Hans van den Heuvel

9 DISCUSSION Main findings Our survey results show the current practice in the Netherlands regarding the use of home monitoring and telemonitoring in high-risk pregnancy. In 1995 pregnancy monitoring with daily home visits was available in only a few obstetric hospitals, yet currently it is used by 26% of all hospitals in the Netherlands. The last five years, a steep increase in provision of telemonitoring is observed, as off 2018 it is used in 17 centers, or 23%, of all obstetric departments. Furthermore, almost half of the hospitals with home monitoring considered switching to telemonitoring using self-measurement of fetal and maternal parameters. Of 17 telemonitoring centers, 10 centers did not evaluate use of this digital health strategy with daily self-measurements prior to implementation in their centers. Six centers were currently participating in an ongoing trial to compare traditional hospital admission and telemonitoring for patient safety, satisfaction and costs. In 2018, 1145 to 1865 pregnant women were monitored from home with home visits or telemonitoring in pregnancy after diagnosis of complication(s). Strengths and limitations Our study is a nationwide survey with high response rate and includes both secondary- and tertiary referral centers, teaching- and nonteaching centers and wide range of small to large units according to annual birth numbers. Responses of the survey depended on voluntary participation of invited hospitals, which could have led to selection bias. Furthermore, the collected data were self-reported and hence subjective. Part of the results on the impact of remote monitoring was based on estimations by respondents, and this may limit the validity of the conclusions. The evaluation of characteristics of pregnant women, relevant clinical outcomes (including safety) and user experiences are critical for future health care improving with use of mobile monitoring. However, this study was not set up to evaluate these outcomes, which might be considered a current limitation of this study. Interpretation The level of application of digital health in prenatal care is evident, with the focus on pregnancy telemonitoring as one of the most promising additions to new care models. 9,15,17 Respondents of our survey identified important (perceived) advantages of telemonitoring: more patient friendly care in respond to their needs, increased patient satisfaction and autonomy and reduced over-medicalisation. These results are in line with previous research of patient experiences with digital health. 15,18,19 Furthermore, obstetric care professionals also underline the importance of digital health in pregnancy care in previous studies. A survey study conducted in Belgium concluded that 28/35 (80%) midwives and 6/9 (67%) obstetricians, who worked with remote blood pressure monitoring in pregnancy, felt that digital technologies are an important component in prenatal monitoring. 20 CURRENT PRACTICE OF HOME-BASED TELEMONITORING IN THE NETHERLANDS 153