209 Summary ambiguity, highlighting the need for clear role definitions and support. Both formal and informal leaders play a crucial role in addressing these challenges, and supporting and facilitating the transition. A complicating factor is the number of stakeholders involved from diverse backgrounds and contexts, each with their own interests and priorities. This can lead to a situation where those with the most power and influence ultimately determine the outcome. In Chapter 7, the general discussion of the thesis, the main findings are summarised and discussed using literature to define the implications of these findings for future steps towards value-based maternity care. The task shift of the aCTG provides high-quality care that is highly valued by pregnant women and can also contribute to limiting capacity problems and rising healthcare costs. We describe that, despite the fact that shifting from the aCTG to midwifery practice is a valuable innovation for maternity care, nationwide implementation is challenging. There is no clear evidence that aCTG improves perinatal outcomes. Healthcare professionals need to consider the potential adverse effects of this form of fetal assessment, such as false positive results, inappropriate interpretation, and unnecessary interventions. Primary midwives are responsible for using the aCTG correctly and preventing unnecessary medicalization. In addition, the quality of aCTG must be guaranteed. Guidelines should be as simple and objective as possible to allow rapid decision-making, even in complex and stressful situations. In addition, the assessment of an aCTG may be improved by an internationally accepted classification system specific for aCTGs. In addition, it seems sensible to organize structural quality discussions and training courses for maternity care professionals to ensure proper use of aCTG. Midwives are the gatekeepers of maternity care, whereby good collaboration with network partners is self-evident. If the above conditions are met, aCTG can be implemented nationally in midwife-led care. VBHC and, with it, task-shifting care requires a different way of working for maternity care professionals, and confidence in each other’s expertise is needed. A fee-forservice payment model is a major barrier to the implementation of innovations such as aCTG in midwife-led care. Our analysis shows that performing aCTGs will increase the income of midwifery practice, but at high expenses. The hospital would lose income, but overhead costs such as housing, personnel, and equipment will not decrease initially. In the short term, shifting aCTG to midwife-led care will create a financial burden for hospitals. Although shifting CTG to midwife-led care reduces healthcare reimbursement, the current funding model does not support the implementation of value-based maternity care. The financial rules and regulations also affect the quality of collaboration and, consequently, the quality of maternity care. Future 8
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