192 Chapter 7 Implementation Continuity of care is improved by performing aCTGs in MLC. It is known that midwifeled continuity of care (MLCC) leads to better maternal and perinatal outcomes, higher satisfaction for women, and increased job satisfaction for midwives.5-7 The impact of a complex intervention, such as MLCC, is highly dependent on the context in which it is delivered and how successfully it is implemented. Our realist review of 45 documents led to a deeper understanding of how and under what circumstances MLCC can be implemented (Chapter 6). The literature on the implementation of MLCC demonstrates its complexity, which is characterized by multifaceted contextual challenges and influences. We grouped the mechanisms involved around macro-level challenges, leadership, role ambiguity and conflict, and personal and professional boundaries. For stakeholders to invest in MLCC, feelings of fear and uncertainty need to be addressed. Changing roles and power dynamics within MLCC can lead to conflict and ambiguity, emphasizing the need for clear role definitions and support. Both formal and informal leaders have a critical role to play in addressing these challenges and in supporting and facilitating the transition. A complicating factor is the number of stakeholders involved from diverse backgrounds and contexts, each with their own interests and priorities. This can lead to a situation where those with the most power and influence ultimately determine the outcome. REFLECTION ON THE FINDINGS The new situation with aCTGs in MLC using e-health equipment showed that a large number of women could be safely cared for in MLC, resulting in more continuity of care. Furthermore, women who had an aCTG in midwife-led care were highly satisfied with this care. Shifting aCTG to midwife-led care may increase the actual costs involved, but at the same time reduce the health care reimbursement. This means that the implementation of aCTG in MLC can address a number of important challenges facing the healthcare sector, such as capacity problems in hospitals and rising healthcare costs. Despite the fact that there is no clear evidence that aCTG improves perinatal outcomes, it has become widely used in maternity care practice.8 It is important to consider the potential adverse effects of this form of fetal assessment. These may include the consequences of false positive results, inappropriate interpretation, and subsequent false non-reassurance of fetal well-being for the mother and the healthcare provider. The consequences of a false positive result also include unnecessary procedures or interventions for the mother, fetus, or newborn and increased use of healthcare resources.8
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