143 Realist review of Midwife-Led Continuity of Care implementation Table 3: CMOCs underpinning the two themes Role ambiguity and conflict, and Personal and professional boundaries. CMO 5 Role conflict There is a division of roles in society, where obstetricians are expected to be primarily responsible for overseeing and managing maternity care. In many hospitals there is a hierarchical structure in which obstetricians hold authority and decision-making power. (C) The implementation of MLCC leads to a shift in roles and power dynamics. The implementation of MLCC creates a discrepancy between the traditional roles and expectations of obstetricians and midwives, and the evolving roles introduced by MLCC. (MRc) Midwives who feel empowered by MLCC may experience greater autonomy and decisionmaking authority in providing holistic care to women throughout the pregnancy and childbirth continuum, whereas midwives who experience uncertainty and anxiety about taking on greater responsibility and authority, may be concerned about their competence or fear potential backlash from medical colleagues. (MRp) Empowered midwives may be willing to collaborate with other stakeholders to address the challenges of implementing MLCC, whereas the anxiety of uncertain midwives may hinder collaboration with other stakeholders. (O) Obstetricians who recognise the potential benefits of MLCC may see added value in the evolving role of midwives, whereas obstetricians who struggle with the role change, may find their established authority and professional boundaries challenged by the increased involvement of midwives, and perceive this as undermining their authority. (MRp) Obstetricians who support the integration of MLCC into the maternity care system, may advocate for collaboration, shared-decision-making, and mutual respect, while resistance to the changes brought by MLCC may lead to conflicts over decision-making authority, patient management, and clinical practice. These conflicts may manifest themselves in strained communication, lack of mutual respect, and difficulties in establishing collaborative relationships between obstetricians and midwives. (O) 36-38 40-43 45-47 50 51 57 59 60 62-64 Role ambiguity and conflict Personal and professional boundaries CMO 6 Work-life balance In a society with a patriarchal norm, there is a disproportionate division of responsibilities for domestic tasks, where women are expected to take on more tasks and are primarily responsible for caregiving roles. As midwifery is a female-dominated profession, the extent to which female midwives are relieved of personal responsibilities such as childcare or informal care determines how the midwife can organise her work. (C) Providing MLCC is associated with the need to be more available for on-call duties, leading to a greater need for flexibility and shared care for personal obligations. (MRc) This leads to feelings of empowerment and autonomy for midwives who experience flexibility, and feelings of frustration, stress, and internal conflict for those who do not. (MRp) Those experiencing flexibility report reduced levels of burnout, improved job satisfaction, and increased motivation to continue providing MLCC, whereas those lacking flexibility tend to experience increased levels of burnout. The latter midwives will explore other ways of doing their work that are more compatible with their personal lives. (O) 34 35 39 42 43 49 51 52 56 58 64 65 69 73 6
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