157 Realist review of Midwife-Led Continuity of Care implementation Intrinsic motivation If midwives have knowledge about the proven benefits of MLCC, then they are willing to look for opportunities and find solutions to the barriers with regard to implementing (elements of) MLCC. If midwives are unaware of how MLCC can be implemented in such a way that it will fit their personal lives, then they will not consider implementation of (elements of) MLCC. If midwives are not encouraged to provide MLCC by the organisation they work in, and when providing MLCC creates more disadvantages than advantages for themselves, then they will not consider ways to implement (elements of) MLCC. If midwives have experienced during internship or work engagement how MLCC can improve their work satisfaction by a reduction of stress and an increased feeling of autonomy, then they are motivated to find ways to implement (elements of) MLCC. If midwives see a role model providing MLCC, then they will consider ways to implement it themselves. If midwives are aware of the proven benefits of MLCC, and have experienced the benefits of MLCC during internship or work engagement, or they see a role model providing MLCC, then they will try to convince their fellow midwives to implement (elements of) MLCC. If community midwives are concerned about the responsibility when providing MLCC, then they are afraid of implementing MLCC, because it gives more responsibilities. If community midwives have a check and control attitude, then they are afraid of implementing MLCC, because they do not have much confidence in the physiology of pregnancy and birth. If midwives experience a fear of change, then they are not motivated to change their organisation of care with implementing (elements of) MLCC. If midwives feel like they are critiqued for the quality of their care without MLCC, then they are not motivated to implement (elements of) MLCC. Extrinsic motivation If women (potential clients) do not have knowledge about the proven benefits of MLCC, then they will not ask for MLCC and accept regular care. If there is no financial incentive or support to improve care and/or implement MLCC, then midwives are not willing to change their practice to MLCC. If healthcare policymakers allocate sufficient funding for MLCC, then it can promote the implementation of MLCC, ensuring accessibility for a wider range of pregnant women. If community midwives are in a situation where they are not dependent on their financial income, such as when they have a partner with sufficient income, then they will consider to reduce their caseload in order to provide MLCC. 6
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