207 Summary 5. To conduct a realist review to examine the interactions between contexts, mechanisms, and outcomes in order to understand how and under what circumstances continuity of care by midwives can be implemented. In Chapter 2, the level of inter- and intraobserver agreement in assessing an aCTG between and within primary care midwives, hospital-based midwives, residents, and obstetricians is examined in a prospective study among 47 healthcare professionals. Respondents were asked to assess twice a set of 10 aCTG traces at one-month intervals. Two different sets of aCTGs have been used for data collection to maximize the number of CTG assessments without extra work for healthcare professionals. The level of inter- and intraobserver agreement for the classification of aCTGs between and within the four professional groups varied from 0.82 to 0.94. The level of intraobserver agreement was slightly higher for each professional group (0.86 – 0.94). For the different CTG components, the level of inter- and intraobserver agreement between and within the four professional groups varied from 0.64 (contractions) to 0.98 (basic heart rate). This study shows that the proportion of agreement levels between and within the maternity care professionals in the classification of aCTG traces among healthy women was comparable. This suggests that the quality of an aCTG assessment is equally good for primary care midwives, hospital-based midwives, residents, and obstetricians. Chapter 3 includes an evaluation of the aCTG for the indications of reduced fetal movements, after external cephalic version and postdate pregnancy in midwife-led care of 1) the process outcomes; 2) the maternal and perinatal outcomes of pregnant women receiving aCTG in midwife-led care; 3) the serious adverse events (with outcomes, causes, avoidability) that occurred during the ‘ aCTG pilot in midwife-led care ’ and possible prevention strategies for serious outcomes. In this cohort study, a total of 1584 pregnant women with a specific aCTG indication were included for whom 1795 aCTGs were performed in midwife-led care. Of the 1795 aCTGs, 1591 (89.7%) were classified as reassuring, meaning these women did not need to be referred to the hospital. Of the 234 women who were referred to the hospital, 86% were referred back to midwife-led care because no abnormalities were found during the repeat of the aCTG in the hospital. Severe neonatal morbidity occurred in 27 neonates (1.7%). Throughout the project (six years), 5,736 aCTGs were performed by a primary care midwife. All cases where potentially serious outcomes have occurred have been discussed with a team of experts, and in one case, it was considered that the cause could be attributed to human factors. 8
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