208 Chapter 8 This study shows that shifting aCTG to the midwifery practice increases the continuity of care. The maternal and perinatal outcomes were in the expected range for women in midwife-led care at the end of pregnancy. The level of satisfaction and experience of pregnant women who received an aCTG in midwife-led care has been investigated with a questionnaire survey based on the Consumer Quality Index (CQI), described in Chapter 4. In addition, factors that influence a high level of satisfaction among pregnant women who have an aCTG in midwife-led care were also investigated. 1,227 respondents were included in this study. The client satisfaction based on the CQ-I was very high. The mean satisfaction level on a 4-point scale varied from 3.98 (SD ± 0.11) for the sub-scale ‘client satisfaction ’ to 3.87 (SD ± 0.32) for the sub-scale ‘ information provision ’. This study showed a mean general satisfaction score of 9.19 on a scale from 1 to 10. In total, 77.4% of respondents rated general satisfaction as nine or higher. Compared with a completely comfortable position during the aCTG, a mostly comfortable or somewhat comfortable level had decreased odds of being associated with a ranking of highly satisfied. Chapter 5 is a report of a budget impact model to estimate the actual costs and costs for the health insurer (declared costs) of an aCTG in midwife-led care from the healthcare perspective. The analysis showed that the national implementation of this care path change could save health insurers more than 30 million euros. With task shifting aCTG to midwife-led care, a hospital may lose income, but overhead costs such as housing, equipment and personnel will not initially decrease. This means that the current reimbursement policy does not support the proposed care path change for maternity care networks. However, it is expected that hospitals can use the freed-up capacity to provide more care for pregnant at increased risk. This will further improve specialized care for the pregnant women who need it most. The implementation of aCTGs in midwife-led care improves continuity of care. Higher continuity of obstetric care leads to better maternal and perinatal results, higher satisfaction for women, and increased job satisfaction for midwives. The impact of a complex intervention, such as midwife-led continuity of care (MLCC), is highly dependent on the context in which it takes place and how successfully it is implemented. Chapter 6 contains a synthesis of 45 documents that have led to a deeper understanding of how and under what circumstances MLCC can be implemented. The literature on the implementation of MLCC demonstrates the complexity, characterized by multifaceted contextual challenges and influences. The mechanisms involved can be grouped around macro-level challenges, leadership, role ambiguity and conflict, and personal and professional boundaries. In order for stakeholders to invest in MLCC, it is important to address feelings of anxiety and uncertainty. Changing roles and power dynamics within MLCC can lead to conflict and
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