Search and selection
The results of the search yielded 3360 citations from the electronic database sources and a further 23 from searching of other sources. Of these 3383 citations, 163 were identified as duplicates and removed leaving 3220, which were assessed on title and abstract. A further 3153 were excluded at title and abstract screening as they were clearly not eligible. The remaining 67 citations were screened at full-text level. Fifty-six of these were subsequently excluded for the following reasons; 30 had no qualitative data specifically on views, experiences or perceptions of assessing FMs, seven were literature reviews, six were letters to journal Editors, three were conference abstracts with insufficient qualitative data to include, two were identified as further duplicate reports, two were not in English, two were randomised trials, one included women at less than 20 weeks of pregnancy, one was a cross-over study with insufficient qualitative data to include, one was a poster abstract of an included study, and, for one, we were unable to obtain the full text to accurately assess eligibility. The references, and exclusion reasons for these 56 excluded studies are provided in Additional File 2. This resulted in the inclusion of nine studies across 11 publications [34-44]. Figure 2 illustrates the search and selection process.
Description of included studies
Table 2 presents the summary characteristics of the included studies. Three studies (four reports) were conducted in Sweden [34, 38-39, 42], three in Australia [40, 41, 43], two in the UK [37, 44] and one (two reports) in New Zealand [35, 36]. The majority of the studies (n=6) were conducted from 2011 onwards, with one conducted in 1986 [37], and for two, the study dates were not provided [35-36, 43]. Data collection involved the use of questionnaires with open-ended response options in six studies [34, 37-41, 43] and interviews in the remaining three studies [35-36, 42, 44]. In total, 2193 multiparous and primiparous women participated in the nine included studies (Table 2).
Quality assessment
Table 3 presents the results of the quality assessment. None of the nine included studies met all 12 quality criteria. Two studies met 11 of the 12 criteria, with both not meeting the criterion of actively involving the participants in the design and conduct of the study [35-36, 44]. Three studies met 10 of the 12 criteria [38-39, 42, 43]. Two studies respectively met nine and eight of the 12 quality criteria [40, 41]. Of the remaining two studies, one met five [34] and the second met three of the 12 criteria only [37].
Findings
Three dominant analytical themes with seven subthemes emerged from the thematic synthesis. Additional file 3 provides an audit trail of the synthesis process from identifying codes, to descriptive themes and finally analytical themes. Table 4 illustrates the studies that contributed data to each of these themes/sub-themes.
Theme 1: How women engage with FMs
All nine included studies contributed data related to women’s engagement with FMs in pregnancy. Three subthemes were identified which encapsulate these narratives. These were informal engagement with FMs, formal engagement with FMs, and strategies used to stimulate FMs.
Informal engagement with FMs
All nine studies referred to how women engaged subconsciously with or monitored their FMs in an informal way. Factors that women perceived to impact on FMs were varied and included their own position or their baby’s position, time of day, and their hunger/eating patterns [34-36, 43]. Although FMs varied throughout the day and from hour to hour, in general, women described experiencing increased fetal activity more often in the evenings [36, 37] and before meals [35, 43] and decreased fetal activity after meals [35]. Drinking coffee, sweet drinks or cold water also had the effect of increasing FMs [38, 39, 43].
‘I lie on my back instead of on the side, otherwise the baby protests because she/he doesn’t like the side [34, p.3]
‘…she gets very excited before dinner time’ [35, p.4]
and, referring to feeling hungry, one woman describes how her baby gets
‘…..really wriggly and really squirmy’ but ‘feels a lot more comfortable after I’ve eaten’ [35, p.4]
Women associated FMs with good fetal health. Regular patterns of FMs were considered reassuring and a way of feeling ‘connected’ to their baby. A pattern of movement was an expectation of healthy fetal behaviour, although this pattern was recognised as being individual for each woman. These individual patterns were also a point of reference for women in identifying reduced FMs [37-39];
‘The baby has not moved at the times that she had moved earlier, following the pattern that she had previously…..the movements felt weaker the past two days compared to before’ [38, p.4]
Women also reported struggling to identify a pattern which made FM monitoring more difficult and interfered with women relaying information about FMs to clinicians. Expressed expectations of frequency and quantity of FMs also varied, ranging from a few times each day, to four per hour or at least 10 per hour. Women’s narratives also highlighted uncertainty around what they should expect of FMs;
‘I would like to know the normal number of movements for babies of different gestations’ [40, p.575]
‘I believe its 4 [movements] per hour on average, maybe?’ [41, p.81]
Women subconsciously engaged with and monitored FMs from the beginning of their pregnancy. Some experienced doubt and uncertainty when attempting to identify first movements, finding it difficult to distinguish between actual FMs and other sensations, until a pattern or more consistent sensations became established;
‘It was just one little tiny movement and I wasn’t sure if it was, but then movements after that felt the same’ [36, p.289]
For women, identifying their first FMs made their pregnancy and baby feel real, although initial sensations could be ‘a little unpleasant’ [42, p.114]. Informal monitoring of FMs also acted as a mechanism of communication between the mother and her baby [34-36]. Women became more aware of the baby ‘as an individual’ and felt more ‘connected’; when FMs were visible and palpable, this experience of FMs could then be shared with family members;
‘my husband is also with me and listens, he has his hands on my tummy during this time’ [34, p.4]
Formal engagement with FMs
Three studies provided data on formally assessing FMs [34, 37, 41]. In one of the studies, women, in practising Mindfetalness, monitored their FMs in a structured way by focusing on the intensity and character of their FMs, without necessarily counting them [34]. In the other two studies the use of the Cardiff count-to-ten was explored [37] and women’s comments on tracking FMs were collected [41], with women recounting that they would take time out to count FMs and the importance of this;
‘take 15 minutes at same time each day and count kicks’ [41, p.81].
For some women, formally assessing FMs caused worry [34, 37]. Although the exact nature of this worry was not specified by all women, they did report feeling anxious until the required number of kicks had been counted and that focusing on FMs in such a structured format could cause more worry. Others expressed doubt about identifying what specifically constitutes a ‘kick’ [37]. Formally engaging in FM recording was also considered an inconvenience by some women, mainly in terms of lack of time, losing count, and forgetting to complete the FM chart, particularly towards the end of pregnancy.
Other women questioned the value of using a ‘kick’ chart, suggesting that they would notice if their babies’ movements stopped and that a chart was not necessary for this [37]. The value of recording FMs formally is further questioned by one woman’s comment where, rather than use a chart, she
‘would have preferred to have been told to notice and report changes in her baby’s movements’ [37, p.336]
In contrast, women also felt that monitoring their babies’ FMs formally was very important so as ‘to gain an understanding over time of what is ‘normal’ for you and your baby’ [41, p.33]. These women were happy to complete a FM chart, and did not view it as an inconvenience [37]. Formal FM monitoring provided women with reassurances that their babies were kicking and that this meant that their baby was well. Some women stated that they felt more confident and less worried about FMs when a method of formally assessing them was used. This was especially so for women using Mindfetalness, where the characteristics of FMs, such as intensity and pattern, are noted;
‘I practice the method more when I get worried about fetal movements. Now, I’m not as worried as before” [34, p.4]
Strategies to stimulate FMs
Women commonly adopt strategies to elicit FMs when they were experiencing altered or reduced FMs [36, 38, 39, 40, 43, 44]. For instance; drinking a sugary, citrus or cold drink to ‘shock the baby and wake it up’ [43], physically moving the body or compressing it by ‘rubbing or prodding the belly’ [36], or ‘pulling and nudging the tummy’ [38]. Other strategies adopted by women included having a warm bath, placing hands on the abdomen, and lying down. Generally, across the studies, women reflected that if these strategies did not elicit FMs, further care from a healthcare professional was required;
‘…..try to encourage movements, stand up, move around, have a sugar, citrus drink. If still no movements/reduced movements, go to hospital’ [41, p. 81].
Theme 2: ‘…like a feather inside my belly’ – articulating and describing FMs
The theme of articulating and describing FMs is illustrated in two sub-themes. These are sensations associated with FMs and timing and frequency of FMs.
Sensations associated with FMs
Women’s descriptions and sensations of FMs differed at different gestational ages. Characteristics of the first fetal sensations included being ‘very soft…like a puff of air…very gentle’ [43] and were described in terms of feeling like a small ‘knock,’ ‘dink’, ‘hiccup’ or ‘jolts’ [36, 43]. One woman, in describing these early FMs commented that it took time for her to become accustomed to the nature of her baby’s FMs;
‘…it felt so jerky and I couldn’t imagine what it was doing, but now I have got used to feeling that way’ [42, p.114].
Women’s descriptions of FMs changed as pregnancy progressed. Descriptions of FMs at the start of the third trimester were varied [35, 36, 42, 43], with women describing more specific limb movements that were sometimes visible on the skin;
‘you can sometimes see the actual skin moving. I can’t tell what it is; like an elbow, knee or foot, but just seeing the skin move’ [36, p.290]
These limb movements were described as ‘punchy’, with whole body movements described using a variety of terms from ‘smooth’ or soft ‘wriggling’ and ‘tapping’ movements to stronger ‘kicking’ or ‘swooping’ movements [36, 43]. As the baby reached term, women described movements as becoming less varied, slower, and stronger [35, 36, 42, 43];
‘like a film in slow motion …there is a lot of power, but everything is going slowly, gliding along. I imagine a wrestling match, maybe in slow motion. You see lots of power, but things move slowly’ [42, p.114]
‘more sustained, rolling, churning sensations’ [43, p.4]
Women interpreted these slower, stronger and altered FMs as the baby having less space as the end of pregnancy approached ‘as the baby gets bigger’ and ‘has less room to move’ [43, p.5] although there appeared to be some confusion amongst women as to expectations of FMs towards term;
‘Close to birth…..movements will less a bit’ [41] and ‘slow down’ because there is ‘less room’ [41, 43] versus ‘movements should not slow down towards the end of pregnancy even if the baby has less room’ [41, p.5]
Timing and frequency of FMs
Variations in frequency and timing of FMs was a common experience for women, with some experiencing regular FMs throughout the day [35, 36, 43], while others experienced less movement during the day, more commonly experiencing FMs in the evening [36, 37]. Expectations as to when first FMs should be felt varied between 12-19 weeks and 17-20 weeks, although many women (approx. 25% in one study [43]) report feeling their first FMs after 20 weeks’ gestation [41, 43].
Women associated unusual or changed FMs with changes in the frequency of FMs, absence of FMs, changes in the sensation of FMs, FMs not occurring at the usual time, occurring less often or becoming weaker and non-specific [38, 43]. Reduced or an absence of movement, including concerns for these, was generally framed in the context of time;
‘I haven't felt any kicking for about 12 hours’ [38, p.3]
‘When the activity had decreased and had not gone in the right direction after 2 days’ [39, p.378]
Theme 3: FMs and help/health seeking
Women provided various accounts related to help and health seeking behaviours and views with respect to FMs in pregnancy. These perspectives are reflected in the sub-themes of information sources and interacting with healthcare professionals
Information sources
Women reported accessing multiple information sources on FMs including, healthcare professionals, antenatal classes, books, the internet, family and friends [36, 40, 41, 43, 44]. There were preferences for receiving information on FMs from healthcare professionals, especially midwives (82% of 526 women in one study [40]), and particularly in the format of printed documentation such as a pamphlet or hand-out, rather than verbal information [40, 41]. The main reason for this was that printed information could be easily referred to if needed;
‘a hand-out to read throughout pregnancy, so we can refresh our cloudy heads’ [40, p.57]
Women also indicated a desire for specific information about monitoring FMs, such as information on movement counts/types/changes and when to seek advice [40, 41, 43]; although a preference for more general information about health and wellbeing rather than information that was specific to FMs only was also expressed
‘so as not to distress or cause too much anxiety’ [41, p.82]
Women commonly sought informal information about FMs from their friends or family [36, 40, 44], and for some women they relied on this information in advance of or as an alternative to contacting their midwife [36]. Others compared experiences with their peers and consulted family members who had experienced pregnancy previously [44]. The internet was a common source of information for women on FMs [40, 41, 43, 44] often as the first source of advice or instead of consulting a healthcare professional as it is ‘more accessible’ [44];
‘if I ever have questions or worries I usually ‘Google it’ or look up a book’ [43, p.6].
Online forums were described as helpful, although they could cause worry too [44], which might explain why women expressed preferences for trusted websites such as ‘NHS direct’ and sought direction to trusted websites from their healthcare providers [40].
Interacting with healthcare professionals
Six of the included studies described women’s interactions with healthcare professionals about FMs [36, 37, 39, 41, 43, 44]. A decrease in FMs was generally perceived as a cause for concern that warranted help from a healthcare professional;
‘…any slowing of movements should be seen about in hospital’ [36, p.290]
Others distinguished between a reduction in FMs, and no movement at all which was a cause for greater concern;
‘… as long as she moved then I consider that to be okay. I think if it’s been a couple of days and they’ve not moved or a full day then it’s something to worry about’ [44, p.3]
Reasons for contacting healthcare professionals due to a decrease or change in FMs included a defined period of time had passed with decreased or altered movement, although this varied from a few hours to a number of days, if the worry became unmanageable, when women experienced a fear of fetal loss, and when strategies to stimulate movements were unsuccessful [39, 40, 44]. Barriers to contacting healthcare professionals were mostly related to doubts or fears of being perceived in a particular way. Concerns experienced by women included fears that they would not be taken seriously, not listened to, or that they may be viewed as ‘hysterical’, ‘overly anxious’, or ‘being a hypochondriac’ [41, 43, 44] with fears often based on previous negative interactions;
‘I was made to feel uneducated and overly anxious, and at times I agonised whether to take my concerns to the professionals or just ‘Dr. Google’ … to save face and stress’ [41, p.80]
Other barriers to contacting healthcare professionals included feelings of uneasiness that they were taking up the healthcare professionals time unnecessarily [39, 41, 44], and concerns that they would be induced or be perceived as trying to get induced;
‘I think I would be more nervous to go in if I felt reduced movements again, because I got the impression that they just thought I’d gone in to try and get induced or to try persuade them to do something’ [44, p.5]
Contrary to this, healthcare professionals were explicit on what to do should women experience reduced or altered FMs and women responded actively to this advice;
‘My midwife at antenatal care has told me clearly that I should call the birth clinic if I experience decreased fetal movements’ [39, p.378]
‘It was the midwife when I saw her…..and straight away she was like, you need to ring triage, we need to get it checked out. So that what prompted me to call in’ [44, p.5]
Advice from healthcare professionals on monitoring FMs and on what to do if they were concerned about FMs varied. This ranged from making contact with a healthcare provider if there was any reduction or change in FMs, not to worry as long as there were some FMs everyday regardless of quantity, specific advice on expected frequency and quantity of FMs, and little or no advice at all [38-40, 43, 44];
‘’During visits I have only been asked if the baby has moved – I reply yes and the conversation ends’ [40, p.57]
Confidence in the review’s findings – CERQual
Overall, confidence in the review’s findings was either high or moderate, with two of 16 discrete findings receiving a low confidence rating, and one only receiving a very low confidence rating. The finding rated very low confidence related to the formal assessment of FMs, and the resulting worry and anxiety, as well as reassurances that can come from this. This finding was downgraded to very low because the majority of the contributing data was from three studies, two of which met five or less of the 12 quality criteria (serious concerns), the data supporting the finding was varied (moderate concerns) and all of the data came from open-ended response options in surveys (moderate concerns). The two findings rated low confidence related to women’s expectations for when first FMs might be felt and that women commonly experience FMs in the evenings. Table 5 provides the summary results of the CERQual assessments. The Evidence Profile and rationale for judgements in each of the four components and overall confidence rating for each discrete finding, is provided in Additional File 4.