Okay, so we're going to move into today's session. So session three is Women's Knowledge and Perception of Feet of Movements in Late Pregnancy with Dr. Robin Cronin and Dr. Billy Bradford. So Dr. Robin Cronin is a research midwife specialist in Auckland, New Zealand. Her midwifery experience spanning nearly four decades includes home birth to high level hospital care and continued care. And she continues to work in clinical practice. Robin is also a lecturer and tutor at the Auckland University of Technology and the University of Auckland. She's part of an international research team working on the effect of COVID-19 restrictions on perinatal bereavement and international collaboration exploring sleep and stillbirth. And it's currently working on a national survey of fetal movements in late pregnancy. Robin is also a member of the steering committee of the Perinatal Society of Australia and New Zealand, a representative of the New Zealand Perinatal and Mortality Review Committee and on the Auckland Committee of the New Zealand College of Midwives. She's completed a master of midwifery on midwives management and perinatal care and a PhD on modified redactors for late silver focusing in maternal late pregnancy sleep position. Joining her we've got Dr. Billy Bradford. Billy is a senior lecturer in midwifery in the School of Nursing, Midwifery and Health Practice at the Torrey University. Billy has extensive midwifery experience practising since 1998. Billy spent 10 years in clinical edutator teaching obstetric emergency skills management as well as writing maternity policy and protocols at the Mid-Central Health. For 10 years, Billy was a local coordinator for the Perinatal and Maternal Mortality Review Committee leading Perinatal Mortality Review at Mid-Central. He sparked a research interest in stillbirth prevention and maternal perception of anal movements. Billy completed a master's in midwifery at the Victoria University of Wellington in 2014 with a thesis titled Internally Perceived Fetal Movements, a qualitative description. In 2020, Billy completed a PhD in obstetrics and gynecology at the University of Auckland with a thesis titled Fetal Movements in Normal and Complicated Precences. Billy is an expert midwifery advisor to the Health Disability Commissioner and a competent reviewer for the Midwifery Council in New Zealand. She is also a member of the Steering Committee of Perinatal Society of Australian New Zealand and the Clinical Advisor of the Board of Still Aware. I'm now going to pass it over to Robin and Billy. Well, look, thank you so much for that lovely introduction, Belle. Billy and I are really pleased to be able to share the findings of our Aotearoa New Zealand survey of women's knowledge and perception of fetal movements during late pregnancy. And we're going to be a double act today, Billy and I, so it's going to be fun. So what is the context for our survey? Well, Aotearoa New Zealand is a South Pacific high income country with around 5 million people and 60,000 births annually. And we're a multicultural nation with 70% European, 16% Indigenous Maori, 15% Asian and 8% Pacific peoples. And we're very fortunate in New Zealand that since 1990, our Midwifery system is based on publicly funded Midwifery-led continuity of care with more than 90% of women choosing a midwife lead maternity carer to provide her care from conception to six weeks postpartum. And midwives may also consult and may transfer care to the hospital if a woman has a complex pregnancy, but the midwife often remains coordinating the woman's care. However, 2.4 in every 1,000 parents in New Zealand are faced with a tragedy of late stillbirth. So that's stillbirths from 28 weeks gestation every year. And that's the loss of around 140 babies annually, with over one third of these stillbirths remaining unexplained despite free post-mortem investigation. And around half of these women will present with decreased fetal movements at the time of diagnosis of stillbirth. And this is the reason why maternal perception of fetal movement is an important topic for us as midwives. So perception of fetal movements by the woman normally begins around the 20 week mark, a little earlier if it's in a subsequent pregnancy. Fetal movement sensations are normally very light at first, but they increase in strength and frequency as the baby grows bigger. The frequency tends to plateau around the 32 week mark. For a woman, the perception of fetal movements is usually a positive experience and it's reassuring of fetal wellbeing for both the woman and for the midwife. So naturally, if the woman notices that the movements have stopped or decreased, then that can be a cause for worry. And this is a reasonably well-founded cause because we know that maternal perception of decreased fetal movements is associated with stillbirth. And in fact, for women that have a stillbirth, around half of them, they're presenting complaint at the time that this stillbirth is diagnosed as decreased fetal movements. However, it's not just stillbirth, that's an issue here. We also know that decreased fetal movements is associated with other adverse pregnancy outcomes, most often fetal growth restriction. And it's for these reasons that it's really important that when women notice that the movements have stopped or decreased, that they contact a care provider and come in to be assessed. However, we also know that perception of decreased fetal movements is very common in pregnancy. And in fact, in around between four and 16% of pregnancies, women will present with a concern about decreased fetal movements. And this is really the leading reason for women to present for care acutely in pregnancy. In an audit from Auckland in New Zealand, we found that one in six women will present with decreased fetal movements. So it's common, it's a significant part of midwives practice certainly in developed countries. So what do some of the recent studies say about management of fetal movements and maternity care? Well, there are really two main ways of promoting awareness of fetal movements amongst pregnant women. And they historically have been counting fetal movements and promoting maternal awareness of fetal movements without necessarily counting. So in a reasonably recent systematic review of fetal movement counting, what was concluded from inclusion of five different studies was that fetal movement counting interventions were not significantly associated with perinatal deaths. So they didn't reduce perinatal deaths or other adverse perinatal outcomes. But there was a statistically significant association of fetal movement counting interventions and increase in preterm delivery, inductions of labor and cesarean section. So what about promoting fetal movement awareness without counting? Well, there have been a number of studies that have looked at this recently. So a UK trial that many of you may have heard of, the Firm trial, tested a package of care that involved encouraging women to pay attention to fetal movements and for clinicians to take action and have a low threshold for induction of labor if the baby was small after 37 weeks. And what was found as a result of this trial was that stillbirths were not significantly reduced. However, inductions of labor and neonatal unit stays of more than 48 hours were increased. So obviously that was less than ideal. And another trial conducted in Australia and New Zealand also promoting maternal awareness of fetal movement this time via a phone app. Similar to the UK study, there was a slight reduction in stillbirths but not statistically significant associated with the fetal movement awareness intervention. Interestingly though, there was, reassuringly at least, there was no increase in intervention or adverse outcome in this trial. And interestingly, there was a reduction in stillbirths across the three years of the trial over time but the reduction was not in the intervention group but was across both groups, which is something that you see a lot in trials of fetal movement awareness. In a Swedish trial, similarly promoting awareness of fetal movements but this time using the mind fetalness method, we saw a similar picture where there was no difference in stillbirth rates with the fetal movement awareness method but reassuringly that in this trial there was actually a reduction in inductions of labor and in caesarean section. So these interventions don't necessarily lead to more adverse outcomes but there doesn't seem to be good evidence that they reduce stillbirths either. So, is decreased fetal movements actually important? Well, in this study which involved this large international study which involved data from case control studies in five different international settings confirmed that a woman who had a stillbirth at 28 weeks or later were more likely to feel decreased frequency of fetal movements. So we do know decreased fetal movements is associated with stillbirth and contemporary studies. The perception by the woman of strong fetal movements and of fetal hiccups and also multiple episodes of unusually vigorous movements however is protective and that's helpful information to have. So what does all this mean? So, together these studies show us that decreased fetal movements is associated with stillbirth but also that the optimal approach to promoting awareness of fetal movements and managing decreased fetal movements hasn't really been established. But something that's good to be aware of is that in each of these trials that I've mentioned although there was an intervention group and a control group, very often the control group were also using the same sort of strategies. They weren't sending women away who had decreased movements, they were assessing them of course. And so it makes it really hard to compare outcomes between a control group and an intervention group in this situation where control groups are often using the same approaches. So the available evidence shouldn't be interpreted as meaning that decreased fetal movements aren't important. So in terms of current evidence-based guidance it's really current guidelines are really just based on consensus. So what experts in this area generally think is probably the best thing to do. In our New Zealand setting we have a practice guidance from the New Zealand College of Midwives but we also use key international guidelines including the SANS-SANDA guideline and the RCOG guideline. And all of these guidelines agree that all pregnant women should be routinely provided with written and verbal information about fetal movements including what to expect and when to contact care. So we were interested to know in our Aotearoa New Zealand setting what practice looks like in relation to those guidelines and I'll now hand over to my lovely colleague Robin to tell you about our survey. Well, Billy and I certainly had many conversations based on our care of pregnant women in the real world. So the questions that remained in our mind included what are the characteristics of maternally perceived fetal movements in the third trimester for women in New Zealand and what fetal movement information do pregnant women receive from their maternity providers and what concerns or what questions do pregnant women have about their babies' movements? So what we did is we formed a research team. We invited midwives, doctors, women who had lost their babies to stillbirths, students, researchers, obstetrician and a neonatologist to work with us to design the Aotearoa New Zealand fetal movement survey. And our team also includes Maori midwives to guide us with the perspective of New Zealand's indigenous Maori people and Indian midwives because this is the ethnic group in New Zealand most likely to lose their baby to stillbirth. And because we wanted to recruit women New Zealand-wide, we decided that we'd use an online survey which we promoted on Facebook. Now, we'd hoped for 800 participants based on previous surveys and to enrich this, we hoped for at least 100 non-European women from the County's Manukau region of Auckland which is a multi-ethnic, predominantly low socioeconomic area with the highest stillbirth rate in the country. And our eligibility criteria was that these women were 28 weeks pregnant or more, had a singleton pregnancy and were living in New Zealand while they were receiving their pregnancy care. So what did we find? Well, we were absolutely delighted that 1,640 women, so more than twice the number we'd expected, participated and were eligible. And it was also heartwarming that some women said that they knew they weren't eligible because they had a twin pregnancy or had already had their baby, also undertook the survey simply for their own benefit because they wanted to learn more about their baby's movements. And of our 1,640 eligible participants, they were largely representative of the New Zealand population. So that is a greater proportion where 30 years old or more, overweight or obese, European ethnicity, had been to university, were married and were living in an urban location. And also looking at the participant's pregnancy, you'll see that most had their midwife as their main maternity provider, which we would have expected. And more than half the participants were pregnant with their first baby and were 28 to 32 weeks pregnant, possibly because this is the gestation when fetal movements are most pronounced and felt by the woman. And you may also notice that despite the COVID Omicron Surge in New Zealand at the time of the survey, so really the first time New Zealand really felt the full force of COVID, the majority of women received adequate or even more than adequate face-to-face antenatal care from their own midwives. So to answer the questions that we'd asked about what sort of information women receive from their maternity care providers, we asked, during this pregnancy, have you been given advice or information about what baby movements to expect? And we found that 63% had, but 37% hadn't. So we also asked, if you choose one way of getting baby movement information, what would that be? And what we found is the great majority said that they would much prefer to have a face-to-face conversation with someone. Just a 14% said that they would like online and 16% written. We also asked, during this pregnancy, what was your most trusted source of baby movement information? And 72% indicated that their midwife was the most trusted source with 14% indicating doctor. So by far and away, health professionals are the preferred source of information and that that information is ideally delivered face-to-face. So because it's well known that pregnant woman's perception of fetal movements can vary by individuals, we thought we would ask, during this pregnancy, how easy is it to feel by baby movements? And we found that 81% indicated that fetal movements were either very or moderately easy to feel. And just 4% said that they found that movements were not easy to feel. So that gives us some confidence that when we're talking with women about fetal movements, most of the time they are feeling their baby and they understand what we're talking about. Because there's a belief that women with obesity are less able to perceive their fetal movements, this is something that we're aware of and have looked into in previous studies and some of our earlier studies have indicated that this is actually not the case that obesity affects perception of fetal movements. But we thought we'd take the opportunity to get some more data on this in this study. And what we found was that there was a small difference in the number of women who reported that fetal movements were not easy to feel by BMI. So just 2% of women with a normal BMI reported that movements weren't easy to feel. And that went up to 5% amongst women who were overweight and 6% of women who were obese. However, you will see that the great majority, over 90% in all categories, report that fetal movements are somewhat moderately or very easy to feel. And so that really affirms that we should be giving the same information, advice and attention to women about fetal movements regardless of their body size. We also had questions about worry and pregnancy, about worry about fetal movements and wanted to know what concerns women had and what they did when they were concerned. So we asked, during this pregnancy, have you ever worried about babies' movements? And interestingly, just 17% said that they were never worried. So most women had some degree of worry at some time. But if you have a look at this chart, most of the incidences of worry were low-key. So they were either worried once or perhaps more than once, but not very often. We asked women, during this pregnancy, who was the first person you talked to when worried about fetal movements? And you can see there from that bar at the bottom showing partner that actually almost half would talk to their partner or another family member first before they would approach health professional. So we also wanted to know what advice are women being given about fetal movements and around what to do when they're worried? And we asked this question, during this pregnancy, have you been given advice about what to do if you're ever worried about baby movements from your midwife or doctor, so from a professional source? And we found that three quarters had been given advice about what to do if they were worried about fetal movements, but a quarter hadn't. We wondered if perhaps women who had were in a subsequent pregnancy had perhaps not received information because they might have already been well-informed from a previous pregnancy. So we thought, let's have a look by parity. But actually we found the opposite was true. Really, there was, that almost looks as a woman who were in a first pregnancy are less likely to get information. Although this difference was not statistically significant. So parity clearly doesn't explain that finding. When we compare that rate of not receiving information to other studies from similar developed countries, what we find is that from a 2013 study in Canada, 40% of women had no not received information about fetal movements. And in a 2015 Australian study, 34% had not received information about fetal movements. And in a study that we conducted in 2012 in New Zealand, 25% had not had information about fetal movements. So even though our rate compares favorably to other countries, actually there's been no improvement in the last 10 years. So there's definitely room for further improvement there. We explored what information women were given when they had, when they talked to their midwife or doctor about some worry. And the largest category there is that women should contact, have a checkup with a midwife or doctor, but somewhat worryingly, many women were given advice to drink water or eat food or not to worry. And I will just clarify here that there is no evidence that drinking water or eating food has any effect on fetal movements. Other than in women with obesity, we have shown that they can experience quieter than normal fetal movements in an hour, in the hour after eating. So it's probably a very counterproductive thing to do to tell people to eat to promote fetal movements. And I will just emphasize here that all pregnant women should be advised that if fetal movements stop or decrease, they should contact their midwife or doctor. So potentially another area for improvement there. We asked women if they were worried about fetal movements, how comfortable they would feel contacting their midwife or doctor. And we were really reassured to see that 84% reported that they were either very comfortable or moderately comfortable contacting their care provider. And just 3% said that they wouldn't be comfortable. And we think this is probably indicative of our midwifery-led continuity of care system where there's a good relationship between woman and their care provider. And we found that quite reassuring. We were also interested to know whether there was any impact of ethnicity on women's comfort with contacting a care provider. We know from UK studies that women from ethnic minority categories that have higher stillbirth risk actually present less often with decreased fetal movements. So we want people to be able to access care optimally regardless of social factors like ethnicity. And it was really reassuring to see that our data showed that comfort with contacting the midwife is not different by ethnicity in this sample. So what do movements look like according to gestation? This is another topic that's of some interest to midwives. And we asked questions around fetal movement strength and frequency and pattern according to and analyzed it according to gestation. And what we found was that strength of fetal movements, most women reported that strength of fetal movements were the same or more than usual across all gestations. There was a very small increase in women reporting that strength of less than usual at turn, but these women were the minority. And we see a similar picture with frequency in that regardless of gestation, most women report that frequency of movements was the same as usual or more than usual. Once again, with a very small number of women reporting less than usual at turn.  And so we asked in the last week, do you ever feel baby move excessively wild or crazy movements? And we found that 80% reported that yes, they had some time within the last week and 64% reported excessive movements more than once in the last week. We asked in the last week, did you feel baby having hiccups? And we asked this question because we know that maternal perception of hiccups is associated with ongoing pregnancy. It's a good protective factor. And we found that around a third of women had felt no hiccups and the remainder had felt hiccups at least once in the last week. So this is a common experience in pregnancy perception of fetal hiccups but not necessarily universal. We asked about the time of day that women noticed baby movements the most and the time of day that women noticed the most busy times. And what we found was that far and away the time period between six PM and midnight was when women noticed the most fetal movements and the most fetal busy times. And unlike strength and frequency, this really did not vary at all by gestation. So that evening time period, six PM to midnight remained the most active time of day for fetuses regardless of gestation. So that's quite helpful information to pass on to women about at term, about what to look out for that's normal. We asked women, would you like to have more information about baby movement? And if so what? And actually 41% said no thanks. I have enough information. But 44% the largest category said yes, I would like more fetal movement information about what's normal. So just to wrap up what we found, really more women would like information about what to expect and about normal fetal movements. And hopefully the data we've presented here gives a good baseline around what sort of things are normal that we can tell women about to give them some reassurance considering that so many have a degree of worry about fetal movements. We also learned that women prefer to have fetal movement information verbally, face to face, ideally from a midwife, and that health professionals are the preferred source for fetal movement information. In terms of what women perceive, that strength and frequency of fetal movements normally stay the same or increase slightly. That vigorous fetal movements are common in reassuring, that hiccups are also reassuring. And we've seen again the pattern where women perceive more fetal movements in the evening, which we know is associated with lower risk of stillbirth. So I will hand over to my lovely colleague, Robin, to look at implications for practice. Thank you, Billy. So what are the implications for our practice as midwives? Well, our findings suggest that midwives do a pretty good job at sharing fetal movement information with women and that women want and trust this information from midwives. And regardless of ethnicity, the large majority of women reported feeling comfortable contacting their midwife or their doctor if they had any concerns about fetal movements. But we also found that worries about fetal movements are common during late pregnancy, only 17% of our women in our survey reported that they never worried. And in fact, Billy and I have an article under review that we wrote along with some international experts from Australia, Sweden and the UK with the aim of providing midwives with information, practical information to share with pregnant women about what fetal movements to expect and what fetal movements are normal. And we hope that this might reduce unnecessary worry in healthy women with healthy babies. And we also hope that by sharing our survey findings that women who report decreased fetal movements will be listened to, that their worries will be understood and respected and that they will receive timely assessment and care. And finally back to Billy. Apologies there. Yep. So in summary, decreased fetal movements and apologies for the typo there, decreased fetal movements remain an important sign of a vulnerable fetus. At present, there's a lack of high quality evidence on how we should be managing decreased fetal movements in practice. But we do know that women would like more information and that midwives are ideally placed to communicate information about what's normal. And if we do share information about what's normal, that might be helpful for reducing some of the unnecessary worry. I would also like to thank our lovely research team who are listed there. And most importantly, the pregnant woman who so generously took part in our online survey. Happy to answer questions. Thank you, Robin and Billy. That was a great presentation. It definitely sort of gave two aspects. Like it sort of gave us a bit more information about what is normal in terms of fetal movements but also what do we need to do to strengthen our education for women. We do have a couple of questions in the chat box. So the first one was, was there any recommendations about how to count fetal movements? Well, that's a good question. Essentially, there is no high quality evidence that supports counting fetal movements as a recommended approach. So I know it's something that's done commonly in our study, we found around 10% of women were advised to count, but it's not an approach that's necessarily supported. What's more important to my mind is that the woman feels fetal movements every day, that she doesn't let a day go by where she hasn't felt the baby move. And evening study, some fetal movement counting studies have found that it's easier for women to count in the evening and engage with fetal movement counting in the evening. So if a woman hasn't felt the baby move all day and it's not moving in the evening, she should certainly not go to sleep on that. She should come in and have a checkup. Thank you. There's also another question or more of a sort of comment that people would be interested to know if there were any other sort of parameters noted for, sorry, Portia Sharan-Anstan, would be interesting to know if they noted other parameters of fetal movement patterns. Yeah, look, the pattern questions are really interesting. I find it slightly problematic because often we recommend women keep an eye on pattern, but we don't give any further explanation about what that is and what a normal pattern is. And really, I would say that a normal pattern is a pattern where the baby moves some of the time and is quiet some of the time. So they have sleep-wake cycles. They don't move all day. They have periods of time when they're awake and periods of time when they're asleep, awake asleep. But the pattern that is associated with reduced risk of stillbirth is the pattern where the fetus is active in the evening. And that's a really easy one for women to keep an eye on feeling stronger movements in the evening. So that would be the pattern information I would give women who are asking about pattern. Thank you. And this comment from Emily, so she sort of particularly was interested in the findings related to BMI booking and really important. So that's, I suppose sort of supports that they do sort of have a very similar feed on movements and just because you have a high BMI doesn't actually reduce your chance of feeling baby. Yeah, this is sort of a topic of mine that I find it very concerning that woman with concerns about fetal movements can have their concerns dismissed because of their body size. And I think that's a very concerning situation and really shouldn't be happening. So even though we found a very small difference in numbers of women who reported that the movements weren't easy to feel, over 90% report found movements somewhat equal or very easy to feel. So we really shouldn't alter our care based on the woman's body size or make judgments about her concern based on her body size. If she's noticed a reduction or she's reported that the movements have stopped, she needs to be assessed. Yeah, Emily has made a comment that she has been in clinical situations where women have reported that reduced fetal movements is like, yeah, but are they normal? What do you mean you don't know? So do you think there's a fine line between placing women's perception of movements at the centre while not projecting all sense of responsibility for the women? We saw this when I was offering the survey face-to-face to non-European women in the counties Manukau region is that some of the women said, you know, that come in with decreased fetal movements had a monitoring which was all normal and their baby was kicking and moving. And they said, when people say, but are the movements now normal? If they're normal, you can go home. They said it became really frightening because they felt that they then was solely responsible. And they said if something happened during the rest of their pregnancy to their baby that they would then be held responsible. It didn't feel like it was a shared responsibility. So it's a really good question and it's something I think would be really good to have more research on. Yeah, I know it sounds like a couple of people would be interested in finding out more about your survey findings. Where would be the best spot they could follow those findings? So we haven't published these yet. This is just a preliminary analysis. You, the audience here are getting a first look, but we do obviously plan to publish these findings. But if you Google our names, you'll find other papers that we've written about normal fetal movements and about fetal movement patterns associated with stillbirth. And we really think that it's important as midwives to communicate with women about what is normal. And we know that women feel a lot of responsibility to understand what's normal and what's not. And we're actually not, I think not really doing our part as well as we might in terms of imparting information about what's normal. So hopefully some of the information in this presentation has been helpful. And I would really encourage people to get online and find some of our earlier papers. And hopefully that will be helpful too. I think your presentation is definitely giving us some food for thought about how we can do it better and why we need to do it better in terms of education, not just for the pregnant women, but also for the partners and support people, particularly if they're one of the first people that the person will turn to. Yeah, we found that really interesting, didn't we, Robin? Yeah, we've got a couple more minutes. Does anyone want to throw into the chat what they're actually doing around the world in terms of what do you actually either provide women or tell women? We've got a couple of minutes. Anyone want to share what you're doing, where you are? Just looking at Celine's comment there saying, normal for whom compared to what? And that's one of the reasons that we've written the article under Billie's guidance with her expertise to actually hopefully provide women with the information about what is normal. Yeah, I think one of my favorite things is that every baby is different, so it's normal for your baby. And each baby, whether you have one or 10, is going to move it a little bit differently. Just like they move differently when they come out. Just wait a couple minutes, sorry. Yeah, Emma, yeah, I still, seeing that have a cold drink or water or a cold glass of juice is still very common, not even just for fetal movements, but you see it for decreased variability. So it's definitely an area that we need to look more into. So if we know that it's not working, or it doesn't help, and how are we going to change if we keep telling people that? Yes, that's a really persistent, that's a really persistent bit of advice. And I think what happens is people here, other practitioners saying it, and I think, oh, that sounds good, I'll say that. And it just has a life of its own, but it's certainly not based in evidence. Drinking water doesn't make fetuses move, and neither does taking sugar. So, and I think perhaps what happens is if a baby's had been in a quiet sleep cycle and haven't been moving much, and the woman then sits down and has a drink, and hey presto, the baby's moving, but it's probably just because it's come out of its sleep cycle, rather than being anything to do with the drink of water. And what's concerning is when women are told to have a drink of water or juice, and then there's no other follow-up, and then they do that, and there's nothing more. And we've certainly here from women who've experienced stillbirth, that that's the advice that they've had. The baby's not moving, they've been told to have a drink of water, the next day when they go in, the baby has died. So it does delay proper formal assessment, and it doesn't increase movement. Yeah, thank you. I think we're almost out of time, so we're just gonna move on to, who don't think you'd like to add Robin before we finish? Oh no, just thank our audience very much for listening, and thank you for your really great comments. You can see there's an enormous amount of interest in fetal movements.