WHO recommendations on antenatal care for a positive pregnancy experience

interventions to assess fetal well-being could help to
address health inequalities by improving detection of
complications in low-resource settings.
Acceptability
SFH and clinical palpation are non-invasive approaches
for fetal assessment, which are widely used and not
known to be associated with acceptability issues.
However, in some settings women experience a sense
of shame during physical examinations, and this
needs to be addressed with sensitivity by health-care
providers (low confidence in the evidence) (22).
Feasibility
Both methods are considered equally feasible,
provided tape measures are available.
B.2.3: Antenatal cardiotocography (CTG)
RECOMMENDATION B.2.3: Routine antenatal cardiotocography is not recommended for
pregnant women to improve maternal and perinatal outcomes. (Not recommended)
Remarks
• CTG is the continuous recording of the fetal heart rate and uterine contractions obtained via an
ultrasound transducer placed on the mother’s abdomen.
• There is currently no evidence on effects or other considerations that supports the use of antenatal
(prelabour) CTG as part of routine ANC.
• A lack of evidence of benefits associated with CTG in high-risk pregnancies suggests that the evaluation
of antenatal CTG in healthy pregnant women is not a research priority.
Summary of evidence and considerations
Effects of routine antenatal CTG versus no
routine antenatal CTG (EB Table B.2.3)
A Cochrane review of routine antenatal CTG for fetal
assessment identified no eligible studies of routine
CTG and all six included studies involved women with
high-risk pregnancies (117).
Additional considerations
• nLow-certainty evidence on antenatal CTG in highrisk
pregnancies suggests that this intervention
may have little or no effect on perinatal mortality
and caesarean section (117).
Values
Please see “Women’s values” in section 3.B.2: Fetal
assessment: Background (p. 54).
Resources
CTG machines are costly (starting from about
US$ 450) 4 , require maintenance and supplies of
ultrasound gel, and require staff training in their use
and interpretation.
4 Crude estimate based on Internet search.
Equity
Simple, effective, low-cost, antenatal interventions to
assess fetal well-being could help to address health
inequalities by improving detection of complications
in low-resource settings, which bear the burden of
perinatal mortality.
Acceptability
Qualitative evidence from a variety of settings
indicates that women generally appreciate the use of
technology to monitor pregnancy (high confidence
in the evidence), and a lack of modern equipment at
ANC facilities in LMICs may discourage women from
attending (moderate confidence in the evidence)
(22). However, in some LMICs, women hold the belief
that pregnancy is a healthy condition and may be
resistant to CTG use unless they have experienced a
previous pregnancy complication (high confidence
in the evidence). Acceptability may be further
compromised if the reasons for using CTG are not
properly explained (high confidence in the evidence).
Feasibility
Health-care providers in LMIC settings feel that a
lack of modern equipment and training limits the
implementation of this type of intervention (high
confidence in the evidence) (45).
Chapter 3. Evidence and <strong>recommendations</strong> 57