14 Chapter 1 In the Netherlands, CTG knowledge is currently included in the initial training of both doctors and midwives. However, fetal monitoring with a CTG has not been the task of community midwives so far, and the aCTG procedure is mostly performed as part of OLC. As a result, approximately 21,000 women (12%) per year need to be referred to OLC for aCTG consultation. However, most of these aCTGs are reassuring, and these women are referred back to MLC. Therefore, many referrals could be prevented if community midwives perform aCTG in MLC for specific indications. To our knowledge, there is no research on the performance and interpretation of CTG by primary care midwives. The antenatal CTG study Since 2014, three regions in the Netherlands (Nijmegen, Zwolle, and Amsterdam) started a pilot with an innovative initiative based on VBHC principles. Antenatal CTGs were performed for healthy pregnant women between 28 and 42 weeks in situations that pose an increased risk, including decreased fetal movements, external cephalic version in primary care and postdate pregnancy (from 41+0 weeks). A trained midwife performed the external cephalic version in primary care according to a national standard.43 Pregnant women were offered the option of MLC-aCTG or OLC-aCTG. If they opted for MLC, the aCTG was autonomously performed and assessed by a primary care midwife. Another primary care midwife performed a real-time second assessment. Midwives are authorized to perform aCTG provided they are competent by training and experience.44 In the case of a reassuring MLC-aCTG, an ultrasound scan was performed within 24 hours in primary care to assess fetal growth, amniotic fluid, and presentation of the fetus. Blood pressure was also measured. If aCTG, ultrasound, and blood pressure findings were normal, antenatal care was continued in MLC. If an MLC-aCTG was classified as non-reassuring or of insufficient quality, the woman was immediately referred to OLC for follow-up. The introduction of MLC-aCTG for specific indications is expected to address capacity problems in hospitals and rising healthcare costs. It may also improve satisfaction with care by reducing unnecessary referrals in women with a reassuring aCTG. This change in the care pathway is accompanied by a restructuring of tasks and responsibilities, which requires evaluation of the quality of care. However, to date, no research exists on how this expansion of roles in midwife-led care with aCTG relates to the VBHC parameters: clinical outcomes, experience of care, and healthcare costs.
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