54 Chapter 3 and six=clearly avoidable). As in other studies, a score of one to three indicated that the SAE was not avoidable, and a score of four or higher indicated that the SAE was avoidable [31]. The assessment form distinguished eleven prevention strategies: peer review, training, evaluation, procedures, motivation, information, communication, technique/equipment, personal, scaling, and financial investment. The experts could select one or more prevention strategies for each SAE. Figure 2: Causal factors of SAEs RESULTS Cohort study During the five-year study period, 1628 women gave informed consent to having their data included in the prospective cohort study. No data could be retrieved for 31 women. In 13 women (0.8%), the aCTG was performed in OLC. These women (n = 44) were excluded from further analyses (Fig. 3). Case series study Throughout the duration of the project (six years), in the three regions, 5736 MLC-aCTGs were performed. Seven potentially serious adverse events cases were retrospectively selected over these years and included in the case series study (Fig. 3).
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