WHO recommendation on daily fetal movement counting

WHO recommendation on daily fetal movement counting

 

Recommendation

Daily fetal movement counting, such as with “count-to-ten” kick charts, is only recommended in the context of rigorous research.

(Context-specific recommendation – research)

 

Publication history

First published: December 2016

Updated: No update planned

Assessed as up-to-date: December 2016

 

Remarks

  • Fetal movement counting is when a pregnant woman counts and records her baby’s movements in order to monitor the baby’s health. Various methods have been described, with further monitoring variously indicated depending on the method used, for example, if fewer than six distinct movements are felt within
  • 2 hours (1) or fewer than 10 distinct movements are felt within 12 hours (the Cardiff “count to ten” method) (2).
  • While daily fetal movement counting is not recommended, healthy pregnant women should be made aware of the importance of fetal movements in the third trimester and of reporting reduced fetal movements.
  • Clinical enquiry by ANC providers at each ANC visit about maternal perception of fetal movements is recommended as part of good clinical practice. Women who perceive poor or reduced fetal movements require further monitoring (e.g. with daily fetal movement counting) and investigation, if indicated.
  • The GDG agreed that more research is needed on the effects of daily fetal movement counting in the third trimester of pregnancy, particularly in LMIC settings with a high prevalence of unexplained stillbirths.

 

Background

Maternal perception of reduced fetal movements is associated with poor perinatal outcomes, including fetal death (2). Daily fetal movement counting, such as the Cardiff “count-to-ten” method using kick charts, is a way of screening for fetal well-being, by which a woman counts daily fetal movements to assess the condition of her baby. The aim of this is to try to reduce perinatal mortality by alerting health workers when the baby might be compromised (3). Daily fetal movement counting may be used routinely in all pregnant women or only in women who are considered to be at increased risk of adverse perinatal outcomes. Early detection of fetal compromise could lead to timely clinical interventions to reduce poor perinatal outcomes but might lead to maternal anxiety or unnecessary clinical interventions. It is also possible that the period between decreased fetal movements and fetal death might be too short to allow effective action to be taken (4).

 

Methods

The ANC recommendations are intended to inform the development of relevant health-care policies and clinical protocols. These recommendations were developed in accordance with the methods described in the WHO handbook for guideline development (5). In summary, the process included: identification of priority questions and outcomes, retrieval of evidence, assessment and synthesis of the evidence, formulation of recommendations, and planning for the implementation, dissemination, impact evaluation and updating of the guideline.

The quality of the scientific evidence underpinning the recommendations was graded using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) (6) and Confidence in the Evidence from Reviews of Qualitative research (GRADE-CERQual) (7) approaches, for quantitative and qualitative evidence, respectively. Up-to-date systematic reviews were used to prepare evidence profiles for priority questions. The DECIDE (Developing and Evaluating Communication Strategies to support Informed Decisions and Practice based on Evidence) (8) framework, an evidence-to-decision tool that includes intervention effects, values, resources, equity, acceptability and feasibility criteria, was used to guide the formulation and approval of recommendations by the Guideline Development Group (GDG) – an international group of experts assembled for the purpose of developing this guideline – at three Technical Consultations between October 2015 and March 2016.

To ensure that each recommendation is correctly understood and applied in practice, the context of all context-specific recommendations is clearly stated within each recommendation, and the contributing experts provided additional remarks where needed.

In accordance with WHO guideline development standards, these recommendations will be reviewed and updated following the identification of new evidence, with major reviews and updates at least every five years.

Further information on procedures for developing this recommendation are available here.

 

Recommendation question

For this recommendation, we aimed to answer the following question:

For pregnant women (P), does daily fetal movement counting (I) compared with standard ANC (C) improve maternal and perinatal outcomes (O)?

 

Evidence summary

The evidence on the effects of daily fetal movement counting was derived from a Cochrane review (3). Two RCTs from HICs contributed data for this comparison. One was a large, multicentre, cluster RCT (68 654 women) conducted in Belgium, Ireland, Sweden, the United Kingdom and the USA, which compared a “count-to-ten” fetal movement counting kick chart with standard ANC in women with uncomplicated pregnancies recruited between 28 and 32 weeks of gestation. Women in the standard ANC group were asked about fetal movements at each ANC visit. The other trial was a multicentre RCT conducted in Norway involving 1123 women that compared a modified “count-to-ten” fetal movement counting protocol with standard care.

Maternal outcomes

Low-certainty evidence suggests that daily fetal movement counting may make little or no difference to caesarean section (1 trial, 1076 women; RR: 0.93, 95% CI: 0.60–1.44) or assisted vaginal delivery rates (1 trial, 1076 women; RR: 1.04, 95% CI: 0.65–1.66). With regard to maternal satisfaction, low-certainty evidence suggests that daily fetal movement counting may reduce mean anxiety scores (1 trial, 1013 women; standardized MD: –0.22, 95% CI: –0.35 to –0.10).

Fetal and neonatal outcomes

Low-certainty evidence suggests that there may be little or no difference to preterm birth (1 trial, 1076 neonates; RR: 0.81, 95% CI: 0.46–1.46) and low birth weight (1 trial, 1076 neonates; RR: 0.98, 95% CI: 0.66–1.44) with daily fetal movement counting. There were no perinatal deaths in the Norwegian trial (1076 women). Low-certainty evidence from the large cluster RCT, which reported the weighted mean difference in stillbirth rates between intervention and control clusters, suggests that fetal movement counting may make little or no difference to stillbirth rates (weighted MD: 0.23, 95% CI: –0.61 to 1.07).

Additional considerations

These trials were conducted in HICs with low stillbirth rates, therefore the findings on effects may not apply equally to settings with high stillbirth rates. In the cluster RCT, despite fetal movement counting, most fetuses detected as being compromised by reduced fetal movements had died by the time the mothers received medical attention. There was a trend towards increased CTG and antenatal hospital admissions in the intervention clusters of the cluster RCT. Antenatal hospital admissions were also more frequent in the intervention arm of the Norwegian RCT (3).

Findings from an additional RCT that was unpublished at the time of the Cochrane review support the Cochrane evidence that daily fetal movement counting may reduce maternal anxiety (1).

Resources

Fetal movement counting is a low-cost intervention on its own, but it could be resource-intensive if it leads to unnecessary additional interventions or hospital admissions.

Equity

LMICs bear the global burden of perinatal morbidity and mortality, and women who are poor, least educated and residing in rural areas of LMICs have lower ANC coverage and worse pregnancy outcomes than more advantaged women (10). Therefore, simple, effective, low-cost antenatal interventions to assess fetal well-being could help to address health inequalities by improving detection of complications in low-resource settings.

Acceptability

Qualitative evidence shows that women generally appreciate the knowledge and information they can acquire from health-care providers during ANC visits, provided this is explained properly and delivered in a consistent, caring and culturally sensitive manner (high confidence in the evidence) (11). It also shows that health professionals want to give appropriate information and advice to women but sometimes they don’t feel suitably trained to do so (high confidence in the evidence) (12).

Feasibility

From the perspective of women who live far from ANC clinics and who may not have the resources or time to attend ANC regularly, and the perspective of ANC providers with limited resources, this intervention may offer a practical and cost–effective approach to monitoring fetal well-being if it’s shown to be effective (high confidence in the evidence) (11, 12).

Further information and considerations related to this recommendation can be found in the WHO guidelines, available at:

http://apps.who.int/iris/bitstream/10665/260215/1/WHO-RHR-18.04-eng.pdf?ua=1

 

Implementation considerations

  • The successful introduction of evidence-based policies related to antenatal care into national programmes and health care services depends on well-planned and participatory consensus-driven processes of adaptation and implementation. These processes may include the development or revision of national guidelines or protocols based on this recommendation.
  • The recommendation should be adapted into locally-appropriate documents and tools that are able to meet the specific needs of each country and health service. Modifications to the recommendation, where necessary, should be justified in an explicit and transparent manner.
  • An enabling environment should be created for the use of this recommendation, including changes in the behaviour of health care practitioners to enable the use of evidence-based practices.
  • Local professional societies may play important roles in this process and an all-inclusive and participatory process should be encouraged.
  • Antenatal care models with a minimum of eight contacts are recommended to reduce perinatal mortality and improve women’s experience of care. Taking this as a foundation, the GDG reviewed how ANC should be delivered in terms of both the timing and content of each of the ANC contacts, and arrived at a new model – the 2016 WHO ANC model – which replaces the previous four-visit focused ANC (FANC) model. For the purpose of developing this new ANC model, the ANC recommendations were mapped to the eight contacts based on the evidence supporting each recommendation and the optimal timing of delivery of the recommended interventions to achieve maximal impact.

 

Research implications

The GDG identified this priority question related to this recommendation:

  • What is the effect of daily fetal movement counting, such as the use of “count-to-ten” kick charts, in the third trimester of pregnancy on perinatal outcomes in LMICs?

 

 

Related links

WHO recommendations on antenatal care for a positive pregnancy experience

(2016) - full document and evidence tables

Managing Complications in Pregnancy and Childbirth: A guide for midwives and doctors

Pregnancy, Childbirth, Postpartum and Newborn Care: A guide for essential practice

WHO Programmes: Sexual and Reproductive health

Maternal Heath

 

 

References

  1. Delaram M, Shams S. The effect of foetal movement counting on maternal anxiety: a randomised, controlled trial. J Obstet Gynaecol. 2015:39–43. doi:10.3109/01443615.2015.10257 26.
  2. . Pearson JF, Weaver JB. Fetal activity and fetal wellbeing: an evaluation. Br Med J. 1976;1(6021):1305-7.
  3. Mangesi L, Hofmeyr GJ, Smith V, Smyth RMD. Fetal movement counting for assessment of fetal wellbeing. Cochrane Database Syst Rev. 2015;(10):CD004909.
  4. Enkin M, Keirse MJNC, Neilson JP, Crowther C, Duley L, Hodnett E et al. A guide to effective care in pregnancy and childbirth, third edition. Oxford: Oxford University Press; 2000.
  5. WHO publication Systematic screening for active tuberculosis: principles and recommendations, 2013. Geneva: World Health Organization; 2013 (http://www.who.int/tb/tbscreening/en/, accessed 29 September 2016).
  6. WHO handbook for guideline development, 2nd edition. Geneva: World Health Organization; 2014 (http://www.who.int/kms/handbook_2nd_ ed.pdf, accessed 6 October 2016).
  7. GRADE [website]. The GRADE Working Group; 2016 (http://gradeworkinggroup.org/, accessed 27 October 2016).
  8. GRADE-CERQual [website]. The GRADECERQual Project Group; 2016 (https://cerqual. org/, accessed 27 October 2016).
  9. The DECIDE Project; 2016 (http://www.decide-collaboration.eu/, accessed 27 October 2016).
  10. State of inequality: reproductive, maternal, newborn and child health. Geneva: World Health Organization; 2015 (http://www.who.int/gho/ health_equity/report_2015/en/, accessed 29 September 2016).
  11. Downe S, Finlayson K, Tunçalp Ö, Gülmezoglu AM. Factors that influence the use of routine antenatal services by pregnant women: a qualitative evidence synthesis. Cochrane Database Syst Rev. 2016;(10):CD012392.
  12. Downe S, Finlayson K, Tunçalp Ö, Gülmezoglu AM. Factors that influence the provision of good quality routine antenatal care services by health staff: a qualitative evidence synthesis. Cochrane Database Syst Rev. 2016 (in press).

 

 

Citation: WHO Reproductive Health Library. WHO recommendation on daily fetal movement counting. (December 2016). The WHO Reproductive Health Library; Geneva: World Health Organization.