70 Chapter 3 growth restriction, and associated conditions [23,35,36]. Our research shows that the number of SGA neonates in the group of mothers who reported reduced fetal movements is 9.6%. This percentage is slightly higher than the incidence rate in a low-risk population of 8.1%, reported in the IRIS study [34]. We could not confirm that reduced fetal movements is associated with stillbirth and adverse severe outcomes. The Cochrane review by Grivell et al. assesses the effectiveness of aCTG in improving outcomes for mothers and babies during and after pregnancy [11]. They found no difference in the risk of a c-section for women with an increased risk of complications for the fetus between having an aCTG performed or having no aCTG performed. We can confirm this observation, as we found that c-sections were performed among 13.6% of women, which is similar to the percentage of c-sections among lowrisk women reported in the IRIS study (13.6%) [34]. Additionally, van der Pijl et al. reported that primary care midwives believed that an important effect of performing aCTG in primary midwife-led care could be a reduced number of inductions of labour [37]. Unfortunately, it was not possible to make a reliable comparison with national numbers. The findings from this study may support further implementation of valuebased healthcare and accelerate the transformation towards personalised care by task shifting. Still, continued governance of quality of care in MLC and OLC remains an important issue. Generalizability Our findings are important for maternity care both in the Netherlands and internationally. Although a referral from MLC to OLC in itself is not an adverse perinatal outcome, discontinuity of care (e.g., in cases of referrals to another care professional) could affect the quality of care due to transmission and loss of information [7]. Evaluation of the new situation with aCTGs in MLC using E-health equipment showed a high rate of women who could receive safe care in MLC, which results in more continuity of care. It might be time to reconsider the current strict task division between MLC and OLC and optimise the roles of these professionals to improve continuity of care and access to key maternal and newborn health interventions where accessibility to obstetrician specialists is limited. CTG has welldocumented limitations and professionals must understand the potential advantages and disadvantages of the technology before it is offered to women [11]. Poor CTG interpretation, limited knowledge of the pathophysiology of fetal oxygenation, and inadequate clinical management may result in either unnecessary or too little obstetric interventions, with additional risk for both mother and newborn [21]. It is recognised that clinical guidelines need to be as simple and objective as possible if implementation is to be consistent, to allow rapid decision-making even in complex and stressful situations [21]. In addition, it seems sensible to organise regular and structured integrated training of health professionals in MLC and OLC to ensure proper use of technology.
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