113 Budget impact analysis of aCTG in primary midwife-led care Average hours using hospital facility when performing an OLC-aCTG 2.00 Online supplementary material 1 Average hours spent on MLC-aCTG quality assessment by a coordinator per year 134 Online supplementary material 1 Average hours spent on MLC-aCTG quality assessment by a midwife per year 1119 Online supplementary material 1 Average hours spent on MLC-aCTG quality assessment by an obstetrician per year 33 Online supplementary material 1 Unit costs Hourly wage of a midwife € 53 (22) Hourly wage of an obstetrician € 125 (14) Hourly wage of a medical resident € 55 (23) Hourly wage of an obstetrician nurse € 42 (23) Hourly wage of a clinical midwife € 53 (22) Hourly wage of a coordinator € 53 (22) Admission day - costs per hour € 21 (14) Training costs per year per midwife € 100 Online supplementary material 1 Equipment costs € 6000 Online supplementary material 1 MLC-aCTG: antenatal cardiotocography in midwife-led care. OLC-aCTG: antenatal cardiotocography in obsterician-led care Base-case analysis The estimated number of MLC-aCTGs performed in the Netherlands in 2020 was 28 597. Shifting aCTG from secondary OLC to primary MLC would lead to an incremental budget impact in terms of actual costs between €311 763 (95% CI €188 574 to €426 072) to 1 247 052 (95% CI €754 296 to €1 704 290) for implementation rates of 25% and 100%, respectively. Reimbursement would decrease by −€7 538 335 (95% CI −€10 302 306 to −€4 559 661) and −€30 153 342 (95% CI −€41 209 225 to −€18 238 645) for implementation rates of 25% and 100%, respectively (table 3, online supplemental material 1, worksheet ‘base-case analysis’). An overview of the costs for 50% and 75% implementation rates is reported in table 3. The break-even analysis shows that the actual costs of implementing the MLC-aCTG per year in midwifery practices in the three regional maternity care networks together would be €423 741, and the reimbursement would be €316 400. The break-even point in the three regional maternity care networks together at which actual costs and reimbursement are equal was 1799 CTGs, as shown in figure 2 (online supplemental material 1, worksheet ‘costing tool’). 5
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