12 Chapter 1 obstetric residents, and hospital-based midwives.14,15 If a significant risk factor or a complication arises during pregnancy or labor in MLC, the midwife refers the woman to OLC for consultation or transfer of care. One of the aims of risk stratification is based on the level of risk is to provide the most appropriate care with the resources available, leading to optimal pregnancy outcomes. However, referral to a different care provider may be associated with potential risks, including loss of information and inconsistencies in advice and information due to discontinuity of care.16,17 Discontinuity of care is associated with reduced client satisfaction, inaccurate communication, and an increase in interventions.16-18 In a Dutch survey, maternity care professionals and other stakeholders indicated that the optimal maternity care system is client-centered, and continuity of care should be given to women during labor and birth.22 Opinions differed regarding the optimal maternity care organization model and type of continuity of care. Although stakeholders agreed that care provided in different echelons should be seamlessly connected, some thought that primary care midwives should continue to look after women with medium risk factors whereas others felt that obstetricians should be responsible in these cases. Midwife-led continuity of care (MLCC) has been found to lead to better maternal and perinatal outcomes, higher satisfaction for women, and increased job satisfaction for midwives.19-21 Implementation of MLCC innovations will affect resources from stakeholders. These resources may be material, financial, social, emotional, or political.23 This, in turn, will trigger a certain reasoning and response from stakeholders, leading to intended or unintended outcomes.23,24 The impact of a complex intervention, such as MLCC, is highly dependent on the context in which it is delivered and how successfully it is implemented.25 It is, therefore, necessary to identify the contexts and mechanisms that will lead to the successful implementation of MLCC in high-income countries. Furthermore, the global healthcare system is under increasing pressure, leading to capacity problems. The main factors contributing to capacity problems in maternity care include a chronic shortage of staff in both MLC and OLC, limited physical space in hospitals, and a rising referral rate.5,26,27 To ensure the provision of high-quality care in the near future, alternative approaches will be needed. Previous studies have shown that reorganizing and shifting tasks and responsibilities between MLC and OLC could reduce the number of women referred to obstetrician-led care.17,28 This will help to balance the workload between MLC and OLC and generate cost savings.5,29 Moreover, expanding the practice of primary care midwives could play an important role in improving the value of care, as shifting responsibilities from secondary care to primary care could improve continuity of care for pregnant women.30
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