Study shows iCTG improves perinatal outcomes in resource-constrained settings

Ninety-nine percent of global newborn deaths occur in low- and middle-income countries (LMICs), where pregnant women often struggle to access adequate fetal monitoring. In Tanzania, with 24 neonatal deaths per 1000 live births, a new wireless fetal heart rate monitoring technology is showing promise in preventing newborn complications and deaths.

A recent study led by researchers from Hiroshima University, Japan, and Muhimbili University of Health and Allied Sciences, Tanzania, evaluated the effectiveness of a mobile cardiotocography device for monitoring fetal heart rate (iCTG) in pregnant women at four primary health facilities in Tanzania's Pwani region. The findings are published in BMC Public Health.

The device increased the detection of abnormal fetal heart rates by 8-10 times and more than halved the risk of stillbirths and neonatal deaths. 

"Introducing an iCTG device dramatically improves the detection of fetal heart rate abnormalities and strengthens perinatal outcomes-even in resource-constrained environments," said study corresponding author Yoko Shimpuku, professor at Hiroshima University's Graduate School of Biomedical and Health Sciences.

iCTG is not a luxury technology; it is a practical, lifesaving tool that can reduce preventable newborn complications."

Yoko Shimpuku, Professor, Hiroshima University

A wireless lifeline

The main causes of stillbirths and neonatal deaths in Tanzania are prematurity and hypoxia. Current fetal monitoring technology in many LMICs is either immobile and expensive to maintain or limited to basic tools like fetoscopes that rely on intermittent listening and can miss critical signs of fetal distress.

The smart, wireless and user-friendly iCTG notifies healthcare providers of fetal heart rate abnormalities, helping them make timely decisions that improve outcomes. If abnormalities are detected, immediate treatment can be given, such as intrauterine resuscitation, including maternal repositioning, provision of fluids and oxygen administration. In emergencies, women are transferred to the hospital via ambulance while the iCTG continues to monitor their condition.

Between October 2023 and September 2024, the researchers enrolled 763 women at 32 weeks gestation or later across four facilities in the Kisarawe and Bagamoyo districts. While 492 women were monitored using iCTG, the other 271 received standard care.

Survival rates rise

The iCTG group achieved significantly better outcomes compared to those not using the device: perinatal mortality dropped to 2.6 % from 6.6 %. The device also proved far more sensitive, with fetal heart rate abnormalities detected 8-10 times more frequently than with standard techniques. The proportion of newborns with low Apgar scores-indicating potential breathing or health problems-also decreased significantly.

Rates of caesarean sections were higher when iCTG was used (27.6 % versus 10.3 %). While surgical delivery can reduce maternal and infant mortality when medically necessary, the researchers highlight the need for clear clinical guidelines to prevent unnecessary procedures.

Expanding access

Attendance at antenatal clinics (ANCs) can be low in LMICs due to barriers, including financial constraints, lack of understanding and distance to facilities. While previous research has shown that women with iCTG access are more likely to attend ANCs, this study found that they attended fewer. The team believe this is because the intervention was introduced late in pregnancy and could not influence earlier attendance patterns. They suggest that in the future, iCTG should be used earlier in pregnancy to engage women by allowing them to hear their baby's heartbeat, and combined with ongoing health education efforts to increase the frequency of ANC visits.

The researchers also emphasized the need to combine heart rate monitoring technology with other aspects of high-quality care to achieve the best outcomes for mother and baby. They plan to expand the use of iCTG to larger, more diverse settings while evaluating cost-effectiveness and long-term outcomes. Shimpuku said: "We aim to integrate mobile CTG into routine antenatal and intrapartum care in low-resource countries, ensuring that every pregnant woman-regardless of where she lives-has access to accurate fetal monitoring and safer childbirth."

Other contributors include Dorkasi L. Mwakawanga, affiliated with both Hiroshima University and Muhimbili University of Health and Allied Sciences; Sanmei Chen, Md Moshiur Rahman, and Naoki Hirose from Hiroshima University; Crystal L. Patil from the University of Michigan; Beatrice Mwilike and Agnes F. Massae from Muhimbili University of Health and Allied Sciences; and Yuryon Kobayashi from The University of Tokyo Hospital. 

The study was funded by the Japan Agency for Medical Research and Development, and devices were developed by Melody International Ltd. The open access publication costs for this paper were supported by Hiroshima University.