206 Chapter 8 The sustainability of health systems is increasingly challenging due to a lack of financial and human capacity. This makes it increasingly important to apply the principles of value-based healthcare (VBHC); strive to organize care based on the best possible quality of care for patients with optimal use of resources. A basic feature is that care is given in the setting with the greatest value: high complex care in hospitals and low complex care not in expensive settings (hospitals or specific hospital departments) by expensive care providers (medical specialists and specialized nurses) but in lower-cost settings costs outside the hospital. Various innovations have been started in Dutch maternity care using value-based care principles. One of these innovations started in 2015 and involved the shift from the antenatal cardiotocogram (aCTG) to midwife-led care for specific indications. While there is no clear evidence that an aCTG improves perinatal outcomes, guidelines are recommended to perform an aCTG to assess fetal well-being during pregnancy in women at increased risk of complications. Until recently, an aCTG was only performed in a hospital. Recent technological developments in healthcare facilitated the performance of aCTG in midwife-led care by a trained midwife using a portable CTG system. It is expected that for approximately 21,000 women (12%) per year in the Netherlands, it will be possible to get an aCTG at the pregnant woman’s home, midwifery practice, or community ultrasound center instead of the hospital. Chapter 1 provides a brief explanation of the change in the care pathway for aCTG in healthy pregnancies as an example of value-based maternity care. The thesis focuses on the quality, experiences, and care costs of shifting the aCTG to midwifeled care and answers whether it is a valuable improvement in the organization of Dutch maternity care. Quality assessment is essential when shifting tasks and responsibilities among healthcare professionals. The quality of care must be as good or better than current care. At the end of the chapter, the objectives of the thesis are given: 1. To assess the level of inter- and intra-observer agreement between different groups of maternity care professionals regarding the overall classification and the various components of aCTG. 2. To evaluate the process-, maternal- and perinatal outcomes and serious adverse events of women receiving aCTG in midwife-led care. 3. To determine the satisfaction of pregnant women who received aCTG in midwifeled care. 4. To evaluate the budget impact of implementing aCTG in midwife-led care compared to aCTG in obstetrician-led care for women with specific indications in the Netherlands at a national level.
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