Hans van den Heuvel

11 experiences and maternal and neonatal perinatal outcomes. Our research with this platform for women at risk of hypertension showed lower health care consumption (antenatal visits and hypertension-related admissions) of pregnancy care. In our sample, no increase of adverse events in pregnancy were observed. Therefore, telemonitoring has the potential to profoundly change antenatal care. In Chapter 6 we describe the economic evaluation of the results of the digital health study in Chapter 5. Costs of pregnancy care, including visits, ultrasounds, admission, laboratory tests were calculated, as well as societal costs such as travel costs and work absence. As a result of the reduction in health care consumption, use of the digital platformwas associated with a 20% cost reduction in antenatal care. (median €3616 [IQR 3071 – 5329] vs €4504 [IQR 3515-6923], p=0.001). Total costs per pregnancy, including societal costs, were also reduced (€7485 [IQR 6338 - 10,173] vs €9150, [IQR 7546 - 12,286] p<0.001). Each euro invested in the platform saved on average €8 of antenatal care resources. Furthermore, we explored the experiences, motivations and recommendations of users of our platform in a mixed-methods study ( Chapter 7 ), which resulted in a number of best practices and recommendations for future implementation of digital health technologies. Surveys of 52 SAFE@HOME participants and 11 interviews resulted in analysis in 4 themes: 2 themes were related to the technologies themselves (expectations, usability), and 2 themes were related to the interaction and use of digital health (autonomy and responsibilities of patients, responsibilities of health care professionals). In part II , our research focused on pregnant women with complications requiring daily fetal and maternal monitoring. To compare standard hospital admission with telemonitoring of cardiotocography and blood pressure from home, we performed different studies in order to increase knowledge of this use of digital health for complicated pregnancies. In Chapter 8 , we describe the experiences of pregnant women during either hospital admission because of pregnancy complications (n=11), opposed to women who participated inapilotwith telemonitoring (n=11). In this focus group study, womenwith cardiotocography at home expressed less feelings of boredom, anxiety or lack of privacy compared to women during hospital admission. Telemonitoring of a high-risk pregnancy provides an innovative manner to monitor fetal and maternal condition from home. Compared to the experiences of hospital admission in high risk pregnancy, it allows women to be in a comforting and private environment during an anxious time in their lives. Chapter 9 is the report of a nationwide survey to all Dutch obstetric departments to determine the number of centres that provide home- and telemonitoring, and to identify the current practice of out-of-hospital care in high-risk pregnancy. In 2018, 38% (28/73) SUMMARY AND GENERAL DISCUSSION 179