Digital fetal monitoring and ethics

I thought I grew up with computers. In my final years at high school, I had my first access to them. The school purchased two Tandy TRS 80 computers and myself and the other students taking Maths B were taught very fundamental BASIC programming skills. (And when we though the teacher wasn’t looking we played an extremely primitive version of Pong.) My parents bought their first computer and installed it in their pharmacy where it replaced their manual type writer for printing labels to go on prescription medications.

I have lived through a period of rapid and unimaginable expansion in digital technologies, affecting my medical practice and my personal life. I remember key moments along the way. Buying my first computer (an Apple Mac – I remain a loyal Apple consumer to this day). The day a fellow registrar dragged her desk top computer to work (laptops were not yet a thing), plugged it into the phone line, and explained what the INTERNET was. Living through the progression of the Cochrane library from the book (called Effective Care in Pregnancy and Childbirth) to a CD ROM, and then to being internet hosted – making it available to anyone, anywhere, anytime as long as they had internet access. Deciding to set out in private practice using digital records when my peers were still using paper records. My first iPod, my first iPhone. Using a digital dictaphone and having the recording transcribed using Dragon Dictate. Online education.

So many changes – each requiring skill acquisition and many offering very new ways to do things and to even be someone different.

Digital technology is not value neutral

This is an important thing to remember. Digital technologies do not come into being in a vacuum. They are created by real people, living in particular contexts. Those people hold particular values and beliefs, and make certain assumptions about how the technology they are designing will be used, how it will work, and what it will do.

I own a digital health monitor. Mostly it gets used as a step counter but it tracks sleep quality and a few other parameters. Embedded into its existence is the belief that health is my personal responsibility, that a certain level of movement each day leads to improved health, that knowing whether I have achieved that level and being reminded of it will change my behaviour, and that all of this will lead to better health. At present I can’t be bothered with all of that so it sits (staring at me somewhat accusingly) on a shelf in by bathroom.

Digital fetal monitoring technology is also not value neutral. But the option to use or not use it is not as simple as my decision to take my step tracker off and leave it on my shelf. Opting out of it is far more difficult for women who are accessing care in the hospital system. Which means we really need to pay close attention to the potential harms and ethical consequences of their use.

Are our ethical systems suitable for this task?

As Jessica Morley writes:

Foundational ethical guidelines … are primarily designed to protect individual patients from harmful physical interventions by individual clinicians. They are not designed to protect groups of patients from potentially harmful digital interventions by algorithms.

This is precisely the sort of protection that we need for fetal monitoring technology.

Imagine a software system used for CTG interpretation uses an algorithm that fails to detect an abnormal heart rate pattern, so it remains unnoticed by maternity professionals, no action is taken, and the baby is born in poor condition and has life-long impacts. Where does the responsibility lie? With the software designer for the choice of algorithm? With the health service who purchased and deployed the software? With the clinician who trusted the interpretation offered by the software? With the women who consented (hopefully) to the use of the fetal monitoring technology?

Unlike fitness trackers were there is a far larger body of evidence, with signs that behavioural and physiological changes are possible (Ferguson et al., 2022) – this is not the case for digital fetal monitoring technologies (like central fetal monitoring and computer interpretation of the fetal heart rate). There is an urgent and ongoing need for discussions with users of maternity care about the use of digital fetal monitoring technologies.

Want nonsense free information about fetal monitoring to support YOUR birth decisions?

I can help you with that. I’m a leading expert on fetal monitoring and an experienced educator – and I have personally designed a course with up-to-date information you can rely on. Knowing what the options are, how they work (or don’t work), and what the latest research says on the benefits and risks of each gets you off to a great start when making a decision. Fetal monitoring: Informed decisions for your birth covers all this and more! You’ll also find practical and effective communication strategies that help make sure you get the type of fetal monitoring you want for your birth.

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References

Ferguson, T., Olds, T., Curtis, R., Blake, H., Crozier, A. J., Dankiw, K., … & Maher, C. (2022). Effectiveness of wearable activity trackers to increase physical activity and improve health: a systematic review of systematic reviews and meta-analyses. Lancet Digital Health, 4(8), e615-e626. DOI: 10.1016/S2589-7500(22)00111-X

Morley, J. (2025). Healthcare and Well-being. In A Companion to Digital Ethics (eds L. Floridi and M. Taddeo).