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.