23 Observer agreement of aCTG assessments INTRODUCTION Value-based healthcare has gained considerable momentum at international and national level. It aims to organize care based on the principle of the best possible quality of care for patients, with optimal use of resources.1, 2 This also holds for maternity care. Recently, three regions in the Netherlands (Nijmegen, Zwolle, and Amsterdam) started an innovative initiative according to this principle. Healthy women whose pregnancies were monitored in midwife-led practices were offered antenatal cardiotocography (aCTG) in midwife-led care, autonomously performed and assessed by a primary care midwife, for specific indications (i.e., reduced fetal movements, external cephalic version, or postdate pregnancy [41+0 to 41+6weeks gestation]) to assess fetal well-being.3, 4 Usually, aCTGs are performed in obstetricianled care only. Within this value-based healthcare initiative, pregnant women fulfilling the above criteria were offered aCTG by their midwife either at home, in the midwifery practice, or in a community healthcare center nearby. This task shift increases value for pregnant women, as it led to a reduction of referrals and an increase in the continuity of maternity care.1, 4-6 There is growing evidence that task shifting to midwife-led care can be safe and effective.7 Unlike in Canada, New Zealand, and Scandinavian countries, the aCTG is not yet part of the diagnostic tools available to Dutch midwives. Now that access to obstetrician-led care in the Netherlands is under pressure due to capacity issues, it is important to study the quality and usability of alternative forms of care provision, such as aCTG, in midwife-led care.8 Assessment of aCTGs between groups of healthcare professionals in obstetrician-led care varies.9-14 Although the interobserver agreement in the assessment of reassuring aCTGs is fair to good, low interobserver agreement was found for non-reassuring aCTGs.11, 12 There is also variation in the assessment of the various aCTG components: baseline heart frequency, accelerations, and contractions showed good to excellent interobserver agreement in aCTG assessment while other aCTG components such as variability and the number of decelerations did not.9, 11, 14 To date, little is known about the inter- and intraobserver agreement in aCTG assessment by different groups of maternity care professionals (primary care midwives, hospital-based midwives, residents, and obstetricians). Regarding the overall classification and the various components of aCTG, the aim of this study was therefore to assess: (1) the level of interobserver agreement between the four professional groups, (2) the level of interobserver agreement within these professional groups, and (3) the level of intraobserver agreement per professional group. 2
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