Hans van den Heuvel

11 blended care strategies that are supported by all stakeholders. Secondly, future prospective studies, including the results of the HOTEL trial, must prioritize the effects of digital technology in the light of evaluation of safety, i.e. the risk for occurrence of (relatively rare) adverse events in perinatal care. Published studies on telemonitoring in high-risk pregnancy are underpowered to assess risk for (relatively rare) adverse maternal, fetal and neonatal outcomes. The effects of self- or home-measurements on medical and shared decision making on interventions such as medication use or induction of labor are not known. It will be very challenging to fill this knowledge gap. Large prospective cohort studies or randomized trials in populations of women with hypertension in pregnancy require considerable efforts by large consortia and substantial funding, questioning their feasibility. Another trend in digital health is the use of wearables for selfmonitoring parameters such as physical activity, sleep, heart rate, condition etc. It is expected that in the Netherlands, 9 million wearables will be used in 2020. 26 Also in pregnancy, personalized monitoring of mentioned parameters can be useful for promotion of health lifestyle, well-being and sleep. 38,39 With the addition of the possibility to measure and monitor blood glucose, telemonitoring is also helpful in the care for pregnant women with (gestational) diabetes mellitus. 40 Lastly, digital health provides opportunities for shared decision making in prenatal care. Patient counseling on test and treatment options within antenatal requires accurate information, for example in prenatal testing, vaginal birth after caesarean section or treatment in imminent preterm labor. Digital decision aids aim to help patients and their families to weigh benefits of different treatment options against their risks. To involve pregnant women in the decisional process, decisional aids need to be developed with use of the criteria from the International Patient Decision Aids Standards (IPDAS). Their uptake and effects of its use need be followed using implementation studies. Concluding remarks This thesis on digital health in obstetric care contributes to the knowledge on development and evaluation of tools for remote monitoring of bothmaternal and fetal parameters. The use of devices and smartphone applications for self-measurements and in-hospital monitoring provides an innovative manner of prenatal care for women with (risk of) complicated pregnancies. Our research underlines that pregnant women are members of ‘Generation Z’ and therefore willing to and capable of working with health tools for remote monitoring. The introduction of digital tools in pregnancy care may enhance appropriate use of resources and services, experience of care and hopefully also safety of care. We hope the results of this thesis will create opportunities for future development and use of digital tools in pregnancy. In a step-by-step approach, scientific evidence of digital care in pregnancy must ultimately lead to highest-value perinatal care, tailored to the needs of pregnant women and obstetric care professionals. SUMMARY AND GENERAL DISCUSSION 189