MOTHERS’ KNOWLEDGE OF FOETAL MOVEMENTS MONITORING DURING PREG- NANCY IN RELATION TO PERINATAL OUTCOME

Over the years, maternal perception of foetal movement has become recognised as a valuable tool for early detection of foetal compromise. Foetal movement is a reliable sign of foetal well-being (Bennett & Brown, 1999:232). Despite being a useful method in attaining clinical foetal monitoring, foetal movement is probably under-utilised, especially in high-risk pregnancy (Nolte, 1998:100). The purpose of this study was to determine the knowledge pregnant mothers have on the monitoring of foetal movement and its effect on perinatal outcome. The findings of the study were used to develop the content of a health education programme that is contextual and relevant to the needs of pregnant mothers. A quantitative research survey design was used to obtain information from pregnant mothers. Simple random probability sampling was used. Ninety-seven (97) pregnant mothers agreed to participate in the study. The results indicated that pregnant women who were able to perceive foetal movement during pregnancy regarded it as important. However, limited information on the importance of foetal movement monitoring in relation to perinatal outcome was displayed. Content on contextual health education for mothers on foetal movement monitoring was proposed.


INTRODUCTION
Foetal movement counting -often called 'kick counting' -represents a maneuver whereby a mother can help monitor the movements of her unborn baby by counting the number of kicks in a given time period.This is an indicator of foetal health and has been used for over a century (Marnoch, 1992:54;Marzano & Hanlon-Lundberg, 2004).
At week 7 of gestation the little embryo is already squirming about, but because at this point it is so small the mother cannot possibly feel its periodic contortions.
By week 16 the mother may feel the first momentous kicks called 'quickening'.By week 20 of gestation most mothers are able to feel the baby's movements and by week 28 the kicks will become stronger and more regular (Babycenter Medical Advisory Board, 1997;Nolte, 1998:100).
Over the years, maternal perception of foetal movement has become recognised as a valuable tool for early detection of foetal compromise.The recording of foetal activity serves as an indirect measure of central nervous system integrity and function (Rayburn, 1990:95;1995:59), indicating that foetal movements are a reliable sign of foetal well-being (Bennett & Brown, 1999:232).In a study on excessive foetal activity as a worrisome sign, Rayburn, Rayburn and Gabel (1983:163) further clarified that foetal inactivity is strongly suggestive of foetal jeopardy.A change in the normal pattern or number of foetal movements may indicate that the foetus is under stress.
A foetus that had been moving according to its normal pattern but stops moving may be giving a sign that it is not receiving enough oxygen (http://www.stronghealth.com).A sudden increase in foetal movement is a sign of foetal distress, such as in case of cord complications or abruption of the placenta, whereas decreased foetal movements are seen in cases of chronic foetal distress such as pre-eclampsia or hypertension in pregnancy.It is well documented that reduction or cessation of foetal movements reported by pregnant women causes anxiety and concern (Sadovsky & Polishuk, 1977:49).
In spite of being a very useful method, foetal movement is probably an under-utilised maneuver of clinical foetal monitoring, especially in high risk pregnancy (Nolte, 1998:100).Thus, formal counting of foetal movements by pregnant women could identify a foetus which is at risk of compromise, thus allowing for prompt and appropriate action (Olesen & Svare, 2004:818).However, the benefit of this intervention has not been proven adequately.

PROBLEM STATEMENT
According to the Saving Babies Report (DOH, 2002:52), the Limpopo Province is subdivided into six district municipalities with the total of 43 hospitals, and 455 clinics and health centers.Forty (40) hospitals and 281 clinics have functional maternity units at which deliveries take place (DOH, 2002:54).In this report it is documented that the inappropriate response to poor foetal movement (8.2% in Limpopo Province) could be classified as patient-related avoidable factors.It was further pointed out that poor reporting of reduced foetal movements is frequently attributed to patient-related avoidable factors (DOH, 2002:26).Neldam (1980Neldam ( :1222) ) observed that formal scoring of foetal movement in a low risk population resulted in a significant reduction in perinatal mortality in Sweden in 1979.In the context of this study, it was not clear whether pregnant mothers understood the importance of foetal movement monitoring during pregnancy in relation to the perinatal outcome.

RESEARCH QUESTION
What knowledge do mothers have on the foetal movement monitoring during pregnancy in relation to perinatal outcome?

PURPOSE
The purpose of this study was to determine the knowledge pregnant mothers have on the foetal movement monitoring in relation to perinatal outcome at certain clinics of Polokwane municipality.The findings of the study were used to develop the content of a health education programme that is contextual and relevant to the needs of the pregnant mothers.

OBJECTIVES
• To determine the knowledge of mothers of foe-tal movement monitoring during pregnancy in relation to perinatal outcome.
• To develop health education programme content that is responsive to the needs of mothers.

DEFINITION OF TERMS
Knowledge: This is the awareness and understanding of facts, truth or information gained from experience (http:www.thefreedictionary.com).In the context of this study knowledge shall refer to the ability to feel, interpret and report the decrease, absence or sudden increase of foetal movements.

Foetal Movement Monitoring:
This refers to the counting and recording of foetal movements.It is a very appropriate and cost-effective means of monitoring foetal well-being and it does not require any expensive equipment (Cronjé & Grobler, 2003:681).In this study foetal movement monitoring shall refer to a common way for mothers to assess the foetal movement by doing kick counts.
Perinatal Outcome: This is the outcome of a child's life during the four or five months before birth and the first month thereafter (Cronjé & Grobler, 2003:695).In this study perinatal outcome shall refer to the importance of foetal movement monitoring in relation to fetal well-being.

RESEARCH DESIGN AND METHOD
A quantitative research approach was undertaken.The survey design was used to obtain information from pregnant mothers.This design was chosen for this study because the survey collected participants' information on knowledge of foetal movement monitoring in relation to perinatal outcome.Data were collected through selfadministered questionnaires (Polit & Hungler, 1993:48).

Population and Sampling
The study population consisted of all pregnant mothers who were attending antenatal care at three clinics of the Polokwane municipality.Simple random probability sampling was used to ensure that all participants had equal chance of being included in the study (Polit & Hungler, 1993:48).At each clinic, the sam-pling was conducted as follows: 100 pieces of paper of which 65 were blank and 35 were numbered 1-35 were put in a box.All mothers who picked a paper with a number were included in the sample.One-hundred-andfive (105) mothers from three clinics were recruited to the study.Only ninety-seven (97) agreed to participate in the study.Two clinics had 32 participants each and one clinic had 33.The clinics had equal numbers of papers.

Data Collection
The statements in questions were used to obtain data of a subjective nature (De Vos, 2002:182)

Pre-Testing
The questionnaires were pre-tested amongst six (6) mothers from each clinic and these mothers were excluded from the main study.Pre-testing was done to ensure that questions were phrased correctly and refinements of the questions were done.

Administration of Questionnaires
The process of data collection occurred over a period

Data Analysis
Descriptive statistical analyses were used, including frequencies and percentages of participants according to the selected characteristics (Polit & Hungler, 1993:275).

Validity and Reliability
Probability sampling was used to ensure inclusion of every member of the study population.

RESULTS AND DISCUSSION
Ninety seven (97) mothers who attended antenatal care at three (3) clinics in the Polokwane municipality participated in the study.The results are summarised in Table 1.
Part 1 of Table 1 is a summary of the demographic characteristics of mothers.Forty-one mothers (42% of total participants) indicated that they never received prenatal education and 18 mothers (19%) were not sure whether they received prenatal education.This could be interpreted as the mother's ignorance of prenatal education and/or her non-involvement in such.Fortyone mothers attended only one to three antenatal care clinic sessions -clearly inadequate as the schedule for return antenatal visits in low risk women should be at least be seven in total (DOH, 2002:26).Only 39% of mothers attended prenatal education classes which may have exposed them to some information on foetal movement monitoring.Lundgren and Dahlberg (2002:158) pointed out that it is important for midwives to collaborate by inviting the mothers to participate in and be responsible for their own care during childbirth.
According to the 'Pregnant Patients' Rights' by Ladewig, London and Olds (1998:795), the patient has the right to be informed by the midwife about the available childbirth education classes, which could help to prepare the mother physically and emotionally to cope with the stress and experience of childbirth and to participate actively during childbirth.
However, in a study on women's perceptions of informed  that it was obvious that not all clients were willing to participate.
Part 2 of Table 1 shows that a high percentage (71%) of mothers perceived foetal movements at 4-6 months whereas seven (7%) perceived foetal movements only at 7-9 months gestation.This confirms that mothers have limited knowledge on the normal physiologic changes of pregnancy.Cronjé and Grobler (2003: 52) indicated that the primigravidae feel foetal movements at 18-20 weeks while multigravidae feel it at 16-18 weeks.Eighty-eight mothers (91%) expressed that it is important to feel the foetal movements, but only 75 (77%) reasoned that this is an indication that the baby is alive.Twenty mothers (21%) stated the significance of foetal movements as a sign that the baby is growing well which is not the accurate reason for perceiving foetal movement.Two mothers (2%) did not know the importance of foetal movements, further pointing to the lack of information on this gestational signal.To correct this deficiency in knowledge Gibbins and Thomson (2001:302) suggested that appropriate information be given during pregnancy to enable the mother to take decisions and to empower her to make informed choices.This suggestion was supported by Nolan (1997Nolan ( :1201) ) who affirmed that women need to be given information and opportunity to discuss how information relates to their particular circumstances in building confidence and self-esteem to enable them to take control over childbirth, ask questions, make informed choices and communicate more effectively with midwives.
Part 3 of  (Cronjé & Grobler, 2003:596).According to Levy (1999:110), pregnant mothers require accurate information during pregnancy and delivery to guide their actions and to raise their awareness of issues to be considered.
Part 4 of • Record all the movements on the chart with a tick (!) when experiencing movement (Table 2) then at the end of an hour to reach the total.
• Have a glucose drink (juice) if less than four counts are experienced in an hour, then recount again for the next hour.
• Call the doctor or visit to the nearest clinic if you still do not feel at least four movements at the end of the second hour.

CONCLUSION
The findings of the study pointed out that there is a need for involving mothers in the care of their unborn foetuses through information sharing.It is envisaged that when mothers become involved they will participate in foetal well-being monitoring and this will save the lives of their babies, enhance foetal-maternal attachment and further empower them to be partners with health professionals.
of three months from February to April 2004.The researchers visited the clinics and sampled mothers.The appointments for questionnaire completion at home were secured with the mothers within two days of contact.The researchers visited pregnant mothers at their homes and assisted them with the filling of questionnaires.This process took place in a quiet room to ensure confidentiality and privacy.It took 20-30 minutes for the questionnaire to be completed because these were translated into the local language (Northern Sotho) to facilitate understanding.
The study was contextualised, only those mothers attending the three clinics were included.No person other than the researchers collected the data.The researchers pre-tested the questionnaires and the same results achieved during pre-testing were also achieved for the actual study.Ethical Considerations Ethical considerations were based on the DENOSA Ethical Standards for Nurse Researchers (Democratic Nurses Association of South Africa, 1998:2.3.2-2.3.4).The quality of the research was ensured by adhering to the highest possible standards of research through accountability and ability of executing the research process.Permission to sample the pregnant mothers was obtained from the clinic supervisor.Each pregnant mother was provided with sufficient and understandable information regarding her participation.Confidentiality and anonymity was ensured by protecting the participants' identity, privacy, self worth and dignity.The right to self-determination was upheld by obtaining informed consent from the participants.There was no victimisation of participants who refused to participate in the research, or who withdrew during the course of the study.The researcher established ongoing rapport with mothers over a sustained period of time -the significance of such a relationship in gaining trust, facilitating data collection and enriching data has been appraised byMuller (1995:69).

Foetal
movement as experienced by mothers is a valuable indicator of foetal wellbeing.These foetal movements monitoring further serve as an indirect measure of central nervous system integrity and function(Christensen & Rayburn, 1999:607).The subjective foetal movement monitoring as perceived by mothers appears to be an accurate reflection of foetal activity and are necessary integral part of obstetric care.It is a cost-effective tool which is pertinent to a developing country such as South Africa.Monitoring can be effective if the mothers are seen as partners in the care of their babies.
choices in maternity care,O'Cathain, Thomas, Walters,   Nicholl and Kirkham (2002:143)  asserted that women who were multiparous and of lower educational status preferred not to participate in decision-making with midwives.The authors further indicated the importance for midwives to at least know how women in their care preferred to be involved in decision-making as an aim to be sensitive and flexible in meeting their needs.According toHalliday and Horgarth-Scott (2000:52), childbirth is a natural process and mothers should be at the center of decisions about their care.However, Pelkonen, Perala and Vehvilainen-Julknnen (1998:22) pointed out

Table 1
In conclusion, the findings of this study directly call for daily schedule at the most convenient time.•Have the kick count chart and a pen ready.The kick count chart should have the information as shown in Table2.

Table 2 : Chart on How to Monitor Foetal Movements •
Lie down preferably on your side or sit upright quietly.•Put your hand on the abdomen and focus only on foetal movements (kicking and rolling), that is those that are definitely felt.