WHO recommendation on woman-held case notes during pregnancy

WHO recommendation on woman-held case notes during pregnancy


It is recommended that each pregnant woman carries her own case notes during pregnancy to improve continuity, quality of care and her pregnancy experience.



Publication history

First published: November 2016

Updated: No update planned

Assessed as up-to-date: November 2016



  • 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.



In many countries, women are given their own case notes (or homebased records) to carry during pregnancy. Case notes may be held in paper (e.g. card, journal, handbook) or electronic formats (e.g. memory stick), and women are expected to take them along to all health visits. If women then move, or are referred from one facility to another, and in the case of complications where immediate access to medical records is not always possible, the practice of women-held case notes may improve the availability of women’s medical records (1). Women-held case notes might also be an effective tool to improve health awareness and client–provider communication (2). Inadequate infrastructure and resources often hamper efficient record-keeping, therefore, case notes may be less likely to get lost when held personally. In addition, the practice may facilitate more accurate estimation of gestational age, which is integral to evidence-based decision-making, due to improved continuity of fetal growth records (3).



The ANC recommendations are intended to inform the development of relevant health-care policies and clinical protocols. These recommendations were developed in accordance with the methods described in the WHO handbook for guideline development (4). In summary, the process included: identification of priority questions and outcomes, retrieval of evidence, assessment and synthesis of the evidence, formulation of recommendations, and planning for the implementation, dissemination, impact evaluation and updating of the guideline.

The quality of the scientific evidence underpinning the recommendations was graded using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) (5) and Confidence in the Evidence from Reviews of Qualitative research (GRADE-CERQual) (6) approaches, for quantitative and qualitative evidence, respectively. Up-to-date systematic reviews were used to prepare evidence profiles for priority questions. The DECIDE (Developing and Evaluating Communication Strategies to support Informed Decisions and Practice based on Evidence) (7) framework, an evidence-to-decision tool that includes intervention effects, values, resources, equity, acceptability and feasibility criteria, was used to guide the formulation and approval of recommendations by the Guideline Development Group (GDG) – an international group of experts assembled for the purpose of developing this guideline – at three Technical Consultations between October 2015 and March 2016.

To ensure that each recommendation is correctly understood and applied in practice, the context of all context-specific recommendations is clearly stated within each recommendation, and the contributing experts provided additional remarks where needed.

In accordance with WHO guideline development standards, these recommendations will be reviewed and updated following the identification of new evidence, with major reviews and updates at least every five years.

Further information on procedures for developing this recommendation are available here.


Recommendation question

For this recommendation, we aimed to answer the following question:

  • Should pregnant women carry their own ANC case notes to improve quality of care?


Evidence summary

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 (1). 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 facility-held in the control groups. Data on ANC coverage for the Mongolian trial were derived separately from another Cochrane review (8).

Maternal outcomes

With regard to maternal satisfaction, moderate-certainty 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

Other 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). A WHO multicentre cohort study of home-based maternal records (HBMR), involving 590 862 women in Egypt, India, Pakistan, Philippines, Senegal, Sri Lanka, Yemen and Zambia, was conducted between 1984 and 1988 (9). The study reported that “The introduction of the HBMR increased the diagnosis and referral of at-risk pregnant women and newborn infants, improved family planning and health education, increased tetanus toxoid immunization, and provided a means of collecting health information in the community. The HBMR was liked by mothers, community health workers and other healthcare personnel because, by using it, the mothers became more involved in looking after their own health and that of their babies.


Resource implications differ depending on whether electronic or paper-based systems are used. Electronic systems require more resources. Paper-based systems require the production of durable, transportable journals, as well as systems for keeping copies. The need to adapt and/or translate journals may add to costs.


The GDG considered that women-held case notes could be subject to abuse and used to discriminate against women who do not have them, or if the information contained in the notes is associated with stigma (e.g. HIV-positive status). Less-educated women with lower health literacy may be less able to read and understand their own case notes, which might perpetuate inequalities.


Qualitative evidence suggests that women from a variety of settings are likely to favour carrying their case notes because of the increased opportunity to acquire pregnancy and health-related information and the associated sense of empowerment this brings (high confidence in the evidence) (10). There may be potential for abuse of the system in some LMIC settings, for example, by limiting access to hospitals for women who do not have case notes, particularly where maternity services are under-resourced (moderate confidence in the evidence). Further evidence from a mixed-methods review supports RCT evidence that women feel more satisfied when they carry, or have access to, their own case notes (11). These review findings were not subject to GRADE-CERQual assessments of confidence, and were derived primarily from high-income settings (36 out of 37 studies). Findings also suggest that providers are generally happy for women to carry their own case notes, but feel the implementation of the approach may generate additional administrative responsibilities. Providers also raised concerns about data security, sensitivity of the shared information, and the potential for data to be lost because of fragmented systems.


There may be prohibitive additional costs associated with using an electronic system (USB memory sticks, software packages, etc.) in some LMIC settings (high confidence in the evidence), although paper-based records may require little in the way of extra cost or resources (12).


Further information and considerations related to this recommendation can be found in the WHO guidelines, available at:



Implementation considerations

  • The successful introduction of evidence-based policies related to antenatal care into national programmes and health care services depends on well-planned and participatory consensus-driven processes of adaptation and implementation. These processes may include the development or revision of national guidelines or protocols based on this recommendation.
  • The recommendation should be adapted into locally-appropriate documents and tools that are able to meet the specific needs of each country and health service. Modifications to the recommendation, where necessary, should be justified in an explicit and transparent manner.
  • An enabling environment should be created for the use of this recommendation, including changes in the behaviour of health care practitioners to enable the use of evidence-based practices.
  • Local professional societies may play important roles in this process and an all-inclusive and participatory process should be encouraged.
  • Antenatal care models with a minimum of eight contacts are recommended to reduce perinatal mortality and improve women’s experience of care. Taking this as a foundation, the GDG reviewed how ANC should be delivered in terms of both the timing and content of each of the ANC contacts, and arrived at a new model – the 2016 WHO ANC model – which replaces the previous four-visit focused ANC (FANC) model. For the purpose of developing this new ANC model, the ANC recommendations were mapped to the eight contacts based on the evidence supporting each recommendation and the optimal timing of delivery of the recommended interventions to achieve maximal impact.


Research implications

The GDG identified this priority question related to this recommendation

  • What should be included in women-held case notes, and how can discrepancies across different records be reduced to improve quality of care?



Related links

WHO recommendations on antenatal care for a positive pregnancy experience

(2016) - full document and evidence tables

Managing Complications in Pregnancy and Childbirth: A guide for midwives and doctors

Pregnancy, Childbirth, Postpartum and Newborn Care: A guide for essential practice

WHO Programmes: Sexual and Reproductive health

Maternal Health




  1. Brown HC, Smith HJ, Mori R, Noma H. Giving women their own case notes to carry during pregnancy. Cochrane Database Syst Rev. 2015;(10):CD002856.
  2. Mori R, Yonemoto N, Noma H, Ochirbat T, Barber E, Soyolgerel G et al. The maternal and child health (MCH) handbook in Mongolia: a cluster-randomized, controlled trial. PLoS One 2015;10(4):e0119772.
  3. Hofmeyr GJ, Pattinson RC, Nikodem VC, Gülmezoglu AM. Charting fetal growth. J Comprehensive Health. 1994;5:62–7.
  4. WHO handbook for guideline development, 2nd edition. Geneva: World Health Organization; 2014 (http://www.who.int/kms/handbook_2nd_ ed.pdf, accessed 6 October 2016).
  5. GRADE [website]. The GRADE Working Group; 2016 (http://gradeworkinggroup.org/, accessed 27 October 2016).
  6. GRADE-CERQual [website]. The GRADECERQual Project Group; 2016 (https://cerqual. org/, accessed 27 October 2016).
  7. The DECIDE Project; 2016 (http://www.decide-collaboration.eu/, accessed 27 October 2016).
  8. Mbuagbaw L, Medley N, Darzi AJ, Richardson M, Habiba Garga K, Ongolo-Zogo P. Health system and community level interventions for improving antenatal care coverage and health outcomes. Cochrane Database Syst Rev. 2015;(12):CD010994.
  9. Shah PM, Selwyn BJ, Shah K, Kumar V and collaborators. Evaluation of the home-based maternal record: a WHO collaborative study. Bull World Health Organ. 1993;71(5):535–48.
  10. Downe S, Finlayson K, Tunçalp Ö, Gülmezoglu AM. Factors that influence the use of routine antenatal services by pregnant women: a qualitative evidence synthesis. Cochrane Database Syst Rev. 2016;(10):CD012392
  11. Hawley G, Janamian T, Jackson C, Wilkinson SA. In a maternity shared-care environment, what do we know about the paper hand-held and electronic health record: a systematic literature review. BMC Pregnancy Childbirth. 2014;14:52. doi:10.1186/1471-2393-14-52
  12. Downe S, Finlayson K, Tunçalp Ö, Gülmezoglu AM. Factors that influence the provision of good quality routine antenatal care services by health staff: a qualitative evidence synthesis. Cochrane Database Syst Rev. 2016


Citation: WHO Reproductive Health Library. WHO recommendation on woman-held case notes during pregnancy. (November 2016). The WHO Reproductive Health Library; Geneva: World Health Organization.