141 Realist review of Midwife-Led Continuity of Care implementation Table 2: CMOCs underpinning the two themes Macro-level challenges and Leadership. (Continued) Leadership CMO 4 Client advocacy In a healthcare system where women have varying levels of influence and access to resources, the model of maternity care is influenced by the demands and preferences of influential clients. (C) Women with access to information and resources, may advocate for MLCC as they seek personalised, holistic maternity care, with better health outcomes. This advocacy may stem from previous experiences with maternity care or a desire for alternatives to traditional models of care. (MRc) Women with influence, such as those with higher socioeconomic status, education, or social connections, may have greater access to information, resources, and decision-making power, enabling them to advocate effectively for MLCC. Women with less influence, may face barriers such as limited access to healthcare services, lack of knowledge about available care options and the potential benefits, and systemic inequalities that hinder their ability to advocate for MLCC. (MRp) Women’s advocacy for MLCC can lead to increased awareness, demand, and uptake of MLCC within the healthcare system. By putting pressure on healthcare professionals and policymakers to respond to their preferences and needs, clients can drive the implementation of the model. This increased demand for MLCC can lead to policy changes, resource allocation, and organisational reforms. (O) 33 39 44 46 54 65 70 71 C, contexts; MLCC, midwife-led continuity of care; MRC, mechanism resource; MRp, mechanism response; O, outcome. Leadership To facilitate the transition to MLCC, healthcare systems need visionary leaders with the courage to challenge and adapt the current norms. These leaders, who can be either formal leaders, such as hospital administrators and senior clinicians, or informal leaders, such as influential midwives and obstetricians, play a crucial part in redefining roles, managing power dynamics, and alleviating fears.16 32 34 35 42 46-48 50 52 54-56 Formal leaders have the authority to implement structural changes, allocate resources, and set organisational priorities. Informal leaders, on the other hand, influence their peers through their actions, attitudes, and informal networks. Their support and endorsement of MLCC can significantly impact the broader acceptance and success of the model. The mechanism is shown in CMO3, Table 2. The implementation and sustainability of MLCC is highly dependent on the individuals occupying leadership positions at all levels within the healthcare system. Leaders’ personal contexts have a significant impact on decisions to adopt, support, and sustain MLCC initiatives. A leader who is supportive of MLCC will create a supportive environment and advocates the model’s benefits. When new leaders who are less supportive of MLCC assume positions of authority, they may prioritise alternative care models or redirect resources away from MLCC, undermining its viability and sustainability.35 47 52 53 57 61 74 Obstetricians often have more direct access to policymakers and greater political influence,45 62 which can impact the balance of roles in maternity care and affect the 6
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