Not enough evidence on counting the baby's movements in the womb to check for wellbeing.
Mothers can usually feel their babies moving in their wombs from around 16 to 20 weeks. Babies' activities in the womb can vary considerably, some being very active and some not so active. A decrease in a baby's normal pattern of movements may be a sign that the baby is struggling for some reason and it might be better for the baby to be born early. Hence, it has been suggested that if the mother counts her babies' movements each day, and there are several ways of doing this, she may be able to identify a decrease in her baby's normal movement patterns. It is further suggested that if the mother informs caregivers of this, then the caregivers can do additional tests and some babies can be prevented from dying before birth. However, sometimes fetal movement-counting tests can cause considerable anxiety for women and may not be easy for some women especially when a mother is busy at work or caring for other small children, so it is important to assess if these tests are helpful in identifying babies in difficulty with time then to intervene.
The review of trials found five studies, involving 71,458 women, comparing two fetal movement counting methods, fetal movement counting versus hormonal analysis and routine fetal movement counting compared with standard antenatal care, as defined by trial authors. In studies that compared routine counting of baby's movements in the womb with mixed or undefined counting, there was no difference in stillbirths, caesarean sections, birth weight less than 10th centile and mother-baby attachment; there was reduction in women's anxiety in the group counting the baby's movements. There was a tendency to more antenatal admissions. When counting of baby's movement was compared with hormonal analysis, there were fewer hospital visits among women who were counting and fewer babies in the hormonal analysis group had low Apgar scores, which assess the baby's condition after birth. There was no difference between the groups in terms of caesarean sections done and other outcomes. 'Perinatal death or severe morbidity' was not reported. When different types of fetal movement counting methods (once a day compared to more than once a day) were compared, women were more compliant in using the once a day counting method, citing less interruption with daily activities as one of the reasons; the incidence of caesarean section did not differ and perinatal death or severe illness was not reported. The numbers and the methodological quality of studies were insufficient to assess stillbirths accurately. Further trials are suggested, and it would be very important to assess women's anxiety and views in addition to the ability of the counting to prevent stillbirths.
This review does not provide sufficient evidence to influence practice. In particular, no trials compared fetal movement counting with no fetal movement counting. Only two studies compared routine fetal movements with standard antenatal care, as defined by trial authors. Indirect evidence from a large cluster-RCT suggested that more babies at risk of death were identified in the routine fetal monitoring group, but this did not translate to reduced perinatal mortality. Robust research by means of studies comparing particularly routine fetal movement counting with selective fetal movement counting is needed urgently, as it is a common practice to introduce fetal movement counting only when there is already suspected fetal compromise.
Fetal movement counting is a method by which a woman quantifies the movements she feels to assess the condition of her baby. The purpose is to try to reduce perinatal mortality by alerting caregivers when the baby might be compromised. This method may be used routinely, or only in women who are considered at increased risk of complications affecting the baby. Fetal movement counting may allow the clinician to make appropriate interventions in good time to improve outcomes. On the other hand, fetal movement counting may cause unnecessary anxiety to pregnant women, or elicit unnecessary interventions.
To assess outcomes of pregnancy where fetal movement counting was done routinely, selectively or was not done at all; and to compare different methods of fetal movement counting.
We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 May 2015) and reference lists of retrieved studies.
Randomised controlled trials (RCTs) and cluster-RCTs where fetal movement counting was assessed as a method of monitoring fetal wellbeing.
Two review authors assessed studies for eligibility, assessed the methodological quality of included studies and independently extracted data from studies. Where possible the effects of interventions were compared using risk ratios (RR), and presented with 95% confidence intervals (CI). For some outcomes, the quality of the evidence was assessed using the GRADE approach.
Five studies (71,458 women) were included in this review; 68,654 in one cluster-RCT. None of these five trials were assessed as having low risk of bias on all seven risk of bias criteria. All included studies except for one (which included high-risk women as participants) included women with uncomplicated pregnancies.Two studies compared fetal movement counting with standard care, as defined by trial authors. Two included studies compared two types of fetal movement counting; once a day fetal movement counting (Cardiff count-to-10) with more than once a day fetal movement counting methods. One study compared fetal movement counting with hormone assessment.
(1) Routine fetal movement counting versus mixed or undefined fetal movement counting
No study reported on the primary outcome 'perinatal death or severe morbidity'. In one large cluster-RCT, there was no difference in mean stillbirth rates per cluster (standard mean difference (SMD) 0.23, 95% CI -0.61 to 1.07; participants = 52 clusters; studies = one, low quality evidence). The other study reported no fetal deaths. There was no difference in caesarean section rate between groups (RR 0.93, 95% CI 0.60 to 1.44; participants = 1076; studies = one, low quality evidence). Maternal anxiety was significantly reduced with routine fetal movement counting (SMD -0.22, 95% CI -0.35 to -0.10; participants = 1013; studies = one, moderate quality evidence). Maternal-fetal attachment was not significantly different (SMD -0.02, 95% CI -0.15 to 0.11; participants = 951; studies = one, low quality evidence). In one study antenatal admission after reporting of decreased fetal movements was increased (RR 2.72, 95% CI 1.34 to 5.52; participants = 123; studies = one). In another there was a trend to more antenatal admissions per cluster in the counting group than in the control group (SMD 0.38, 95% CI -0.17 to 0.93; participants = 52 clusters; studies = one, low quality evidence). Birthweight less than 10th centile was not significantly different between groups (RR 0.98, 95% CI 0.66 to 1.44; participants = 1073; studies = one, low quality evidence). The evidence was of low quality due to imprecise results and because of concerns regarding unclear risk of bias.
(2) Formal fetal movement counting (Modified Cardiff method) versus hormone analysis
There was no difference between the groups in the incidence of caesarean section (RR 1.18, 95% CI 0.83 to 1.69; participants = 1191; studies = one). Women in the formal fetal movement counting group had significantly fewer hospital visits than those randomised to hormone analysis (RR 0.26, 95% CI 0.20 to 0.35), whereas there were fewer Apgar scores less than seven at five minutes for women randomised to hormone analysis (RR 1.72, 95% CI 1.01 to 2.93). No other outcomes reported showed statistically significant differences. 'Perinatal death or severe morbidity' was not reported.
(3) Formal fetal movement counting once a day (count-to-10) versus formal fetal movement counting method where counting was done more than once a day (after meals)
The incidence of caesarean section did not differ between the groups under this comparison (RR 2.33, 95% CI 0.61 to 8.99; participants = 1400; studies = one). Perinatal death or severe morbidity was not reported. Women were more compliant in using the count-to-10 method than they were with other fetal movement counting methods, citing less interruption with daily activities as one of the reasons (non-compliance RR 0.25, 95% CI 0.19 to 0.32).
Except for one cluster-RCT, included studies were small and used different comparisons, making it difficult to measure the outcomes using meta-analyses. The nature of the intervention measured also did not allow blinding of participants and clinicians..