106 Chapter 5 that out-of-hospital care reduces healthcare costs, evidence specific to the MLCaCTG is lacking. Therefore, the aim of this study was to evaluate the budget impact of the implementation of MLC-aCTG for healthy pregnant women compared with OLC-aCTG in the Netherlands at a national level. METHODS This study was conducted and reported according to the Dutch guideline for conducting economic evaluations in healthcare13,14 and the International Society for Pharmacoeconomics and Outcomes Research (ISPOR) Principles of Good Practice for Budget Impact Analysis.15 Design and target population A budget impact analysis was conducted to estimate the actual costs and reimbursement of implementing MLC-aCTG (ie, innovation care path) compared with OLC-aCTG (ie, usual care path). The target population included healthy pregnant women receiving antenatal care from a primary care midwife and who were between 28 and 42 weeks gestation with specific aCTG indications, that is, reduced fetal movements, external cephalic version in MLC or postdate pregnancy in the Netherlands. Patient and public involvement Due to the objective of our study, it was not appropriate to involve patients or the public in our research’s design, conduct, reporting or dissemination plans. Time horizon and perspective A 1-year time horizon was used to evaluate the budget impact of implementing MLCaCTG compared with OLC-aCTG from the Dutch healthcare perspective. Care pathways In the Netherlands, healthy pregnant women receive MLC from primary care midwives. In contrast, those with risk factors (eg, hypertension, diabetes) or complications receive OLC in the hospital from obstetricians, obstetric residents and hospital-based midwives.16 These women were outside the scope of this study. Figure 1 shows the process steps of the two care paths compared in this study. Usual care path: OLC-aCTG In the usual care path, when an aCTG is indicated for a healthy pregnant woman, the primary care midwife refers the woman to OLC for consultation. The woman receives an OLC-aCTG in the hospital. Subsequently, an ultrasound scan is performed to assess fetal growth, amniotic fluid and the presentation of the fetus. Blood pressure
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