195 General Discussion relationship with patients, and the feeling that the midwifery profession is changing.21 In addition, the Dutch Board of Obstetrics and Gynaecology has raised concerns regarding the extended care responsibilities of primary care midwives in performing aCTG.22 Multilevel contextual influences affect the views of these stakeholders on implementing MLC-aCTG, specifically, the interactive aspects of collaboration in healthcare networks, such as interpersonal processes of collaboration, exchange of norms and values, power dynamics, and trust processes (Chapter 6). For most of the twentieth century, Dutch midwives and obstetricians had a cooperative relationship, and the division of tasks was defined and regulated by an ‘indication-list’ that indicated who was responsible for which types of care.23 In the 1980s, efforts to revise this list created tensions between the two professions, with each group seeking to protect and expand its own jurisdiction.24 This resulted in a shift from collaboration to competition, and with it, displaced the scope from the provision of the most effective maternity care to the promotion of service value of one profession over the other. Recognizing and naming these barriers to the implementation of MLCaCTG can be the start of developing effective strategies and building alliances to overcome them.25 To overcome disparities in power within maternity care networks and to promote a collaborative approach, midwives need the ability to navigate knowledge acquisition and develop a professional identity across different domains, a skill known as ‘knowledgeability’. This ability makes them recognizable as reliable sources of information and enables them to effectively implement change based on their knowledge and expertise. Sociocultural learning theories could help to develop this skill and play a crucial role in the education of medical and midwifery students.26 Payment models in integrated maternity care A fee-for-service payment model is a major barrier to the implementation of innovations such as MLC-aCTG (Chapter 5). Our analysis shows that performing aCTGs would increase income for midwifery practices, but at a higher cost. The hospital would lose income if it performed fewer aCTGs, but overhead costs such as housing costs, staff, and equipment in obstetrician-led care would not decrease initially.27,28 It is expected that hospitals will use the freed-up capacity to provide more care to pregnant women at increased risk. This will further improve specialized care for those pregnant women who need it most, while generating additional revenue for hospitals as more specialized procedures are required.27 However, in the short term, shifting aCTG from OLC to MLC would result in a financial burden for hospitals. Thus, although shifting aCTG to MLC reduces healthcare reimbursement and, thereby, healthcare costs, the current reimbursement policy does not support the proposed change in care pathways for maternity care networks.28-32 Financial rules and regulations also affect the quality of collaboration and, consequently, the 7
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