{"paper_id":"c304d399-c3ef-487e-adab-6d04106c1c43","body_text":"1 \nWomen’s perspectives on fetal movement monitoring in high and \nlow stillbirth settings: a qualitative study \nNola Dubuisson1, Monica Diez Campa1,2, Abhishek K. Ghosh3, Fionnuala M McAuliffe4, and Niamh \nC. Nowlan1,2, * \n1School of Mechanical and Materials Engineering, University College Dublin, Dublin, Ireland, \n2UCD Conway Institute, University College Dublin, Dublin, Ireland, \n3Department of Robotics and Mechatronics Engineering, University of Dhaka, Dhaka 1000, Bangladesh, \n4UCD Perinatal Research Centre, School of Medicine, University College Dublin, National Maternity Hospital, Dublin 2, Ireland, \n*Corresponding author: Niamh Nowlan, niamh.nowlan@ucd.ie \nOctober 21, 2025 \nAbstract \nIntroduction: Maternal fetal movement monitoring during pregnancy is commonly advised to assess fetal wellbeing. \nHowever, qualitative research exploring how women perceive and implement such advice is lacking, particularly in \nregions with the highest burden of stillbirth. This study investigates women’s experiences and opinions on fetal movement \nmonitoring during pregnancy across high- and low-stillbirth settings. \nMethods: Women from three countries with low-stillbirth rates and five with high rates of stillbirth  were surveyed \nand interviewed regarding their experiences with fetal movement monitoring  advice. Open-ended answers from the \nsurveys and interview were analysed using inductive thematic methods, while categorical answers were examined using \nnon-parametric statistical analysis. \nResults: 234 women were included in the study. The nature and extent of fetal movement monitoring advice varied \nconsiderably by country , encompassing active monitoring methods  such as kick counting, pattern awareness and \nmovement presence detection, as well as guidance on responding to fetal movements concerns. Notably, 33% (37/112) \nof women in high-stillbirth countries and 8% (10/122) in low -stillbirth countries reported a lack of any fetal movement \nmonitoring advice. Globally, h alf of women rated the advi ce easy to follow, while one-third experienced difficulty \nunderstanding their healthcare provider’s guidance . Key facilitators of following advice included having an active baby \nand a clear understanding and confidence in the received advice , whereas  barriers included a lack of clarity and \nunderstanding, difficulty perceiving movements, competing time demands and challenges in  identifying patterns of \nmovements. Maternal anxiety was prevalent, with 78% of participants report ing at least occasional anxiety about fetal \nmovements during pregnancy. \nConclusion: Wide variation in the type and consistency of fetal movement monitoring advice across countries \nindicates the need for further research into the comparative effectiveness of current recommendations, particularly in \nhigh-stillbirth settings. High rates of maternal anxiety worldwide highlight the importance of providing support to women \nnavigating fetal movement monitoring. \n \nKeywords: Fetal Movement Monitoring, Stillbirth, Pregnancy, Qualitative Study, Survey, Interview \n  \n1 Introduction \nStillbirth remains a persistent global health challenge, \nwith an estimated 1.9 million cases occurring in 2023, \nequivalent to 14.3 stillbirths per 1000 total births \nworldwide [1]. It is an issue that disproportionally affects \nlow-resource settings, with sub -Saharan Africa and South \nAsia accounting for 77·4% stillbirths of the global total [2]. \nNotably, the worst affected country has 20 times higher \nrisk than the country with the lowest stillbirth rate (SBR) \n[3]. \nSelf-monitoring of fetal movement (FM) is widely \nadvised as a method to monitor fetal well -being and \nprovide an early warning signal for stillbirth risk. Changes \nor reductions in movements as sensed by the expectant \nmother have been associated with fetal growth restriction \n[4, 5], placental abnormalities [ 6], oligohydramnios [ 7] \nand stillbirth [ 8]. In a study by Warland et al., 63% of \nwomen perceived a change in FM before experiencing a \nstillbirth [9]. \nDespite the link between reduced FM and stillbirth \noccurrence, there is currently no universally accepted or \nstandardised method of FM monitoring. Clinical advice \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted November 14, 2025. ; https://doi.org/10.1101/2025.11.12.25340103doi: medRxiv preprint \nNOTE: This preprint reports new research that has not been certified by peer review and should not be used to guide clinical practice.\n\n2 \ngiven about how and when to monitor movements is \ninconsistent both between and within countries [ 10–15]. \nLarge randomised controlled trials (RCTs) and systematic \nreviews have evaluated a range of FM monitoring \nstrategies, including fetal kick counting [ 16, 17], \nincreasing maternal awareness of FM with standardised \nclinical management [ 18] and the Mindfetalness method \nwhich encourages consistent awareness of FM intensity, \nfrequency and character [ 19]. However , a recent meta -\nanalysis by Hayes et al. (2023) fo und that there was no \ndefinitive proof that any of the FM monitoring approaches \nreduced stillbirth. A key limitation of prior large -scale \nRCTs is that they were conducted in high -income settings \nwith a low SBR, and therefore most studies were \nunderpowered to detect  the relatively rare outcome of a \nstillbirth and lacked generalisability to a high -burden \nsettings [ 20]. In the absence of conclusive evidence, \nclinical advice about and approaches to FM monitoring \nvary between different healthcare providers and systems. \nVariation in advice provided on FM monitoring in \nAustralia was highlighted by Raynes et al. (2013). They \nfound that several different themes of advice were \nprovided to women, varying from being told about being \naware of the normal pattern of movement, to n oticing the \npresence of movement rather than the quantity, to formal \nkick counting. A number of qualitative studies have sought \nto understand the experiences of pregnant women \nengaging with FM monitoring advice. McArdle et al. \n(2015) surveyed pregnant wome n in Sydney, Australia \nand found that they preferred to be given as much \ninformation as possible about fetal movements, and that \nthey favoured receiving advice directly from a healthcare \nprofessional [ 12]. Linde et al. (2016) used modified \ncontent analysis to determine what types of perceived FM \nchanges prompted women to attend hospital with \nconcerns. Women reported that feeling decreased, absent, \nweaker , slower and/or a changed pattern of movement  \nwould prompt them to seek healthcare advice  [11]. \nAkselsson et al. studied women’s experiences of using the \nMindfetalness method and found that the majority of \nwomen were positive about the method, with reports of \ndecreased worry, relaxation, creating a connection and \nincreased knowledge of the unborn baby. Some \nparticipants expressed that they didn’t have the time to \nmonitor , or that they had no need for the method since \ntheir baby was regularly active [21]. A qualitative study by \nSmyth et al. described the barriers women faced when \nseeking healthcare support when  concerned about FMs \nand found that participants were worried about being \ntaken seriously, feared interventions such as induction of \nlabour , or had received inconsistent and variable advice \nabout the definition of ‘normal’ movements [ 14]. AlAmri \nand Smith conducted a meta -analysis investigating the \neffect of kick counting on anxiety and fetal -maternal \nattachment, and found that kick counting did not increase \nanxiety and promoted fetal-maternal attachment [22]. \nAlthough LMICs account for 98.1% of the world’s \nstillbirths [ 23], almost no qualitative studies on FM \nmonitoring have been conducted in these settings [ 10]. A \nrecent review by Dube et al. (2022) surveyed the reported \nviews and experiences of pregnant women in low -income \nsettings relating to reduced FM. Only four relevant studies \nwere identified, none of which were qualitative. We are \naware of only one quali tative study focused on the \nexperiences of pregnant women in LMICs, which was \npublished in 2023 [ 24]. Weller et al. studied perceptions, \nknowledge and practices of F M self -monitoring among \nwomen and healthcare providers in Zanzibar , Tanzania. It \nfound that women often did not know how to monitor FM \nor when to report concerns, but had an instinctual \nawareness of their baby’s movement patterns. FM \nassessment was not routinely discussed in clinical \npractice, and no protocol was in place for the management \nof abnormal FM [24]. \nThe majority of studies focused on FM monitoring are \nbased in a single country or setting, and thus a \ncomprehensive comparative cross -country analysis of \nwomen’s experiences of FM monitoring remains to be \nexplored. This study addresses this gap, exploring \nwomen’s knowledge and experience of following FM \nmonitoring advice across diverse global settings. \nSpecifically, it investigates the types of FM monitoring \npregnant women in eight countries in high - and low - \nstillbirth settings are advised to perform, the ease of \nfollowing advice, the barriers and facilitators to adhering \nto the advice, and their experiences of anxiety while \nmonitoring movements. \n2 Methods \n2.1 Participants and recruitment \nParticipants were mainly recruited through worldwide \nsocial media advertisements between December 2024 \nand April 2025. Participants were also recruited through \nposters in the National Maternity Hospital in Dublin , \nIreland. Women were eligible to participate if they were in \nthe third trimester of pregnancy, or if they had given birth \nwithin the last year . In addition, participants were \nrequired to be over 18 years of age and  have a sufficient \nlevel of English proficiency to understand and complete \nthe survey  or interview. For study integrity and \nconsistency, only participants who had answered at least \n80% of the key domain survey questions were included in \nthe final analysis of the survey data. Survey participants \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted November 14, 2025. ; https://doi.org/10.1101/2025.11.12.25340103doi: medRxiv preprint \n\n3 \nindicated in their responses whether they wished to \nparticipate in an optional follow -up interview. \nSocial media (Meta: Facebook and Instagram) \nadvertisements were used to target a sample of countries \nthat either had a high or low SBR according to WHO data \n[25]. Stillbirth was defined as a baby who died after 28 \nweeks of pregnancy before or during birth , in accordance \nwith the WHO  study on stillbirth [3]. A country was \ndefined as having a high SBR if there w ere more than 12 \nstillbirths per 1000 births, in accordance with the WHO \nEvery Newborn Action Plan (ENAP) goal for 2030, while \nall the low SBR countri es included had fewer than 3 \nstillbirths per 1000 births. To ensure generalisability and \na large enough sample population, online targeting \nfocused on countries that had a high proportion of English \nspeakers and people with internet access. The final \nselection of countries included in the study were chosen \nbased on recruitment success rates of more than 5 \nparticipants per country. The low SBR countries included \nin the analysis were Ireland, the USA and the United \nKingdom. The high SBR countries included wer e Kenya, \nSouth Africa, Zimbabwe, Ghana and Nigeria. Online \ntargeted advertising concluded when the number of \nparticipants was roughly equivalent between the low and \nhigh SBR regions. \n2.2 Ethics \nEthical approval for this study was granted by the Human \nResearch Ethics Committee in University College Dublin \n(Ref: LS -C-24-317-Nowlan and LS -25-03Nowlan). \nParticipants were provided with an information sheet \nprior to accessing the survey and they were required to \nprovide informed consent by clicking “I consent to taking \npart in the study” before continuing with the survey. A \nseparate information sheet and consent form were \nprovided to the participants before interviewing. All \nresponses were voluntary and no incentives were offered. \nParticipants could skip questions if they wished and could \nwithdraw at any point. \n2.3 Survey & Interview development \nThe survey and interview questions were developed for \nthe study, informed by existing literature and clinical \nguidance. The survey consisted of both categorical and \nopen-ended questions designed to gain an understanding \nof pregnant women’s experiences and perspectives of \nmonitoring their baby’s movements. Demographic \ninformation (pregnancy status, age, parity, country), \npresence of pregnancy complications or risk factors, and \nhistory of miscarriage or stillbirth were collected. Key \ndomain questions were ask ed about the advice they \nreceived about monitoring their baby’s movements, how \neasy or hard they found it to follow the advice they were \ngiven on monitoring their baby’s movements and why, and \nhow often they felt worried or anxious about their baby’s \nmovements. The full list of survey and interview questions \ncan be found in Supplemen tary Section 2 and Section 3.  \n2.4 Data analysis \nData analyses were conducted using Microsoft Excel 365 \n(Version 2504), IBM SPSS Statistics (Version 29) and \nNVIVO (Release 1.7). Frequencies and proportions were \nused to describe participant demographics and \ncategorical survey questions. Categorical survey  \nquestions were compared across demographic subgroups \nand the statistical effect of demographic parameters on \nthe variable was assessed using either Mann -Whitney \ntests (for cases of 2 independent groups) or Kruskal -\nWallis tests (for k independent groups). \nQualitative responses to open -ended questions were \nstudied using inductive thematic analysis, based on the \nprinciples outlined by Braun and Clarke (2006) [ 26]. The \nanalytical process started with intensive familiarisation of \nthe data, allowing for the development of an initial coding \nframework by the primary researcher (ND) based on \nemerging concepts and recurring patterns. The coding \nframework was developed t hrough multiple iterations \nand through discussion with the research team.  \nA subset of 100 participant responses (42% of the total \ndataset) was then independently coded by a second \nresearcher (MDC), who was blinded to the initial coding. \nDiscrepancies in the coding were identified and resolved \nthrough consensus -based discussion between the two \ncoders and a third member of the re search team (NCN). \nDuring this iterative process, the coding framework was \nfurther refined to clarify code definitions. The remaining \nresponses were then coded using the new framework by \nND, ensuring consistency across the entire dataset. Finally, \nthe refined codes were iteratively grouped into broader \nthemes. Response quotes that demonstrated the themes \nwere selected and tagged according to whether they were \nfrom the survey (S) or from the interview (I), with the \nparticipant number and country. \nQuantitative findings were strategically used to provide \ncontext and identify patterns in the qualitative responses. \nFrequencies of qualitative themes were compared \nbetween settings to understand notable patterns and to \nhighlight prominence, but do not imp ly statistical \nsignificance. \n3 Results \nA total of 359 women responded to the survey, of which \n234 were included in the study. Of those excluded, 111 did \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted November 14, 2025. ; https://doi.org/10.1101/2025.11.12.25340103doi: medRxiv preprint \n\n4 \nnot answer the required number of questions, two \nprovided incomplete or nonsensical answers, seven did \nnot specify a country, four were from countries with fewer \nthan five  participants, and one was not yet in the third \ntrimester . Fifteen of the included participants opted in for \na follow-up interview. \nThe demographics of the survey and interview \nparticipants are shown in Table 1. Survey participants \nwere recruited to be evenly distributed between high ( n = \n112) and low ( n = 122) stillbirth rate countries. Most \nsurvey participants were currently pregnant (66.7%), \nbetween 30 -39 years of age (64.1%) and multiparous \n(56.8%). Interviews had more participants from countries \nwith a low SBR (80%).  \nPregnancy complications and/or risk factors were \nreported by more than half of survey participants (62.6%). \nApproximately a quarter of survey participants reported \nhaving a prior miscarriage (27.2%) and 14 participants \n(6.0%) reported having a prior stillbirth. Interview \nparticipants were not asked about their age, pregnancy \ncomplications or prior losses. \n3.1 Movement monitoring advice \nWe identified three categories of the type of advice \nreceived on FM monitoring, namely a) active monitoring; \nb) reactive monitoring (when and how to act  if concerned \nabout FM) and c) no advice. \nActive monitoring advice \nParticipants reported a variety of advice about how to \nkeep track of FMs, including counting kicks, tracking \npatterns of movement, and checking periodically for the \npresence of movements. \nParticipants described being advised to do kick \ncounting to assess the frequency of FMs, often with the \naim of reaching a defined number of kicks within a certain \ntime period. The expected number of kicks and the \nprescribed timing varied between responses.  A count of \n10 kicks in 2 hours was the most commonly advised \nguideline. However , different participants mentioned \ncounts of 10 kicks per day, 20 kicks per day, 10 kicks per \nhour and 20 kicks per hour. As shown in  Figure 1, kick \ncounting was mentioned by a  few participants in every \ncountry, but it was most prevalent in the USA with 59% of \nparticipants referencing it in their responses. Although \ndescribed by fewer participants overall, kick counting was \nalso one of the more common types of advice in South \nAfrica. \n“Every day, pick the same time, and in the 2 hours, count \nmovement at least 10 times.” (S69, USA) \n \nTable 1: Maternal characteristics \nCharacteristic Survey Interview \n (n=234) (n=15) \nPregnancy status \nCurrently 156 (66.7%) 5 (33.3%) \nRecently 78 (33.3%) 10 (66.7%) \nCountry stillbirth rate \nHigh 112 (47.9%) 3 (20.0%) \nLow 122 (52.1%) 12 (80.0%) \nCountry \nKenya (High SBR) 18 (7.7%) 1 (6.7%) \nSouth Africa (High SBR) 55 (23.5%) – \nZimbabwe (High SBR) 26 (11.1%) 1 (6.7%) \nOther* (High SBR) 13 (5.6%) 1 (6.7%) \nIreland (Low SBR) 47 (20.1%) 4 (26.7%) \nUK (Low SBR) 36 (15.4%) 1 (6.7%) \nUSA (Low SBR) 39 (16.7%) 7 (46.7%) \nAge group (years) \n18–29 64 (27.4%) – \n30–39 150 (64/1%) – \n40–49 20 (8.5%) – \nParity \nPrimiparous 101 (43.2%) 5 (26.7%) \nMultiparous 133 (56.8%) 9 (60.0%) \nUndisclosed – 1 (6.7%) \nComplication/risk factor \nYes 146 (62.4%) – \nNo 88 (37.6%) – \nPrior miscarriage \nYes 63 (26.9%) – \nNo 171 (73.1%) – \nPrior stillbirth \nYes 14 (6.0%) – \nNo 218 (93.2%) – \nUndisclosed 2 (0.9%) – \n*“Other” countries in the survey (with <10 respondents) included Ghana \n(n=7) and Nigeria (n=6). One interview participant was from Nigeria. \n \nPattern tracking was described by participants as \nlearning the baby’s normal movement routine and being \naware of changes. It was the most commonly described \nmethod in Ireland and the UK, with approximately a third \nof Irish and half of UK participants menti oning pattern \ntracking. Pattern tracking was also reported by some \nparticipants in every high SBR country as a method of FM \nmonitoring. \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted November 14, 2025. ; https://doi.org/10.1101/2025.11.12.25340103doi: medRxiv preprint \n\n5 \n“Monitor over the next 6 weeks for a pattern and track to \nmake sure baby stays in that pattern” (S195, UK) \nDetecting the presence of movement regularly was \ndescribed by several participants, with time frames \nranging from hourly to daily. Unlike kick counting, this \nadvice did not involve counting movements but  focused \nonly on confirming that movement had occurred. \nPresence-based advice was a more predominant method \nin high SBR countries than in low SBR countries. It was the \nmost common form of advice in Zimbabwe, described by \napproximately a fifth of participants. \n“Listen 3 to 4 times a day if the baby is moving ” (S114, \nZimbabwe) \nSeveral participants described receiving advice about \nmonitoring movements, but their responses did not \nspecify what type of monitoring they were instructed to \ndo. These cases are labelled as non -specific in Figure 1. \nIn low SBR countries, advice type was dominated by one \ncategory of monitoring method, with pattern recognition \ndominating in Ireland and the UK, and kick counting \ndominating in the US. In contrast, there was less \ncoherence in the advice received in high SB R countries, \nwith advice types split between kick counting, pattern \nrecognition, presence detection, as shown in Figure 1. \nReactive monitoring advice (when and how to act) \nAdvice about what to watch out for as warning signs of \nfetal distress was often described in participant \nresponses, often reported alongside other forms of advice. \nA reduction, absence or change in movements w ere the \ntypes of warning signs most commonly advised. An \nincrease in movements was only referenced by two \nparticipants, one each from Ireland and the UK. Maternal \nconcern or intuition was sometimes referenced by \nparticipants as a trigger for seeking care, especially in  \nIreland and the UK. \n“Trust your gut. If you are worried at all attend (...) \nhospital” (S21, Ireland) \nReactive monitoring advice was particularly \nemphasised in Ireland and the UK, reported in over half of \nresponses. UK and Irish participants most commonly \nreferred to reduced or changed movements as a reason to \nseek care, but absence of movements and genera l \nmaternal concern were also mentioned.  \n“Get in touch with the Midwife team if I notice any \nchanges in Baby’s movements. This includes them being \nquieter/less active than normal, but also if they’re being \nmore active than normal.” (S89, UK) \nMost participants from the USA did not report being \ntold about warning signs. Of the small number who did, \nchanges in movements were most frequently referenced. \nA large proportion of Kenyan participants were advised \nabout warning signs, in particular with a focus on  the \nreduction or absence of movements. In South Africa and \nZimbabwe, the warning signs were almost exclusively \nreported as a complete absence of movement, with time \nperiods ranging from no movements in several hours to \nnone in a day. \n“If your baby doesn’t move in 24 hours, visit the hospital” \n(S170, South Africa) \nAs illustrated in the quote above, participants often \ndescribed being instructed on what actions to take if they \nwere concerned about movements. Over a quarter of all \nparticipants (27%) explicitly mentioned being told to seek \nmedical care, by calling their  midwife or doctor , or by \ngoing into the hospital directly. This was particularly \nemphasised in Ireland, the UK and Kenya, while only a few \nparticipants from the other high SBR countries stated \nexplicitly that they were told to seek medical care. In \ncontrast to other low SBR countries, only three \nparticipants from the USA (8%) explicitly describe being \nadvised to seek medical care for concerns about FMs. \nA few participants described being told to postpone \nseeking direct care by trying to stimulate movement first \nand monitoring for resulting movements. Stimulation \nstrategies included drinking or eating something and lying \non one side. Overall this type of a dvice was not common, \nwith the highest occurrence of it in Ireland where 9% of \nparticipants referred to it. \n“If no movements felt, drink a fizzy drink/eat something \n& wait half an hour to see if response” (S25, \nIreland) \nNo advice \nSome participants described getting no advice on FM \nmonitoring in their responses. In other instances, when \nspecifically asked what type of advice they were given \nabout FM monitoring, some participants would describe \nadvice that was unrelated to movements, possibly \nindicating they were not aware of the concept.  \n“Very little to none” (S36, Ireland) \n“How to sit and sleep ...exercises to do, what to eat and \nwhat not to eat” (S223, South Africa) \nBetween the two types of responses, a fifth of \nparticipants responses indicated a lack of sufficient \nadvice. This was particularly prevalent in countries with a \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted November 14, 2025. ; https://doi.org/10.1101/2025.11.12.25340103doi: medRxiv preprint \n\n6 \nhigh stillbirth rate, with between 31 -44% of participants \nfrom Kenya, South Africa and Zimbabwe indicating a lack \nof advice compared to 3 -13% in low SBR countries, as \nshown in Figure 1. The UK had the lowest incidence of \nreceiving no/unrelated advice, while South Africa had the \nhighest. \n3.1.1 Ease of following advice \nApproximately half of the participants (115/234) found it \neasy to follow advice (very easy/easy/somewhat easy), \nwhile about a third (74/234) reported some degree of \ndifficulty (very difficult/difficult/somewhat difficult).  \nParticipants from countries with a low SBR found it \nsignificantly more difficult to follow advice compared to \nparticipants from countries with a high SBR (p < 0.001), as \nshown in Supplementary Table 2. There was also a \nsignificant difference in the rating of ease of following \nadvice between individual countries (p = 0.017), although \nno significant pairwise groupings were found between \ncountries. As seen in  Figure 2, Irish, UK and South African \nparticipants found it most difficult to follow advice, while \nparticipants from the USA, Kenya, and ‘Other high SBR’ \ncountries found it easiest.  \nAge was also shown to have a significant impact on ease \nof following advice (p = 0.030), with participants aged 18 -\n29 years reporting significantly greater ease than those \naged 30 -39 years, as seen in Figure 2. While not \nstatistically significant, trends were observed suggesting \nthat primiparous participants, those with pregnancy \ncomplications or risk factors, and those with a history of \nprior miscarriage or stillbirth tended to report greater \ndifficulty with following advice. \nFacilitators \nTwo main factors were identified in participant \nresponses as reasons for increased ease of following \nadvice: firstly, having a clear understanding and \nconfidence in monitoring, and secondly, having an active \nbaby. \nHaving a clear understanding of how to monitor FMs \nand what to expect was identified as a factor that made \nmonitoring easier by 19% of survey participants. This was \nfacilitated by clear instructions from medical \nprofessionals, knowledge from a prior pregnancy, and/or \na strong confidence in their own understanding of what to \nexpect and how to identify reduced movements, as \ndescribed by the following participants. Participants from \nhigh SBR countries described having a clear \nunderstanding and confidence in th e advice more \nfrequently than low SBR countries.  \n \n“Information was included in hospital notes and \nhighlighted by midwife during appointment. Movement \nwas discussed at each appointment to reiterate \ninformation” (S135, UK) \n“Well since I was pregnant before I go on what I know ” \n(S135, South Africa) \nKick counting \n Pattern \n Presence \n Non-specific \n No/Unrelated advice \n Reactive \n% \n0 \n% \n10 \n% \n20 \n% \n30 \n% \n40 \n50 \n% \n60 \n% \nIreland \n(n=47) \nUK \n(n=36) \nUSA \n(n=39) \nKenya \n(n=18) \nS. Africa \n(n=55) \nZimbabwe \n(n=26) \nOther high \nSBR(n=13) \nL \no \nw \nSBR \n High SBR \n0 \n% \n% \n10 \n% \n20 \n30 \n% \n% \n40 \n% \n50 \n% \n60 \nLow SBR \n(n=122) \nHigh SBR \n(n=112) \na. \n b. \nFigure 1: FM monitoring advice varied between countries and settings. 31-44% of participants from high SBR countries had received \nno/unrelated advice, compared to <15% of participants from low SBR countries. Pattern based monitoring was predominantly \nadvised in Ireland and the UK, while kick counting was more predominant in the USA. Kick counting, pattern recognition and \npresence-based monitoring were all advised to a similar extent in high SBR countries, with higher rates of kick counting advice in \nSouth A frica and of presence -based monitoring in Zimbabwe. Reactive advice about when and how to act was particularly \nemphasised in Ireland, the UK and Kenya. \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted November 14, 2025. ; https://doi.org/10.1101/2025.11.12.25340103doi: medRxiv preprint \n\n7 \nHaving an active baby who moved often made \nmonitoring easier for women in both high and low SBR \nsettings, particularly in the USA, South Africa, Zimbabwe \nand ‘Other Countries’ . An active baby made it easier to \nkeep track of movements, gave reassurance that  the baby \nwas healthy , and increased confidence in being able to \nidentify changes easily. \n“My baby was a very active baby so I definitely would \nhave been able to pick up any slightest change.” (S41, \nUK) \nBarriers \nThe primary themes identified by participants who \nreported difficulty in following FM monitoring advice \nwere 1) lack of clarity and understanding; 2) struggling to \nidentify a pattern; 3) difficulty perceiving movements; and \n4) competing time demands. \nThe most frequently observed challenge participants \nreported was a lack of clarity and understanding about \nself-monitoring of FM. This was especially prevalent in \nlow SBR countries with 28% of participants indicating it \nin their responses compared to 12% of participants from \nhigh SBR countries. Participants expressed that they felt \nthe advice was insufficient, that they didn’t know  what to \nexpect, and were uncertain about when to worry about \nFigure 2: (a) Reported ease of following FM monitoring advice was significantly higher in high stillbirth countries  than in low \nstillbirth countries. (b) There was also a significant difference in ease between countries, however no pairwise groupings we re \nsignificant. (c) Participants aged 18 -29 years found it significantly easier to follow advice than participants aged  30-39 years. No \nother factors had a significance effect on reported ease of following advice . \n \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted November 14, 2025. ; https://doi.org/10.1101/2025.11.12.25340103doi: medRxiv preprint \n\n8 \ntheir baby’s movements. In Ireland and the UK, where an \nemphasis is placed on identifying “normal” movement \nrhythms, as described in Section 3.1, participants \nexpressed that they did not know what normal or healthy \nmovement should be. This was described by an interview \nparticipant from the UK: \n“It’s very difficult to know what’s normal. And when you \nask a professional, they basically say: “we can’t tell you, \nbecause everybody’s different”, which I appreciate, but it \ndoes leave a lot of room for interpretation, so it is very \nunsettling.” (I11, UK) \nStruggling to identify a pattern in their baby’s \nmovement was frequently reported by Irish and UK \nparticipants, but also by some participants in the USA and \nZimbabwe. Participants expressed that they found it hard \nto recognise a pattern in their baby’s mov ements, or that \nvariations in their baby’s movements made monitoring \nmore difficult, as described by this Irish participant:  \n“I don’t feel my baby has developed a pattern and is \nquieter some days and more active others” (S40, Ireland) \nAnother challenge experienced by participants was \ndifficulty perceiving movements or having a “quiet baby” . \nParticipants sometimes attributed this to their anterior \nplacenta, which can cushion the fetus and reduce the \nability to feel movements clearly. Others found it difficult \nwhen their babies were quiet or had periods of reduced \nmovement, which often contributed to anxiety about their \nbaby’s wellbeing. As an interviewee from Zimbabwe said:  \n“It’s [the advice] not easy to follow, because you can’t really \ntell if the fetus is moving, or if it’s not sometimes, you can’t \ntell if your baby is alive or not, or if your baby is in distress, \nyou can’t tell.” (I13, Zimbabwe)  \nHalf of the interview participants and 14% of survey \nparticipants expressed that other demands on their time, \nsuch as work, childcare or other responsibilities, made it \nmore difficult to keep track of movements. This was \nobserved as a challenge that was un iversal across most \ncountries; however , it was particularly prevalent in the \nUSA, with 23% of survey participants identifying it as an \nissue. For example, a participant said: \n“I also have another child and it’s hard to sit and relax to \ncount them, I’m often busy and don’t remember the last \ntime I felt her move.” (S76, USA) \nAs reported in Section 3.1, many survey participants \nreported receiving no or unrelated information about FM \nmonitoring. In such cases, most participants answered \n“n/a” or “neither easy or difficult” to the question about \nease of following FM monitoring advice. Although the \nabsence of advice generally did not contribute to the \ndifficulty rating, it represents a clear barrier to the overall \neffectiveness of FM monitoring. \n \nFigure 3: Across most countries, participants who could easily feel their baby moving found it easier to follow advice, while  \nparticipants who had difficulty perceiving movements found it harder. Having a clear understanding of and confidence in recei ved \nadvice contributed to higher ease in monitoring in high SBR countries, while lack of clarity and understanding contributed to \nhigher difficulty in low SBR countries. A common barrier across all countries was competing time demands, while struggling to  \nidentify a consistent pattern was a barrier in countries which advised pattern-based monitoring. \n0 \n% \n% \n10 \n% \n20 \n% \n30 \n40 \n% \nLow SBR \n(n=122) \nHigh SBR \n(n=112) \nActive baby \nClear understanding and confidence \nLack of clarity and understanding \nDifficulty perceiving movements \nCompeting time demands \nStruggle identifying pattern \n% \n0 \n10 \n% \n20 \n% \n30 \n% \n% \n40 \nIreland \n(n=47) \nUK \n(n=36) \nUSA \n(n=39) \nKenya \n(n=18) \nS. Africa \n(n=55) \nZimbabwe \n(n=26) \nOther high \nLo \nw \nSBR \n High SBR \nSBR(n=13) \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted November 14, 2025. ; https://doi.org/10.1101/2025.11.12.25340103doi: medRxiv preprint \n\n9 \n3.2 Anxiety about fetal movements \nThe majority of participants (78%) reported feeling \nanxious or worried about their baby’s movements at least \nsome of the time (24% always, 14% usually and 40% \nsometimes), while the remainder felt anxious rarely (16%) \nor never (6%). \nParticipants from countries with a high stillbirth rate \nwere significantly more likely to report anxiety about their \nbaby’s movements than participants from countries with a \nlow stillbirth rate (p=0.039). Although the difference \nbetween individual countrie s was not significant, South \nAfrica and Kenya had the highest proportion of participants \nreporting always or usually anxious, while Kenya and the \nUSA had the highest levels of participants who were \n“ Always” anxious, as seen in Figure 4. Factors other than \nlocation that significantly impacted frequency of anxiety \nwere pregnancy complications or risk factors (p=0.005), \nand experience of a prior stillbirth (p=0.012), as shown in \nSupplementary Table 4. The effects of pregnancy \ncomplications or the experience of a prior loss w ere also \nnoted as a source of anxiety by several of the interview \nparticipants. \n“Yes, with my first I did [feel anxious] a lot because I had \ncomplications, and one of them was [obstetric] cholestasis, \nwhich has the increased risk of stillbirth,  so I was always \nconvinced that if I didn’t feel her for a long time, that she \nwas like actively passing away.” (I6, USA) \n“I was actually very anxious, especially after losing the 1st \npregnancy.” (I10, Kenya) \nParity, age and experience of a prior miscarriage were not \nshown to have a significant effect on anxiety, although \nwomen between the ages of 18 -29 and those with a prior \nmiscarriage trended towards more frequent anxiety than \nother participants. \n3.3 Synthesis across countries and settings \nThe countries where participants found it hardest to follow \nadvice on fetal activity monitoring were Ireland, the UK and \nSouth Africa. The country -specific themes most associated \nwith difficulty in following advice were lack of clarity and \nunderstanding (I reland, UK) and difficulty in perceiving \nmovements (UK). No predominant theme emerged from \nthe reports of the South African participants to provide \ninsight into the challenges experienced by women there in \nfollowing the advice. The USA, Kenya and ‘Other high SBR’ \ncountries found it easiest to follow FM monitoring advice. \nThe themes that were most associated with countries that \nfound following advice easiest were having an active baby \n(USA) and having a clear understanding and confidence in \nthe advice (Kenya). Our findings suggest that some types of \nadvice may be easier to follow than others. Given the ratings \nof difficulty in Ireland and the UK, pattern recognition \nmonitoring may be more difficult for women to follow, \nwhile the results from the USA imply tha t kick counting \nmight be easier to follow. \nParticipants in high-SBR countries reported receiving no \nadvice or unrelated advice more commonly than in low-SBR \ncountries. Furthermore, fewer participants in high -SBR \ncountries reported receiving active monitoring advice (kick \ncounting/pattern recognitio n/presence) than in low -SBR \ncountries. An interesting difference between the included \nhigh- and low-SBR countries is that in each of the low -SBR \ncountries there was a dominant theme of advice (either \npattern recognition or kick counting, Figure 1), while n one \nof the high -SBR countries exhibited a dominant type of \n“active” monitoring advice (Figure 1). \nWomen in high-SBR countries were more likely to report  a \nclear understanding and confidence in FM monitoring than \nthose in low -SBR countries, with the exception of \nZimbabwe. Zimbabwe participants reported “lack of clarity \nand understanding” more than any other high-SBR country, \nbut also reported the lowest rates of anxiety among the \nhigh-SBR countries. Zimbabwe did not stand out from other \nhigh-SBR countries in terms of the types of advice received, \nexcept for a slight decrease in the proportion of “reactive \nadvice” given in Zimbabwe com pared to other high -SBR \ncountries. \nKenya and the USA had the highest incidences of “always” \nanxious women, while simultaneously being the countries \nthat reported the greatest ease of following advice. Both \ncountries have vastly different SBRs [ 25], and different \ntypes of advice received (Figure 1). This finding implies that \nproviding advice that is easy to follow does not necessarily \nprovide reassurance in terms of anxiety about FMs. \n4 Discussion \nThis study is unique in its inclusion of women from eight \ndifferent countries, spanning both low and high stillbirth \nrate settings, allowing comparisons of how advice on FM \nmonitoring is given, interpreted and experienced across \ndiverse settings. In this regard, w e observed marked \ndifferences between both individual countries and between \ngroups of countries categorised by stillbirth rate. In \nparticular , we found a systemic difference in the coherence \nof advice messaging between settings . Low SBR countries \ndemonstrated greater consistency in the themes of advice, \ncompared to high SBR countries. Despite such differences, \na shared global concern among pregnant women was \nmaternal anxiety about FMs - 78% of women reported \nfeeling anxious about their baby’s movements at least \noccasionally during their pregnancy. Our findings highlight \nthe importance of clear and consistent advice on FM \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted November 14, 2025. ; https://doi.org/10.1101/2025.11.12.25340103doi: medRxiv preprint \n\n10 \nmonitoring and the need for supportive care that \nacknowledges and eases maternal anxiety. \n \nCoherence of advice was observed as a distinct difference \nbetween high and low SBR settings. The type of FM \nmonitoring advice also varied considerably across \ncountries. In low SBR countries, a predominant theme of \nadvice, e.g. kick counting in the USA and FM pattern \nrecognition in Ireland and the UK, were evident. In contrast, \nwomen in high SBR countries frequently reported receiving \nlittle or no advice , and among the women who did receive \nadvice, the content varied widely. This aligns with previous \nfindings reporting limited awareness of absent or reduced \nFMs as a warning sign in LMIC, with awareness rates as low \nas around 4.6% in Ghana [ 27], 11.7% in Jordan [ 28] and \n16.4% in Nigeria [ 29]. Differences in the number of \nmidwives and obstetricians across countries may affect the \nconsistency and quantity of advice given to pregnant \nwomen. Without standardisation of advice about FM \nmonitoring, particularly given that women may find \ninformation on websites from other countries, can lead to a \nconfusing mix of advice from  healthcare providers, family \nand friends and the internet . Such inconsistency risks \nmisinformation, or delayed care as reported by Smyth et al. \n[14]. One of the barriers to effective FM monitoring \nidentified in our study was a lack of understanding and \nFigure 4: (a) There was no significant difference between ratings of anxiety frequency between countries, however some trend \ntowards more or less frequent anxiety. (b) Participants from high SBR countries are significantly more frequently anxious abo ut \nmovements than those from low SBR countries. (c) Participants with pregnancy complications/risk factors generally rated their \nfrequency of anxiety as higher than those without. (d) Participants with experience of a prior stillbirth were significantly more \nfrequently anxious than those who hadn’t. \n \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted November 14, 2025. ; https://doi.org/10.1101/2025.11.12.25340103doi: medRxiv preprint \n\n11 \nclarity about advice, to which variation in received advice \ncan contribute. While the  standardisation of national \nguidelines about FM monitoring might be expected to \nimprove clarity for both healthcare providers and pregnant \nwomen, our findings suggest otherwise. Participants in the \nUK [30], Ireland [31], and South Africa [ 32], countries with \nnational FM monitoring guidelines, were among those who \nreported the greatest difficulty in following advice.  This \nsuggests that the challenge may lie less in the cons istency \nof the advice, and more in the content and delivery of the \nadvice itself. \nThe variability in the advice received, particularly in \nhigh-SBR countries, may be attributable to the absence \nof conclusive evidence on the effectiveness of FM \nmonitoring. Several large -scale randomised trials have \ninvestigated the potential of FM monitor ing to reduce \nstillbirth occurrence, including the AFFIRM trial in the \nUK [18], the Mindfetalness trial in Sweden [ 19], and the \nMy Baby’s Movements trial in Australia and New Zealand \n[33]. However , none of the trials found significant \nreductions in stillbi rth rates. As highlighted by \nHousseine et al., the global applicability of these trials is \nlimited as the se trials were conducted in places with \nalready low stillbirth rates and relatively high maternal \nawareness of FM monitoring . Consequently, these \nstudies may have been underpowered to detect the \nrelatively rare outcome of stillbirth [ 34] and may not \naccurately present the potential benefits  of FM \nmonitoring in lower -resource settings. It is imperative \nthat further research is conducted in LMICs to determine \nwhether FM monitoring awareness could be an effective \nmethod of reducing stillbirth rates in populations \nbearing the highest burden of stillbirth.  \nFor FM monitoring methods to be effective, it is \nimportant to understand pregnant women’s \nperspectives, including the facilitators and barriers they \nexperience while trying to follow the advice they are \nprovided. Our study found that participants from \ncountries with a high SBR generally found it easier to \nfollow FM monitoring advice, with the exception of \nZimbabwe, participants described that they felt \nconfident in their knowledge of what to expect and that \nthey had a clear understanding of how to monitor . \nConversely, participants from low SBR countries and \nZimbabwe expressed a higher level of uncertainty and \nlack of understanding about received advice, in \nparticular when it came to the specifics of how to \nmonitor , when to worry and what was “normal” . These \nfindings align with those of McArdle et al., who reported \nthat pregnant women would prefer to receive as much \ninformation as possible [ 12]. These results suggest that \nthe provision of a clear comprehensive guideline about \nhow to monitor FMs would be beneficial. \nAcross all settings, a key factor that affected ease of \nfollowing FM monitoring advice was how frequently \nparticipants could feel their fetus moving. Participants \nwho described their fetus as more active found it easier \nto follow the advice they were given, whereas those who \nexperienced difficulty in perceiving FMs found it harder \nto follow the FM monitoring advice given. Additionally, \nparticipants across all settings reported that being busy \nwith other time demands, such as work or children, \nmade it more difficult to both sense and monitor \nmovements. Strategies to monitor FMs should therefore \nbe considerate of these commonly experienced barriers. \nResearch is ongoing to develop wearable FM monitors, \nfor example [ 35, 36], but none are yet available \ncommercially. \nAcross the diverse range of settings in this study, a \nshared global factor was the high prevalence of maternal \nanxiety about FMs, with four out of five women reporting \nexperiencing anxiety about FMs at least  occasionally. \nNotably, countries with a higher ease of following advice \nwere not necessarily associated with lower rates of \nanxiety, indicating that even when advice is easy to \nfollow, anxiety persists. Participants from countries with \na high stillbirth  rate, and participants with pregnancy \ncomplications, risk factors, and experience of a prior \nstillbirth were significantly more frequently anxious \nabout FMs. These findings are consistent with previous \nstudies that demonstrated elevated levels of anxiety in \nmedically complicated pregnancies [ 37] and in \npregnancies following a stillbirth [ 38]. Additionally, \nparticipants from high SBR settings are more likely to \nknow other people who have had a stillbirth  and \ntherefore may have a greater understanding of the \nimportance of FM monitoring. Several studies have \nexplored the effect of kick counting on anxiety, and a \nmeta-analysis by AlAmri and Smith found no difference \nin maternal anxiety between women who formally \ncounted FMs and those who did not [ 22]. To our \nknowledge, there has not been a large-scale study on the \neffect of pattern -based monitoring or presence -based \nmonitoring on maternal anxiety, or a study comparing \nthe impact of different methods of advice types on \nanxiety. Since maternal anxiety can impact the health of \nboth the expectant mother and fetus [ 39, 40], it is \nimportant that the impact of FM monitoring guidelines \non anxiety should be appropriately investigated and \nassessed alongside other outcome metrics. Particular \ncare should be taken when providing advice to cohorts \nwho experience higher rates of anxiety about FM \nmonitoring.  \nThere were some limitations to our study. \nParticipation was limited to women who spoke English \nand had internet access. Additionally, as participants \nopted in to answer the online survey and interviews, \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted November 14, 2025. ; https://doi.org/10.1101/2025.11.12.25340103doi: medRxiv preprint \n\n12 \nfindings may be influenced by self -selection bias. Finally, \nwomen in our study were interviewed and surveyed up \nto a year after giving birth, which may introduce recall \nbias. \n \n5 Conclusion \nThis study revealed substantial variation in the consistency \nand type of FM monitoring advice received by women \nacross both high and low stillbirth rate countries, with a \nhigh rate of women receiving no advice at all. Our findings \nhighlight the need for clarity and consistency in FM \nmonitoring communication. Further studies on the \ncomparative effectiveness of FM monitoring type are \nwarranted. The research gap regarding FM monitoring is \nparticularly pronounced in places with the highest burden \nof stillbirth. The high rates of anxiety related to FM \nreported by women from across the globe indicate a need \nfor further support and sensitivity when designing FM \nmonitoring methods and guidelines.  \nAcknowledgments \nThis research was funded by the Wellcome Leap In Utero \nProgramme.  \nConflicts of interest \nNCN is CEO and co -founder of a start -up developing a \nwearable fetal activity tracker . \n \nAvailability of data and materials \nThe anonymous survey data is stored on a public repository \nand can be found at : \nhttps://doi.org/10.5281/zenodo.17572671 [41]. \nInterview transcripts available upon reasonable request.  \nReferences \n[1] UNICEF . Stillbirths and Stillbirth Rates;. Available \nfrom: https://data.unicef.org/topic/ child-\nsurvival/stillbirths/. \n[2] Comfort H, McHugh TA, Schumacher AE, Harris A, May \nEA, Paulson KR, et al. 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CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted November 14, 2025. ; https://doi.org/10.1101/2025.11.12.25340103doi: medRxiv preprint","source_license":"CC-BY-4.0","license_restricted":false}