The death of a baby through stillbirth is a painful, bewildering experience and an extreme trauma for any family. The cause of death is often undetermined and sometimes these deaths come without warning.
However, sometimes there are warning signs before a stillbirth. Decreased fetal movement (DFM) is associated with increased stillbirth. There is agreement on this in the scientific community and recent studies re-confirm this . In addition, it has been observed in many instances that in populations where women are educated about DFM or asked to "count kicks", that the stillbirth rate decreases. The medical community is giving increasing thought to the idea that raising a mother's awareness of her baby's movements in utero can be helpful in monitoring her baby's health and ultimately may help save lives. Hence the key question: whether at this time, while researchers are working on scientifically explaining the relationship between DFM and lower stillbirth rates, it is premature or appropriate timing for implementing public health efforts designed to educate and raise awareness about the importance of fetal movement monitoring among potential parents and the medical community.
While scientists and health educators are contemplating the research in countries around the world, for expectant mothers this is a very personal choice, and kick counting is already viewed by many as an opportunity to participate in a proactive way and receive reassurance that their baby in-utero is active and developing on schedule.
Scientifically explaining the mechanisms involved in the observed relationship between DFM and stillbirth rates has been a challenge. Even more intriguing is the apparent fall in stillbirth rates that occurs simply by encouraging mothers to have greater awareness about DFM. It is not known whether it is "counting kicks" that specifically helps to reduce the stillbirth rate or some other factor.
There have been many studies done on various aspects of fetal movement counting and the results varied in terms of its role in the reduction of stillbirth. Accordingly, "kick counting" has gained and lost and gained popularity over the years.
The Cochrane Collaboration reviewed studies written in English up until 2008 in order to determine whether kick counting helps in the reduction of stillbirth. Nine studies were not included because they were not considered scientifically rigorous enough. Four studies were included because they passed the litmus test for scientific rigor.
The Cochrane review concluded that, "there is not enough evidence to recommend or not to recommend formal fetal movement counting". It also stated that, "because of indirect evidence from these studies that fetal movement counting may be beneficial, more research is needed in this area" . The indirect evidence is the observation that the stillbirth rate decreased in study populations where mothers learned of the importance of DFM, usually through distribution of Kick Charts [2, 3].
Since the Cochrane Review, a large study conducted in Norway has shown more such evidence. These researchers designed an intervention that gave written information to all women at 17-19 weeks gestation about decreased fetal movement (including a kick chart that mothers could use as a tool) as well as guidelines for management of DFM for health-care professionals. Following more than 65,000 pregnancies and 4,200 reports of decreased fetal movements, they found that during the intervention the stillbirth rate fell by one third in the overall study population of singleton pregnancies and fell by 50% among women who reported DFM. There was no increase in the rates of preterm births, fetal growth restriction, transfers to neonatal care units or severe neonatal depression among women with DFM during the intervention. The use of ultrasound scans increased, while additional follow up visits and admissions for induction were reduced. Also, the number of women presenting with DFM did not increase. .
In another study conducted in 1989, and the largest one done to date, the stillbirth rate in both the kick counting group and the control group decreased . The study also revealed that more mothers in the kick count group presented with live babies because of less movement, but these babies were not saved because of falsely reassuring fetal testing (much of which has improved since that time).
Researchers continue to study baby's movements, which vary in their type and include kicks, jabs, twists, or rolls, to identify exactly how and why kick counting appears to be associated with better birth outcomes. One example of a method for counting baby's movements is to ask a mother to be still in a laying or sitting position, roughly at the same time every day when the baby is usually most active, and note the time it takes for her to feel 10 movements within her womb. This usually takes less than 15-20 minutes. She records this time on the chart. She is to contact her maternity care provider promptly if she notices that it is taking longer than usual to feel the 10 movements.
The threshold point at which pregnant mothers experiencing decreased fetal movement should seek medical care is undetermined. As such, using a standard number (10 kicks in 20 minutes vs. 10 kicks in 2 hours) may not be helpful while counting kicks. Research on this may someday provide specific guidelines, however, every pregnancy is different; and what is normal for one mother is not normal for another. This issue is addressed further in the Pros and Cons of Using Kick Charts.
Kick Charts are an optional tool that may help women identify patterns that are relatively "normal" for her baby. Kick Charts are a visible and objective record of baby’s movements and one that shows clearly when there has been a decrease in movement. A good record can allow pregnant mothers to easily visualize a change from her baseline. Seeing it in black and white may convince her that she needs to visit her doctor immediately when DFM occurs instead of wondering and waiting. She can bring the chart to her regular prenatal visits too. Examples of kick charts can be found at the websites of First Candle.
Rather than be discouraged by the incomplete information currently available, we might be heartened by the realization that after years of research to understand the association of the back sleeping position and reduction in SIDS deaths, the phenomena is still not fully understood. Yet, by the year 2000 prevention advice calling for vigilance to put babies asleep on their back has successfully reduced the annual rate of SIDS deaths by 50-70% in developed countries around the world. If even more lives of precious infants can be saved by educating women about the risk of stillbirth and counting fetal movements, and guidelines developed for care management after they perceive DFM, then perhaps Kick Counting will one day be viewed as the comparable campaign of the 21st century.
In 2008, First Candle, a group that supports research and bereaved families in the U.S., made the decision to act on what is currently known about stillbirth concluding that the epidemiological evidence is strong enough to warrant starting a stillbirth risk reduction campaign with a pamphlet and public service announcement in selected cities. First Candle's Medical Directors and Board made this decision based on their review of the literature and data indicating the extent of the problem in the US.
This campaign is now being expanded, in part, due to survey results of medical providers using the materials. 81% of providers responded that they were already talking to expectant parents about stillbirth, but until recently did not have educational materials to share with parents. First Candle's Kicks Count brochure explains how to kick count and includes a kick chart for mothers to use. To date, over 500,000 educational brochures have been distributed to OB providers, nurse practitioners, health departments, and home visiting programs working with parents-to-be. See their website for details.
Pros and cons of using kick charts
There are arguments for and against using Kick Charts.
- Against: Some have suggested that keeping a daily kick count chart may not be necessary since the stillbirth rate in a 1989 study fell in both the counting and control study populations and that could have been because of more awareness of DFM in both groups . It is possible that just increased vigilance by doctor, an "informal inquiry of movements" when mother comes for her checkup to monitor baby's movements is enough.
- For: Even if kick count charts are not essential for a campaign to reduce stillbirth, kick charts (plus explanatory brochures) will heighten awareness amongst pregnant women on this topic. They are a simple, pragmatic tool that teaches mothers to be vigilant every day and the charts help them see patterns as they come to better understand their baby's movements. (Though women who do not want to keep the chart should not be pressured to do so.) "Informal inquiry of movements" could be misinterpreted by medical professionals and could end up being skipped or deemed unimportant.
It has been observed that health care providers sometimes ask questions about fetal movement in a vague manner, such as "How is the baby moving?" or "How much is your baby moving?" at prenatal appointments. The information they get back is not particularly good or useful. These kinds of questions might also confuse parents. A kick chart would provide specific (and perhaps life-saving) information on each baby. The brochure handed to parents would help to educate them and clear up any concerns.
Other possible benefits of kick charts
There are other possible arguments for Kick Charts and its benefits:
- Maternal vigilance of fetal movement can decrease delayed presentation to the health care facilities and thus may allow more timely intervention .
- Doctors often feel they cannot gather enough information on each baby because they see the pregnant mother only once a month and just for a few minutes. Kick charts can provide the doctor with more detailed information on the baby. Also, when the mother brings in her kick chart every month, this gives her a chance to talk in more detail to the doctor thereby making kick charts the cause of forming closer relationships and having better communication with doctor and medical staff .
- Fetal movement counting increases the mother's involvement and lets her take more responsibility for her own prenatal care. It might be that the reason counting does not produce anxiety in mothers is that mothers are excited about their new baby and enjoy recording their baby's movements. They may also feel they are mothering and protecting their baby by being involved in this way.
- By spending less than half an hour each day to be still and pay attention to her baby, kick charts promote acute awareness of body and of baby by mother. This could also encourage psychological bonding to baby.
- Kick count charts kept by pregnant women could give us important data that would provide directions for further research.
References and acknowledgements
- Froen JF. Management of Decreased Fetal Movements. Elsevier Seminars in Perinatology 2008: 32: 307-311.
- Mangesi L, Hofmeyr GJ. Fetal movement counting for assessment of fetal wellbeing. Cochrane Database Syst Rev 2007; (1): CD004909. Link
- Froen JF. A kick from within - fetal movement counting and the cancelled progress in antenatal care. J Perinat Med 2004; 32 (1): 13-24.
- Holm Tveit JV, Saastad E, et al. Reduction of late stillbirth with the introduction of fetal movement information and guidelines - a clinical quality improvement. BMC Pregnancy Childbirth 2009; 9 (32).
- Grant A, et al. Routine formal fetal movement counting and risks of antepartum late deaths in normally formed singletons. Lancet 1989; 2: 345-347.
- Mother's and Children's Health and Welfare Association. Maternal and Child Health Statistics of Japan, 2009.
- Takemura H. Symposium Abstracts: Stillbirth cases that were not predicted. Onwa Society Newsletter 2006; No. 88.
- Kuwata T, Matsubara S, et al. Establishing a reference value for the frequency of fetal movements using modified 'count to 10' method. J Obstet Gynaecol Res 2008; 34 (3): 318-323.
- Froen JF. Fetal movement assessment. Elsevier Seminars in Perinatology 2008; 32: 243-246.
- Lindqvist PG, et al. Does antenatal identification of small-for-gestational age fetuses significantly improve their outcome? Ultrasound Obstet Gynecol 2005; 25: 258-264.
- Liston RM, et al. The psychological effects of counting fetal movements. Birth 1994; 21-135.
- Takemura H. Counting movements: a signal from baby! Japanese Journal of Perinatal Care 1996; 185: 86-88.
Thank you to Drs. Shigeki Matsubara, Hideo Takeuchi, Toshimasa Obonai, Alex Heazell, and Peter Blair for their valuable contributions to this report. Thanks also to Kathleen Graham, Dana Kaplin, and Dr. Diep Nguyen.