two days now” “The movements have been different for three days” Some women described how they first waited but when there was no difference and no improvement they contacted care. “Believed that the movements would improve” “When the activity decreased and had not gone in the right direction after two days again” 3.1.2. Receiving advice from health care professionals Of a total of 808 women, 289 stated that they have been advised to contact health care for a check-up. The women had usually received this advice from a midwife, antenatal care or the birth clinic. “Because my midwife told me” In some cases it was the midwife who made the appointment at the birth clinic for a check-up. This action was often taken after the women had visited the antenatal clinic or had called their midwife and reported decreased fetal movements. “Was at the midwife who called and made the appointment for me” Indirect advice was also a factor, i.e. when the midwife on a previous occasion had informed the women how to handle decreased fetal movements and when they should contact health care. “My midwife at antenatal care has told me clearly that I should call the birth clinic if I experience decreased fetal movements.” 3.1.3. Undergoing unmanageable worry Worry was a common reason for contacting care due to decreased fetal movements at a specific point in time. The feeling of worry combined with the experience of reduced fetal movements determined when the woman contacted health care. “Now I am starting to get worried”
Table 2 Reasons to contact care at a specific point of time. Categories
Themes
N = 808 (100%) N (%)*
Reached deadline
Days have passed Movements decreased or ceased today Advice from different care instance The bounds for worry is reached Worry Physical symptoms No reaction on stimuli Better safe than sorry
211 (26) 137 (17) 280 (35) 140 (17) 56 (7) 102 (13) 21 (3) 18 (12)
Advice from health care professionals Unmanageable worry External factors Did not want to jeopardize the health of the baby *
The quotes may appear in more than one category and theme.
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An increased and ultimately, unmanageable worry sometimes led to the decision to contact care at the specific point in time. “The worry became too great” “I couldn’t stop thinking of it, which made it even worse” The worry was continuously centered on the decreased, different or ceased fetal movements. Some women described the worry as an indicator that something was wrong and wanted to have a check-up to confirm that the baby was healthy. Decreased fetal movements seem to be interpreted as a threat to the baby’s health. A few women mentioned they were worried that it would be too late to contact care, which can be interpreted as a fear that the baby would die. “Worry that it would be too late to contact care” Other women described how the worry disturbed them in their daily life and it was therefore necessary to act. Some reported that they could not get rid of the thoughts about the baby moving less. “The worry escalated. Decided that it was time to check instead of walking around being worried” 3.1.4. Contributing external factors In this category the reason to contact care at a specific point in time was an external occurrence. The fact that there was a physical symptom in combination with decreased fetal movements led to the decision to contact care. Examples of physical symptoms related to pregnancy were: bleeding, contractions or rupture of membranes. “Because I have had strong contractions during the night” “Because there was vaginal bleeding and considerably fewer movements” Other symptoms mentioned were: headache, dizziness, loss of vision, nausea, hypertension, rash, itch, proteinuria, back pain, an infection or cold, in combination with decreased fetal movements. A few even mentioned symptoms of hepatosis, liver test results and lack of sleep. “due to hypertension, decreased fetal movements” Some women contacted care when it was not possible to stimulate the baby to move. The most common ways to try to stimulate fetal movements were to push the tummy or to drink cold and sugary drinks. “I did not feel any movements during the morning despite pushing at my tummy and intake of sugary drinks” 3.1.5. Not wanting to jeopardize the health of the baby Some expressed that it was better to be safe than sorry and check the baby’s health rather too often than risking the health of the baby.
“Better to check once too often” “think it is better to check an extra time” The women sometimes explained that they already knew that they should contact care when experiencing reduced fetal movements. One woman stated that she had received information from her sister, but most of the women did not mention where they had received the information. “I have read a lot about reduced fetal movements and the importance of trusting one’s instinct.” “I have heard that one should contact care if it suddenly feels different” “Know that one should go for a check-up if you feel the baby less often or it feels different” 3.2. Reasons for delaying a consultation Of the 960 women, 88 did not answer the question and 227 women responded “No”. The results are presented in Table 3. The most common reason for not having consulted care earlier was that decreased fetal movement was a new experience. Several women stated that they wanted to wait because they thought it was a coincidence that the movements had decreased and that they waited for the baby to move again. Some women stated that they did not want to burden the health care service unnecessarily, that they felt excessively worried, stupid and ridiculous. Further, some women had not contacted care earlier because they had still felt movements, although fewer. Few women referred to practical problems such as: having children at home, no car and that it was too late in the evening or night. Also, a few women felt reassured due to the baby kicking when the tummy was stimulated in various ways. 4. Discussion The amount of time that had elapsed, together with the feeling of having waited long enough with the experience of decreased or different fetal movements were crucial in determining the point in time when the women consulted care. Advice from health care, most commonly from the midwife, to come for a check-up, and increasing worry about the health of the fetus were additional factors which determined the point in time for taking action. Various physical symptoms also affected the decision to consult care. Restraining factors were that the experience of decreased fetal movements was new to the woman and that she believed that it was temporary. Even a feeling of not wanting to burden the health care services unnecessarily or being considered too annoying and overly worried, led to hesitation to go to hospital for a check-up.
Table 3 Reasons for not contacting care earlier. Statements N = 872
N (%)
No reason Not been like this before Thought it was temporary – waited Did not want to burden/contact care services unnecessarily. Did not want be annoying, feel stupid, seem ridiculous Not been worried before Still some movements Believed it was normal with decreased fetal movements Recommended to wait by the midwife at the antenatal care unit Waiting for antenatal care visit Consulted care before and had a check-up Practical problems such as siblings, no car, weekend, too late at night Insecure, did not trust oneself Stimulation which led to increased fetal movements
227 (26) 130 (15) 89 (10) 69 (8) 68 (8) 55 (6) 20 (2) 20 (2) 15 (2) 14 (2) 14 (2) 10 (1) 7 (1)
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4.1. Reaching deadline The most common reason to contact care was that a certain amount of time had passed. Although the length of time varied, many women reported having experienced that too long a time had passed and that they wanted reassurance that everything was alright with the baby. The definition of too long may be affected by the information and recommendations the women receive about fetal movements and when they are supposed to consult care. Pregnant women do not receive information about what is regarded as normal fetal movements.1,3,6 Disparate and sometimes even inaccurate information about fetal movements and varying advice about when an examination is appropriate may delay the check-up of the fetus. In a study by Tveit et al.,3 one third of the women waited until the movements had ceased before consulting care. A quarter of the women waited 24 h or more after the movements had ceased. This is in line with the results of the present study. Many women reported having waited for several days. The risk for a negative outcome increases with a delayed contact with health care.11 If the fetal movements have ceased, research shows that intrauterine fetal death increases up to eight times if more than one day passes before the examination. Cardiotocography (CTG) and an ultrasound examination within two hours are recommended if the woman experiences no fetal movements at all. If she experiences decreased fetal movement the recommendation is to perform these examinations within twelve hours.12 When women wait before consulting care due to decreased or absent fetal movements, as many women did in the present study, the recommended examinations are impossible to perform within the recommended timeframe. Consequently, the risk for a negative pregnancy outcome and intrauterine fetal death increases. In a study by Erlandsson et al.13 women’s premonitions about something being wrong with the baby were explored before they were informed (after an ultrasound examination) that their unborn child was dead. Some of the women said that they had postponed contacting care because they were afraid of being regarded as too worried or hysterical by the care givers. None of the women in the present study stated that they were afraid to be regarded as excessively worried or hysterical. However, in the analysis of obstacles, women reported feeling that they did not want to burden care unnecessarily or to be regarded as troublesome. Further, compared to the study of women who lost their child, few expressed that they did not want to feel stupid. A possible explanation for this is that they may have stronger self-esteem; they are not prepared to compromise the health of their unborn child. All women in the present study had a fetus assessed as healthy after the examination at the hospital. Conversely, low selfesteem may be a risk factor for intrauterine fetal death. 4.2. Receiving advice from health care professionals The second most stated reason for contacting care at a specific point in time was advice from health care professionals. The women had often been in contact with a midwife working in antenatal care or at the birth clinic. Indirect advice, i.e. previous information about when one should contact healthcare was also reported. In a study by McArdle et al.,9 the women stated that they preferred to receive information from a midwife. In the same study the women requested more written information about fetal movements. In the Guide for Caregivers given out by Stockholm County,14 caregivers are recommended to send women who experience decreased fetal movements to a birth clinic at a hospital immediately. Further, the recommendations include that all women in around gestational week 25 should be asked about fetal movements. They should also be informed about the
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importance of contacting a birth clinic as soon as possible if the fetal movements decrease or cease. Midwives are exhorted to actively ask about fetal movements at every check-up from gestational week 25, and to document all deviations in the medical record. In the present study, some women mentioned that it was the previous information from the midwife which determined the point in time when they contacted care. High levels of confidence in the midwife may explain why more than one third of the women stated that it was this advice that was crucial in determining the point in time when they consulted care. A further explanation for contacting the midwife at a specific point in time may be a need to receive advice from an expert before contacting the hospital. The woman may not trust her own ability to decide when she is supposed to consult care or may be afraid of being dismissed if the decision has not been made in consultation with health care professionals. The reason why so many women needed advice from their midwife may indicate that the previous information they have received has been insufficient for making an informed choice. In the study by McArdle et al.,9 only 67% stated that they had received information about fetal movements and what to expect during pregnancy. According to a study by Saastad et al.,11 women who had received information about fetal movements consulted care earlier than those who had not received information. The same study demonstrated a decrease of intrauterine fetal death. Information and advice from the midwife seem to have a significant role regarding the point in time the woman consults care. 4.3. Undergoing unmanageable worry Worry was an important factor in deciding when to contact care. Some women reported that they contacted care when the worry increased. The recommendations are not to wait until the next day before contacting care and checking on the baby’s health.6 According to Bayrampour et al.15 pregnancy is associated with some worry and motivates behavior that favors the fetus. Worry is considered as a facilitator during the pregnancy, protecting the baby from harmful behavior. This may be one of the reasons why many of the women in the present study describe worry as an indicator that something is wrong and therefore crucial regarding the point in time for contacting care. According to Malm et al.,16 the reason to consult care due to decreased fetal movements was increased worry. In the present study, the women described how they had reached the limit of their worry. Bayrampour et al.15 describe that worry may cause a dysfunction and make it difficult to concentrate in daily life, which may have been the case in the present study. Only one woman expressed that she contacted care due to her worried partner. However, the women often expressed themselves in terms of “we” not “I”, which may be interpreted that the decision to contact care was not taken alone. That the decision was not made according to one person’s subjective opinion may strengthen the feeling of having made the right decision. 4.4. Contributing external factors Some women stated that they tried to stimulate the fetus to move by drinking cold, sweet drinks or by pushing their belly. When these strategies did not work they contacted care and decided to go to the birth clinic. Some studies show increased fetal movements when the maternal blood glucose is increased but there are also studies with contradictory results.6 Sometimes the decision when to contact care was determined by a physical symptom, such as bleeding or stomach pain in addition to the decreased fetal movements. The opposite also occurred; that a physical symptom was already present and when the fetal
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movements decreased the women contacted care. The physical symptoms may have been regarded as more objective and therefore facilitated making the decision. An alternative explanation is that women had knowledge about some physical symptoms being an indication that the fetus is not healthy. 4.5. Not wanting to jeopardize the health of the baby An intuitive feeling that something was wrong was given by the women as a reason for contacting care at a specific point in time, which should be met with respect and be encouraged. In a study by Malm et al.,16 which explored women’s experiences in the period before being informed of their baby’s intrauterine death, the category, “the feeling that something was wrong” revealed that the women were aware of a growing feeling that something was wrong. Some of the women stated that they knew it was important to contact care due to decreased fetal movements but that this knowledge had not come from health care professionals. One can assume that women had searched for information themselves. Common sources of information about fetal movements are: the internet, one’s own mother, other family members or friends, articles, books, prophylaxis courses, doulas and brochures.9 The pregnant woman should receive the information necessary to make an informed decision about when she is supposed to contact care from the midwife in antenatal care. 4.6. Strengths and limitations A large number of all women who contacted care due to decreased fetal movements during a one-year period in Stockholm was included in the study. It is not known if all women who fulfilled the inclusion criteria were asked to participate in the study. How many women declined to participate, and if the individuals among the drop-outs differ from those in the study group is unclear. The fact that only English and Swedish-speaking women were selected for analysis may have affected the results. Those speaking other languages may have related differently to decreased fetal movements. Some may have come from another socio-economic background, some may have been influenced by another culture and may have chosen to contact care at different points in time. 5. Conclusions Worry about the baby is the crucial reason for consulting care as well as the amount of time that has elapsed since the first experience of decreased fetal movements. Obstacles were that the experience of decreased fetal movements was new to the woman, who believed it to be a temporary decrease. Prehospital delay was due to not wanting to burden the health care service unnecessarily.
Pregnant women are supposed to receive clear information about how to recognize the normal pattern of movements of the unborn baby, and at what point in time they are should consult care due to decreased fetal movements. The midwife has a crucial role regarding counseling and imparting basic information about fetal movements to the pregnant women. National guidelines about information regarding fetal movements may be a support both for health care professionals and pregnant women. Conflict of interest The authors declare that they have no conflict of interest. References 1. Saastad E, Ahlborg T, Frøen F. Low maternal awareness of fetal movement is associated with small for gestational age infants. Am Coll Nurse-Midwives 2008;53(4):345–52. 2. Nowlan NC. Biomechanics of fetal movement. Eur Cells Mater 2015;29:1–21. 3. Tveit JVH, Saastad E, Stray-Pedersen B, Børdahl PE, Flenady V, Fretts R, et al. Reduction of late stillbirth with the introduction of fetal movement information and guidelines—a clinical quality improvement. BMC Pregnancy Childbirth 2009;9. 4. Frøen JF. A kick from within: fetal movement counting and the cancelled progress in antenatal care. J Perinat Med 2004;32:13–24. 5. Hijazi ZR, East CE. Factors affecting maternal perception of fetal movement. Obstet Gynecol Surv 2009;64(7):489–97. 6. RCOG. Green-top guideline No. 57: reduced fetal movements. London: Royal College of Obstetricians and Gynaecologists (2011). http://www.rcog.org.uk/ womens-health/clinical-guidance/reduced-fetal-movementsgreen-top-57 (Accessed 24 November 2017). 7. Linde A, Pettersson K, Rådestad I. Women’s experiences of fetal movements before the confirmation of fetal death; contractions misinterpreted as fetal movement. Birth Issues Perinat Care 2015;42(2):189–94. 8. Warland J, Glover P. Fetal movements: what are we telling women? Women Birth 2017;30(1):23–8. 9. McArdle A, Flenady V, Toohill J, Gamble J, Creedy D. How pregnant women learn about foetal movements: sources and preferences for information. Women Birth 2015;28(1):54–9. 10. Malterud K. Kvalitativa metoder i medicinsk forskning: En introduktion (3. uppl.). Lund : Studentlitteratur AB. Malterud, K., 2014. [In Swedish]. 11. Saastad E, Tveit JVH, Flenady V, Stray-Pedersen B, Fretts RC, Børdahl PE, et al. 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. BMC Res Notes 20103(2). 12. Tveit JVH, Saastad E, Stray-Pedersen B, Børdahl PE, Frøen JF. Concerns for decreased fetal movements in uncomplicated pregnancies—increased risk of fetal growth restriction and stillbirth among women being overweight, advanced age or smoking. J Matern-Fetal Neonat Med 2010;23(10):1129–35. 13. Erlandsson K, Lindgren H, Davidsson-Bremborg A, Rådestad I. Women’s premonitions prior to the death of their baby in utero and how they deal with the feeling that their baby may be unwell. Acta Obstet Gynecol Scand 2012;91 (1):28–33. 14. Guide for caregivers. Stockholm County. www.vardgivarguiden.se, Minskade fosterrörelser. [In Swedish]. 15. Bayrampour H, Ali E, McNeil DA, Benzies K, McaQueen G, Tough S. Pregnancyrelated anxiety: a concept analysis. Int J Nurs Stud 2015;55:115–30. 16. Malm MC, Lindgren H, Rådestad I. Losing contact with one’s unborn baby— mothers’ experiences prior to receiving news that their baby has died in utero. Omega: J Death Dying 2011;62(4):353–67.
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