Interpretations
Of the 2.6 million pregnancies that end in stillbirth, the overwhelming
majority occur in LMICs. However, the evidence to guide optimal fetal
monitoring is limited. Although strong evidence suggest that reduced
fetal movement is associated with intrauterine fetal death, it remains
unclear whether it is a symptom of inevitable fetal death or whether it
can be used as an alert to prompt action and improve outcome.(23, 24)
This study showed that FMs assessment during labor, including on
admission to the labor ward may be important as many women who
prospectively and retrospectively reported abnormal FMs during labor had
subsequently developed perinatal adverse outcomes.
The little evidence available in LMIC indicates that women’s awareness
of the importance of FMs and reduced FMs as a danger sign of adverse
pregnancy outcomes was shown to be low and varied from 3.1% to 62.3%
across LMICs; and no studies were found to assess healthcare providers’
knowledge of FMs.(25) In this study setting, it was found that all women
were aware of the unique patterns of FMs – supporting an individualized
definition of abnormal/reduced FMs in accordance with the perception of
the mother. Also, most women and all their healthcare providers knew the
importance and interpretations of FMs as a sign of health of the child
and mother. However, there were no assessment of FMs or management
guidelines for women presenting with reduced fetal movement which also
reflects the lack of evidence and international consensus.(24)
Although there has been recent interest in maternal perception of FMs
and evidence is being sought in large trials in high-income countries,
there is no single RCT in settings with the highest burden.(17) Recent
trials in HICs showed educational and management packages or FMs
awareness intervention did not improve perinatal outcomes.(23, 26)
However, awareness of fetal movement is already incorporated in
stillbirth reduction strategies in HIC and stillbirth are much less
common. We can assume, therefore, that the high baseline knowledge of
FMs of both women and health provider and the already-existing protocols
on reduced FMs minimizes the effect of new or specific package of
intervention being tested. Thus, the current evidence might not be
readily applicable to settings with lower awareness and knowledge and no
established guidelines for assessment and management of abnormal FMs.
The role of maternal perception of fetal movement as part of a
stillbirth prevention strategy needs to be explored in these settings
where the stillbirth rates are much higher. It is especially relevant in
low-resource settings like MMH, where human resource is scarce and the
workload is considerably high, with little time for adequate fetal heart
monitoring, that an educated, alert and involved woman might help
improve her own care. Whether formally or informally monitored, FMs can
be the only signal in absence of regular antenatal and
intrapartum checks especially in high-risk pregnancies.
Whether or not fetal movement monitoring is advised or encouraged, some
women did have concerns about fetal movement. They should be able to
express their concerns and healthcare providers should be equipped with
evidence-based knowledge and practice to address them. However, in this
study, women lacked the agency to express concerns and staff did not
always assess FMs due reasons related to attitude/unfamiliarity with
assessing them, workload, lack of (human) resources and staff
misconception and mistrust of women’s perceptions and knowledge of FMs.
Trust in women’s perception of FMs was even less during labor where the
general view is that labor pain obscures maternal perception of FMs. The
potential benefits and harms of FMs monitoring and interventions,
including unnecessary maternal anxiety and obstetric interventions,
prematurity, hospital admissions, and increased work overload for staff
in an already overwhelmed system, makes it a priority area for
research.(18)
Conclusion
This study shows that women and their healthcare providers in a
low-resource setting have high awareness of maternal perception of fetal
movements, but little use of FMs assessment in routine clinical practice
to improve care. Thus evidence-based monitoring and management guidance
for reduced FMs is essential and an opportunity to prevent adverse
outcomes in low-resource settings.