47 Clinical outcomes of aCTG in primary midwife-led care INTRODUCTION Internationally, maternity care is organised in various ways within healthcare systems. Organising care based on value-based healthcare (VBHC) principles has gained momentum both nationally and internationally [1]. VBHC is a system that prioritises persons’ health goals in care decisions and quality improvement, with optimal use of resources (money, time, carbon, and space) [2]. To achieve high-value healthcare, healthcare organisations should be organised as complex adaptive systems centred around persons’ needs rather than around separate levels of care [2]. The Dutch maternity care system is divided into primary low-risk midwife-led care (MLC) and secondary high-risk obstetrician-led care (OLC) [3]. Hereby recognising that women eligible for MLC sometimes do have risk factors for poor perinatal outcome, but that risk is being assessed and managed in MLC. Women are referred from MLC to OLC for actual or suspected complications or risk factors that need to be managed in OLC. If no abnormalities are found, the obstetrician in OLC will refer the woman back to MLC, where she continues her care. Continuity of care improves quality of care and contributes to positive pregnancy and childbirth experiences [4–6]. Previous studies have shown that pregnant women in the Netherlands in MLC receive more continuity of care than women referred to OLC, possibly due to the smaller number of healthcare professionals involved in MLC [7]. The women who are referred see new healthcare professionals and hence perceive a discontinuity of care because of the dichotomous healthcare system. Over recent decades, the number of referrals in the Netherlands from MLC to OLC has increased [8]. Continuity of care in pregnancy and childbirth may be improved by providing more services in MLC, thereby reducing referrals [9,10]. A candidate procedure for this shift is antenatal cardiotocography (aCTG) in situations in pregnancy that pose an increased risk to fetal health, including reduced fetal movements, after external cephalic version performed in primary care and postdate pregnancy. Although there is no clear evidence that aCTG improves perinatal outcomes [11], guidelines widely recommend using aCTG in assessing fetal wellbeing during pregnancy in women at increased risk of complications [12–15]. ACTG has in the past only been carried out in the hospital by a professional in OLC. Developments in E-health facilitate MLC-aCTG, as the aCTG recording can be assessed in real-time by a second professional who is not present at the location where the aCTG is being performed [3, 16]. In three regions in the Netherlands, MLCaCTG has been implemented for women with the abovementioned indications. In any restructuring of tasks and responsibilities, it is essential to evaluate the quality of care according to VBHC principles, i.e. outcomes measured by important parameters: 3
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