Antenatal CTGs in the Netherlands: the impact on midwifery continuity of care

While last week’s post questioned whether we should be doing antenatal CTGs at all, this week’s post explores the positive impact of a shift from referring women into obstetric care for antenatal CTG monitoring to providing this in primary midwife-led care.

Maternity care in the Netherlands

The Netherlands offers a very different approach to maternity care than most other high income countries. Midwifery care is very much accepted and supported as the ideal approach to care for women with uncomplicated pregnancies. Very clear guidelines set out who gets their care from a midwife (usually based in a community setting) and who gets care from an obstetrician (typically hospital based). Birth at home or in free-standing birth centres is more common in the Netherlands than in most other countries. Care is government funded and free at the point of service, though a copayment is required for women who choose hospital care without a guideline listed reason for hospital based obstetric care.

New research about the use of antenatal CTG monitoring in the Netherlands caught my eye recently (Neppelenbroek, et al., 2023).

What was the research about?

A recent change in guidelines has supported women to stay in community based midwifery care when selected indications for an antenatal CTG arose. These were (for women between 28 and 42 weeks): reduced fetal movements, after external cephalic version (performed by the midwife in their clinic), or for women over 41 weeks pregnant. Previously, when would attend the hospital for antenatal CTG monitoring, disrupting continuity of care with their midwife.

The authors of this paper report on their initial experience with this change, looking at who was making use of antenatal CTG monitoring and why, and the maternal and neonatal outcomes for women who received midwife-led antenatal CTG monitoring. They also describe the outcomes of a ‘serious adverse event” monitoring system set up to check that midwife-led antenatal CTG use was not having a harmful impact.

5,736 antenatal CTGs were performed during a six year period in three regions in the Netherlands. 1,628 women gave permission for their data to be included in a prospective cohort study. Seven cases were reported to the serious adverse event monitoring team (a rate of 1.2 per 1000 CTGs performed).

What did they find?

Most of the CTGs were done close to term, with a mean gestation age of 40 weeks and 1 day. 67% of the CTGs were for reduced fetal movements, 19% for postdate pregnancy, and 14% after external cephalic version. Most of the CTGs were performed in a midwifery practice or ultrasound clinic, with 1.5% being conducted in the woman’s home. The CTG was interpreted as reassuring in 90% of cases. 13% of women were referred into obstetric care after the CTG was performed (some for reasons other than the CTG being non-reassuring) with 86% of these women referred back to primary midwifery care after obstetric review. For women who remained in obstetric care, only 31% of the time this related to the CTG, with 72% having abnormal ultrasound findings.

After investigation, five of the seven serious adverse events were determined to not be related to the clinical management of the woman’s pregnancy. One was felt to probably not be related to clinical care. The final case related to the incorrect assessment of the CTG in a preterm pregnancy with fetal death occurring subsequently. (It is important to note that there is no evidence antenatal CTGs can prevent fetal death, even though this is a commonly held assumption). The expert panel recommended additional education in CTG interpretation and consideration of whether women should be referred to hospital for antenatal CTG monitoring prior to 32 weeks.

How does this research help?

Neppelenbroek and colleagues research provides reassurance that shifting antenatal CTG in selected situation into primary midwifery care in the community is safe. It enabled more women to have a complete episode of care with their midwife, avoiding the need for a separate trip to hospital for 87% of the women in this study. I’m sure women were grateful for this. Midwives in other parts of the world who are considering using antenatal CTGs in their clinics will find these findings reassuring.

I was particularly impressed that they set out to assess the impact of this change in practice. Often practice changes happen without a formal plan for evaluation, or evaluation happens but is not shared with the broader academic community, leading to lost potential for learning from the experiences of others. I would still argue of the need to critically challenge the use of antenatal CTG monitoring, but if women and their midwives choose to use it in full knowledge of the evidence, then community based, midwife supervised antenatal CTG monitoring makes sense.

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References

Neppelenbroek, E. M., Verhoeven, C. J. M., van der Heijden, O. W. H., van der Pijl, M. S. G., Groenen, C. J. M., Ganzevoort, W., Bijvank, B., & de Jonge, A. (2023, Aug 28). Antenatal cardiotocography in dutch primary midwife-led care: Maternal and perinatal outcomes and serious adverse events. A prospective observational cohort study. Women & Birth, in press. https://doi.org/10.1016/j.wombi.2023.08.006