191 General Discussion Based on the reliability study (Chapter 2), the proportion of agreement for interobserver agreement on the classification of aCTG between and within primary care midwives, hospital-based midwives, residents, and obstetricians varied from 0.82 to 0.94. The proportion of agreement for each professional group were slightly higher for intra-observer (0.86-0.94) than for interobserver agreement. For the various aCTG components, the proportions of agreement for interobserver agreement ranged from 0.64 (presence of contractions) to 0.98 (baseline heart frequency). No significant differences were found in inter- and intraobserver agreements between the professional groups. In the cohort study (Chapter 3), 89,7% of the 1795 aCTGs were classified as reassuring, meaning that these women did not need to be referred to the hospital where they would normally have received the aCTG. Referral to OLC after an MLCaCTG occurred in 234 women (13.0%), of whom 86.3% (202/234) were referred back. In the total innovation project, an expert group assessed one case of serious perinatal outcome as a severe adverse event attributable to human factors. Severe neonatal morbidity, defined as a composite measure of severe outcomes, occurred among 1.7% of neonates. Four perinatal deaths were reported. The causes were asphyxia, Potter’s sequence, and tight umbilical cord entanglement. In one case, the cause of death was unknown. In terms of women’s satisfaction, our research showed that overall satisfaction based on the Consumer Quality Index was very high. Mean satisfaction scores varied from 3.98 (SD ± 0.11) for the subscale ‘client satisfaction’ to 3.87 (SD ± 0.32) for the subscale ‘information provision’ (Chapter 4). The study showed a mean general satisfaction score of 9.2 on a scale from 1 to 10. Overall, 77.4% of the respondents rated their general satisfaction as nine or higher. Women between 33 and 36 weeks’ gestation were more likely to be highly satisfied. Compared with a completely comfortable position during the aCTG, women in a mostly comfortable or somewhat comfortable position had decreased odds of being highly satisfied. Costs In addition to safe and effective care, care must be of value to those who provide it, those who receive it, and those who pay for it. In addition to quality, costs are also a factor in the value equation, as postulated by Porter and Teisberg. In our national budget impact model (Chapter 5), the results of the base-case analysis suggest that implementing aCTG in MLC would increase actual costs by €311,763 and €1,247,052 and decrease reimbursement costs by €7,538,335 and €30,153,342 per year for implementation rates of 25% and 100%, respectively. 7
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