Stillbirth (the death of the fetus prior to birth) is typically an awful experience for women and their families. It’s also awful for those of us who work in maternity care. We so desperately want to prevent stillbirth, that as a consequence we will grasp at the merest hint of a suggestion that we have a solution and run with it with great enthusiasm. Sometimes we then continue to do this, despite mounting evidence that what we are doing is at best ineffective, and at worst may be harmful.
Throughout the years of my practice, there has been a continued focus on asking pregnant women to attend to the movement pattern of their fetus, sometimes with the use of aids such as kick charts, and to report changes in the pattern of movements. This generally prompts further screening tests, such as CTG monitoring and / or ultrasound, and increasingly it is accompanied by a recommendation that labour should be induced. In recent years, large scale programmes, such as the Saving Babies Lives care bundle in the UK, have included an emphasis on educating pregnant women to monitor fetal movements.
A new systematic literature review has examined the effectiveness of giving women advice to monitor fetal movements. The authors, Bellussi et al., searched for randomised controlled trials. They identified five trials (including the large AFFIRM trial published in 2018), which together report on findings from 468,601 fetuses. (Note that the My Baby’s Movement trial is still underway and also examines this issue.) Similar to the findings of the 2015 Mangesi et al. Cochrane review, Bellussi et al. found that the rate of stillbirth was no different between women who were routinely advised to monitor the movements of their fetus and women were no such advice was given.
Specifically, the rate of stillbirth in the fetal movement monitoring group was 3.9 deaths per 1000 births, and 4.1 deaths per 1000 births in the control group. In addition, the overall rate of perinatal death (stillbirth plus neonatal deaths) was also not significantly different at 5.4 per 1000 in the fetal movement monitoring group and 5.9 per 1000 in the control group who were given no instructions to monitor movements. While there was no reduction in mortality, there were statistically significant increases in the rates of preterm birth, labour induction, and caesarean section.
If we take the 0.5 per 1000 difference in perinatal mortality and assume that this is an accurate representation of what happens in practice, then for each additional one fetal life saved by advice to monitor fetal movements there would be an extra 10 preterm births, 100 women with induced labour, and 58 additional caesarean sections. I wonder whether parents would consider this as a fair trade off?
So, as clinicians what do we do with this information? Advising women about fetal movements has become an integrated practice, supported by professional practice guidelines, and as such is now the standard of care. To not give such advice risks being found deficient in your care. I am not suggesting that you tell women to ignore a change in fetal movements, or to stop advising women to be mindful of a change in fetal movements. However, we do need to revisit our professional guidelines with the evidence in mind, rather than wishes, hopes, and prayers that movement monitoring might work if we just tried hard enough. We also need to be critical about funding expensive campaigns to spread the fetal movement monitoring message. Such funding could be better channelled into measures (such as midwifery continuity of carer models) where there is clear evidence that the stillbirth rate is lower.
Do you have any suggestions on how to put this evidence into use in practice? Add your comment below.
The abstract for the paper can be found here – Bellussi, F., Po, G., Livi, A., Saccone, G., De Vivo, V., Oliver, E. A., & Berghella, V. (2020). Fetal Movement Counting and Perinatal Mortality: A Systematic Review and Meta-analysis. Obstetrics and Gynecology.