WHO recommendation on routine antenatal cardiotocography

WHO recommendation on routine antenatal cardiotocography



Routine antenatal cardiotocography is not recommended for pregnant women to improve maternal and perinatal outcomes.

(Not recommended)


Publication history

First published: December 2016

Updated: No update planned

Assessed as up-to-date: December 2016



  • 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.


CTG is a continuous recording of the fetal heart rate and uterine contractions obtained via an ultrasound transducer placed on the mother’s abdomen. CTG is widely used in pregnancy as a method of assessing fetal well-being, predominantly in pregnancies with increased risk of complications and during labour.



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 (1). 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) (2) and Confidence in the Evidence from Reviews of Qualitative research (GRADE-CERQual) (3) 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) (4) 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:

For pregnant women (P), does routine antenatal CTG (I) compared with standard ANC (C) improve maternal and perinatal outcomes (O)?


Evidence summary

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 (5).


Additional considerations

Low-certainty evidence on antenatal CTG in highrisk pregnancies suggests that this intervention may have little or no effect on perinatal mortality and caesarean section (5).


CTG machines are costly (starting from about US$ 450), require maintenance and supplies of ultrasound gel, and require staff training in their usea nd interpretation.


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.


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) (6). 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).


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) (7).


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 did not identify any priority question related to this recommendation


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. 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).
  2. GRADE [website]. The GRADE Working Group; 2016 (http://gradeworkinggroup.org/, accessed 27 October 2016).
  3. GRADE-CERQual [website]. The GRADECERQual Project Group; 2016 (https://cerqual. org/, accessed 27 October 2016).
  4. The DECIDE Project; 2016 (http://www.decide-collaboration.eu/, accessed 27 October 2016).
  5. Grivell RM, Alfirevic Z, Gyte GML, Devane D. Antenatal cardiotocography for fetal assessment. Cochrane Database Syst Rev. 2015;(9):CD007863.
  6. State of inequality: reproductive, maternal, newborn and child health. Geneva: World Health Organization; 2015 (http://www.who.int/gho/ health_equity/report_2015/en/, accessed 29 September 2016).
  7. 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


Citation: WHO Reproductive Health Library. WHO recommendation on routine antenatal cardiotocography. (December 2016). The WHO Reproductive Health Library; Geneva: World Health Organization.