69 Clinical outcomes of aCTG in primary midwife-led care DISCUSSION Key results This study evaluated an innovation project of aCTG in MLC. In the cohort study of 1795 aCTGs, 89.7% of the aCTGs were classified as reassuring, meaning that these women did not need to be referred to the hospital where they normally would have received the CTG. Referral to OLC after an MLC-aCTG occurred for 234 women (13.0%), of whom 86.3% (202/234) were referred back. In the total innovation project, the expert group assessed one case of a serious perinatal outcome as an SAE attributable to human factors. Severe neonatal morbidity, defined as a composite measure of severe outcomes, occurred among 1.7% of neonates. Four cases of perinatal death were reported. The causes were asphyxia, Potter’s sequence, and tight umbilical cord entanglement. For one case, the cause of death was unknown. Interpretation Our findings indicate that the task shift in this innovation project significantly reduces the number of referrals to OLC: only 13.0% of the women were referred. In the traditional care process, all women in MLC with an aCTG indication are referred to OLC. This shows the improvement in continuity of care, contributing to women’s satisfaction with care [5–7]. We found that 89.7% of the aCTGs performed by primary care midwives were classified as reassuring. The high rate of reassuring MLC-aCTGs was to be expected due to the healthy population [32]. Saastad et al. investigated 3014 Norwegian pregnant women with reduced fetal movements in whom an aCTG was performed in a hospital setting. They found fetal distress, intrauterine growth restriction, oligohydramnios, or another abnormality in 3.2% of pregnancies [33]. In our study, we found a higher percentage of aCTG and ultrasound abnormalities for pregnant women who received an MLC-aCTG in primary midwife-led care for the indication reduced fetal movements, as our results show 9.6% referral for nonreassuring CTG, 3.3% for ultrasound abnormalities, and 0.7% for another reason. An explanation for this higher percentage in the current study might be that the criteria of an assessment of MLC-aCTG are more strict than in OLC to ensure safety, because performing aCTG in MLC is an innovation, and a first step in the detection of potential chronic fetal hypoxia. In the case series study, midwifery care was evaluated among women with a potential SAE attributable to the aCTG-innovation project. The maternal and perinatal outcomes were in the expected range for women with an indication for aCTG among a previously low-risk population. We compared these results to the Dutch IRIS study [34]. The IRIS study included women at 28 weeks gestation with healthy pregnancies in MLC. This study showed a similar neonatal mortality rate (0.3%) and composite severe neonatal outcome rate (1.7%) during pregnancy for low-risk women. The literature shows that pregnancies in which the mother reports decreased fetal movements are associated with adverse outcomes: stillbirth, fetal 3
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