Remote home cardiotocography: A systematic review and meta-analysis

Cardiotocography (CTG) is a common investigative modality in obstetrics to evaluate the fetal condition. Advancements in digital technology has enabled the innovation of CTG monitoring for usage in the home setting. This review aims to comprehensively examine the current evidence on the effectiveness and applicability of home antenatal CTG monitoring. MEDLINE, EMBASE, Cochrane, Web of Science, and PubMed databases were searched from inception to June 2025. Primary studies examining home antenatal CTG were included. For randomised controlled trials (RCTs), the joint primary outcomes were perinatal mortality and emergency caesarean section. For observational studies, the feasibility, diagnostic accuracy, qualitative and economic burden of home CTG were evaluated. RCTs were eligible for meta-analysis using risk ratio or mean difference, with 95% confidence intervals. Included observational studies were narratively described due to significant methodological heterogeneity. 39 studies (28 observational, seven RCTs and four qualitative studies), comprising of 7240 participants were included. Home antenatal CTG monitoring was non-inferior to conventional care across all meta-analysed maternal, perinatal and healthcare usage outcomes. GRADE assessments were low/very low quality of evidence. Home CTG monitoring was feasible in several settings and remote interpretation was graded as moderate to excellent. Transmission failures were frequently low but commonly occurred due to infrastructure and/or equipment errors. Remote CTG monitoring demonstrated comparative capabilities to conventional CTG with respect to coincidence and beat-to-beat variability. Overall acceptability ratings were high for patient and providers. Often implementation costs were high but accrued back by non-fixed savings when compared against routine care. High-quality studies were underrepresented, particularly when assessing service-led and safety outcomes. Home antenatal CTG monitoring demonstrates noninferiority to conventional care across several outcomes, representing a promising avenue for antenatal management However, current evidence is of low quality and additional high-quality evidence with sufficient methodological detail and standardised outcome assessment is required prior to making definitive recommendations.Author summary: In an era where the number of pregnant women classified as high-risk is increasing, the demand for regular antenatal fetal monitoring has subsequently surged, which has increased the number of consultations in outpatient maternity services. Developments in digital technology has enabled devices, such as cardiotocography to be used in the home setting, which may alleviate the burden on the outpatient department. However, currently there is limited research which comprehensively examines the available literature on home CTG monitoring. Our review identified 39 papers, comprising of 7240 participants which incorporated a range of different study types and outcomes to be evaluated Meta-analysis of 16 maternal, perinatal and service-led outcomes demonstrated consistent non-inferiority when compared to conventional care across seven randomised controlled trials. However, high risk of bias, poor methodological quality and inconsistent results led to low or very low certainty of evidence using the GRADE approach. Narrative description of observational studies enabled a global assessment of the feasibility, diagnostic accuracy, clinical utility, qualitative and economic burden of home antenatal CTG monitoring. This review provides recommendations to shape future study design, whilst ensuring consistent outcome reporting, ultimately aiming to improve research quality for remote fetal monitoring technology interventions.