Effect of Fetal Movement Counting on Prenatal Attachment and Maternal Worries among Primigravidae

Rincy K.¹, Nalini S. J.²

¹M.Sc. Nursing, Faculty of of Nursing, Sri Ramachandra University, Chennai, India

²Reader, Faculty of Nursing, Sri Ramachandra University, Chennai, India.

*Corresponding Author Email: rincyk1985@gmail.com, sirala.nalini@rediffmail.com

ABSTRACT:

Fetal movement counting is quantification of fetal movements as perceived by the mother that interprets the general condition of the fetus in the womb. This method may be used for continuous monitoring and evaluation of the fetal health by the mother as it is inexpensive, non invasive, easy and simple in nature. This study aims at identifying the effect of fetal movement counting on maternal-fetal attachment and maternal worries.

Objectives

• Evaluate the effect of foetal movement counting on prenatal attachment and maternal worries among primi gravidae mothers

• Identify the relationship between foetal movement counting compliance, prenatal bonding and maternal worries among the primi gravidae mothers

Methodology

The research design adopted for this study was two group pretest-posttest experimental design.100 primigravidae of 32-36 weeks, attending antenatal outpatient department at Sri Ramachandra Hospital, who fulfilled the inclusion criteria were samples. The outcome measures were prenatal attachment and maternal worries. Tools consist of demographic, clinical and social variables; prenatal attachment inventory and Cambridge worry scale.

Results

A significant level of improvement in prenatal attachment was seen in the study group mothers. A highly significant statistical difference in PAI between the groups at p<.001 was identified. Maternal worries reduced among mothers in the study group the independent t value between the group shows a statistical significance at the level of p<.001.Weak negative correlation was seen between PAI and CWS. Correlation between PAI and fetal movement counting performance showed a weak positive correlation.

Conclusion

Maternal-fetal attachment is an inimitable bonding that is quite different from any other form of succeeding affection. Prenatal attachment is an ideal method to encourage parenting process. Through this study, fetal movement counting is proved to be the paramount measure to improve maternal fetal attachment and reduce maternal worries.

KEY WORDS: Fetal movement counting, prenatal attachment, mother-fetal bonding, maternal worries

INTRODUCTION:

The ultimate dream of every woman is to become a mother, as motherhood gives the completeness of a woman. Overall, pregnancy rates were higher in the developing countries than in the developed ones.

According to Ministry of Health and Family Welfare, March 2008 statistics, the birth rate in India is 22.8 per 1000 population.

It has been noticed that a mother's relationship with her unborn child is both extraordinary and amazingly powerful. This relationship between the mother and her fetus is termed as maternal- foetal attachment or prenatal attachment by health care professionals.

Researchers have shown that the process of maternal foetal bonding or prenatal attachment starts by ten weeks of gestation (Johnson, Robinson and Barna, 1991) and escalates further by 16 weeks of gestation (Grace 1989) and becomes intense from 32- 36 weeks of gestation (Alhausen and Yercheski, 2008). Cranely (1981) defined prenatal attachment as “the extent to which women engage in behaviours that represent affiliation and interaction with their unborn child”. Numerous studies, almost exclusively of non-hospitalized women, have also looked at how maternal-foetal attachment is associated with other factors, such as age, ethnicity, parity, anxiety, depression, and relationship with partner, social support, pregnancy acceptance, and risk status (Cannella, 2005).

Mangesi and Hofmyer (2007) conducted a meta analysis of four studies involving 71,370 women, on assessment of pregnancy outcome with routine, selective and non fetal movement counting. It was found that women practising formal fetal movement counting had lesser antenatal hospital visits, and women practising Cardiff 'count to ten' method had better compliance than formal fetal movement counting. The review concluded that there was no significant evidence to persuade the practice of FMC from the review analysis.

Every pregnant woman experience a variety of physical, emotional and hormonal changes that may trigger anxiety which would make them to feel overwhelmed. Elevated anxiety can affect mother-infant interaction and cause adverse outcomes for mother and fetus. Pregnancy and worries go hand in hand. Some women start worrying as soon as they discover their pregnancy. Such worries are more common in woman pregnant for the first time.

One of the most common worry during pregnancy is fear of miscarriage. Women start worrying about pregnancy symptoms much before than they actually experience them. Morning sickness, fatigue and mood swings are common during pregnancy and also the worries regarding the treatment, diet, exercise, travelling, labour and delivery process, etc. occur. The best way to combat pregnancy worries is to be fully informed about pregnancy. Provision of right information can ward off the unnecessary worries.

After conception a woman becomes committed to protect the wellbeing of the baby. As soon as the mother perceives fetal movement, maternal bonding is developed with the unborn baby. Fetal movement counting is a method used by the mother to quantify her baby’s movements. A healthy baby usually moves atleast 10 times in two hours (American College of Obstetrics and Gynaecology, 2007). There are certain interventions that focus to boost the maternal-foetal bonding and reduction of maternal worries. As these interventions like interacting with the fetus, massaging the belly and paying attention to baby’s movements and following fetal development are not proved logically, it was believed to have an effect in improving the attachment between the mother and the fetus. Hence to reduce worries and promote bonding between the mother and fetus and to substantiate research based findings in Indian setting, the investigator proposed to study the effect of fetal movement counting on prenatal attachment and maternal worries and the relationship prenatal attachment, maternal worries and foetal movement counting compliance had with each other.

MATERIALS AND METHODS:

A true experimental pretest-posttest control group design was used for this study. This study was conducted in the antenatal outpatient patient department of Sri Ramachandra Hospital. Target population of this study were the primigravidae women. The sample size consisted of 100 mothers, 50 mothers in the study group and 50 mothers in the control group. Consecutive non-probability sampling technique was used in this study.

Primigravidae with gestational age of 32-36 weeks who could understand English and Tamil and willing to participate were included as samples. Primi gravidae excluded from the study were unwed pregnant mothers, adolescent pregnancy, mothers with high risk pregnancy such as twin pregnancy, Pregnancy Induced Hypertension, gestational diabetes and other medical complication.

The tools utilized in the study comprised of five sections namely, (1) demographic variables: age, education, family income, and occupation, (2) clinical variables: gestational age, mother’s body weight, and married years, (3) social variables: type of family, satisfaction with married life, social support availability, (4) Prenatal attachment inventory (PAI) and (5) Cambridge worry scale (CWS). Total score of PAI is 84. Higher scores indicate good prenatal attachment and scores less than 42 indicate lesser prenatal attachment. The total score of Cambridge worry scale is 80. Higher scores indicate the presence of more worries and lesser scores confirm perception of minimal worries during pregnancy by primigravidae mothers. The validity of the tool was obtained from nursing experts and obstetrician. For reliability Cronbach’s alpha was calculated. The scores were 0.86 for PAI and 0.83 for CWS.

The investigator obtained the permission from Ethical committee and Head of the department of Obstetrics and Gynaecology before the study. Then the primimothers with inclusion criteria were identified. The researcher initially established rapport and purpose of the study was explained to each mother in Tamil and consent was obtained. Then samples were randomized in to study and control groups using lottery method. During pretest, researcher assessed the mother’s prenatal attachment and maternal worries. Formal instruction was given to the mothers in the study group to monitor fetal movement and maintain kick chart by primi mothers themselves, twice daily for 14 days i.e., 28 times for 14 days along with routine antenatal care. A kick chart performance sheet and a ribbon to knot, when the mother perceived fetal movements during the counting time were given to each mother in the study group.

Table 1. Mean, standard deviation, mean difference, paired t and p value of prenatal attachment during pretest and posttest in the study group and control group.

Prenatal attachment	Pretest	Post test		Paired ‘t’ value and p value	Independent ‘t’ value
Prenatal attachment	Mean(SD)	Mean(SD)	MD(SD)	Paired ‘t’ value and p value	Independent ‘t’ value
Study group	54.22 (10.88)	64.38 (7.53)	-9.87 (6.31)	-10.71 0.000***	7.49 0.000***
Control group	49.68 (12.95)	49.29 (11.46)	-.20 (2.78)	-.482 0.632(NS)	7.49 0.000***

Table 2. Mean, standard deviation, mean difference, paired t and p value of maternal worries during pretest and posttest in the study group and control group.

Cambridge worry score	Pretest	Post test		Paired ‘t’ value and p value	Independent ‘t’ value
Cambridge worry score	Mean(SD)	Mean(SD)	MD(SD)	Paired ‘t’ value and p value	Independent ‘t’ value
Study group	22.16 (9.38)	16.87 (6.99)	5.68 (4.33)	8.985 0.000***	-3.961 0.000***
Control group	19.90 (8.74)	23.56 (9.10)	-3.77 (2.71)	-9.342 0.000***	-3.961 0.000***

Routine antenatal teaching was given to primigravidae in the control group.

Posttest was conducted on the 14^th day to reassess the changes in prenatal attachment and maternal worries for both the study and the control group. Kick chart performance compliance was assessed by the investigator on the 14^thday for the study group women based on the DFM chart submitted by primigravidae.

RESULTS:

The significant findings of the study were:

The distribution of demographic, clinical and social variables indicated that in the study group 56% of the primi mothers were in the age group of 23-27 years and 50% of them were in the age group of 18-22 years in the control group.

60% of the primimothers in the study and 52% in the control group had gestational age 32-34 weeks. 44% primi mothers weighed between 50- 60 kgs in study group and 50% weighed between 61-70 kgs in control group. Social support depicted that majority of the primi mothers 74% were supported by husband and maternal relatives; 10% were supported by their husband in the study group. In the control group 80% were supported by their husband and maternal relatives, 12% were supported by their husband and 8% were supported by only maternal relatives. In study group 96% of primi mothers were satisfied and 4% were not satisfied with their married life. In control group 98% were satisfied and remaining 2% not satisfied in marriage life.

The comparison of the prenatal attachment scores (table 1) shows that there was a statistically significant improvement in the prenatal attachment at the level of p<0.001 in the study group between pretest and posttest. No statistical significance was seen within the control group between pretest and posttest. The independent t test denotes a highly significant statistical difference between the groups at p<.001. This indicates improvement in the PAI scores in the study group after the intervention.

Table 2 shows that the difference between pretest and posttest maternal worries was statistically significant in the study group, at p=<.001. In control group too statistical significance was noted. It clearly denotes that maternal worries reduced among mothers in the study group whereas the maternal worries increased among the mothers in the control group. The independent t value between the groups shows a statistical significance at the level p = <0.001 for maternal worries.

Table 3. Correlation among fetal movement counting performance, prenatal attachment and maternal worry scores during posttest in the study group.

Variables

CWS

r & p value

Fetal movement counting performance

r & p value

PAI

-0.25 (0.09)

0.053 (0.73)

CWS

-0.090 (0.55)

A weak negative non significant correlation existed between PAI and CWS (-0.25) which indicated that as the prenatal attachment increased, the maternal worries decreased. Correlation between PAI and fetal movement counting performance showed a weak positive correlation, non significant in nature. With performance compliance, the PAI increased and the relationship between CWS and fetal movement counting showed a weak negative correlation; with compliance in performance, CWS decreased.

DISCUSSION:

The results of this study indicated a statistical significant improvement in the prenatal attachment and a decrease in the maternal worries following fetal movement counting. Similarly, a study by Saastad, Winje, Gunnes and Froen (2011) conducted among 1,123 women on the effect of fetal movement counting on maternal-fetal attachment showed the mean difference of prenatal attachment inventory was 0.20 (95% CI: 1.02-1.42) between the intervention and the control group. There was no significant difference between the intervention and the control groups regarding the prenatal attachment score with a mean and standard deviation of 59.54 (9.39) and 59.43 (9.35). Thus the authors concluded that there was no significant effect in antenatal maternal-fetal attachment with third trimester fetal movement counting.

Also a study conducted by Kathy and Susan (2009) explored the relationship between fetal palpation and massage instruction in third trimester of pregnancy with maternal attachment behaviours during postpartum among 69 low income primiparas and multi‐paras. As no significant relationship was found between the prenatal intervention and maternal behaviours during the postpartum period, the authors emphasized the need for further research regarding bonding behaviours in various cultures.

This study showed that maternal worries reduced among mothers in the study group whereas the maternal worries increased among the mothers in the control group. The independent t value showed a statistical significance at the level p=<0.001 between the groups. Similar results were shown in a study conducted by Saastad, Winje, Israel and Froen (2012) who investigated the effect of fetal movement counting on maternal concern and experiences among 1,013 women. The mean and SD of the study and the control group on Cambridge Worry Scale scores were 0.77 (0.55) and .90 (0.62) with a mean difference of 0.14.

The study depicted a weak negative correlation between PAI and CWS (-.25). This indicated that as the prenatal attachment was improved the maternal worries were reduced. The relationship between PAI and fetal movement counting performance showed a weak positive correlation with performance and the PAI increased. Similarly a weak negative correlation existed between CWS and fetal movement counting; with performance CWS scores decreased among women in the study group. These effects might be attributed to the daily fetal movement counting that improved the maternal fetal bonding and reduced the maternal worries. But these results were not statistically significant. In Indian scenario, every pregnant woman enjoys her state with a revel in her advancing pregnancy. Pregnancy also changes the lifestyle of the mother in order to foster the growing fetus into a healthy and strong baby. This study has further helped the interaction between the mother and the fetus, which strengthens the existing relationship.

Association of prenatal attachment and maternal worry score with background variables of the study group and control group was assessed using ANOVA. Due to small sample structure, no association was found among prenatal attachment and maternal worries with background, clinical and social variables.

Limitations in the study were: the smaller sample size, two weeks study duration between pre and posttest, self reporting of performance compliance. The implication on nursing practice denotes the need for education on counting the fetal movements among antenatal mothers and creating awareness about the importance of the practice during pregnancy period.

Recommendations for future research include conducting a study with mothers in first and second trimesters or between high risk mothers and low risk mothers and utilizing other interventions to assess prenatal attachment and bonding with adequate follow-up at time intervals.

CONCLUSION:

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Received on 19.08.2013 Modified on 25.09.2013

Asian J. Nur. Edu. & Research 4(2): April- June 2014; Page 224-227