137 Realist review of Midwife-Led Continuity of Care implementation majority of these documents are based on qualitative data, and provide an in-depth insight into the experiences and perspectives of stakeholders involved in MLCC. Key characteristics of the documents included are tabulated in online supplemental material 3. Substantive theory According to RAMESES II, theory and CMOCs should be described at a middle level of abstraction.25 For recognisability in the field of maternity care, it was decided to describe the theory and CMOCs in a concrete manner rather than at an abstract level. To make our findings generalisable and applicable to similar cases, such as model change in other healthcare fields, they are linked to substantive theory. The substantive theories that seemed most appropriate for understanding the challenges of implementing MLCC, are the role theory and power (conflict) theory.30 31 Together, these theories provide a comprehensive framework for understanding the complex interplay of roles and power in implementing MLCC. Role theory elucidates how individuals’ roles within organisations and societies are defined, enacted, and evolve. Roles refer to the social position people hold (e.g. midwife, obstetrician, leader, mother) and the behaviour associated with that position.30 31 Power theory focuses on the power dynamics within social systems, examining how power is distributed, exercised, and contested among individuals and groups.30 31 In the context of MLCC implementation, role theory highlights the complexity of changing established roles and norms, while power theory underscores the challenge of altering traditional power structures. Refined programme theory The literature illustrates the complex web of factors influencing MLCC implementation, with a multifaceted interplay between societal, regional, interpersonal, and personal factors. A framework has been developed to conceptualise the multilevel contextual influences that may affect the reasoning of stakeholders involved in MLCC implementation (Figure 3). Healthcare providers, including midwives and obstetricians, and other stakeholders, such as managers, professional organisations, and policy makers, are accustomed to specific roles and power dynamics within the current maternity care model. The implementation of MLCC disrupts these established roles and power structures, creating uncertainty and anxiety at all levels. This includes anxiety about the change itself, the unknown aspects of the new model, the potential impact on job roles, and the potential loss of job components or authority.32-45 The profound changes that come with the implementation of MLCC require bold realignments within the healthcare system.33 39 46 To successfully navigate through these complexities, both 6
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