Encouraging awareness of fetal movements is harmful
Authors: Kate F Walker, Jim G Thornton
Journal: The Lancet (2018)

The concept that perception by pregnant women of reduced or altered movements of their fetuses can be used to predict stillbirth, thereby enabling early birth to save the baby, seems plausible.1Sadovsky E Yaffe H Daily fetal movement recording and fetal prognosis.Obstet Gynecol. 1973; 41: 845-850PubMed Google Scholar However, although mothers of stillborn babies, with hindsight, remember altered movements preceding the diagnosis of the death more often than controls,2Heazell AEP Budd J Li M et al.Alterations in maternally perceived fetal movement and their association with late stillbirth: findings from the Midland and North of England stillbirth case-control study.BMJ Open. 2018; 8: e020031Crossref PubMed Scopus (32) Google Scholar, 3Stacey T Thompson JM Mitchell EA Ekeroma A Zuccollo J McCowan LM Maternal perception of fetal activity and late stillbirth risk: findings from the Auckland Stillbirth study.Birth. 2011; 38: 311-316Crossref PubMed Scopus (73) Google Scholar to our knowledge, no one has ever shown this prospectively. With few exceptions,4Sovio U White IR Dacey A Pasupathy D Smith GCS Screening for fetal growth restriction with universal third trimester ultrasonography in nulliparous women in the Pregnancy Outcome Prediction (POP) study: a prospective cohort study.Lancet. 2015; 386: 2089-2097Summary Full Text Full Text PDF PubMed Scopus (382) Google Scholar the accuracy of tests of fetal health done in response to altered movements has been poorly evaluated, and the only treatment—delivery—can harm as well as benefit.5Thornton JG Hornbuckle J Vail A Spiegelhalter DJ Levene M Infant wellbeing at 2 years of age in the Growth Restriction intervention Trial (GRIT): multicentred randomised controlled trial.Lancet. 2004; 364: 513-520Summary Full Text Full Text PDF PubMed Scopus (258) Google Scholar A 2015 Cochrane review6Mangesi L Hofmeyr GJ Smith V Smyth RM Fetal movement counting for assessment of fetal wellbeing.Cochrane Database Syst Rev. 2015; 10 (CD004909.)Google Scholar on routine perinatal fetal movement counting was dominated by a cluster trial by Adrian Grant and colleagues,7Grant A Valentin L Elbourne D Alexander S Routine formal fetal movement counting and risk of antepartum late death in normally formed singletons.Lancet. 1989; 2: 345-349Summary PubMed Scopus (213) Google Scholar who investigated routine use of movement counting among 68 000 women and found that this method "did not translate into reduced perinatal mortality". Nevertheless, encouraging maternal awareness of changes in fetal movements remains popular; this suggestion was advocated by the Saving Babies' Lives publication by NHS England,8NHS EnglandSaving Babies' Lives: a care bundle for reducing stillbirth.https://www.england.nhs.uk/wp-content/uploads/2016/03/saving-babies-lives-car-bundl.pdfDate: March 21, 2016Date accessed: August 24, 2018Google Scholar largely on the basis of a study9Tveit JV Saastad E Stray-Pedersen B et al.Reduction of late stillbirth with the introduction of fetal movement information and guidelines—a clinical quality improvement.BMC Pregnancy Childbirth. 2009; 9: 32Crossref PubMed Scopus (130) Google Scholar that compared awareness campaigns with historical controls. This is weak evidence because other changes, such as increasing the frequency of term inductions and reduced smoking among pregnant mothers, could also have prevented stillbirth. However, in The Lancet, Jane Norman and colleagues10Norman JE Heazell EPA Rodriguez A et al.Awareness of fetal movements and care package to reduce fetal mortality (AFFIRM): a stepped wedge, cluster-randomised trial.Lancet. 2018; (published online Sept 27.)http://dx.doi.org/10.1016/S0140-6736(18)31543-5Summary Full Text Full Text PDF Scopus (90) Google Scholar have more thoroughly evaluated this policy. This stepped-wedge, cluster-randomised trial assessed a programme that encouraged enhanced maternal awareness and rapid reporting of changes in fetal movement, which was combined with training of staff to respond with a defined programme of further testing and, if necessary, to induce delivery. The advice to pregnant women was that they should monitor changes in movements from 24 weeks, and that they should refer themselves immediately if they detected altered movement after 28 weeks. Control centres gave usual care, and the primary outcome was stillbirth. More than 400 000 pregnancies at 33 hospitals were included, so the study was powered to exclude even modest effects. The intervention was associated with an induction rate of 41%, compared with 36% in the control group (adjusted odds ratio [AOR] 1·05, 95% CI 1·02–1·08); if the correct women had been induced and no harm caused, this intervention should have had a substantial effect. The Saving Babies' Lives stated that the AFFIRM trial "will give us the best evidence yet".8NHS EnglandSaving Babies' Lives: a care bundle for reducing stillbirth.https://www.england.nhs.uk/wp-content/uploads/2016/03/saving-babies-lives-car-bundl.pdfDate: March 21, 2016Date accessed: August 24, 2018Google Scholar Unfortunately, stillbirths were not significantly reduced by this intervention (AOR 0·90, 95% CI 0·75–1·07) and there was no effect on perinatal mortality (0·98, 0·83–1·17). However, appendix data showed a higher number of postneonatal deaths in those receiving the intervention than in the control group. The intervention also had associated costs, including a significantly higher use of caesarean sections of 28%, compared with 25% in the control group (1·09, 1·06–1·12), and more prolonged admissions to the neonatal unit (1·12, 1·06–1·18). The trial was prospectively registered and well conducted, and the results are plausible. Altered fetal movements are so commonly reported that the specificity of these reports must be low; some hospitals have more women attending for this reason than for births over the same period. Repeated episodes of reduced fetal movement can be so stressful to the mother that some doctors are persuaded to induce, even if further tests are normal. There are also anecdotes of women feigning reduced fetal movements to attain an ultrasound scan or induction of labour. The prevalence of women falsifying reduced fetal movement is important because, although induction of birth at full term is unlikely to seriously harm the mother or the baby,11Walker KF Bugg GJ Macpherson M et al.Randomized trial of labor induction in women 35 years of age or older.N Engl J Med. 2016; 374: 813-822Crossref PubMed Scopus (152) Google Scholar preterm induction has risks. With hindsight, the recommendation to encourage mothers to report changes from as early as 28 weeks might have been misguided. Although overall deaths were not stratified by duration of gestation, it is plausible that limiting awareness campaigns to beyond 37 weeks would be safer. Two other cluster trials are ongoing: My Baby's Movements among 250 000 women in Australia (Australian New Zealand Clinical Trials Registry, ACTRN12614000291684) and Mindfetal among 39 000 women in Sweden (ClinicalTrials.gov, NCT02865759), so the AFFIRM authors suggest delaying policy changes until results of these trials are reported. Nevertheless, given that the AFFIRM trial assesses a large population and is in agreement with the only previous large trial,7Grant A Valentin L Elbourne D Alexander S Routine formal fetal movement counting and risk of antepartum late death in normally formed singletons.Lancet. 1989; 2: 345-349Summary PubMed Scopus (213) Google Scholar opinion and practice leaders need to consider how current guidelines might be revised. Failure of health-care providers to respond to reported changes to fetal movement is probably impossible. However, discouraging campaigns that promote awareness preterm, improving induction guidelines, and not inducing delivery in response to perception of altered movement alone would seem to be sensible first steps. This online publication has been corrected. The corrected version first appeared at thelancet.com on October 3, 2018This online publication has also been corrected on October 25, 2018. This online publication has been corrected. The corrected version first appeared at thelancet.com on October 3, 2018 This online publication has also been corrected on October 25, 2018. JGT reports personal fees and non-financial support from Ferring Pharmaceuticals, outside the area of work commented on here. KFW declares no competing interests. Awareness of fetal movements and care package to reduce fetal mortality (AFFIRM): a stepped wedge, cluster-randomised trialThe RFM care package did not reduce the risk of stillbirths. The benefits of a policy that promotes awareness of RFM remains unproven. Full-Text PDF Open AccessDepartment of ErrorWalker KF, Thornton JG. Encouraging awareness of fetal movements is harmful. Lancet 2018; published online Sept 27. http://dx.doi.org/10.1016/S0140-6736(18)31720-3—This Comment is eligible for Open Access. The copyright line has been added. This has been corrected online as of Oct 3, 2018, and is correct in the print Comment. Full-Text PDF Open AccessDepartment of ErrorWalker KF, Thornton JG. Encouraging awareness of fetal movements is harmful. Lancet 2018; published online Sept 27. http://dx.doi.org/10.1016/S0140-6736(18)31720-3—In this Comment, the reference to the linked Article was incorrect. This correction has been made to the online version as of Oct 25, 2018. Full-Text PDF