One size does not fit all: Perspectives from Swedish midwives on fetal movement counselling.

PROBLEM: Migration continues to play a role in determining health outcomes related to pregnancy and childbirth in Sweden. BACKGROUND: Migrant women have, compared to Swedish-born women, increased risks of adverse birth outcomes. Previous research suggests that migrant women seek care for decreased fetal movements less than Swedish-born women. Given these documented risks, understanding midwives' perspectives in this context is crucial to address maternal health inequities. AIM: To explore midwives' experiences conveying information about fetal movement to migrant women in antenatal healthcare settings. METHODS: Semi-structured, individual interviews with midwives (n=15) experienced in providing information about fetal movements to migrant women. The interviews were analysed using reflexive thematic analysis. FINDINGS: The midwives' efforts to compensate for the deficiencies within the antenatal healthcare organisation and to ensure that all women received access to information and care regarding fetal movements are described in four themes: (a) building a trusting relationship; (b) empowering women through guidance and support; (c) overcoming communication challenges; and d) navigating safety measures. DISCUSSION: Our findings suggest that the standard antenatal care programme does not support midwives to provide holistic and individualised care that aligns with midwifery care philosophy. CONCLUSION: To reduce health inequities for migrant women, this study highlights the need for more flexible guidelines within the standard antenatal care programme. These guidelines should prioritise the individual woman's needs over institutional protocols, acknowledge the midwife-woman relationship as the core of midwifery practice and support midwives to build a partnership with women through continuity of care.

Obstetric outcomes and uptake of care among 149 non-Swedish speaking migrant women attending a birth preparation visit during pregnancy - An observational study from Sweden.

Introduction: In Sweden almost one third of the population is born in another country and a large number of the women who do not speak Swedish are of reproductive age. Women migrating from low-income countries have higher risks for poor obstetric outcomes than receiving country-born citizens. INFOR (a Swedish word for "before" or "ahead of") is an intervention offering language-assisted, individual birth preparation for non-Swedish speaking pregnant women unfamiliar with the maternity care system. The aim of this study was to describe the uptake of care and obstetric outcomes among non-Swedish speaking migrant women attending INFOR. Methods: A descriptive study of the obstetric outcomes and uptake of care was conducted of the 149 non-Swedish speaking pregnant women who participated in INFOR between 2016 and 2020. The data were accessed retrospectively from the medical record system Obstetrix and the population-based Swedish Pregnancy Registry and analysed descriptively. Results: Women participating in INFOR originated from 44 countries and spoke 35 different languages. During late pregnancy, 20 percent of the women sought care for decreased fetal movements and 80 percent of the women attended the postpartum visit. While the majority of the participants were offered professional language support during pregnancy, almost none had a professional interpreter present during labour and birth. After birth, 80 percent of the primiparous women were asked to rate their birth experience, but only half of the multiparous women were asked. Further, only half of the primiparous women attending the postpartum visit were asked about their self-rated health. Conclusion: INFOR may increase uptake of some important aspects of care during pregnancy, birth and postpartum among migrants of diverse backgrounds. The findings raise concerns however about communication support for migrant women, especially during labour and birth. The offer of professional interpreting as part of standard maternity care for women who need it is essential and must be improved in order to provide equitable care for all.

Decreased fetal movements: Report from the International Stillbirth Alliance conference workshop.

Maternal reports of decreased fetal movement (DFM) are a common reason to present to maternity care and are associated with stillbirth and other adverse outcomes. Promoting awareness of fetal movements and prompt assessment of DFM has been recommended to reduce stillbirths. However, evidence to guide clinical management of such presentations is limited. Educational approaches to increasing awareness of fetal movements in pregnant women and maternity care providers with the aim of reducing stillbirths have recently been evaluated in a several large clinical trials internationally. The International Stillbirth Alliance Virtual Conference in Sydney 2021 provided an opportunity for international experts in fetal movements to share reports on the findings of fetal movement awareness trials, consider evidence for biological mechanisms linking DFM and fetal death, appraise approaches to clinical assessment of DFM, and highlight research priorities in this area. Following this workshop summaries of the sessions prepared by the authors provide an overview of understandings of fetal movements in maternity care at the current time and highlights future directions in fetal movement research.

Miscommunication influences how women act when fetal movements decrease an interview study with Swedish Somali migrant women.

OBJECTIVE: To explore how Swedish Somali migrant women perceive fetal movements, process information about fetal movements, and take actions if decreased fetal activity occurs. DESIGN: A qualitative study based on individual semi-structured interviews. The interviews were analysed using content analysis. SETTING: The study was conducted in Sweden. PARTICIPANTS: Swedish Somali migrant women (n=15) pregnant in their third trimester or recently given birth. FINDINGS: The analysis led to the main category: tailored information about fetal movements enhances the possibility to seek care if the movements decrease. The results are described in the generic categories: explanatory models determine action; and understand and interpret information. KEY CONCLUSIONS: Miscommunication on fetal movements can be a hurdle for Swedish Somali migrant women that may have impact on stillbirth prevention and the quality of care. Improved communication and information tailored to individual needs is essential to achieve equality for women and their newborns. IMPLICATIONS FOR PRACTICE: The midwife can be used as a hub for reassuring that adequate information about fetal movements reaches each individual woman in antenatal care. Individualised information on fetal movements based on the women's own understanding is suggested to increase the possibility that the pregnant woman will seek care if the movements decrease. Somali women's verbal communication can be used to spread accurate information in the Somali community on the importance of seeking care if fetal movements decrease.

Prolonged pregnancy and stillbirth among women with overweight or obesity - a population-based study in Sweden including 64,632 women.

BACKGROUND: The proportion of overweight or obese pregnant women is increasing in many countries and babies born to a mother who is overweight or obese are at higher risk for complications. Our primary objective was to describe sociodemographic and obstetric factors across Body Mass Index (BMI) classifications, with secondary objective to investigate stillbirth and other pregnancy outcomes in relation to BMI classifications and gestational week. METHODS: This population-based cohort study with data partly based on a cluster-randomized controlled trial includes 64,632 women with singleton pregnancy, giving birth from 28 weeks' gestation. The time period was January 2016 to 30 June 2018 (2.5 years). Women were divided into five groups according to BMI: below 18.5 underweight, 18.5-24.9 normal weight, 25.0-29.9 overweight, 30.0-34.9 obesity, 35.0 and above, severe obesity. RESULTS: Data was obtained for 61,800 women. Women who were overweight/obese/severely obese had lower educational levels, were to a lesser extent employed, were more often multiparas, tobacco users and had maternal diseases to a higher extent than women with normal weight. From 40 weeks' gestation, overweight women had a double risk of stillbirth compared to women of normal weight (RR 2.06, CI 1.01-4.21); the risk increased to almost four times higher for obese women (RR 3.97, CI 1.6-9.7). Women who were obese or severely obese had a higher risk of almost all pregnancy outcomes, compared to women of normal weight, such as Apgar score < 7 at 5 min (RR1.54, CI 1.24-1.90), stillbirth (RR 2.16, CI 1.31-3.55), transfer to neonatal care (RR 1.38, CI 1.26-1.50), and instrumental delivery (RR 1.26, CI 1.21-1.31). CONCLUSIONS: Women who were obese or severely obese had a higher risk of almost all adverse pregnancy outcomes and from gestational week 40, the risk of stillbirth was doubled. The findings indicate a need for national guidelines and individualized care to prevent and reduce negative pregnancy outcomes in overweight/obese women. Preventive methods including preconception care and public health policies are needed to reduce the number of women being overweight/obese when entering pregnancy.

Effect of encouraging awareness of reduced fetal movement and subsequent clinical management on pregnancy outcome: a systematic review and meta-analysis.

OBJECTIVE: Reduced fetal movement, defined as a decrease in the frequency or strength of fetal movements as perceived by the mother, is a common reason for presentation to maternity care. Observational studies have demonstrated an association between reduced fetal movement and stillbirth and fetal growth restriction related to placental insufficiency. However, individual intervention studies have described varying results. This systematic review and meta-analysis aimed to determine whether interventions aimed at encouraging awareness of reduced fetal movement and/or improving its subsequent clinical management reduce the frequency of stillbirth or other important secondary outcomes. DATA SOURCES: Searches were conducted in MEDLINE, Embase, CINAHL, The Cochrane Library, Web of Science, and Google Scholar. Guidelines, trial registries, and gray literature were also searched. Databases were searched from inception to January 20, 2022. STUDY ELIGIBILITY CRITERIA: Randomized controlled trials and controlled nonrandomized studies were eligible if they assessed interventions aimed at encouraging awareness of fetal movement or fetal movement counting and/or improving the subsequent clinical management of reduced fetal movement. Eligible populations were singleton pregnancies after 24 completed weeks of gestation. The primary review outcome was stillbirth; a number of secondary maternal and neonatal outcomes were specified in the review. METHODS: Risk of bias was assessed using the Cochrane Risk of Bias 2 and Risk of Bias in Non-Randomized Studies I tools for randomized controlled trials and nonrandomized studies, respectively. Variation caused by heterogeneity was assessed using I2. Data from studies employing similar interventions were combined using random effects meta-analysis. RESULTS: A total of 1609 citations were identified; 190 full-text articles were evaluated against the inclusion criteria, 18 studies (16 randomized controlled trials and 2 nonrandomized studies) were included. The evidence is uncertain about the effect of encouraging awareness of fetal movement on stillbirth when compared with standard care (2 studies, n=330,084) with a pooled adjusted odds ratio of 1.19 (95% confidence interval, 0.96-1.47). Interventions for encouraging awareness of fetal movement may be associated with a reduction in neonatal intensive care unit admissions and Apgar scores of <7 at 5 minutes of age and may not be associated with increases in cesarean deliveries or induction of labor. The evidence is uncertain about the effect of encouraging fetal movement counting on stillbirth when compared with standard care with a pooled odds ratio of 0.69 (95% confidence interval, 0.18-2.65) based on data from 3 randomized controlled trials (n=70,584). Counting fetal movements may increase maternal-fetal attachment and decrease anxiety when compared with standard care. When comparing combined interventions of fetal movement awareness and subsequent clinical management with standard care (1 study, n=393,857), the evidence is uncertain about the effect on stillbirth (adjusted odds ratio, 0.86; 95% confidence interval, 0.70-1.05). CONCLUSION: The effect of interventions for encouraging awareness of reduced fetal movement alone or in combination with subsequent clinical management on stillbirth is uncertain. Encouraging awareness of fetal movement may be associated with reduced adverse neonatal outcomes without an increase in interventions in labor. The meta-analysis was hampered by variations in interventions, outcome reporting, and definitions. Individual studies are frequently underpowered to detect a reduction in severe, rare outcomes and no studies were included from high-burden settings. Studies from such settings are needed to determine whether interventions can reduce stillbirth.

Fetal movements: A framework for antenatal conversations.

BACKGROUND: Presentations for decreased fetal movements comprise a significant proportion of acute antenatal assessments. Decreased fetal movements are associated with increased likelihood of adverse pregnancy outcomes including stillbirth. Consensus-based guidelines recommend pregnant women routinely receive information about fetal movements, but practice is inconsistent, and the information shared is frequently not evidence-based. There are also knowledge gaps about the assessment and management of fetal movement concerns. Women have indicated that they would like more accurate information about what to expect regarding fetal movements. DISCUSSION: Historically, fetal movement information has focussed on movement counts. This is problematic, as the number of fetal movements perceived varies widely between pregnant women, and no set number of movements has been established as a reliable indicator of fetal wellbeing. Of late, maternity care providers have also advised women to observe their baby's movement pattern, and promptly present if they notice a change. However, normal fetal movement patterns are rarely defined. Recently, a body of research has emerged relating to maternal perception of fetal movement features such as strength, presence of hiccups, and diurnal pattern as indicators of fetal wellbeing in addition to frequency. CONCLUSION: Sharing comprehensive and gestation-appropriate information about fetal movements may be more satisfying for women, empowering women to identify for themselves when their baby is doing well, and importantly when additional assessment is needed. We propose a conversational approach to fetal movement information sharing, focusing on fetal movement strength, frequency, circadian pattern, and changes with normal fetal development, tailored to the individual.

Language-supported labor ward visits for pregnant migrant women: Staff experiences in a Swedish hospital.

INTRODUCTION: The aim of this study was to explore midwives' and assistant nurses' experiences of providing extra support to non-Swedish-speaking migrants by offering individual language-supported visits to the labor ward during pregnancy. METHODS: Semi-structured interviews were conducted with six guides, midwives or assistant nurses, working in the INFÖR (Individuell förlossningsförberedelse) project at Södertälje hospital in Sweden. INFOR includes a two-hour individual language-supported visit at the labor ward, for non-Swedish speaking pregnant women and their partners. An inductive thematic analysis was conducted. RESULTS: The guides described INFOR as being a bridge and creating safety, achieved by meeting with women and providing practical information. The guides felt that they fulfilled an important purpose, they were dedicated and adapted to the women's individual needs. Providing extra language-assisted support to migrant pregnant women was developing and enriching, but the guides highlighted some barriers. Communicating via an interpreter was a challenge and the women were in need of more and extended meetings. The guides wished that INFOR could become a standard part of antenatal care, but the model needs to be further developed, and a better system for recruitment must be introduced. CONCLUSIONS: The guides experienced that the INFOR model is valuable in creating safety to pregnant migrant women before birth. The model is appreciated by the expectant couples, midwives and assistant nurses, and could be implemented as standard care. However, it is important to adapt the visits to the women's and their families' needs and goals, and structure needs to be developed before implementation.

Midwives' communication with non-Swedish-speaking women giving birth: A survey from a multicultural setting in Sweden.

INTRODUCTION: The European Union faces challenges related to migration, cultural diversity and health. Immigration to Sweden has increased and a third of all women giving birth were born outside Sweden. A higher risk for negative pregnancy outcomes is seen among foreign-born women and one of the explanations given is inadequate communication. Midwives in Sweden have responsibility for normal birth. This study aimed to investigate labor ward midwives' experiences of caring for and communicating with women who do not speak and understand the Swedish language. METHODS: A questionnaire based on the Migrant Friendly Hospital questionnaire was distributed to all 46 midwives working on the Södertälje Hospital labor and postpartum ward in 2018 and 32 completed it (70%). RESULTS: Most of the midwives thought communication and giving support to non-Swedish speaking women during birth was difficult or very difficult (n=31; 97%). The quality of the professional interpreters' work was reported as good or very good by most of the midwives (n=31; 97%). However, the most common resource for facilitating communication during labor was an adult relative (always/often: n=25; 83%). Increased availability was the most common response for improving the interpreter service (n=22; 69%), as well as increasing the number of languages available for interpreter services (n=8; 25%). CONCLUSIONS: When women are giving birth, it is of the highest priority to improve communication between midwives and non-Swedish-speaking women. Better strategies for improving communication must be implemented in order to comply adequately with Swedish law and achieve equitable care of high quality for all, regardless of linguistic background.

Epidural use among women with spontaneous onset of labour - an observational study using data from a cluster-randomised controlled trial.

OBJECTIVE: To investigate whether the proportion of pregnant women who use epidural analgesia during birth differed between women registered at a maternity clinic randomised to Mindfetalness or to routine care. DESIGN: An observational study including women born in Sweden with singleton pregnancies, with spontaneous onset of labour from 32 weeks' gestation. Data used from a cluster-randomised controlled trial applying the intention-to-treat principle in 67 maternity clinics where women were randomised to Mindfetalness or to routine care. ClinicalTrials.gov (NCT02865759). INTERVENTIONS: Midwives were instructed to distribute a leaflet about Mindfetalness to pregnant women at 25 weeks' gestation. Mindfetalness is a self-assessment method for the woman to use to become familiar with the unborn baby's fetal movement pattern. When practising the method in third trimester, the women are instructed to daily lie down on their side, when the baby is awake, and focus on the movements' intensity, character and frequency (but not to count each movement). FINDINGS: Of the 18 501 women with spontaneous onset of labour, 47 percent used epidural during birth. Epidural was used to a lower extent among women registered at a maternity clinic randomised to Mindfetalness than women in the routine-care group (46.2% versus 47.8%, RR 0.97, CI 0.94-1.00, p= 0.04). Epidural was more common among primiparous women, women younger than 35 years, those with educational levels below university, with BMI ≥25 and with a history of receiving psychiatric care or psychological treatment for mental illness. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: Pregnant women who were informed about a self-assessment method, with the aim of becoming familiar with the unborn baby's fetal movement pattern, used epidural to a lower extent than women who were not informed about the method. Future studies are needed to investigate and understand the association between Mindfetalness and the reduced usage of epidural during birth.

Country of birth, educational level and other predictors of seeking care due to decreased fetal movements: an observational study in Sweden using data from a cluster-randomised controlled trial.

OBJECTIVES: To identify predictors of seeking care for decreased fetal movements and assess whether care-seeking behaviour is influenced by Mindfetalness. DESIGN: Observational study with data from a cluster-randomised controlled trial. SETTING: 67 maternity clinics and 6 obstetrical clinics in Sweden. PARTICIPANTS: All pregnant women with a singleton pregnancy who contacted the obstetrical clinic due to decreased fetal movements from 32 weeks' gestation of 39 865 women. METHODS: Data were collected from a cluster-randomised controlled trial where maternity clinics were randomised to Mindfetalness or routine care. Mindfetalness is a self-assessment method for women to use daily to become familiar with the unborn baby's fetal movement pattern. OUTCOME MEASURES: Predictors for contacting healthcare due to decreased fetal movements. RESULTS: Overall, 5.2% (n=2059) of women contacted healthcare due to decreased fetal movements, among which 1287 women (62.5%) were registered at a maternity clinic randomised to Mindfetalness and 772 women (37.5%) were randomised to routine care. Predictors for contacting healthcare due to decreased fetal movements were age, country of birth, educational level, parity, prolonged pregnancy and previous psychiatric care (p<0.001). The main differences were seen among women born in Africa as compared with Swedish-born women (2% vs 6%, relative risk (RR) 0.34, 95% CI 0.25 to 0.44) and among women with low educational level compared with women with university-level education (2% vs 5.4%, RR 0.36, 95% CI 0.19 to 0.62). Introducing Mindfetalness in maternity care increased the number of women seeking care due to decreased fetal movements overall. CONCLUSION: Women with country of birth outside Sweden and low educational level sought care for decreased fetal movements to a lesser extent compared with women born in Sweden and those with university degrees. Future research could explore whether pregnancy outcomes can be improved by motivating women in these groups to contact healthcare if they feel a decreased strength or frequency of fetal movements. TRIAL REGISTRATION NUMBER: NCT02865759.

Midwives' experiences of using the Mindfetalness method when talking with pregnant women about fetal movements.

BACKGROUND: Information given to pregnant women about fetal movements is important in maternity care and decreased fetal movements is associated with fetal growth restriction and stillbirth. The fetal movement pattern is different for every fetus and women perceive different types of movements. Mindfetalness is a self-assessment method for a woman to use to become familiar with her unborn baby's fetal movement pattern. AIM: We aimed to explore midwives' perceptions about informing pregnant women about fetal movements and their experiences of working with Mindfetalness in their daily work. METHODS: A web-questionnaire was distributed to midwives who participated in a randomized controlled trial evaluating Mindfetalness, a method for the observation of fetal movements. In total, 67 maternity clinics in Stockholm, Sweden, were randomized to Mindfetalness or routine care. Of the 144 midwives working in maternity clinics randomized to Mindfetalness, 80% answered the questionnaire. FINDINGS: The midwives thought that the leaflet about Mindfetalness was supportive in their work when informing women about fetal movements and the majority wanted to continue to distribute the leaflet when the trial ended. The midwives also expressed that the study increased their own knowledge about fetal movements. Women embraced the information about Mindfetalness positively and appreciated the written material. The midwives thought that talking about fetal movements in maternity care is an important but challenging task. CONCLUSION: Mindfetalness is a useful tool to use in maternity clinics when informing pregnant women about fetal movements. The written information was appreciated by both pregnant women and midwives.

A decrease in cesarean sections and labor inductions among Swedish women by awareness of fetal movements with the Mindfetalness method.

BACKGROUND: Maternal perception of decreased fetal movements is commonly used to assess fetal well-being. However, there are different opinions on whether healthcare professionals should encourage maternal observation of fetal movements, as researchers claim that raising awareness increases unnecessary interventions, without improving perinatal health. We aimed to investigate whether cesarean sections and labor induction increase by raising women's awareness of fetal movements through Mindfetalness. Further, we aimed to study perinatal health after implementing Mindfetalness in maternity care. METHODS: In a cluster randomized controlled trial, 67 maternity clinics were allocated to Mindfetalness or routine care. In the Mindfetalness group, midwives distributed a leaflet telling the women to focus on the character, strength and frequency of the fetal movements without counting each movement. The instruction was to do so for 15 min daily when the fetus was awake, from gestational week 28 until birth. In this sub-group analysis, we targeted women born in Sweden giving birth from 32 weeks' gestation. We applied the intention-to-treat principle. RESULTS: The Mindfetalness group included 13,029 women and the Routine-care group 13,456 women. Women randomized to Mindfetalness had less cesarean sections (18.4% vs. 20.0%, RR 0.92, CI 0.87-0.97) and labor inductions (19.2% vs. 20.3%, RR 0.95, CI 0.90-0.99) compared to the women in the Routine-care group. Less babies were born small for gestational age (8.5% vs. 9.3%, RR 0.91, CI 0.85-0.99) in the Mindfetalness group. Women in the Mindfetalness group contacted healthcare due to decreased fetal movements to a higher extent than women in the Routine care group (7.8% vs. 4.3%, RR 1.79, CI 1.62-1.97). The differences remain after adjustment for potential confounders. CONCLUSIONS: Raising awareness about fetal movements through Mindfetalness decreased the rate of cesarean sections, labor inductions and small-for-gestational age babies. TRIAL REGISTRATION: ClinicalTrials.gov ( NCT02865759 ). Registered 12 August 2016, www.clinicaltrials.gov .

Pregnancy outcomes among women born in Somalia and Sweden giving birth in the Stockholm area - a population-based study.

BACKGROUND: Studies report that women born in some African countries, after migrating to the Nordic countries, have worse pregnancy outcomes than women born in the receiving countries. With the aim of identifying unmet needs among Somali-born women, we here study this subgroup. OBJECTIVE: We compared pregnancy outcomes among women born in Somalia to women born in Sweden. Further, we investigated whether the proactive maternal observation of fetal movements has effects on birth outcomes among women born in Somalia. METHODS: In Stockholm, half of the maternity clinics were randomized to intervention, in which midwives were instructed to be proactive towards women by promoting daily self-monitoring of fetal movements. Data for 623 women born in Somalia and 26 485 born in Sweden were collected from a population-based register. RESULTS: An Apgar score below 7 (with stillbirth counting as 0) at 5 minutes was more frequent in babies of women born in Somalia as compared to babies of women born in Sweden (RR 2.17, 95% CI 1.25-3.77). Babies born small for gestational age were more common among women born in Somalia (RR 2.22, CI 1.88-2.61), as were babies born after 41 + 6 gestational weeks (RR 1.65, CI 1.29-2.12). Somali-born women less often contacted obstetric care for decreased fetal movements than did Swedish-born women (RR 0.19, CI 0.08-0.36). The differences between women born in Somalia and women born in Sweden were somewhat lower (not statistically significant) among women allocated to proactivity as compared to the Routine-care group. CONCLUSIONS: A higher risk of a negative outcome for mother and baby is seen among women born in Somalia compared to women born in Sweden. We suggest it may be worthwhile to investigate whether a Somali-adapted intervention with proactivity concerning self-monitoring of fetal movements may improve pregnancy outcomes in this migrant population.

Daily structured approach to awareness of fetal movements and pregnancy outcome - a prospective study.

OBJECTIVES: We investigated how women, seeking care due to decreased movements, had paid attention to fetal movements and if the method of monitoring was associated with pregnancy outcome. METHODS: A questionnaire was distributed to women from gestational week 28, who had sought care due to decreased fetal movements in Stockholm between January 1st and December 31st, 2014. Women were included in the study if the examination did not reveal any signs of a compromised fetus requiring immediate intervention. Birth outcome and sociodemographic data were collected from the obstetric record register. RESULTS: There were 29166 births in Stockholm in 2014, we have information from 2683 women who sought care for decreased fetal movements. The majority (96.6%) of the women stated that they paid attention to fetal movements. Some women observed fetal movements weekly (17.2%) and 69.5% concentrated on fetal movements daily (non-structured group). One in ten (9.9%) used counting methods daily for observing fetal movements (structured group). Women in the structured group more often had caesarean section before onset of labor (RR 1.6, 95% CI 1.2-2.2) and a lower risk of their baby being transferred to neonatal nursery (RR 0.25, 95% CI 0.03-0.94) compared to women in the non-structured group. CONCLUSIONS: Women, who had a daily and structured approach to awareness of fetal movements, were more likely to have a caesarean section but their babies were less likely to be transferred to a neonatal nursery as compared with women who used a non-structured method daily.

Increased labor induction and women presenting with decreased or altered fetal movements - a population-based survey.

INTRODUCTION: Women's awareness of fetal movements is important as perception of decreased fetal movements can be a sign of a compromised fetus. We aimed to study rate of labor induction in relation to number of times women seek care due to decreased or altered fetal movements during their pregnancy compared to women not seeking such care. Further, we investigated the indication of induction. MATERIAL AND METHODS: A prospective population-based cohort study including all obstetric clinics in Stockholm, Sweden. Questionnaires were distributed to women who sought care due to decreased or altered fetal movements ≥ 28 week's gestation in 2014, women for whom an examination did not indicate a compromised fetus that required induction of labor or cesarean section when they sought care. Women who gave birth at ≥ 28 weeks' gestation in 2014 in Stockholm comprises the reference group. RESULTS: Labor was induced more often among the 2683 women who had sought care due to decreased or altered fetal movements (RR 1.4, 95% CI 1.3-1.5). In women who presented with decreased or altered fetal movements induction of labor occurred more frequently for fetal indication than those with induction of labor and no prior fetal movement presentation (RR 1.6, 95% CI 1.4-1.8). The rate of induction increased with number of times a woman sought care, RR 1.3 for single presentation to 3.2 for five or more. CONCLUSIONS: We studied women seeking care for decreased or altered fetal movements and for whom pregnancy was not terminated with induction or caesarean section. Subsequent (median 20 days), induction of labor and induction for fetal indications were more frequent in this group compared to the group of women with no fetal movement presentations. Among women seeking care for altered or decreased fetal movements, the likelihood of induction of labor increased with frequency of presentation.

Women's attitudes, experiences and compliance concerning the use of Mindfetalness- a method for systematic observation of fetal movements in late pregnancy.

BACKGROUND: Maternal perception of decreased fetal movements and low awareness of fetal movements are associated with a negative birth outcome. Mindfetalness is a method developed for women to facilitate systematic observations of the intensity, character and frequency of fetal movements in late pregnancy. We sought to explore women's attitudes, experiences and compliance in using Mindfetalness. METHODS: We enrolled 104 pregnant women treated at three maternity clinics in Stockholm, Sweden, from February to July of 2016. We educated 104 women in gestational week 28-32 by providing information about fetal movements and how to practice Mindfetalness. Each was instructed to perform the assessment daily for 15 min. At each subsequent follow-up, the midwife collected information regarding their perceptions of Mindfetalness, and their compliance. Content analyses, descriptive and analytic statistics were used in the analysis of data. RESULTS: Of the women, 93 (89%) were positive towards Mindfetalness and compliance was high 78 (75%). Subjective responses could be binned into one of five categories: Decreased worry, relaxing, creating a relationship, more knowledge about the unborn baby and awareness of the unborn baby. Eleven (11%) women had negative perceptions of Mindfetalness, citing time, and the lack of need for a method to observe fetal movements as the most common reasons. CONCLUSION: Women in late pregnancy are generally positive about Mindfetalness and their compliance with daily use is high. The technique helped them to be more aware of, and create a relationship with, their unborn baby. Mindfetalness can be a useful tool in antenatal care. However, further study is necessary in order to determine whether the technique is able to reduce the incidence of negative birth outcome.

Rationale, study protocol and the cluster randomization process in a controlled trial including 40,000 women investigating the effects of mindfetalness.

BACKGROUND: Shortening pre-hospital delay may decrease stillbirth rates and rates of babies born with a compromised health. Stillbirth may be preceded by a decrease in fetal movements. Mindfetalness has been developed as a response to the shortcomings of kick-counting for the monitoring of fetal movements by the pregnant woman. We do not know if practicing Mindfetalness may diminish pre-hospital delay. Nor do we know if practicing Mindfetalness may increase or decrease the percentage of women seeking health care for unfounded, from a medical perspective, worry for her fetus' well-being. METHODS: This article describes the rationale, study protocol and the randomization process for a planned study randomly allocating 40,000 pregnant women to receive, or not receive, proactive information about practicing Mindfetalness. The unit of randomization is 63 antenatal clinics in the Stockholm area. Midwives in the antenatal clinics randomized to Mindfetalness will verbally inform about practicing Mindfetalness, hand out brochures (printed in seven languages) and inform about a website giving information about Mindfetalness. Routine care will continue in the control clinics. All information for the analyses, including the main endpoint of an Apgar score below 7 (e.g., 0-6 with stillbirth giving a score of 0), measured five minutes after birth, will be retrieved from population-based registers. RESULTS: We have randomized 33 antenatal clinics to Mindfetalness and 30 to routine care. In two clinics a pilot study has been performed. One of the clinics randomly allocated to inform about Mindfetalness will not do so (but will be included in the intention-to-treat analysis). In October 2016 we started to recruit women for the main study. CONCLUSION: The work up to now follows the outlined time schedule. We expect to present the first results concerning the effects of Mindfetalness during 2018.