145 Realist review of Midwife-Led Continuity of Care implementation literature, it is likely that a shared philosophy is important not only among midwives, but at all levels of the healthcare system.53 54 58 DISCUSSION The synthesis of 45 documents led to a deeper understanding of how and under what circumstances MLCC can be implemented. The CMOCs highlight the resources that comprise MLCC, the mechanisms that enable midwives to implement MLCC in high-income countries, and the factors that influence the degrees of implementation. Additionally, this review revealed both intended and unintended outcomes of MLCC implementation for midwives, organisations, and the healthcare system. The literature on the implementation of MLCC demonstrates the complexity, characterised by multifaceted interplay between societal, regional, interpersonal, and personal factors. The mechanisms involved, can be grouped around macro-level challenges, leadership, role ambiguity and conflict, and personal and professional boundaries. In order for stakeholders to invest in MLCC, it is important to address feelings of anxiety and uncertainty. Changing roles and power dynamics within MLCC can lead to conflict and ambiguity, highlighting the need for clear role definitions and support. Both formal and informal leaders play a crucial role in addressing these challenges, and supporting and facilitating the transition. A complicating factor is the number of stakeholders involved from diverse backgrounds and contexts, each with their own interests and priorities. This can lead to a situation where those with most power and influence ultimately determine the outcome. Comparison with existing literature Despite the evidence supporting MLCC, a division remains between proponents and opponents of this model, resulting in a diversity of care provided. To ensure consistency of care, a societal prioritisation of healthcare strategies with less ambiguity and more concrete directives is essential. This review highlights the multiple barriers to the implementation and sustainability of MLCC. Recognising and naming these barriers, is a starting point for developing effective strategies and for building alliances to overcome them. Acknowledging power imbalances helps to reduce the power of those who maintain or create these barriers, thereby facilitating the implementation of MLCC.61 In settings where diverse stakeholders are involved, such as primary care professionals, medical specialists, hospital directors, and local government, the power dynamics stemming from their diverse backgrounds, mandates and hierarchical positions may hinder the implementation of MLCC. Similar findings have been reported in social science research. Van der Weert et al. described that mechanisms such as 6
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