139 Realist review of Midwife-Led Continuity of Care implementation Macro-level challenges Despite government policies supporting the benefits of MLCC in some countries, its implementation remains challenging.35 39 46 49-51 Financial structures are most often mentioned as having a major impact on the potential to integrate MLCC into the healthcare system.34 35 38 41 45 49 52-58 Traditional fee-for-service models ensure that MLCC generates less financial income for healthcare organisations, as preventive care leads to fewer interventions.35 37 45 59 A changed financing system should be based on providing the best possible care for the client, rather than reinforcing conflicting interests between professionals and organisations.40 45 60 “One of the biggest problems faced by the birth center has been financial. Inpatient obstetrical care and normal newborn care are not moneymakers for any hospital. In the case of the birth center, the small volume combined with high percentage of women that are publicly funded makes it a target for hospital executives looking to cut costs. It has taken significant effort to demonstrate the financial and nonfinancial benefits of the birth center to the hospital.” 59(Page 306) Inequitable funding models between disciplines can lead to perverse incentives. Similarly, unequal or unclear legal and regulatory rules can lead to interpersonal conflicts. In addressing these systemic barriers, MLCC involves a shift in roles and responsibilities among care providers, which can lead to potential role conflicts. A description of this mechanism is presented in Table 2, CMO1. Healthcare systems allow for diverse interpretations of government recommendations. When hospitals are run as independent businesses, they have considerable autonomy in how services are organised and provided. Each hospital has some freedom to decide which facilities to invest in and how to allocate resources. The variation is exacerbated by the diverse approaches taken to meet the increasing pressures on healthcare systems to optimise resource allocation and reduce expenditure while maintaining or improving the quality of services. Table 2, CMO2 gives insight in the polarisation that can result. 6
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