71 Clinical outcomes of aCTG in primary midwife-led care The expert team recommended performing MLC-aCTGs only closer to term (for example, from 32 weeks instead of 28 weeks gestation) because of the difficulty of the assessment of aCTGs at lower gestations. While this consideration may sound plausible, this was based on only one case and merits further research. Research on the quality of aCTG assessment should be evaluated with some urgency and should focus on the benefit of aCTG for specific indications, inter- and intraobserver agreement in aCTG-assessment between professionals in MLC en OLC, and the use of computerised aCTG, to establish whether these strategies add value to the quality of maternity care. Strengths and limitations To our knowledge, this is the first prospective cohort study on MLCaCTG. A strong aspect of this study is the large number of aCTGs (5736) performed in MLC. Our approach of combining descriptive data with an in-depth case series study gives a complete and transparent insight into the care process in MLC. Our study has some limitations. We did not collect data on process outcomes, maternal and perinatal outcomes, or SAEs among healthy pregnant women who received an OLC-aCTG. For this reason, it was impossible to compare maternal- and perinatal outcomes when shifting aCTG to MLC. The same applies to the critical incident analysis among SAEs: we did not evaluate the care in OLC in the reported cases. We could therefore not investigate potential cases of suboptimal care associated with aCTGs in OLC. Another limitation is that potential SAEs were collected retrospectively by each regional quality committee, which engenders the risk of recall bias. For this reason, the incidence of SAEs in our study may be an underestimation. However, we expect this effect to be small as the respondents were all members of the regional quality committees to which all cases with a serious outcome should be reported and discussed. Lastly, not all eligible women were invited to participate in the cohort study as this evaluation was initiated after a run-in period when the pilot started. Furthermore, some midwives did not include women during the inclusion period due to logistical problems, lack of time, or emergencies. This means selection bias of the study population within the cohort study cannot be excluded, and this may have impacted the results. However, it is unlikely that there was a systematic bias in the women included in the study. All women with a potential SAE were taken from the total population, and the number of these cases was therefore likely to be complete. CONCLUSION Our prospective cohort study showed that continuity of care improved for most women who received MLC-aCTG if indicated. Data about the maternal and perinatal outcomes of women who had an MLC-aCTG were in the expected range for women in MLC. However, to evaluate rare outcomes a larger sample size would be required. 3
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