In this study, we found that women were able to recognise qualitative changes in fetal movements throughout gestation. The data also revealed an overall identifiable pattern associated with pregnancy, beginning with descriptions of ‘gentle’ movements, ‘bubbles’ and ‘butterflies’. Towards mid pregnancy these were described as ‘bigger’ and ‘sharper’ movements which included association with limb movements. Finally women towards the end of pregnancy, generally described fetal movements as ‘smooth’, ‘sustained rolling sensations’. These movement descriptions coincide with fetal development at this gestation which includes improved fetal coordination and limb control [3, 22] and increased fetal size . This overall pattern is supported by physiological data of fetal motor development understanding [24, 25]. Importantly, only two women interpreted this change as reduced frequency of fetal movement but still described an increase in strength of movements.
Most women used words that described an increase in strength of movements throughout their pregnancy regardless of gestation. From 32 to 41 weeks gestation, some women reported less movements but all described increasing strength. Our findings suggest that pregnant women are aware of the quantitative movement changes and are aware of increasing strength. The mean gestation for women to perceive first movements was 19 weeks, in accordance with previous research [16, 23]. However, our results also found that over a quarter of women recognised their first movement after 20 weeks, and this may be useful information for both clinicians and pregnant women. Earliest detection of fetal movement was 7 weeks, which concurs with a small ultrasound study of women who reported that there are “just discernible movements” from 7 weeks (10).
Perception of movement increased as the day progressed, peaking during the night which is consistent with previous research [23, 24]. We speculate that this may partly be a function of women’s attention, as many women reported that they noticed increased movement in the early morning when they are likely to be in bed when other distractions are likely to be minimised.
Importantly few women felt the need to seek advice immediately when they noticed an unusual fetal movement. Of the women concerned about unusual fetal movements, only one sought help within 24 hours. The remaining who told their care-provider, did so at the next antenatal appointment which (most likely) was past a critical time point for intervention. Previous research has shown that around 50% of women affected by unexplained stillbirth and observing an absence of fetal movement waited more than 24 hours before they contacted their health professional [7, 26]. Guidelines recommend that women who are concerned about reduced fetal movements should not wait until the next day for assessment , again women in our study did not act in this way, although we did not collect data to measure if they had been instructed to do this.
Overall, routine antenatal care in regards to fetal movement was varied and inconsistent. This may be a reflection of several factors some of which are specific to this setting, including the lack of a policy on fetal movement monitoring at the time of this study, (there is now a policy) there is a now a current policy . More generally it may be a function of the overall uncertainty regarding the evidence surrounding fetal movement monitoring, the lack of definitions of normal fetal movements or the definition of abnormal movements for identifying fetal compromise [26, 28]. Although some women reported being unsatisfied with the general nature of the fetal movement questioning during their care, this may actually be the most appropriate type of questioning, as it aims to assess woman’s assessment of her baby’s movement .
Caregiver advice on the normal number of fetal movements varied greatly. Most women could not confidently recall the number or the time frame that fetal movements should be counted. Very many “Kick counting” methods exist and are used in antenatal settings around the world, however the evidence is unsupportive of routine use . Almost all women reported being asked about fetal movements in their routine care, most of this questioning was centred on the woman’s qualitative assessment. This study provides evidence that supports the value of women’s perception of fetal movements to clinicians.
Strengths of our study include the large sample size of qualitative data. We developed an explicit analysis process (Table 2), and used multiple coders for research triangulation which adds validity to the findings . The limitations of our study include lack of data regarding placental position or amniotic fluid volume, both of which have been shown to affect maternal perception of fetal movement . The generalisability of the coding frame may be limited to similar cultural and language populations. Although there is no reason that the types of movements will differ in different cultures the words used to describe them may and thus these words would need to be tested for cultural specificity.
This work is the first step towards defining normal fetal movement using a qualitative framework, work such as this may help identify ‘alert words’ that women and care-providers could use in a clinical setting to screen for babies at risk of demise.