Recently I was in a room full of ‘intelligent’ people. Many clinicians, researchers, bereaved parents, or all of the above, ALL passionate about reducing preventable Stillbirth in Australia. It was curious to me therefore, how very little I heard anything about the woman during the day. Perhaps it’s because I am a midwife and the midwifery philosophy of care is woman-centered but it was concerning to me how much of what was said and agreed to, completely lacked consideration of what the pregnant woman might be able to contribute to protecting her baby from the calamity of stillbirth, and instead how much paternalism was in the room.
One particular comment that stood out as a shining example was this one, in relation to the group considering evidence that any change in fetal behaviour was important for the woman to report, rather than simply a decrease:
I think we need to be careful about not worrying too many women and getting the whole cascade of intervention… “decrease versus change”, sounds simple but its going to alter the number of women who come in, we need to stick to safe evidence and make sure we evaluate a potential increase in adversity for the potential benefits we might get. We need to carefully balance benefit with potential risk, solid evidence rather than stuff that’s “possibly true.”
I was tempted to respond BUT this comment was almost immediately followed by someone saying that perhaps they should change their flight and I thought, “if I get started on what was a load of !@## .well… we would all have needed to change our flights!”
So let me jump on my soap box here and say what I should have said …if we had all had many more hours there.
Firstly to ‘safe’ evidence. The evidence that we have that ANY change in fetal behaviour is a potential cause of concern is from case-control studies, one of our highest forms of strong evidence. In fact, the VERY SAME case-control studies that provide us with evidence that settling to sleep on your back increases the risk of stillbirth. So IF we are going to say we need to stick to “safe” evidence, then we need to also steer clear of giving the side-to-sleep message until we get ‘safe’ evidence that isn’t reliant on ‘recall bias’. We really can’t be so inconsistent as to accept some of the findings from these studies and “worry” women about sleeping position and be afraid to “worry” women with evidence FROM THOSE SAME STUDIES that shows ANY change in strength, frequency or pattern is something the woman should report.
There also seemed to be a misconception in the room that ‘change’ was only to do with a change in frequency (decrease or sudden increase) however the evidence from ALL the aforesaid studies VERY consistently points to change in strength and pattern (especially not moving at bed time) as also being concerning symptoms, that need to be properly assessed. So the “change” evidence we have is to do with strength, frequency and pattern.
So saying this again and louder, Decrease in frequency of fetal movement is undoubtably one of the most common SYMPTOMS that something may be amiss with the unborn baby. We now know from case-control studies that a decrease in strength, or a change in pattern, or a sudden burst of activity (described by the mother as “crazy”), are also ALL potential symptoms that the unborn baby MAY not be well.
For a 20 minute youtube summary about this evidence go to this youtube video https://youtu.be/vVW8E4psnDk
I often use heart attack as an analogy by way of making a point about how we currently treat the symptom of altered fetal activity so very differently from the symptom of chest pain, when perhaps we shouldn't. The prevailing symptom of heart attack is chest pain BUT we all know it is not the only symptom. Imagine for a minute that we regressed to the dark ages where doctors thought giving people life saving information about ALL symptoms to be aware of and report was not a good thing … (wait :) …anyway), image that we thought that we would have too many presentations to emergency room if we gave the general public all the symptoms of heart attack and so to keep things simple for ourselves and catch MOST of the heart attack victims we only said present to emergency if you have chest pain. Would we not miss those people who presented with atypical symptoms such as pain or discomfort in one or both arms, the back, neck, jaw or stomach, or shortness of breath without chest discomfort, or other less typical , but still concerning signs, such as breaking out in a cold sweat, nausea or lightheadedness. YES …WE …WOULD.
So WHY do we feel we shouldn’t give ALL women, every bit of strong repetitively validated evidence we have to help them keep themselves and their baby safe? …………………..it comes down to that word “worry”. I put “worry” in quotes because we have ABSOLUTELY NO evidence that giving women information about how to keep herself and her baby safe during pregnancy is worrying. In fact, withholding vital health care information because we think it might be worrying is the stuff of dark ages that we have moved on from in EVERY other field of health care provision, apart from obstetrics. Even so we do routinely give pregnant women all sorts of other ‘worrying’ information without worrying that we are worrying her :). We tell her to avoid soft cheese, and alcohol yet the risks of her actually losing her baby to Listeriosis or FASD are astronomically low, FAR FAR lower than the number of babies who die following an episode of altered fetal activity.
Some smart people in that room were worried that giving more information, might increase unscheduled presentations to antenatal care and therefore the potential for harm such as induction of labour, but here’s the thing, IF more women present to be assessed because we have given them more information then OF COURSE that presentation MAY result in detecting the baby who is showing signs of being unwell, and that baby being induced and the thing about that is that if we induce and the baby is born alive and well then some clinicians seem to think that is an adverse outcome. This kind of thinking is totally illogical and akin to those who seem to staunchly believe in the concept of the “unnecessarean”, people who think that if a baby was born alive and well following an emergency caesarean that the caesarean was unnecessary!!
So let’s all get a grip and trust care providers that they are not going to intervene to end a pregnancy unless they see a good reason and also trust women that they are not vulnerable people to be protected, but mothers who can be trusted , have agency and thus need to be given ALL the evidence we have at hand to enable them to advocate for their unborn baby and help protect them from harm.