83 Women’s satisfaction of aCTG in primary midwife-led care INTRODUCTION Healthcare systems are increasingly being set up according to value-based healthcare (VBHC) principles, aiming to organize care based on the best possible quality of care for patients with optimal use of resources.1 In the Netherlands, the maternity care system is divided into primary (midwife-led) and secondary (obstetrician-led) care. Independent primary care midwives provide care for healthy pregnant women during pregnancy and childbirth.2 In cases of suspected complications, the midwife refers the woman to hospital-based obstetrician-led care.3,4 Over recent years, the referral rate from primary to secondary care has increased.5 Women’s suggestions for improving midwifery care in the current maternity care model include client-centered communication and information provision, a personal approach, sufficient time and attention for the individual, and continuity of care provider throughout the prenatal, intrapartum, and postnatal period.6 A previous study showed that pregnant women in the Netherlands who received midwife-led care perceived more continuity of care than women referred to obstetrician-led care.7 In Dutch maternity care, innovations based on VBHC principles have been initiated. One of these innovations started in 2015 (and is still ongoing) and concerned the possibility of pregnant women having an antenatal CTG (aCTG) to assess fetal wellbeing, if indicated, in primary midwife-led care. Currently, the procedure is mostly carried out as part of obstetrician-led care.8 E-health developments enable aCTGs to be performed outside the hospital in midwife-led care for specific indications: reduced fetal movements, after external cephalic version, and postdates pregnancy.8 It is expected that in the Netherlands approximately 21,000 women (12%) a year could be offered an aCTG in midwife-led care.9 Within the innovation project, 89.7% of the aCTGs were reassuring, meaning these women continued their care in midwife-led care and were not referred to the hospital where they otherwise would have had the aCTG, thus increasing rates of midwife-led continuity of care.8,10 Implementing aCTGs in primary midwife-led care meets the aim of VBHC; it improves patient outcomes by providing more continuity- and client-centered care while also lowering healthcare costs and eliminating (often harmful) waste.8,9,11 Only one study has addressed the strategy of offering an aCTG to healthy women with a specific aCTG indication in primary midwife-led care.10 Van der Pijl et al. focused on the experiences and views of midwives performing an aCTG. This study showed that, in general, midwives were satisfied and felt that performing aCTGs in primary care contributed positively to the midwife-client relationship. However, it was also a challenge: providing aCTGs in the primary care setting was seen by some midwives as promoting a pathology-based approach to midwifery care. The authors recommended exploring the experiences of pregnant women once aCTG in primary care setting is introduced as there is currently no evidence about women’s satisfaction and experiences with aCTGs performed in primary midwife-led care. 4
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