15 Introduction Outline of the thesis The work presented in this thesis was conducted alongside the implementation pilot. The thesis focuses on the clinical process, experience, and cost outcomes of implementing aCTG in midwife-led care. The aims were: 1. To assess the level of inter- and intra-observer agreement between different groups of maternity care professionals regarding the overall classification and the various components of aCTG. 2. To evaluate the process-, maternal- and perinatal outcomes and serious adverse events of women receiving aCTG in midwife-led care. 3. To determine the satisfaction of pregnant women who received aCTG in midwifeled care. 4. To evaluate the budget impact of implementing aCTG in midwife-led care compared to aCTG in obstetrician-led care for women with specific indications in the Netherlands at a national level. 5. To conduct a realist review of the interactions between contexts, mechanisms, and outcomes in order to understand how and under what circumstances continuity of care by midwives can be implemented. Chapter 2 shows the results of a study on the level of interobserver and intra-observer agreement for aCTG assessments between and within four professional groups involved in Dutch maternity care regarding the overall classification and assessment of the various components of aCTG. Chapter 3 reports the results of a prospective cohort study conducted among women who received an MLC-aCTG, focusing on the care processes, maternal- and neonatal outcomes, and serious adverse events that occurred during the innovation project. Chapter 4 presents a quantitative study on women’s experiences with MLC-aCTG. Chapter 5 provides a budget impact model to estimate the actual costs and reimbursement of aCTG performed in MLC and OLC from the Dutch healthcare perspective. In addition, in chapter 6, a realist review is given on how and under what circumstances continuity of care by midwives can be implemented. Finally, chapter 7 consists of the general discussion of the thesis, and chapter 8 contains the summary of the thesis in English and Dutch. 1
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