198 Chapter 7 appropriate financing and fees for professionals who can continue to be paid. This increased collaboration within an integrated maternity care organization requires financial, administrative, organizational, clinical, and service integration. Adequate support is needed for healthcare providers who want to engage in this intensive collaboration to alleviate the risks of giving up some of their autonomy. In addition, policymakers, organizations, and other stakeholders need to recognize that personal and organizational values, opinions, fears, and interests can affect collaboration and take these into account when taking steps to improve integrated care. METHODOLOGICAL CONSIDERATIONS Measuring value In this thesis, we aimed to measure the value of care of women receiving aCTG in midwife-led care. The close collaboration with care professionals in MLC and OLC has led to the large number of aCTGs (5736) performed in MLC. Our approach of combining descriptive data of clinical outcomes, experiences of women and costs, and an in-depth case series study gives a complete and transparent insight into the care process in MLC. The results of this thesis were highly relevant for clinical practice and directly integrated by policymakers, as the Dutch Care Institute (Zorginstituut) has decided that this care is to be provided by midwives. We recognize one main challenge in this approach. This lies in the fact that it was not possible to compare the maternal and perinatal outcomes of women receiving aCTG in MLC to those of usual care in OLC. We were not able to collect data on process outcomes, maternal and perinatal outcomes, or SAEs among healthy pregnant women who received an OLC-aCTG (Chapter 3). For this reason, it was impossible to compare maternal- and perinatal outcomes when shifting aCTG to MLC. The same applies to the critical incident analysis among SAEs: we did not evaluate the care in OLC in the reported cases. Therefore, the latter could not be investigated in OLC. The complexity of evidence in maternity care The knowledge base about health and disease derived from randomized controlled trials (RCTs) has contributed greatly to the design and implementation of complex models for integrated care delivery and, consequently, to the policies that have shaped our healthcare and public health systems.40 Research based on data collected in RCTs is still considered the ‘gold standard’ due to its unique ability to control treatment conditions for a well-defined study population strictly and to maximize compliance and internal validity.40-43 At the same time, observational studies come
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