“EFM is a waste of extremely scarce resources…”

In my April Birth Information Update, I highlighted an interesting paper and promised to share the link to the full article when it was published. The paper was written by a team whose work I have shared before; lawyer Tom Sartwelle and consultant neurologist Jim Johnston, who have written a number of papers highlighting the lack of evidence to support electronic fetal monitoring (EFM) in different settings and situations. This time, they have looked at the use of EFM as a means of reducing cerebral palsy (CP) in sub-Saharan Africa (SSA).

As they note, “CP is a significant problem in SSA where it is characteristically albeit erroneously considered synonymous with birth asphyxia, leading to the increasing use of EFM in a misguided effort to reduce perinatal morbidity and mortality.” (Johnston et al 2019).

However, their literature review again demonstrated that EFM is not beneficial.

“EFM has a 99.8% false positive rate, does not predict or prevent CP or any other neonatal neurological injury and has no proven efficacy in routine childbirth. EFM causes significant harm to mothers and babies by prompting unnecessary C-sections with all of the attendant complications of that procedure, leading to considerable risks in subsequent pregnancies including lifelong repeat C-sections with high rates of operative complications, uterine rupture, and placental abnormalities, all having a higher morbidity and mortality in SSA. Recent evidence suggests babies born by C-sections suffer an increased risk of chronic and autoimmune diseases. Additionally, while EFM use without informed consent is unethical, it may be challenging to obtain true informed consent in the SSA population.” (Johnston et al 2019)

I do love that this team always comes straight to the point. They conclude that, “EFM is a waste of extremely scarce resources while simultaneously adding another layer of useless staff training complexity as well as significant morbidity and mortality to a desperately critical situation. The authors recommend ending continuous EFM in routine pregnancies in SSA, which aligns with the Australian, Canadian, New Zealand and United Kingdom guidelines, follows recent USA recommendations, and comports with the World Health Organization Quality of Care Network goals. EFM related funding should be redirected to improve healthcare for mothers, train birth attendants, and focus on therapeutic intervention for children with CP and related neurological disorders.” (Johnston et al 2019).

This paper will be really helpful for those seeking change and needing to show why such interventions are not justified. You can read the full-text version here.


Click here to see all of our fetal monitoring research resources.


Johnston JC, Sartwelle TP, Arda B & Zebenigus M (2019). Electronic Fetal Monitoring as a Remedy for Cerebral Palsy in Africa: First Do No Harm. Neurology 92 (15 Supplement)