In 2016, I joined the University of Leicester’s Department of Health Sciences to undertake a funded PhD exploring barriers to and facilitators of the implementation of national clinical guidelines for reduced fetal movement. The ethnographic study on which my PhD is based is a collaborative project between SAPPHIRE (Social sciences APPlied to Health Improvement Research) and TIMMS (The Infant Mortality and Morbidity Studies group), with qualitative methods and sociological theory shaping an exploration of this widely-recognised risk factor for stillbirth. In this article, I describe how I have moved away from a focus on guideline implementation (or not) towards a PhD with a more theoretical slant, which nonetheless aims to have a positive impact on maternity care. I hope that an overview of my journey will be useful to other, particularly postgraduate, researchers who are tasked with balancing elements of applied health and sociological research, including researchers from a clinical background.
As the initial focus of my PhD was to identify barriers and facilitators with regard to the implementation of national clinical guidelines, those containing recommendations for the care of women with reduced or altered fetal movement were an obvious place to start. Of particular interest was the original version of the Saving Babies’ Lives care bundle (O’Connor, 2016, ‘Care Bundle v1’), which aimed to tackle stillbirth and early neonatal death by bringing together a small number of focused interventions exemplifying ‘known best practice’ (p. 12) in four key areas of care, one of which was ‘Raising awareness of reduced fetal movement’. A second version of the Care Bundle was published in March 2019 (NHS England (NHSE), 2019, ‘Care Bundle v2’), with a continued emphasis on improving care for women with altered fetal movement as one means of reducing avoidable stillbirth. The Care Bundle v1 recommended that all pregnant women should receive the leaflet Feeling your baby move is a sign that they are well from 24 weeks’ gestation (Tommy’s & NHSE, 2016). This leaflet included statements about how babies typically move, and how mothers should feel and respond to these movements, including, ‘Your baby will have their own pattern of movement that you should get to know’.
In the process of writing this article, I revisited the Care Bundle v2, and was interested to see that, in the updated version of the fetal movement leaflet, women are no longer told that their baby will have a normal pattern of movement that they should get to know. Now, the advice is simply, ‘Get to know your baby’s movements’ (Tommy’s and NHSE, 2019). Notwithstanding this, both versions of the leaflet imply that mothers should be able to identify typical movements for their baby, and any departure from this norm.
However, there is wide variation in how long women wait before contacting maternity services, with one UK study exploring care-seeking behaviours following altered fetal movement reporting delays ranging from six hours to two weeks (Smyth et al., 2016). Such delays, despite national campaigns raising awareness of the importance of prompt reporting, indicate that there may be reasons why women hesitate to report their fetal-movement concerns that go beyond a lack of knowledge or understanding. In a previous article (Clark, 2018), I have suggested that there are three characteristics in particular that can make altered fetal movement difficult to identify:
- First, that abnormal fetal movement cannot be defined. There is no clear evidence that any one method of formal fetal-movement counting is a more effective method of identifying the ‘at risk’ fetus than maternal perception of changes in fetal movement (Heazell & Froen, 2008);
- Second, that fetal movement does ‘normally’ change. The quality of fetal movements is thought to change over the course of a pregnancy (Raynes-Greenow et al., 2013), and a woman’s experience of her baby’s movement might be influenced by the time of day, whether she is eating and/or hungry, and her level of activity and body position (Ehrstrom, 1984, Raynes-Greenow et al., 2013, Bradford & Maude, 2014, Sheikh et al., 2014);
- Third, that there is no objective test for altered fetal movement. There is no obstetric technology that can measure how fetal movement now compares to the mother’s experience of it before.
With this in mind, it is not surprising that some mothers will struggle to determine precisely when a ‘normal’ quiet period becomes an ‘abnormal’ one, or when a qualitative change in fetal movement should be interpreted as problematic. Nonetheless, there is a clear expectation that mothers will pay close attention to their unborn child and promptly report any movement-related concerns. To learn more about how this combination of maternal uncertainty and responsibility might affect experiences of pregnancy, I started to explore literature from within the social sciences, particularly in the field of reproduction research.
Recent work in the sociological discipline has highlighted an intensified pressure on parents, particularly mothers, to be accountable for their reproductive choices and behaviours (see for example Lowe, 2016, Faircloth & Gürtin, 2017). These developments have been situated within an era of ‘intensive mothering’, which sees ‘Euro-American’ mothers in particular assume ever greater responsibility for reducing actual and potential risks to their offspring, regardless of the personal sacrifice required (Wolf, 2011). The mother’s moral imperative to reduce risk to her offspring while optimising its development is portrayed as being particularly acute in pregnancy, where the bodily needs of mother and baby are uniquely intertwined, with the needs of the mother generally portrayed as secondary to those of the fetus (Lupton, 2012, Cummins, 2014). An increased emphasis on the fetus as a patient or person in its own right, along with the assumption that pregnant women will play an active role in its surveillance (i.e. by closely monitoring fetal movement), creates new pressures and obligations for pregnant women to comply with doctors’ orders in order to maximise the safety of the unborn child (Bessett, 2010). As part of a wider shift towards risk consciousness, Faircloth and Gürtin (2017) suggest we are now living in a time of ‘anxious reproduction’, which has profound consequences for contemporary individuals, couples and communities.
Early in my data collection, it become clear to me that maternal anxiety was going to be one key theme of my research. Around the same time, I became aware of the BSA Postgraduate Regional Forums, and applied for a grant to host an event on ‘Reproduction and Risk’. The aim of the forum was to explore the benefits of a joined-up approach to reproduction research in terms of stimulating theoretical development, and deepening our understanding of how pregnant women/individuals and fathers/parents experience risk and anxiety throughout their reproductive journeys (a summary of the event can be read here).
The presentations and discussions on the day prompted a leap forward in my own thinking, helping me to understand how my own research might sit within existing and emerging work from across the reproductive subfields. The nature of the relationship between anxiety and monitoring was now at the forefront of my mind, and I started to focus on the phrase ‘monitoring for reassurance’, which had been regularly used by clinicians throughout my fieldwork. Now the focus of my analysis is how the multifaceted task of monitoring the fetus, and in particular its movement, is enacted by various human and non-human actors, and on just what influences whether processes of monitoring are indeed ‘reassuring’, or whether, contrary to their intended purpose, they actually seem to generate further anxiety among women and/or clinicians.
At this stage of my PhD, I feel as though I am unpicking a perfect storm of pressure/responsibility (the Government mandate to reduce avoidable stillbirth has led to an unprecedented focus on this area of maternity care, with a related emphasis on the mother’s role in monitoring fetal movement) and uncertainty (we have seen that the symptom of fetal movement can be a very slippery – or ‘wriggly’ – customer, hard for some mothers to identify and/or clinicians to confirm). It seems inevitable that some women and clinicians will experience increased anxiety as they strive to respond appropriately to a symptom they are not entirely sure existed in the first place. I hope that my research will provide useful opportunities to learn about how we – researchers and maternity clinicians – can make women aware of risks to their fetus without, to quote one midwife, ‘Scaring the life out of them’, and to explore whether heightened anxiety in women is the inevitable consequence of them becoming, or being made, active participants in the surveillance of their own reproductive experience/s. In this way, I hope to make my own contribution both to social theory in this field, and to improving the care and experiences of women who experience and report altered fetal movement.
Bessett, D. (2010) Negotiating normalization: The perils of producing pregnancy symptoms in prenatal care, Social Science & Medicine, 71, pp. 370-377. DOI: 10.1016/j.socscimed.2010.04.007
Bradford, B. & Maude, R. (2014) Fetal response to maternal hunger and satiation: novel finding from a qualitative descriptive study of maternal perception of fetal movements, BMC Pregnancy and Childbirth, 14, pp. 1-9. DOI: 10.1186/1471-2393-14-288
Clark, J. (2018) Altered Fetal Movement: challenges in self-diagnosis and implications for practice, MIDIRS Midwifery Digest, 28(1), pp. 43-48.
Cummins, M.W. (2014) Reproductive Surveillance: The Making of Pregnant Docile Bodies, Kaleidoscope: A Graduate Journal of Qualitative Communication Research, 13(4), pp. 33-51.
Ehrstrom, C. (1984) Circadian rhythm of fetal movements. Acta Obstetricia et Gynecologica Scandinavica, 63.
Faircloth, C. & Gürtin, Z.B. (2017) Fertile connections: thinking across assisted reproductive technologies and parenting culture studies, Sociology, pp. 1-18. DOI: 10.1177/0038038517696219
Heazell, A.E.P. & Frøen, J.F. (2008) Methods of fetal movement counting and the detection of fetal compromise. Journal of Obstetrics and Gynaecology, 28, pp. 147-54. DOI: 10.1080/01443610801912618
Lowe, P. (2016) Reproductive Health and Maternal Sacrifice: Women, Choice and Responsibility, London: Palgrave Macmillan. DOI: 10.1057/978-1-137-47293-9
Lupton, D. (2012) ‘Precious cargo’: foetal subjects, risk and reproductive citizenship, Critical Public Health, 22(3), pp. 329-340. DOI: 10.1080/09581596.2012.657612
NHS England (2019) Saving Babies’ Lives Version Two A care bundle for reducing perinatal mortality. Available at https://www.england.nhs.uk/wp-content/uploads/2019/07/saving-babies-lives-care-bundle-version-two-v5.pdf (Accessed: 30 January 2020.)
O’Connor, D. (on behalf of NHS Englad) (2016) Saving Babies’ Lives: A care bundle for reducing stillbirth. Available at https://www.england.nhs.uk/wp-content/uploads/2016/03/saving-babies-lives-car-bundl.pdf (Accessed: 10 February 2020.)
Raynes-Greenow, C.H., Gordon, A., Li, Q. et al. (2013) A cross-sectional study of maternal perception of fetal movements and antenatal advice in a general pregnant population, using a qualitative framework, BMC Pregnancy and Childbirth, 13, pp. 1-8. DOI: 10.1186/1471-2393-13-32
Sheikh,M., Hantoushzadeh, S. & Shariat, M. (2014) Maternal perception of decreased fetal movements from maternal and fetal perspectives, a cohort study. BMC Pregnancy and Childbirth, 14(286). DOI: :10.1186/1471-2393-14-286
Smyth, R.M.D., Taylor, W., Heazell, A.E., Furber, C., Whitworth, M. & Lavender, T. (2016) Women’s and clinicians perspectives of presentation with reduced fetal movements: a qualitative study, BMC Pregnancy and Childbirth, 16(280). DOI: 10.1186/s12884-016-1074-x
Tommy’s and NHS England (2016). Leaflet: Feeling your baby move is a sign that they are well. Available at https://www.tommys.org/reduced-fetal-movement-leaflet (Accessed: 2 January 2017.)
Tommy’s and NHS England (2019) Leaflet: Feeling your baby move is a sign that they are well, Version 2. Available at https://www.tommys.org/reduced-fetal-movement-leaflet (Accessed: 7 February 2020.)
Wolf, J. (2010) Is Breast Best? Taking on the Breastfeeding Experts and the New High Stakes of Motherhood, New York: New York University Press.
Julia Clark, MA (Cantab) Modern and Medieval Languages, BSc Midwifery Studies with Registration, RM, PhD student in the Department of Health Sciences, University of Leicester.
Supervisors Professor Natalie Armstrong, Social Science APPlied to Healthcare Improvement REsearch (SAPPHIRE) group, and Dr Lucy Smith, The Infant Mortality and Morbidity Studies (TIMMS).