Kelli - 00:00:02:
Welcome to the Maternal Health Innovation Podcast, Season 4 I'm your host, Kelli Sheppard, Communications Director at the Maternal Health Learning and Innovation Center. On this podcast, we listen to maternal health innovators about ways we can implement change to improve maternal health in the US. Be sure you're subscribed. In today's episode, I'm talking with Emily Price, CEO of Healthy Birth Day, Inc. Emily oversees the national expansion of the evidence-based Count the Kicks public health campaign that educates and empowers expectant parents to track their baby's movements in the third trimester of pregnancy. The proven stillbirth prevention campaign helped lower Iowa's stillbirth rate by nearly 32% in the first decade, while the rest of the country remained relatively stagnant. Additionally, the stillbirth rate among Black women in Iowa decreased by a promising 39% in the first five years of the program. Price leads the vision of Healthy Birth Day, Inc. stillbirth prevention work with an overall goal of realizing a 32% stillbirth rate reduction in all 50 states, which would save 6,000 babies every year. She knows the power of Count the Kicks because it helped with the safe arrival of her son Hayden in 2010. Thank you for joining me, Emily.
Emily - 00:01:37:
Thank you so much for having me, Kelli. It's great to be with you.
Kelli - 00:01:41:
Same. My first question, can you tell us what is stillbirth?
Emily - 00:01:48:
Sure. Stillbirth is typically defined as the loss of a baby at 20 weeks or greater during pregnancy. Some states may measure it by grams, but overall, the overall definition in America is the loss of a baby at 20 weeks or greater during pregnancy.
Kelli - 00:02:05:
And how prevalent is it and who is most affected?
Emily - 00:02:09:
Absolutely. Right now, according to national vital statistics, one out of every 175 pregnancies in America ends in stillbirth. The racial disparities in birth outcomes persist in stillbirth as well. So for Black women, one out of every 101 pregnancies ends in stillbirth. It is the same for Native Hawaiian or other Pacific Islander women. One out of every 101 pregnancies ends in stillbirth. And that is horrible statistic. It should not be this way in 2024. That one out of every 101 Black or Native Hawaiian or Pacific Islander pregnancies ends in stillbirth. White women fairly better at around one out of every 204 pregnancies ending in stillbirth. Hispanic are at around the same rate as White women. There are Indigenous women, one out of every 130 pregnancies ends in stillbirth and their stillbirth rate happens to be on the decline. They've been declining over the last several years. And so it's something our organization monitors, tries to improve. And so those racial disparities are what was most significant right now.
Kelli - 00:03:28:
So can you tell us what is the importance of counting fetal movements?
Emily - 00:03:34:
Sure. This may be a long-winded answer, but it's going to be really comprehensive to give you a good understanding of why fetal movement monitoring is important. What decades of research shows that oftentimes a change in a baby's movements are a precursor or something that happens before a stillbirth, not in every case, but oftentimes in interviews and conversations with moms after they have endured the tragedy of stillbirth, they're telling doctors, clinicians, researchers that I noticed a change in my baby's movements before I lost them, but I didn't know it was an urgent warning sign. I didn't know it was something that could be an indication that something is going wrong. And so there is decades of research that shows a change in a baby's movements is an urgent red flag, an urgent maternal warning sign that there might be something happening, a complication coming up in that pregnancy that needs to be addressed by a doctor. And so that's why fetal movement monitoring in the third trimester is so important. Because what doctors have discovered and clinicians have discovered over the years, that if we can educate and empower expectant parents, get to know their baby's normal movement patterns in the third trimester speak up to your doctor. If you notice a change, there could be an opportunity for intervention. There could be a window of time that if a doctor knows that a baby's movements have changed, perhaps there are things that they can do to get that baby here safely. One of the things that we've also noticed in recent time is that Count the Kicks started off as a stillbirth prevention program, but the CDC's here at our campaign, which is a maternal warning sign campaign. One of its 15 urgent warning signs is a change in a baby's movement. And one of the things we've started to see with Count the Kicks is that our tools and our resources, our method of getting to know your baby's normal and the encouragement. To speak up if you notice a change and tell your doctor, tell your nurse, go to labor and delivery triage and let them know something has changed, that not only can baby's life be saved, but mom's lives have been saved as well. And an example of that is things like baby's movements alerting mom to preeclampsia that has gone undiagnosed or the start of a maternal fetal hemorrhage, which is absolutely can be deadly for both mom and baby, or the start of a placental abruption, which absolutely can put both mom and baby at risk as well. And so those are some really strong connections. Research does show that moms who endure stillbirth are now four to five times more likely to lose their own life as well.
Kelli - 00:06:05:
Wow. That makes me think about my own pregnancy journey and how toward the end of the pregnancy you have the app and I followed the app and it was telling me like how big the baby is. But then toward the end of the pregnancy, it was telling me how, you know, this is the time where you need to start monitoring the baby's movements and keeping track. I remember I actually went through my phone last night and found old videos where I recorded the baby's movements and watched my stomach move. And that just things like that, for all I know, could have helped save me. I appreciate that information. Can you explain how a change in fetal movement can indicate changes in the birthing person's health?
Emily - 00:06:58:
Just like we tell adults that a droopy face might be a sign of a stroke, chest pains could be a sign of a heart attack, a change in a baby's movements are the early warning sign that something might be going wrong with your pregnancy. And so there are a variety of things that could be cropping up in pregnancy to cause baby and mom distress. There are things like a placental abruption, a maternal fetal hemorrhage, an umbilical cord complication, like a cord becoming wrapped tightly around a baby's neck or a knot taking place in the umbilical cord, which could cut off nutrients and oxygen to a baby. Just like things like calcification of a placenta or blood clots within the placenta. There are things that can happen during pregnancy, things that can develop that will lead to a change in a baby's movements. We believe and researchers believe that what happens, the reason why their movements change is either maybe the cord is restricting their movements. Maybe they're also conserving energy. Maybe they're also doing all they can to keep going, even though their placenta is failing. So when you and I don't feel well, when we have COVID or the flu, or we're just really horrible cold as adults, we want to lay on the bed. We want to lay on the couch. We're going to move differently. We're going to become weaker. It is the same thing for babies in the third trimester. If something is causing them distress, which may also be an issue that's cropping up in mom's health. If something is causing them distress, the earliest warning sign is that their baby's movements are going to change. And mom, not always, but oftentimes can feel that or be in touch with something is different. And what Count the Kicks does is give you a data download for your intuition. So if you're paying attention to your baby's movements daily in the third trimester, if you're getting to know your baby's normal movement pattern daily in the third trimester, you're going to be much more likely to notice a change compared to a mom who maybe has never been told that this is important, that this is something to pay attention to. And so I think that's the difference with the introduction of Count the Kicks in this country 15 years ago. Before that, you probably had lots of moms who noticed a change. And we know, but they were never told this is an urgent warning sign. This is something you should look out for. But now we have Count the Kicks and we want every expectant parent to know about it, that this is a change in a baby's movements are potentially an early warning sign, not just for your baby and your pregnancy, but potentially also for your own life as well. We've had quite a few moms in recent years and recent months say, I had preeclampsia that went undiagnosed. I noticed a change in my baby's movements. I went to my doctor and sure enough, preeclampsia had developed and it was something that really needed to be addressed. Preeclampsia can be deadly, both for mom and baby. And so that's why we believe Count the Kicks, fetal movement monitoring, paying attention to your baby's movements is so important.
Kelli - 00:09:57:
It is. I agree. The Count the Kicks campaign, earlier you were talking about how it started off as a stillbirth campaign. Can you talk a little bit more about Count the Kicks and how it's evolved?
Emily - 00:10:10:
I'd be honored to talk about that. Our organization called Healthy Birth Day Inc. was founded by five women who all endured the loss of their baby girl in the early 2000s. Four of them lost their baby to stillbirth. And our fifth founder, Kate Sasafras, her daughter lived eight days. She had a congenital heart defect. And so these women came together. They were connected by mutual friends and pastors in their grief simply to get through this horrible tragedy that they had all endured. And after a long time getting to know each other and their families getting to know each other, they kind of looked at each other and said, how do we keep other moms from joining this horrible club? How do we keep other families from enduring the loss of their baby in many cases that they were learning could have been prevented? And so there were two things kind of simultaneously happening after they decided that they wanted to do something powerful with their grief. The first thing that happened was they discovered those Norway researchers who had studied the impact of raising awareness about fetal movement monitoring in the third trimester among women, pregnant women in Norway. And that whole campaign that happened in Norway with a 30% reduction. They heard about what had happened over there. And they said, great campaigns start in Iowa. Let's see if we even save one baby by raising awareness about fetal movement here in Iowa. And let's just see what would happen. At the same time, an amazing woman named Kim Piper, who oversees Iowa's stillbirth surveillance program for the Iowa Department of Health and Human Services, had met the women and said, have you ever thought about something related to fetal movement monitoring? Maybe there's a program, something we could work on together, the health department and with you as founders to help raise awareness about this early warning sign in pregnancy. They took all of that advice and research and they turned it into a mom-centered campaign that looks like this. They worked with a local marketing firm here in Iowa called Strategic America. They've been our partners from the very beginning who created what this looks like. And so the five founders, even though they had endured the loss of their daughters, they knew how dark and scary and terrible that experience was, but they didn't want the campaign to be dark and scary. They wanted the program to be bright and empowering, something a mom would want to pick up at her doctor's office or at her birthing triage and childbirth ed classes. They wanted it to be something that would invite women in to learn about this in an empowering way. And so this is what it looks like. It's a very kind of Dr. Seussical. And in fact, we have permission from Dr. Seuss's widow for it to be kind of Dr. Seussical. And so this is our English brochure that we have. We also have posters that hang throughout birthing hospitals, WIC clinics, public libraries, OBGYN, midwife offices, home visitors use these, doulas. I mean, anyone who cares for an expectant parent or serves an expectant parent is welcome to these free materials. They're free in about 30 states right now. The other 20 states do not have funding behind them yet. So they're at very low cost on our website at countthekicks.org. So going back to how these were developed and how they came to be and how they save lives is working with the Iowa Department of Health and Services and Strategic America created the campaign, kind of did a soft launch in late 2007, early 2008, throughout 2008, just to see if it would work. We wanted to ensure it would work before we took it anywhere else. And sure enough, it did. Within just a few months of having radio PSAs out and things like that, it saved the life of a little boy named Danny in Sioux City, Iowa in that area. And it happened around Christmas time of 2007, I believe. And it was such a celebration. And now it was like, okay, there's proof that it works. How are we going to keep this going? And so they received a very small grant from March of Dimes in Iowa to have more of the brochures and things printed and get them out. And they did a lot of really one-on-one training of health workers, nurses, doctors. Because the thing about it is, is that doctors, providers in this country know that fetal movement monitoring is important. They know that it is a precursor oftentimes to stillbirth. But what this country never had was a centered campaign on it. Just like you have the Back to Sleep campaign for SIDS and Safe Sleep that has been wildly successful in reducing the SIDS rate and keeping babies from dying from SIDS, just how that has been a wildly successful campaign. We wanted it to do the same. We wanted it to be the same, but related to fetal movement monitoring. So we had the buy-in of the systems in Iowa. So health departments, health systems, hospital systems, doctors, doulas, nurses, midwives, all bought into it and then quickly saw how effective it was. And so oftentimes in Iowa, it's kind of fun. Not only is it doctors talking about it, but now you'll have moms come into their prenatal appointment and say, hey, Doc. I've downloaded this app. Or my girlfriend told me about this and I saw it on Instagram. And now I'm paying attention to my baby's movements. And I want you to know, I'm going to tell you if my baby's movements change and I'm going to come in and I'm going to let you know if I notice a change. And so it's kind of working both ways now. Doctors are talking about it, but moms are also taking the initiative to talk to their doctors about it too.
Kelli - 00:15:29:
That's really good to hear. And just for our audio listeners, Emily shared brochures that we will link to in the show notes. Moving to the program and its reach, how do you ensure that the program reaches expectant parents where they are? How do you work with health departments, doulas, community-based organizations, and providers?
Emily - 00:15:58:
Sure. I'll start with how we meet expectant parents where they are, because that is central and most important to this work. So AMCHP, the Association of Maternal and Child Health Programs, named Count the Kicks a best practice back in 2021. And one of the things that they did in their clinical research of Count the Kicks is the only way we would have been named a best practice is to ensure that all levels of individuals who care for expectant parents are included in our program, which is very true. So home visitors are a huge part of our work. WIC clinics, big part of our work. Doulas, big part of our work. In addition to, of course, birthing hospitals, childbirth educators, OBGYNs, midwives, and things like that. And so many of the ways of how we ensure that every mom can have access to this program, not only do we have those bright, empowering materials that I showed you, we also have, I'm just digging here in my drawer to get, we have something what we call at a glance materials. And so they are materials that are really for like second, third grade reading levels. So that's one way we're ensuring that anyone, no matter your education level, no matter how long you've been in this country, you can understand it simply. Pay attention to your baby's movements, get to know their normal, speak up to your provider if you notice a change. It really is those three steps. And they're very visual posters and brochures that we have. And they've been, another way that we ensure we're reaching as many moms as we can is our printed educational materials are in about 14 languages right now. Our free app, which we can talk about in a little bit, is available in 21 languages. So as a nonprofit organization, we're doing everything we can to center those most marginalized by an oppressive society that they will have access to this. Other ways that we ensure we're reaching all moms is through social media, billboards, news stories in the media. Word of mouth is huge. Learning from your girlfriend or your sister about this program. We also have a wonderful ambassador program, women all across the country who are the voice of Count the Kicks in their state, educating other fellow expectant parents on fetal movement monitoring and Count the Kicks in our website, things like that are other ways that we reach expectant parents. We also have paper kick counting charts that you can download from our website. So if you don't, again, have access to a smartphone, you can very easily just, maybe your provider has them, but you can also download them from our website. And those are also available in 14 languages.
Kelli - 00:18:37:
That's awesome. The fact that you are able to reach so many people no matter their circumstance is, I think is really, really great. Going back to the app, what are the key features of the Count the Kicks app?
Emily - 00:18:53:
Absolutely. So the app is totally free. It's available in Google Play and Apple iTunes Store. Again, available in 21 languages. You can set daily reminders to remind yourself to track your baby's movements once a day in the third trimester. That is what ACOG recommends that starting at 28 weeks or 26 weeks if you're high-risk is to pay attention to your baby's movements daily in the third trimester. And the app is our hallmark tool. It is how expectant parents can get to know their baby's normal. And here's how they do it. When you open the app, every time you have your daily Kick Counting session, every time you feel a movement. So let's say your baby is normally active every night right after dinner. Every night right after dinner, we want you to sit down with the app or sit down with a paper kick counting chart or sit down with your wristband. And you're going to time how long it takes your baby to get to 10 movements. So if you're using the app, you're going to tap a little teal footprint. Every time you feel a movement. A kick, a jab, a roll, a poke, everything except for hiccups. Because hiccups are involuntary. So even though it's called Count the Kicks, it's really counting movements. So what you're going to do is time how long and the app is going to do is time how long it takes your baby to get to 10 movements because babies are so cool. They have a pattern. Starting at that 26, 28 weeks timeframe, they have a pattern of how long it takes them to get to 10 during that session each day. And every baby is different. So Kelli, my baby might take 25 minutes to get to 10 movements each day, but your baby might take four minutes to get to 10 movements in that kick counting session each day. So you need to know that four minutes is normal for your baby. And I need to know that 25 minutes is normal for my baby. And after about a week, say you've been counting for every day for one week after about a week is when you're going to see that trend and that average. And you need to know what that average is. So all of a sudden, Kelli, if your baby that normally takes four minutes on average to get to 10 movements, if all of a sudden that baby takes four hours to get to 10 movements, that is a sign that you need to call your doctor or you need to go to labor and delivery triage. You need to let a provider know that your baby's movements have changed and let them take it from there. The things that they can do would be a non-stress test, a biophysical profile, an ultrasound. They can look at your baby non-invasively and look and see if something is off and see if something is going wrong or is your baby just having an off day? But you're never going to know that unless you have them checked, unless they are proactive about looking at your baby from the outside and see if, in fact, there is something going wrong. The other aspects of the app that are helpful are you're going to see your trend line. So you don't just count one day and then lose your data. It keeps weeks and weeks of data so you can see what your baby's normal has been. Because really in the third trimester, normal should not change very much. Even up to and even during labor, your baby should be moving. There are these old myths and old wives tales that, oh, your baby's just running out of room. Your baby's just settling down for birth. That is not true. Your baby should move up to and even during labor. And that's why Count the Kicks, paying attention to movement is vital during your entire third trimester. Sometimes even more vital in the final weeks. You need to be paying attention. But do it the day you hit 28 weeks or 26 weeks of your high-risk, start then, do it every day during the third trimester.
Kelli - 00:22:18:
So as we wind down, Emily, I'd like to ask for our listeners who want to learn more or get involved with Count the Kicks, where can they find more information?
Emily - 00:22:34:
Absolutely. We invite you to go to countthekicks.org and you can learn more about the prevalence of stillbirth in your state or your community. You can learn about the racial disparities that persist. You can also learn about our partners and who we partner with. We have about 21 state health departments that we partner with. We also partner with county health departments. Healthy Start Coalitions are big partners of ours. PQCs, PMRs, all of them are big partners of ours. We invite you to come partner with us to improve outcomes in your state, in your community. So I invite you to reach out to me by email. It's price.emily@healthybirthday.org. That's price.emily@healthybirthday.org if you're interested in partnering to bring this to your community. Because when we partner with health departments or county health departments, FIMRs and things like that, oftentimes that funding removes a significant barrier for providers, doulas, to be able to have access to these free resources. And we do have loads of free resources on our website that are available to you now that you can have, like those downloadable kick counting charts. But to be able to have things like the posters and brochures that we talked about, we do need funding in still about half the country to make those free to providers so that we are reaching every expectant parent in this country. And we need your help. We invite you to be a part of this. We want your help. I know that we can make big change together. It is amazing when we get that call from a mama or a doctor or a partner that says, I was using your app. I noticed a change in movement. My doctor acted quickly and investigated. They found that something was in fact wrong. My baby was in distress and they got him here safely, like just in the nick of time. Like, thank goodness you exist. And that's the kind of success that we're having with health departments across the country and FIMRs and PQCs. And they're reporting back to their governor, their state health, their state legislature, their surgeon general, back to HRSA. HRSA, by the way, has a new stillbirth outcome measure. And just since last September, there is a new stillbirth outcome measure for HRSA. So if you are someone listening in a health department, this is something you can report back to your health department on. Use your Title V funds to help improve outcomes in the bottom line in your state. We'd love to partner with you.
Kelli - 00:24:51:
Thank you for all this information, Emily. It's always wonderful to hear that a maternal health innovation is succeeding. And then to hear your organization's evolution throughout the years and all the success stories. And just keep them coming. I'd love to check back in with you in the future.
Emily - 00:25:14:
I would love that too, Kelli. Thank you so much for your kindness. We've saved babies in 36 states and in six countries so far. And we need to get to 50 and we need this to be everywhere and commonplace in pregnancy. So I'm deeply grateful for the opportunity to talk with you today.
Kelli - 00:25:30:
Thank you, Emily, for taking time to join us today. And thank you for listening. For more podcast videos, blogs, and maternal health content, visit the Maternal Health Learning Innovation Center website at maternalhealthlearning.org. We do want to hear from you. Tell us what you want to hear more of. Leave a review of our podcast and share our podcast with like-minded innovators. We've got some great episodes recording now. Be sure you're subscribed and let's keep talking. Tag us in your posts using #MaternalHealthInnovation. I'm Kelli Sheppard, and we'll talk with you again soon on the Maternal Health Innovation podcast.
Speaker 1 - 00:26:13:
This project is supported by the Health Resources and Services Administration, HRSA, of the U.S. Department of Health and Human Services, HHS, under grant number U7-CMC-33636, State Maternal Health Innovation Support and Implementation Program Cooperative Agreement. This information or content and conclusions are those of the author and should not be construed as the official position or policy, nor should any endorsements be inferred by HRSA, HHS, or the US government.