129 Realist review of Midwife-Led Continuity of Care implementation INTRODUCTION Midwife-led continuity of care (MLCC) results in better maternal and perinatal outcomes, higher satisfaction among women, and increased job satisfaction among midwives than other models of care.2-4 The World Health Organisation (WHO) guidelines for antenatal and intrapartum care recommend MLCC in regions with wellfunctioning midwifery programs.5 Despite the high-quality evidence supporting MLCC, access to this model is limited, both within individual countries and internationally. The MLCC model has been defined as care where ‘the midwife is the lead professional in the planning, organisation, and delivery of care given to a woman from initial booking to the postnatal period’.4 Globally, there are considerable variations in the organisation of midwifery services.6 Some models of MLCC provide continuity of care to a defined group of women through a team of midwives sharing a caseload, often called ‘team midwifery’. Here, a woman will receive her care from a number of midwives in the team, the size of which can vary. Another model, often called ‘caseload midwifery’, aims to offer better relational continuity by ensuring that women receive care from one midwife, sometimes together with a practice partner.7 Women receiving MLCC are more likely to have a spontaneous vaginal birth, to report more positive birthing experiences, and are less likely to experience a caesarean section, vaginal assisted birth, and may be less likely to experience episiotomy.4 For women with social risk factors, MLCC appears to have a protective effect on preterm birth and low birth weight.2 8 Although there are concerns that some aspects of MLCC models may negatively impact midwives, such as increased availability outside working hours, inadequate staffing levels, and difficulties with work-life balance,9-11 most midwives working in MLCC experience lower levels of burnout,12 anxiety and depression, compared to those working in standard models of care.13 In response, various formats of MLCC models have been implemented internationally. However, the number of women having access to MLCC varies among countries. With the exception of New Zealand, none of the high-income countries, as defined by the World Bank, managed to scale-up MLCC to being the standard of care for all women.14 Barriers to expanding or implementing MLCC are establishment funding, availability of midwifery staff, and lack of strong support for the innovation.15 On the other hand, leadership that builds trusting relationships across all practice and organisational boundaries, staff involvement, and ongoing evaluation of progress and impact develops the context for successful implementation of MLCC.16 17 For a deeper understanding of a complex intervention, like MLCC implementation, it is essential to identify and understand both contextual factors as well as underlying mechanisms. Complex interventions comprise multiple components that interact with 6
RkJQdWJsaXNoZXIy MTk4NDMw