WHO recommendations on antenatal care for a positive pregnancy experience

E.1: Women-held case notes
RECOMMENDATION E.1: It is recommended that each pregnant woman carries her own case
notes during pregnancy to improve continuity, quality of care and her pregnancy experience.
(Recommended)
Remarks
• The GDG noted that women-held case notes are widely used and are often the only medical records
available in various LMIC settings.
• The GDG agreed that the benefits of women-held case notes outweigh the disadvantages. However,
careful consideration should be given as to what personal information it is necessary to include in the
case notes, to avoid stigma and discrimination in certain settings. In addition, health-system planners
should ensure that admission to hospitals or other health-care facilities do not depend on women
presenting their case notes.
• Health-system planners should consider which form the women-held case notes should take (electronic
or paper-based), whether whole sets of case notes will be held by women or only specific parts of them,
and how copies will be kept by health-care facilities.
• For paper-based systems, health-system planners also need to ensure that case notes are durable and
transportable. Health systems that give women access to their case notes through electronic systems
need to ensure that all pregnant women have access to the appropriate technology and that attention is
paid to data security.
• Health-system planners should ensure that the contents of the case notes are accessible to all pregnant
women through the use of appropriate, local languages and appropriate reading levels.
Summary of evidence and considerations
Effects of women-held case notes compared
with other practices (EB Table E.1)
The evidence on the effects of women-held case
notes was mostly derived from a Cochrane review that
included four small trials involving 1176 women (168).
Trials were conducted in Australia, Mongolia and the
United Kingdom (2 trials). In three trials, women in
the intervention groups were given their complete
antenatal records (paper) to carry during pregnancy.
In the remaining trial, a cluster randomized controlled
trial (RCT) involving 501 women in Mongolia, women
in the intervention group carried a maternal and child
health handbook that included antenatal, postnatal and
child health records. Antenatal records were facilityheld
in the control groups. Data on ANC coverage
for the Mongolian trial were derived separately from
another Cochrane review (175).
Maternal outcomes
With regard to maternal satisfaction, moderatecertainty
evidence indicates that women who carry
their own case notes are probably more likely to feel
in control of their pregnancy experience than women
whose records are facility-held (2 trials, 450 women;
RR: 1.56, 95% CI: 1.18–2.06). Low-certainty evidence
suggests that women-held case notes may have
little or no effect on women’s satisfaction with ANC
(2 trials, 698 women; RR: 1.09, 95% CI: 0.92–1.29).
Evidence on caesarean section was very uncertain
and other guideline outcomes were not reported in
the review.
Fetal and neonatal outcomes
Low-certainty evidence suggests that women-held
case notes may have little or no effect on perinatal
mortality (2 trials, 713 women; RR: 0.77, 95% CI:
0.17–3.48). No other fetal and neonatal outcomes
were reported in the review.
Coverage outcomes
Low-certainty evidence suggests that women-held
case notes may have little or no effect on ANC
coverage of four or more visits (1 trial, 501 women;
RR: 1.25, 95% CI: 0.31–5.00).
Additional considerations
• nOther evidence from the review suggests that
there may be little or no difference in the risk of
case notes being lost or left at home for a visit
(2 trials, 347 women; RR: 0.38, 95% CI: 0.04–
3.84).
• nA <strong>WHO</strong> multicentre cohort study of home-based
maternal records (HBMR), involving 590 862
women in Egypt, India, Pakistan, Philippines,
Chapter 3. Evidence and <strong>recommendations</strong> 87