Count the Kicks app, started in Iowa, hopes to decrease preventable stillbirths throughout the US
By Emily Barske, Business Record editor
For Emily Price, the work of Count the Kicks is personal. It saved her son’s life.
In 2010, she noticed Hayden’s movement was starting to change when she was 30 weeks pregnant with him. This prompted her to talk with her doctor, who was able to address the problem in the last 10 weeks until Hayden’s healthy birth near his due date.
Price now leads the nonprofit Healthy Birth Day Inc. as its executive director and is responsible for the national expansion of Count the Kicks, an initiative that helps expectant parents track movements of their baby so they see what level is normal and can speak up if they notice a change.
The initiative was founded by five Iowa moms who each lost a baby to stillbirth or infant death and began working together to find solutions in the early 2000s. Count the Kicks was officially launched in 2008 to support research that showed kick counting and other movement tracking could reduce stillbirths. It started as written materials, and was launched as a web-based app in 2013 and became a mobile app in 2015.
The app is particularly important as 40 birthing units have closed in Iowa over the last 20 years and the state ranks last in the U.S. in OB-GYNs per capita. It serves as a tool to help patients track the health of the baby on their own.
Since its launch, it’s now spread to 16 states. That’s thanks to connections formed at conferences, policy efforts and organizations like the Iowa Department of Public Health that sing its praises in interactions with those from outside of Iowa.
“[The health department] didn’t have to work with five grieving women to implement something like this, but they did and they believed that this was important,” Price said. “Our connections and advocates within the state health department, all the way up to leadership, have been instrumental in making it a success in Iowa by telling their colleagues in other states [they] should do this too. You need to save Missouri babies and you need to save Florida babies, and so on and so forth.”
The materials continue to be adapted over time. The app is available for smartphones and computers, and other materials are also available for those without a good internet connection.
Addressing health equity is an important part of the organization’s mission. Black mothers were more than twice as likely to experience stillbirth compared with Hispanic and white mothers, according to a 2020 study published by the CDC. Social determinants of health – the economic and social conditions that influence individual and group differences in health status – and racial bias in the health care system contribute to the issue.
The Healthy Birth Day staff has also forged community partnerships to promote on its platforms, including providing expectant parents information about child care or mental health resources so they know they aren’t alone, since doing so can help reduce effects of postpartum depression or adverse childhood experiences, said Megan Aucutt, director of programs.
We sat down with Price and Aucutt to learn more.
The following Q&A has been edited for brevity and clarity.
To start off, could you provide me with a little bit of background on the app and what you all do?
Price: Count the Kicks is an evidence-based stillbirth prevention campaign. It started in Iowa in 2008, and within a decade reduced the state stillbirth rate by 32% while the rest of the country has remained stagnant. We were founded out of loss here in Iowa by five Greater Des Moines women. But it was so effective that it’s being picked up in many other states. In fact, there is legislation being written to get us in even more states on the national level in Congress. [U.S. Rep. Ashley Hinson, along with Rep. Alma Adams, Sen. Jeff Merkley and Sen. Bill Cassidy, introduced the bipartisan Maternal and Child Health Stillbirth Prevention Act of 2022 into Congress in March. The legislation recognizes that stillbirth and the disparity of those who have a stillbirth require further research, support and prevention programming. The status of the legislation was unavailable at press time.]
We are saving 1 in 3 at-risk babies from preventable stillbirth. We are a solution to the crisis: According to the American College of Obstetricians Gynecologists, Iowa ranks dead last for access to obstetricians. So women are driving two hours to just even try to give birth – for some women that’s just way too long.
Particularly when COVID hit, we were so glad we had our free kick-counting app because it is a bridge. It was a bridge between patient and provider, especially when appointments were being canceled or they were being moved to telehealth. The app is a way for moms to sit at home or in their office and track your baby’s movements once a day. Changes in a baby’s movements are a red flag and an early warning sign. Just like if your blood pressure spikes, that’s a warning sign for a potential stroke or heart attack. A change in a baby’s movements is the earliest and sometimes only indication that there might be an issue of pregnancy.
And that’s why the app is so important, especially during COVID, when you’re not with your provider as often, you’re being moved to telehealth. We can email your results, text your results to your doctor, and so we feel like we have been a bridge during COVID. [State of Iowa data from 2020 and 2021 shows] remarkably, we have maintained a record low stillbirth rate in our state. At the same time, states like Mississippi, their stillbirth rate doubled during COVID. And they have one of the worst stillbirth rates in the country. And so I think that the bridge is working during COVID because it allows the mom to be in touch with her body, be in touch with her baby during pregnancy and then can speak up. She’s highly educated to know when she should call her doctor or when she should go to her doctor.
Aucutt: It’s offered in 14 languages and is completely free. And there’s no ads, so there’s no pop-ups and things like that.
What the founders wanted and created is something easy and an empowering way to bond with baby. It puts the data into the mom’s hands, into the expectant parents’ hands, to say, “I have this data now. I have what’s going on with my baby that I can show my provider so they know if there is a significant change.” They can decide, “I can’t wait till the next day. I need to go now to the hospital to get this checked out.”
[They know of at least five Iowa babies saved in 2021 because of expectant parents using the app.]
What you two are both alluding to is that it really is an empowerment tool because it allows you to have control. Nobody has access to a doctor 24/7, regardless of if you’re in an urban area or an area without a birthing unit, so can you talk to me about the importance of that?
Price: In many cases, there are moms who have a gut feeling about something and they know something is wrong. I think sometimes in general, humans have a way of talking ourselves out of things in many cases. We think we’re being paranoid or we think that we’re just bothering someone. And what the app does is provide that voice in your head to say, “No, you really should go in” or “Here are the consequences sometimes if you don’t know to go in.” I think in the case of the app, it is the extra nudge that is needed to reach out to your provider or go straight to the hospital. Because a lot of our messaging is urgent: Get to know your baby’s normal, speak up if you notice that change. Hospitals are open 24/7, you can go anytime. That’s what your doctor is here for is to pay attention and to listen to you.
Aucutt: The app is very visual. So when you start counting, there is a big red button, a timer starts and you count every time you feel the baby move. Then you get this graph so that after a couple of sessions you start to see the average time it takes them to get to 10 movements. So you have that visual graph that really anybody can read. It’s very simple and easy.
So when movements perhaps take a lot longer, that graph is going to shoot up and it’s visually going to show you “Oh, that’s another flag. I need to look at this seriously and contact somebody.”
We ask moms to monitor the strength of those movements, and that’s what research now states as well. Not only do we want expecting parents to monitor how long it takes me to get to 10 movements, but the strength of those baby’s movements because that can also indicate that baby needs to get checked out.
How does the relationship with providers work?
Price: Every year in Iowa, through a grant that we received through Iowa Department of Public Health, we send out sample materials to providers across the state. [The materials are on] what’s happening in birthing hospital triage units. We also have brochures that go out as well. So if you go into a triage unit, and you say, “I haven’t felt my baby move in the last 24 hours,” that OB nurse or doctor needs to first investigate to see why that baby’s movements have changed, but during that they need to talk to them about the importance of daily monitoring.
[When it comes to] reaching as expectant parents as we can, our education is picture-based. So minimal wording if you are new to this country, or if you just happen to have a low literacy level. This is very easy to understand that you need to pay attention to your baby’s movements and tell your doctor if something has changed. Tell your doctor that you’re paying attention, and then you can show them the data on the app, you can email it to them, text it to them and share on your social. You could just hand your app to them during your appointment. Providers can order materials on our website, countthekicks.org, and then it sparks that kick-counting conversation.
There are so many things to talk to women about during the prenatal appointments. The point of our organization is to make this top of mind, especially in the third trimester. We want them to start talking about it in the first trimester, but if they don’t, they really need to be talking about it in all third-trimester appointments.
So that was the gap that was missing before our organization existed. The five women who started us in the early 2000s were never told. They all lost their daughters. They were never told you need to pay attention to your baby’s movements and speak up if you notice a change. Many of them did notice a change, but it was far too late once they noticed or said anything.
We have about 36,000 live births in Iowa in a year. Typically we have about 42,000 pieces of educational material across Iowa for providers. So we are in a way oversaturating, which is a good thing. One woman may have an obstetrician, but she may also have a doula, so she may get this brochure from her OB nurse and she may also get it from a doula – and that’s great if you’re seeing it twice.
We also have [continuing education] trainings, where not only can providers order materials to spark the conversation with their patients, they have a training that they can take that is also provided by funds from the Iowa Department of Public Health. They’re going to learn exactly how to know if a mom is concerned with the change in fetal movement, what to say and what to do if mom comes in. It also has a health equity component where we talk about checking your biases at the door and a reminder that you need to listen to women of color, you need to listen to women who live in communities that have been marginalized by an oppressive system.
We have an extremely strong uptake by providers in our state because we’ve been around so long. Because they have witnessed the success of what happens if a mom is informed and speaks up, and then allows them as a provider to try to get that baby here safely. There’s full buy-in. We have a 96% saturation rate of providers in our state ordering our materials, using the campaign. That takes a few years to build that by hand, but it’s strong here in Iowa because they know that it works and they know the power of what happens when it works. We also train a lot of home visitors and nontraditional providers as well.
Aucutt: [We stress] the importance of home visitors or community-based organizations with clinics. We’ve recently been working with rural health care centers, especially when we talk through birthing unit closures. We want to make sure family practice doctors, who are really seeing people from all ages that they are treating, are educated on this and can share this with their patients is really important. We have libraries ordering materials. When you think through the “Iowa nice” mentality, that’s kind of what it is with this too – they’re more than willing to give these resources out. The more touch points the better.
You talked about Count the Kicks being launched here in Iowa because of the founders’ connection to it. But just curious, are there reasons why it’s particularly effective in Iowa?
Price: [The providers] just see the effectiveness of it and it has been around for so long – now a decade or so. It just becomes part of their routine and prenatal appointments. There’s just such a strong buy-in because of the power of what happens when it works. And we’re seeing it in other states too.
It’s a slow build. It’s not something that’s immediate. It’s immediate with some OB offices, it’s immediate with some clinics, but it’s a slow build as doctors talk to each other, as nurses talk to each other. I would say it probably takes three to five years before you would reach that 96% saturation rate, but that’s our goal in all the states that we launch.
Aucutt: I think part of the success is how easy it is and how empowering it is. Stillbirth is tragic. We know it affects everybody, the medical unit, the community – nobody wants that. As providers, they don’t want that, so if there’s something that they can do to prevent that and it’s noninvasive, it’s inexpensive – absolutely. This is research-backed, so I think that really helps. That’s why it’s expanded outside of Iowa because it is evidence-based. We have seen that success in Iowa and while it is a slow build, it’s still simple and easy to use so anybody can implement it.
Tell me a little bit about the technology itself. At the time it launched, even just a few years before that, people probably didn’t even know what an app was. Tell me a little bit about how technology is helpful in working toward your mission.
Price: I’m one of those moms. My son was saved by Count the Kicks in 2010. So he’s almost 12 years old. There was no app in 2010 and instead I was simply just paying attention and luckily my doctor took me seriously and investigated and got him here safely. So as far as technology is concerned, it started as a web-based app in 2013. And by 2015, it was a mobile app on tablets and smartphones. I think the most powerful quote that’s ever come up related to our app was in 2017. We had a local mom from Waukee and we had a press conference with Mercy because she was saved there, and she told the reporters after her baby was saved, “I realized I could have been having a burial instead of a birth.” It was the most powerful way to describe the power of the app, the power of Count the Kicks. Because for many, that is the alternative.
And we know that to be true because of all the women who contact us after they’ve lost their babies. And they asked us why didn’t they know about kick counting. Why isn’t this in my state? Why didn’t my doctor talk to me about this?
In so many of our save stories, the doctor discovers that there is some sort of an issue and needs to get that baby here quickly and safely. And when they pull baby out after an emergency C-section, they realize that the issue was the baby was entangled in the cord four times, or it was wrapped around their neck five times. Or there were two knots in the cord that were cutting off all nutrients and oxygen or the placenta was failing or there was a maternal fetal hemorrhage. And the first clue was a change in movement that alerted the whole process, the whole domino effect that happened after mom alerted her doctor. In so many of those cases, and so many save stories that we received, it is a matter of hours. A doctor will say, “Congratulations, you saved your baby’s life. If you hadn’t spoken up, if you hadn’t come in, you maybe had five more hours.” We’ve had some even closer calls where it is a maternal-fetal hemorrhage. And the doc will say, “You had like 45 more minutes – this was so close.”
Many of us already realize in our gut, or because something feels different, that something is off, something has changed. But if you’ve been tracking every single day, you know it’s normal for your baby. And then all of a sudden one day you notice that baby that used to take about 10 minutes to get to 10 movements now takes an hour and a half. The graph shoots up on the app, it’s a red flag, and the domino effect happens from there. That’s the power of the technology and it’s also why minutes absolutely matter.
Editor’s note: This story has been edited to update a quote.