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Dutch pilot CTG by midwives in primary care demonstrates: the correct care close to the client

A characteristic feature of obstetric care in the Netherlands is the independent midwifery practices in “primary care”. These midwives monitor pregnant women with uncomplicated pregnancies and deliveries. At the client’s home, or as an outpatient in the hospital. From 2023, a reimbursement will be available for Dutch midwives in primary care to make a CTG. Fourteen midwifery practices in the Nijmegen area already have six years of experience with this technology. They took part in a pilot, which was then expanded to include another two regions. What are their experiences?

Although Dutch midwives learn how to record a CTG during their training and to interpret the data, this procedure was usually reserved for gynaecologists. A midwife would refer a woman to the hospital for an antenatal CTG if the pregnant woman observed reduced movement, following an external version or in case of impending serotinicity. During a study trip with colleagues of the cooperative midwives Nijmegen and surrounding areas in 2012 (CVN) – to Canada amongst other countries – midwife Siegrid Hoekstra saw that it was completely normal in other countries to perform a CTG in primary care. This care offered close to the client was partly due to the long distances that may women had to travel to a hospital, but also due to the importance attached in Canada to continuity of care. We have known for many years that the fewer faces a pregnant woman sees during her pregnancy and delivery, the greater she values the care and the fewer medical interventions are required. Canada implemented the system accordingly.

This approach appealed to Hoekstra: “In Canada they consider a CTG physiological instead of pathological. They consider it an extension of performing an ultrasound scan. As midwives are able to perform a CTG themselves, they refer to the hospital far less frequently. This not only saves on expensive diagnostic tests and travel time for the women, but also saves on – often unnecessary – stress. In short, a CTG in primary care contributes directly to a higher quality of care.”

Participation of the professional field
Hoekstra had already witnessed the inception of two previous innovations relating to substitution of care: the ultrasound at twenty weeks gestation and the overarching external version in the Nijmegen obstetric centre, performed by midwives. She knew: the first thing that you need to do if you want to innovate is to ensure participation of the professional field. She ensured that other midwives within the cooperation became enthusiastic about the idea: would a model like the one in Canada be feasible in the Netherlands? For which indications would that be possible? She drafted a concept plan and discussed it with the insurance company. The insurance company was immediately enthusiastic and in 2014 asked her to work out the concept in more detail into a thorough plan for a pilot. She did this together with three other midwives and Carola Groenen. An important question that needed to be answered was: which technology are we going to use? Hoekstra knew the market fairly well thanks to a previous project for recording a CTG in the ambulance and soon concluded that there was only one product available at the time that allows you to upload the data from a CTG to the cloud, so that others can view the CTG remotely in real-time or at a later stage: Sense4Baby. “This is proven technology that is used worldwide and that meets the highest standards”, according to Hoekstra. “Sense4Baby is also suitable for mobile use, because it has been developed specifically for telemonitoring of high-risk pregnancies. Everything you need is contained in a handy case. This was great in our case, because the pilot would start with three devices and fourteen practices.”

Quality assurance
The team contacted the two hospitals in the region: the Radboudumc and the Canisius Wilhelmina Hospital. As the Radboudumc is also a teaching hospital where research is conducted, this hospital became the primary partner in working out the details of the plan. Potential legal and logistical problems were critically evaluated at the start. For example, how can we ensure that only authorised individuals gain access? These criteria were very important in offering good and safe care.

It was also a good opportunity to evaluate the quality of the care. The Midwifery Academy Maastricht developed an e-learning module, which needs to be completed by all midwives who are going to perform a CTG. In addition to this training, the quality is also assured in the Nijmegen region by a joint meeting of gynaecologists and midwives to discuss the CTGs each quarter.

Fewer referrals
Following a year of preparations, the Nijmegen region started with fourteen midwifery practices and two hospitals in March 2015. The midwives produce approximately 450 CTGs per year for the three indications. This means that roughly 2700 CTGs have now been produced in the Nijmegen region. In 86 per cent of cases, the CTG did not contain any abnormalities that would require referral of the woman to the hospital.  

The very high degree of client satisfaction emphasises that women preferred this substitution of care. The satisfaction across all the components of the process was monitored as part of the pilot. The figures varied from 3.86 to 3.99 out of a maximum of 4. This translates to an average “grade” of 94%. Hoekstra beams: “That is ultimately our reason for doing this. We can offer safe care in an effective manner and close to the client. This allows the region as a whole to save on costs. But the main reason for doing this is of course the mothers. You cannot help but feel proud when they give you such a glowing assessment.”

Feeling inspired by these results, two other regions soon joined the pilot. Once again the evaluations were positive. Hoekstra hopes that many more regions will see this success and copy it. “An implementation manual has now been published by the Amsterdam UMC Midwifery Science Study Group (lead by Prof. Verhoeven and Elise Neppelenbroek (PhD student)), which describes all aspects: the effect on the quality of care, the way in which you can organise this in your own practice and in the region, the business side of things and so on. This should prevent the various regions from reinventing a wheel that already exists. This will allow us to build on the wide-ranging experience that has already been acquired.”

Would you like to know more? Please contact Marco van Elst.

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