97 Women’s satisfaction of aCTG in primary midwife-led care 34 was 80.5% in 2018 24, which is comparable with our study population in which 84.4% of the women were aged between 20 and 36. According to CBS, 38% of women between 25 and 44 had a medium socioeconomic position in 2018.25 This is in line with the socioeconomic position of the respondents in our study population (42.7% medium). For future research, various additional personal and pregnancy characteristics should be included in the questionnaire. This can help to determine the representativeness of the study population and allows adjustments for relevant factors in the data analysis. Another limitation of the study is that the question about general satisfaction with an aCTG in primary midwife-led care was not included in the version of the questionnaire in one of the three regions (Nijmegen). Despite the large study population, only slightly more than half of the women answered the general satisfaction question. Furthermore, aCTGs for the indications “external cephalic version” and “postdates pregnancy” were only performed in the Nijmegen region. It was therefore impossible to analyze the association between these indications and the general satisfaction of pregnant women with an aCTG in primary midwife-led care. Not all women who received an aCTG in midwife-led care were invited to participate in the study as some midwives did not approach women during the inclusion period due to logistical issues, time constraints, or emergencies. This means selection bias of the study population cannot be excluded and may have affected the results. Lastly, the questionnaire was filled out by pregnant women receiving primary midwifeled care and not by pregnant women receiving an aCTG in obstetrician-led care. In this study, we intended to include women who received an aCTG in obstetrician-led care to compare satisfaction rates. However, this was not achieved as there was reluctance among professionals in obstetrician-led care to take part in the study. However, the high levels of satisfaction suggest that performing aCTG in midwife-led instead of obstetrician-led care does not negatively influence women’s satisfaction. Recommendations We found a very high satisfaction score among healthy pregnant women with an aCTG in primary midwife-led care. Although the high satisfaction levels leave little room for improvement, securing a comfortable position during the aCTG could be valuable to maintain or improve satisfaction further. In this study, we found no association between aCTG performed by the woman’s own midwife compared to an unknown professional and high satisfaction. This suggests that centralizing aCTGs in a community ultrasound or birth center could be an acceptable option. 4
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