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  • 1.
    Akselsson, Anna
    Sophiahemmet University.
    Awareness of fetal movements and pregnancy outcomes2020Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    Fetal movements are one, among others, of the measurable factors indicating wellbeing of the fetus. Decreased fetal movements are associated with intrauterine growth restriction and stillbirth. Women with experience of stillbirth have often noticed decreased and weaker fetal movements preceding the intrauterine death. Further, seeking care for decreased fetal movements is a common reason for unscheduled contact with health care. The aim of this thesis was to investigate whether a method, aimed to increase women’s awareness of the fetal movement pattern, had an effect on pregnancy outcomes. Further, the thesis aimed to study pregnancy outcomes for women seeking care for decreased or altered fetal movements.

    In Study I, 2683 women completed questionnaires when they presented for decreased fetal movements, after an examination of their unborn baby, that did not result in any interventions aimed at ending the pregnancy. In Studies II–IV, we evaluated Mindfetalness, a method aimed to increase women’s awareness of the fetal movement pattern. Women were given a leaflet of how to practise Mindfetalness in third trimester: lie down on your side when the baby is awake and focus on the strength, character and frequency of the movements for about 15 minutes daily (but do not count each movement). Women’s attitudes to and compliance with Mindfetalness were investigated in Study II, comprising 104 women. In studies III-IV we studied the effect of Mindfetalness on pregnancy outcomes and, through cluster-randomisation, 19 639 women in Stockholm were randomised to Mindfetalness and 20 226 to routine care. Study IV comprised a sub-analysis, where we compared women born in Somalia and Sweden.

    Women in the Mindfetalness group (Study III) had spontaneous onset of labour to a higher extent (RR 1.02, CI 1.01–1.03), less cesarean sections (RR 0.95, CI 0.91–0.99) and labour inductions (RR 0.96, CI 0.92–1.00), than women in the Routine-care group. More women in the Mindfetalness group contacted healthcare due to decreased fetal movements (RR 1.72, CI 1.57–1.87). A decreased number of babies born small for gestational age (RR 0.95, CI 0.90–1.00) and those transferred to neonatal care (RR 0.93, CI 0.86–1.00) was seen in the Mindfetalness group. No differences were found in Apgar score <7 at 5 minutes. Women born in Somalia had a higher risk of Apgar score <7 at 5 minutes (RR 2.17, CI 1.19–3.61) and of having a baby small for gestational age (RR 2.19, CI 1.85–2.56), than women born in Sweden (Study IV). The majority of the women had a positive attitude towards Mindfetalness and practised the method daily (Study II). Women contacting healthcare due to decreased fetal movements had labour induction to a higher extent than women not seeking care due to decreased fetal movements (Study I).

    Increased maternal awareness of fetal movements by Mindfetalness in the third trimester is advantageous for mother and baby. Spontaneous start of labour increased and interventions, notably cesarean sections, decreased. Fewer babies were born small for gestational age and in need of neonatal care. Women expressed having positive attitudes to the method and feelings of safety and calm, when they practised Mindfetalness.

  • 2.
    Akselsson, Anna
    et al.
    Sophiahemmet University.
    Cabander, Lisa
    Thorarinsdottir, Steinunn
    Small, Rhonda
    Ternström, Elin
    Language-supported labor ward visits for pregnant migrant women: Staff experiences in a Swedish hospital2022In: European Journal of Midwifery, E-ISSN 2585-2906, Vol. 6, article id 42Article in journal (Refereed)
    Abstract [en]

    INTRODUCTION: The aim of this study was to explore midwives' and assistant nurses' experiences of providing extra support to non-Swedish-speaking migrants by offering individual language-supported visits to the labor ward during pregnancy.

    METHODS: Semi-structured interviews were conducted with six guides, midwives or assistant nurses, working in the INFÖR (Individuell förlossningsförberedelse) project at Södertälje hospital in Sweden. INFOR includes a two-hour individual language-supported visit at the labor ward, for non-Swedish speaking pregnant women and their partners. An inductive thematic analysis was conducted.

    RESULTS: The guides described INFOR as being a bridge and creating safety, achieved by meeting with women and providing practical information. The guides felt that they fulfilled an important purpose, they were dedicated and adapted to the women's individual needs. Providing extra language-assisted support to migrant pregnant women was developing and enriching, but the guides highlighted some barriers. Communicating via an interpreter was a challenge and the women were in need of more and extended meetings. The guides wished that INFOR could become a standard part of antenatal care, but the model needs to be further developed, and a better system for recruitment must be introduced.

    CONCLUSIONS: The guides experienced that the INFOR model is valuable in creating safety to pregnant migrant women before birth. The model is appreciated by the expectant couples, midwives and assistant nurses, and could be implemented as standard care. However, it is important to adapt the visits to the women's and their families' needs and goals, and structure needs to be developed before implementation.

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  • 3.
    Akselsson, Anna
    et al.
    Sophiahemmet University.
    Georgsson, Susanne
    Sophiahemmet University.
    Lindgren, H
    Pettersson, K
    Rådestad, Ingela
    Sophiahemmet University.
    Women's attitudes, experiences and compliance concerning the use of Mindfetalness: A method for systematic observation of fetal movements in late pregnancy2017Conference paper (Other academic)
  • 4.
    Akselsson, Anna
    et al.
    Sophiahemmet University.
    Georgsson, Susanne
    Sophiahemmet University.
    Lindgren, H
    Pettersson, K
    Steineck, G
    Skokic, V
    Rådestad, Ingela
    Sophiahemmet University.
    Mindfetalness and pregnancy outcomes: a randomized controlled trial including 39,337 women2019Conference paper (Other academic)
  • 5.
    Akselsson, Anna
    et al.
    Sophiahemmet University.
    Georgsson, Susanne
    Sophiahemmet University.
    Lindgren, Helena
    Pettersson, Karin
    Rådestad, Ingela
    Sophiahemmet University.
    Women's attitudes, experiences and compliance concerning the use of Mindfetalness- a method for systematic observation of fetal movements in late pregnancy2017In: BMC Pregnancy and Childbirth, ISSN 1471-2393, E-ISSN 1471-2393, Vol. 17, no 1, article id 359Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Maternal perception of decreased fetal movements and low awareness of fetal movements are associated with a negative birth outcome. Mindfetalness is a method developed for women to facilitate systematic observations of the intensity, character and frequency of fetal movements in late pregnancy. We sought to explore women's attitudes, experiences and compliance in using Mindfetalness.

    METHODS: We enrolled 104 pregnant women treated at three maternity clinics in Stockholm, Sweden, from February to July of 2016. We educated 104 women in gestational week 28-32 by providing information about fetal movements and how to practice Mindfetalness. Each was instructed to perform the assessment daily for 15 min. At each subsequent follow-up, the midwife collected information regarding their perceptions of Mindfetalness, and their compliance. Content analyses, descriptive and analytic statistics were used in the analysis of data.

    RESULTS: Of the women, 93 (89%) were positive towards Mindfetalness and compliance was high 78 (75%). Subjective responses could be binned into one of five categories: Decreased worry, relaxing, creating a relationship, more knowledge about the unborn baby and awareness of the unborn baby. Eleven (11%) women had negative perceptions of Mindfetalness, citing time, and the lack of need for a method to observe fetal movements as the most common reasons.

    CONCLUSION: Women in late pregnancy are generally positive about Mindfetalness and their compliance with daily use is high. The technique helped them to be more aware of, and create a relationship with, their unborn baby. Mindfetalness can be a useful tool in antenatal care. However, further study is necessary in order to determine whether the technique is able to reduce the incidence of negative birth outcome.

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  • 6.
    Akselsson, Anna
    et al.
    Sophiahemmet University.
    Linde, Anders
    Sophiahemmet University.
    Georgsson, Susanne
    Sophiahemmet University.
    Lindgren, H
    Pettersson, K
    Rådestad, Ingela
    Sophiahemmet University.
    Structured daily observation of fetal movements and transfer to neonatal clinic2017Conference paper (Other academic)
  • 7.
    Akselsson, Anna
    et al.
    Sophiahemmet University.
    Lindgren, H
    Georgsson, S
    Pettersson, K
    Steineck, G
    Skokic, V
    Rådestad, Ingela
    Sophiahemmet University.
    Mindfetalness to increase women's awareness of fetal movements and pregnancy outcomes: a cluster-randomised controlled trial including 39 865 women2020In: British Journal of Obstetrics and Gynecology, ISSN 1470-0328, E-ISSN 1471-0528, Vol. 127, no 7, p. 829-837Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: To examine whether a method for raising women's awareness of fetal movements, Mindfetalness, can affect pregnancy outcomes.

    DESIGN: Cluster-randomised controlled trial.

    SETTING: Sixty-seven maternity clinics in Stockholm, Sweden.

    POPULATION: Women with singleton pregnancy with birth from 32 weeks' gestation.

    METHODS: Women registered at a clinic randomised to Mindfetalness were assigned to receive a leaflet about Mindfetalness (n = 19 639) in comparison with routine care (n = 20 226). Data were collected from a population-based register.

    MAIN OUTCOME MEASURES: Apgar score <7 at 5 minutes after birth, visit to healthcare due to decrease in fetal movements. Other outcomes: Apgar score <4 at 5 minutes after birth, small-for-gestational-age and mode of delivery.

    RESULTS: No difference (1.1 versus 1.1%, relative risk [RR] 1.0; 95% CI 0.8-1.2) was found between the Mindfetalness group and the Routine care group for a 5-minute Apgar score <7. Women in the Mindfetalness group contacted healthcare more often due to decreased fetal movements (6.6 versus 3.8%, RR 1.72; 95% CI 1.57-1.87). Mindfetalness was associated with a reduction of babies born small-for-gestational-age (RR 0.95, 95% CI 0.90-1.00), babies born after gestational week 41+6 (RR 0.91, 95% CI 0.83-0.98) and caesarean sections (19.0 versus 20.0%, RR 0.95; 95% CI 0.91-0.99).

    CONCLUSIONS: Mindfetalness did not reduce the number of babies born with an Apgar score <7. However, Mindfetalness was associated with the health benefits of decreased incidence of caesarean section and fewer children born small-for-gestational-age.

    TWEETABLE ABSTRACT: Introducing Mindfetalness in maternity care decreased caesarean sections but had no effect on the occurrence of Apgar scores <7.

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  • 8.
    Akselsson, Anna
    et al.
    Sophiahemmet University.
    Lindgren, H
    Georgsson, Susanne
    Sophiahemmet University.
    Pettersson, K
    Skokic, V
    Rådestad, Ingela
    Sophiahemmet University.
    Awareness of fetal movements and pregnancy outcomes among women born in Somalia and Sweden: A cluster-randomised controlled trialManuscript (preprint) (Other academic)
  • 9.
    Akselsson, Anna
    et al.
    Sophiahemmet University.
    Lindgren, Helena
    Georgsson, Susanne
    Pettersson, Karin
    Rådestad, Ingela
    Sophiahemmet University.
    Increased labor induction and women presenting with decreased or altered fetal movements: A population-based survey2019In: PLOS ONE, E-ISSN 1932-6203, Vol. 14, no 5, article id e0216216Article in journal (Refereed)
    Abstract [en]

    INTRODUCTION: Women's awareness of fetal movements is important as perception of decreased fetal movements can be a sign of a compromised fetus. We aimed to study rate of labor induction in relation to number of times women seek care due to decreased or altered fetal movements during their pregnancy compared to women not seeking such care. Further, we investigated the indication of induction.

    MATERIAL AND METHODS: A prospective population-based cohort study including all obstetric clinics in Stockholm, Sweden. Questionnaires were distributed to women who sought care due to decreased or altered fetal movements ≥ 28 week's gestation in 2014, women for whom an examination did not indicate a compromised fetus that required induction of labor or cesarean section when they sought care. Women who gave birth at ≥ 28 weeks' gestation in 2014 in Stockholm comprises the reference group.

    RESULTS: Labor was induced more often among the 2683 women who had sought care due to decreased or altered fetal movements (RR 1.4, 95% CI 1.3-1.5). In women who presented with decreased or altered fetal movements induction of labor occurred more frequently for fetal indication than those with induction of labor and no prior fetal movement presentation (RR 1.6, 95% CI 1.4-1.8). The rate of induction increased with number of times a woman sought care, RR 1.3 for single presentation to 3.2 for five or more.

    CONCLUSIONS: We studied women seeking care for decreased or altered fetal movements and for whom pregnancy was not terminated with induction or caesarean section. Subsequent (median 20 days), induction of labor and induction for fetal indications were more frequent in this group compared to the group of women with no fetal movement presentations. Among women seeking care for altered or decreased fetal movements, the likelihood of induction of labor increased with frequency of presentation.

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  • 10.
    Akselsson, Anna
    et al.
    Sophiahemmet University.
    Lindgren, Helena
    Georgsson, Susanne
    Sophiahemmet University.
    Pettersson, Karin
    Rådestad, Ingela
    Sophiahemmet University.
    Mindfetalness - a systematic method for observing fetal movements: A randomized controlled trial2019Conference paper (Other academic)
  • 11.
    Akselsson, Anna
    et al.
    Sophiahemmet University.
    Lindgren, Helena
    Georgsson, Susanne
    Sophiahemmet University.
    Pettersson, Karin
    Rådestad, Ingela
    Sophiahemmet University.
    Mindfetalness: A useful tool when informing pregnant women about fetal movements2019Conference paper (Other academic)
  • 12.
    Akselsson, Anna
    et al.
    Sophiahemmet University.
    Lindgren, Helena
    Georgsson, Susanne
    Sophiahemmet University.
    Pettersson, Karin
    Rådestad, Ingela
    Sophiahemmet University.
    Mindfetalness: En metod som kan stärka kvinnors uppmärksamhet av fosterrörelser2018Conference paper (Other academic)
  • 13.
    Akselsson, Anna
    et al.
    Sophiahemmet University.
    Lindgren, Helena
    Georgsson, Susanne
    Pettersson, Karin
    Skokic, Viktor
    Rådestad, Ingela
    Sophiahemmet University.
    Pregnancy outcomes among women born in Somalia and Sweden giving birth in the Stockholm area: a population-based study2020In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 13, no 1, article id 1794107Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Studies report that women born in some African countries, after migrating to the Nordic countries, have worse pregnancy outcomes than women born in the receiving countries. With the aim of identifying unmet needs among Somali-born women, we here study this subgroup.

    OBJECTIVE: We compared pregnancy outcomes among women born in Somalia to women born in Sweden. Further, we investigated whether the proactive maternal observation of fetal movements has effects on birth outcomes among women born in Somalia.

    METHODS: In Stockholm, half of the maternity clinics were randomized to intervention, in which midwives were instructed to be proactive towards women by promoting daily self-monitoring of fetal movements. Data for 623 women born in Somalia and 26 485 born in Sweden were collected from a population-based register.

    RESULTS: An Apgar score below 7 (with stillbirth counting as 0) at 5 minutes was more frequent in babies of women born in Somalia as compared to babies of women born in Sweden (RR 2.17, 95% CI 1.25-3.77). Babies born small for gestational age were more common among women born in Somalia (RR 2.22, CI 1.88-2.61), as were babies born after 41 + 6 gestational weeks (RR 1.65, CI 1.29-2.12). Somali-born women less often contacted obstetric care for decreased fetal movements than did Swedish-born women (RR 0.19, CI 0.08-0.36). The differences between women born in Somalia and women born in Sweden were somewhat lower (not statistically significant) among women allocated to proactivity as compared to the Routine-care group.

    CONCLUSIONS: A higher risk of a negative outcome for mother and baby is seen among women born in Somalia compared to women born in Sweden. We suggest it may be worthwhile to investigate whether a Somali-adapted intervention with proactivity concerning self-monitoring of fetal movements may improve pregnancy outcomes in this migrant population.

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  • 14.
    Akselsson, Anna
    et al.
    Sophiahemmet University.
    Lindgren, Helena
    Georgsson, Susanne
    Sophiahemmet University.
    Warland, Jane
    Pettersson, Karin
    Rådestad, Ingela
    Sophiahemmet University.
    Daily structured approach to awareness of fetal movements and pregnancy outcome - a prospective study2019In: Sexual & Reproductive HealthCare, ISSN 1877-5756, E-ISSN 1877-5764, Vol. 20, p. 32-37, article id S1877-5756(18)30321-5Article in journal (Refereed)
    Abstract [en]

    OBJECTIVES: We investigated how women, seeking care due to decreased movements, had paid attention to fetal movements and if the method of monitoring was associated with pregnancy outcome.

    METHODS: A questionnaire was distributed to women from gestational week 28, who had sought care due to decreased fetal movements in Stockholm between January 1st and December 31st, 2014. Women were included in the study if the examination did not reveal any signs of a compromised fetus requiring immediate intervention. Birth outcome and sociodemographic data were collected from the obstetric record register.

    RESULTS: There were 29166 births in Stockholm in 2014, we have information from 2683 women who sought care for decreased fetal movements. The majority (96.6%) of the women stated that they paid attention to fetal movements. Some women observed fetal movements weekly (17.2%) and 69.5% concentrated on fetal movements daily (non-structured group). One in ten (9.9%) used counting methods daily for observing fetal movements (structured group). Women in the structured group more often had caesarean section before onset of labor (RR 1.6, 95% CI 1.2-2.2) and a lower risk of their baby being transferred to neonatal nursery (RR 0.25, 95% CI 0.03-0.94) compared to women in the non-structured group.

    CONCLUSIONS: Women, who had a daily and structured approach to awareness of fetal movements, were more likely to have a caesarean section but their babies were less likely to be transferred to a neonatal nursery as compared with women who used a non-structured method daily.

  • 15.
    Akselsson, Anna
    et al.
    Sophiahemmet University.
    Lindgren, Helena
    Skokic, Viktor
    Rådestad, Ingela
    Sophiahemmet University.
    A decrease in cesarean sections and labor inductions among Swedish women by awareness of fetal movements with the Mindfetalness method2020In: BMC Pregnancy and Childbirth, ISSN 1471-2393, E-ISSN 1471-2393, Vol. 20, no 1, article id 577Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Maternal perception of decreased fetal movements is commonly used to assess fetal well-being. However, there are different opinions on whether healthcare professionals should encourage maternal observation of fetal movements, as researchers claim that raising awareness increases unnecessary interventions, without improving perinatal health. We aimed to investigate whether cesarean sections and labor induction increase by raising women's awareness of fetal movements through Mindfetalness. Further, we aimed to study perinatal health after implementing Mindfetalness in maternity care.

    METHODS: In a cluster randomized controlled trial, 67 maternity clinics were allocated to Mindfetalness or routine care. In the Mindfetalness group, midwives distributed a leaflet telling the women to focus on the character, strength and frequency of the fetal movements without counting each movement. The instruction was to do so for 15 min daily when the fetus was awake, from gestational week 28 until birth. In this sub-group analysis, we targeted women born in Sweden giving birth from 32 weeks' gestation. We applied the intention-to-treat principle.

    RESULTS: The Mindfetalness group included 13,029 women and the Routine-care group 13,456 women. Women randomized to Mindfetalness had less cesarean sections (18.4% vs. 20.0%, RR 0.92, CI 0.87-0.97) and labor inductions (19.2% vs. 20.3%, RR 0.95, CI 0.90-0.99) compared to the women in the Routine-care group. Less babies were born small for gestational age (8.5% vs. 9.3%, RR 0.91, CI 0.85-0.99) in the Mindfetalness group. Women in the Mindfetalness group contacted healthcare due to decreased fetal movements to a higher extent than women in the Routine care group (7.8% vs. 4.3%, RR 1.79, CI 1.62-1.97). The differences remain after adjustment for potential confounders.

    CONCLUSIONS: Raising awareness about fetal movements through Mindfetalness decreased the rate of cesarean sections, labor inductions and small-for-gestational age babies.

    TRIAL REGISTRATION: ClinicalTrials.gov ( NCT02865759 ). Registered 12 August 2016, www.clinicaltrials.gov .

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  • 16.
    Akselsson, Anna
    et al.
    Sophiahemmet University.
    Rossen, Jenny
    Sophiahemmet University.
    Storck-Lindholm, Elisabeth
    Rådestad, Ingela
    Sophiahemmet University.
    Prolonged pregnancy and stillbirth among women with overweight or obesity: A population-based study in Sweden including 64,632 women2023In: BMC Pregnancy and Childbirth, ISSN 1471-2393, E-ISSN 1471-2393, Vol. 23, article id 21Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: The proportion of overweight or obese pregnant women is increasing in many countries and babies born to a mother who is overweight or obese are at higher risk for complications. Our primary objective was to describe sociodemographic and obstetric factors across Body Mass Index (BMI) classifications, with secondary objective to investigate stillbirth and other pregnancy outcomes in relation to BMI classifications and gestational week.

    METHODS: This population-based cohort study with data partly based on a cluster-randomized controlled trial includes 64,632 women with singleton pregnancy, giving birth from 28 weeks' gestation. The time period was January 2016 to 30 June 2018 (2.5 years). Women were divided into five groups according to BMI: below 18.5 underweight, 18.5-24.9 normal weight, 25.0-29.9 overweight, 30.0-34.9 obesity, 35.0 and above, severe obesity.

    RESULTS: Data was obtained for 61,800 women. Women who were overweight/obese/severely obese had lower educational levels, were to a lesser extent employed, were more often multiparas, tobacco users and had maternal diseases to a higher extent than women with normal weight. From 40 weeks' gestation, overweight women had a double risk of stillbirth compared to women of normal weight (RR 2.06, CI 1.01-4.21); the risk increased to almost four times higher for obese women (RR 3.97, CI 1.6-9.7). Women who were obese or severely obese had a higher risk of almost all pregnancy outcomes, compared to women of normal weight, such as Apgar score < 7 at 5 min (RR1.54, CI 1.24-1.90), stillbirth (RR 2.16, CI 1.31-3.55), transfer to neonatal care (RR 1.38, CI 1.26-1.50), and instrumental delivery (RR 1.26, CI 1.21-1.31).

    CONCLUSIONS: Women who were obese or severely obese had a higher risk of almost all adverse pregnancy outcomes and from gestational week 40, the risk of stillbirth was doubled. The findings indicate a need for national guidelines and individualized care to prevent and reduce negative pregnancy outcomes in overweight/obese women. Preventive methods including preconception care and public health policies are needed to reduce the number of women being overweight/obese when entering pregnancy.

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  • 17.
    Akselsson, Anna
    et al.
    Sophiahemmet University.
    Rådestad, Ingela
    Sophiahemmet University.
    Fostrets rörelser2022In: Reproduktiv hälsa: Barnmorskans kompetensområde / [ed] Helena Lindgren, Kyllike Christensson & Anna-Karin Dykes, Lund: Studentlitteratur AB, 2022, 2, p. 374-380Chapter in book (Other academic)
  • 18.
    Akselsson, Anna
    et al.
    Sophiahemmet University.
    Rådestad, Ingela
    Sophiahemmet University.
    Improving outcomes for women with decreased fetal movement: An interactive educational workshop2021Conference paper (Other academic)
  • 19.
    Akselsson, Anna
    et al.
    Sophiahemmet University.
    Westholm, Lena
    Small, Rhonda
    Westholm, Lena
    Midwives’ communication with non-Swedish-speaking women giving birth: A survey from a multicultural setting in Sweden2022In: European Journal of Midwifery, E-ISSN 2585-2906, Vol. 6Article in journal (Refereed)
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  • 20.
    Andrén, Anna
    et al.
    Sophiahemmet University.
    Akselsson, Anna
    Sophiahemmet University.
    Rådestad, Ingela
    Sophiahemmet University.
    Ali, Salma Burhan
    Lindgren, Helena
    Sophiahemmet University.
    Osman, Hodan Mohamoud
    Erlandsson, Kerstin
    Miscommunication influences how women act when fetal movements decrease: An interview study with Swedish Somali migrant women2023In: Midwifery, ISSN 0266-6138, E-ISSN 1532-3099, Vol. 126, article id 103796Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: To explore how Swedish Somali migrant women perceive fetal movements, process information about fetal movements, and take actions if decreased fetal activity occurs.

    DESIGN: A qualitative study based on individual semi-structured interviews. The interviews were analysed using content analysis.

    SETTING: The study was conducted in Sweden.

    PARTICIPANTS: Swedish Somali migrant women (n=15) pregnant in their third trimester or recently given birth.

    FINDINGS: The analysis led to the main category: tailored information about fetal movements enhances the possibility to seek care if the movements decrease. The results are described in the generic categories: explanatory models determine action; and understand and interpret information.

    KEY CONCLUSIONS: Miscommunication on fetal movements can be a hurdle for Swedish Somali migrant women that may have impact on stillbirth prevention and the quality of care. Improved communication and information tailored to individual needs is essential to achieve equality for women and their newborns.

    IMPLICATIONS FOR PRACTICE: The midwife can be used as a hub for reassuring that adequate information about fetal movements reaches each individual woman in antenatal care. Individualised information on fetal movements based on the women's own understanding is suggested to increase the possibility that the pregnant woman will seek care if the movements decrease. Somali women's verbal communication can be used to spread accurate information in the Somali community on the importance of seeking care if fetal movements decrease.

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  • 21.
    Andrén, Anna
    et al.
    Sophiahemmet University.
    Akselsson, Anna
    Sophiahemmet University.
    Rådestad, Ingela
    Sophiahemmet University.
    Ali, Salma Burhan
    Lindgren, Helena
    Sophiahemmet University.
    Osman, Hodan Mohamoud
    Erlandsson, Kerstin
    Miscommunication influences how women act when fetal movements decrease an interview study with Swedish Somali migrant women2023Conference paper (Other academic)
  • 22.
    Andrén, Anna
    et al.
    Sophiahemmet University.
    Akselsson, Anna
    Sophiahemmet University.
    Rådestad, Ingela
    Sophiahemmet University.
    Ali, Salman Burhan
    Lindgren, Helena
    Sophiahemmet University.
    Osman, Hodan Mohamoud
    Erlandsson, Kerstin
    Brister i kommunikationen påverkar hur kvinnor agerar vid minskade fosterrörelser: En intervjustudie med svensksomaliska kvinnor2023Conference paper (Other academic)
  • 23.
    Andrén, Anna
    et al.
    Sophiahemmet University.
    Rådestad, Ingela
    Sophiahemmet University.
    Lindgren, Helena
    Sophiahemmet University.
    Erlandsson, Kerstin
    Akselsson, Anna
    Sophiahemmet University.
    Ökad uppmärksamhet av fosterrörelser och graviditetsutfall: Ett projekt riktat mot svensksomaliska kvinnor2023Conference paper (Other academic)
  • 24. Bradford, Billie F
    et al.
    Cronin, Robin S
    Warland, Jane
    Akselsson, Anna
    Sophiahemmet University.
    Rådestad, Ingela
    Sophiahemmet University.
    Heazell, Alexander Ep
    McKinlay, Christopher J D
    Stacey, Tomasina
    Thompson, John M D
    McCowan, Lesley M E
    Fetal movements: A framework for antenatal conversations2023In: Women and Birth, ISSN 1871-5192, E-ISSN 1878-1799, Vol. 36, no 3, p. 238-246, article id S1871-5192(22)00321-3Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Presentations for decreased fetal movements comprise a significant proportion of acute antenatal assessments. Decreased fetal movements are associated with increased likelihood of adverse pregnancy outcomes including stillbirth. Consensus-based guidelines recommend pregnant women routinely receive information about fetal movements, but practice is inconsistent, and the information shared is frequently not evidence-based. There are also knowledge gaps about the assessment and management of fetal movement concerns. Women have indicated that they would like more accurate information about what to expect regarding fetal movements.

    DISCUSSION: Historically, fetal movement information has focussed on movement counts. This is problematic, as the number of fetal movements perceived varies widely between pregnant women, and no set number of movements has been established as a reliable indicator of fetal wellbeing. Of late, maternity care providers have also advised women to observe their baby's movement pattern, and promptly present if they notice a change. However, normal fetal movement patterns are rarely defined. Recently, a body of research has emerged relating to maternal perception of fetal movement features such as strength, presence of hiccups, and diurnal pattern as indicators of fetal wellbeing in addition to frequency.

    CONCLUSION: Sharing comprehensive and gestation-appropriate information about fetal movements may be more satisfying for women, empowering women to identify for themselves when their baby is doing well, and importantly when additional assessment is needed. We propose a conversational approach to fetal movement information sharing, focusing on fetal movement strength, frequency, circadian pattern, and changes with normal fetal development, tailored to the individual.

  • 25. Bradford, Billie F
    et al.
    Hayes, Dexter J L
    Damhuis, Stefanie
    Shub, Alexis
    Akselsson, Anna
    Sophiahemmet University.
    Rådestad, Ingela
    Sophiahemmet University.
    Heazell, Alexander E P
    Flenady, Vicki
    Gordijn, Sanne J
    Decreased fetal movements: Report from the International Stillbirth Alliance conference workshop.2023In: International Journal of Gynecology & Obstetrics, ISSN 0020-7292, E-ISSN 1879-3479Article, review/survey (Refereed)
    Abstract [en]

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

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  • 26. Hayes, Mr Dexter Jl
    et al.
    Dumville, Jo C
    Walsh, Tanya
    Higgins, Lucy E
    Fisher, Margaret
    Akselsson, Anna
    Sophiahemmet University.
    Whitworth, Melissa
    Heazell, Alexander Ep
    Effect of encouraging awareness of reduced fetal movement and subsequent clinical management on pregnancy outcome: A systematic review and meta-analysis2023In: American Journal of Obstetrics & Gynecology MFM, ISSN 2589-9333, Vol. 5, no 3, article id 100821Article, review/survey (Refereed)
    Abstract [en]

    OBJECTIVE: Reduced fetal movement (RFM), defined as a decrease in maternal perception of frequency or strength of fetal movements, is a common reason for presentation to maternity care. Observational studies demonstrate an association between RFM, stillbirth, and fetal growth restriction related to placental insufficiency. However, individual intervention studies have described varying results. This systematic review and meta-analysis aimed to determine whether interventions aiming to encourage awareness of reduced fetal movement and/or improve its subsequent clinical management reduce the frequency of stillbirth or other important secondary outcomes.

    DATA SOURCES: Searches were conducted in MEDLINE, EMBASE, CINAHL, The Cochrane Library, Web of Science and Google Scholar. Guidelines, trial registries, and grey literature were also searched. Databases were searched from inception to the 20th January 2022.

    STUDY ELIGIBILITY CRITERIA: Randomised controlled trials (RCTs) and controlled non-randomised studies (NRS) were eligible if they assessed interventions aiming to encourage awareness of fetal movement or fetal movement counting and/or improve the subsequent clinical management of RFM. Eligible populations were singleton pregnancies after 24 completed weeks of gestation. The primary review outcome was stillbirth; a number of secondary maternal and neonatal outcomes were specified in the review.

    STUDY APPRAISAL AND SYNTHESIS METHODS: Risk of bias was assessed using Cochrane Risk of Bias 2 and ROBINS-I for RCTs and NRS respectively. Variation due to heterogeneity was assessed using I2. Data from studies employing similar interventions was combined using random effects meta-analysis.

    RESULTS: 1,609 citations were identified; 190 full text papers were evaluated against the inclusion criteria, 18 studies (16 RCTs and 2 NRS) were included. The evidence is uncertain about the effect of encouraging awareness of fetal movement on stillbirth compared with standard care (two studies, n=330,084); pooled aOR 1.19 (95% CI 0.96, 1.47). Interventions for encouraging awareness of fetal movement may be associated with a reduction in NICU admissions and Apgar scores <7 at five minutes of age and may not be associated with increases in caesarean section or induction of labour. The evidence is uncertain about the effect of encouraging fetal movement counting on stillbirth compared with standard care; pooled OR 0.69 (95% CI 0.18, 2.65), data from three RCTs (n=70,584). Counting fetal movements may increase maternal fetal attachment and decrease anxiety compared with standard care. When comparing combined interventions of fetal movement awareness and subsequent clinical management with standard care (one study, n=393,857) the evidence is uncertain about the effect on stillbirth (aOR 0.86, 95% CI 0.70, 1.05).

    CONCLUSIONS: The effect of interventions for encouraging awareness of RFM alone or in combination with subsequent clinical management on stillbirth is uncertain. Encouraging awareness of fetal movement may be associated with reduced adverse neonatal outcomes without an increase in interventions in labour. Meta-analysis is hampered by variation in interventions, outcome reporting and definitions. Individual studies are frequently underpowered to detect a reduction in severe, rare outcomes and no studies were included from high-burden settings. Studies from such settings are needed to determine whether interventions can reduce stillbirth.

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  • 27. Lindgren, Helena
    et al.
    Rådestad, Ingela
    Sophiahemmet University.
    Pettersson, Karin
    Skokic, Viktor
    Akselsson, Anna
    Sophiahemmet University.
    Epidural use among women with spontaneous onset of labour: An observational study using data from a cluster-randomised controlled trial2021In: Midwifery, ISSN 0266-6138, E-ISSN 1532-3099, Vol. 103, article id 103156Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: To investigate whether the proportion of pregnant women who use epidural analgesia during birth differed between women registered at a maternity clinic randomised to Mindfetalness or to routine care.

    DESIGN: An observational study including women born in Sweden with singleton pregnancies, with spontaneous onset of labour from 32 weeks' gestation. Data used from a cluster-randomised controlled trial applying the intention-to-treat principle in 67 maternity clinics where women were randomised to Mindfetalness or to routine care. ClinicalTrials.gov (NCT02865759).

    INTERVENTIONS: Midwives were instructed to distribute a leaflet about Mindfetalness to pregnant women at 25 weeks' gestation. Mindfetalness is a self-assessment method for the woman to use to become familiar with the unborn baby's fetal movement pattern. When practising the method in third trimester, the women are instructed to daily lie down on their side, when the baby is awake, and focus on the movements' intensity, character and frequency (but not to count each movement).

    FINDINGS: Of the 18 501 women with spontaneous onset of labour, 47 percent used epidural during birth. Epidural was used to a lower extent among women registered at a maternity clinic randomised to Mindfetalness than women in the routine-care group (46.2% versus 47.8%, RR 0.97, CI 0.94-1.00, p= 0.04). Epidural was more common among primiparous women, women younger than 35 years, those with educational levels below university, with BMI ≥25 and with a history of receiving psychiatric care or psychological treatment for mental illness.

    CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: Pregnant women who were informed about a self-assessment method, with the aim of becoming familiar with the unborn baby's fetal movement pattern, used epidural to a lower extent than women who were not informed about the method. Future studies are needed to investigate and understand the association between Mindfetalness and the reduced usage of epidural during birth.

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  • 28.
    Rådestad, Ingela
    et al.
    Sophiahemmet University.
    Akselsson, Anna
    Sophiahemmet University.
    Georgsson, Susanne
    Sophiahemmet University.
    Lindgren, H
    Pettersson, K
    Steineck, G
    Rationale, study protocol and the cluster randomization process in a controlled trial including 40,000 women investigating the effects of mindfetalness.2016In: Sexual & Reproductive HealthCare, ISSN 1877-5756, E-ISSN 1877-5764, Vol. 10, p. 56-61Article in journal (Refereed)
    Abstract [en]

    BACKGROUND:

    Shortening pre-hospital delay may decrease stillbirth rates and rates of babies born with a compromised health. Stillbirth may be preceded by a decrease in fetal movements. Mindfetalness has been developed as a response to the shortcomings of kick-counting for the monitoring of fetal movements by the pregnant woman. We do not know if practicing Mindfetalness may diminish pre-hospital delay. Nor do we know if practicing Mindfetalness may increase or decrease the percentage of women seeking health care for unfounded, from a medical perspective, worry for her fetus' well-being.

    METHODS:

    This article describes the rationale, study protocol and the randomization process for a planned study randomly allocating 40,000 pregnant women to receive, or not receive, proactive information about practicing Mindfetalness. The unit of randomization is 63 antenatal clinics in the Stockholm area. Midwives in the antenatal clinics randomized to Mindfetalness will verbally inform about practicing Mindfetalness, hand out brochures (printed in seven languages) and inform about a website giving information about Mindfetalness. Routine care will continue in the control clinics. All information for the analyses, including the main endpoint of an Apgar score below 7 (e.g., 0-6 with stillbirth giving a score of 0), measured five minutes after birth, will be retrieved from population-based registers.

    RESULTS:

    We have randomized 33 antenatal clinics to Mindfetalness and 30 to routine care. In two clinics a pilot study has been performed. One of the clinics randomly allocated to inform about Mindfetalness will not do so (but will be included in the intention-to-treat analysis). In October 2016 we started to recruit women for the main study.

    CONCLUSION:

    The work up to now follows the outlined time schedule. We expect to present the first results concerning the effects of Mindfetalness during 2018.

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  • 29.
    Rådestad, Ingela
    et al.
    Sophiahemmet University.
    Doveson, Sandra
    Sophiahemmet University.
    Lindgren, Helena
    Georgsson, Susanne
    Akselsson, Anna
    Sophiahemmet University.
    Midwives' experiences of using the Mindfetalness method when talking with pregnant women about fetal movements2021In: Women and Birth, ISSN 1871-5192, E-ISSN 1878-1799, Vol. 34, no 5, p. e498-e504, article id S1871-5192(20)30364-4Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Information given to pregnant women about fetal movements is important in maternity care and decreased fetal movements is associated with fetal growth restriction and stillbirth. The fetal movement pattern is different for every fetus and women perceive different types of movements. Mindfetalness is a self-assessment method for a woman to use to become familiar with her unborn baby's fetal movement pattern.

    AIM: We aimed to explore midwives' perceptions about informing pregnant women about fetal movements and their experiences of working with Mindfetalness in their daily work.

    METHODS: A web-questionnaire was distributed to midwives who participated in a randomized controlled trial evaluating Mindfetalness, a method for the observation of fetal movements. In total, 67 maternity clinics in Stockholm, Sweden, were randomized to Mindfetalness or routine care. Of the 144 midwives working in maternity clinics randomized to Mindfetalness, 80% answered the questionnaire.

    FINDINGS: The midwives thought that the leaflet about Mindfetalness was supportive in their work when informing women about fetal movements and the majority wanted to continue to distribute the leaflet when the trial ended. The midwives also expressed that the study increased their own knowledge about fetal movements. Women embraced the information about Mindfetalness positively and appreciated the written material. The midwives thought that talking about fetal movements in maternity care is an important but challenging task.

    CONCLUSION: Mindfetalness is a useful tool to use in maternity clinics when informing pregnant women about fetal movements. The written information was appreciated by both pregnant women and midwives.

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  • 30.
    Rådestad, Ingela
    et al.
    Sophiahemmet University.
    Pettersson, Karin
    Lindgren, Helena
    Skokic, Viktor
    Akselsson, Anna
    Sophiahemmet University.
    Country of birth, educational level and other predictors of seeking care due to decreased fetal movements: An observational study in Sweden using data from a cluster-randomised controlled trial2021In: BMJ Open, E-ISSN 2044-6055, Vol. 11, no 6, article id e050621Article in journal (Refereed)
    Abstract [en]

    OBJECTIVES: To identify predictors of seeking care for decreased fetal movements and assess whether care-seeking behaviour is influenced by Mindfetalness.

    DESIGN: Observational study with data from a cluster-randomised controlled trial.

    SETTING: 67 maternity clinics and 6 obstetrical clinics in Sweden.

    PARTICIPANTS: All pregnant women with a singleton pregnancy who contacted the obstetrical clinic due to decreased fetal movements from 32 weeks' gestation of 39 865 women.

    METHODS: Data were collected from a cluster-randomised controlled trial where maternity clinics were randomised to Mindfetalness or routine care. Mindfetalness is a self-assessment method for women to use daily to become familiar with the unborn baby's fetal movement pattern.

    OUTCOME MEASURES: Predictors for contacting healthcare due to decreased fetal movements.

    RESULTS: Overall, 5.2% (n=2059) of women contacted healthcare due to decreased fetal movements, among which 1287 women (62.5%) were registered at a maternity clinic randomised to Mindfetalness and 772 women (37.5%) were randomised to routine care. Predictors for contacting healthcare due to decreased fetal movements were age, country of birth, educational level, parity, prolonged pregnancy and previous psychiatric care (p<0.001). The main differences were seen among women born in Africa as compared with Swedish-born women (2% vs 6%, relative risk (RR) 0.34, 95% CI 0.25 to 0.44) and among women with low educational level compared with women with university-level education (2% vs 5.4%, RR 0.36, 95% CI 0.19 to 0.62). Introducing Mindfetalness in maternity care increased the number of women seeking care due to decreased fetal movements overall.

    CONCLUSION: Women with country of birth outside Sweden and low educational level sought care for decreased fetal movements to a lesser extent compared with women born in Sweden and those with university degrees. Future research could explore whether pregnancy outcomes can be improved by motivating women in these groups to contact healthcare if they feel a decreased strength or frequency of fetal movements.

    TRIAL REGISTRATION NUMBER: NCT02865759.

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