171 Realist review of Midwife-Led Continuity of Care implementation (continued) Macro-level challenges Theory Context Mechanism Proximal outcome Supporting references Resource Response Financial consequences The funding system for community midwives varies per country. Midwives can be employed where they receive a fixed salary, or they can be self-employed where they are compensated per client. Providing MLCC requires more time per client compared to standard care. Reducing the caseload per midwife creates opportunity for the midwives to provide MLCC, though more midwives are needed for the same amount of clients. Transitioning from standard care to MLCC comes with financial loss for employers or self-employed midwives. Employers can look for funding to be able to offer employee midwives the same salary. Self-employed midwives can look for funding to be able to maintain the same financial income. When midwives can provide MLCC with a lower caseload, keeping the same salary and the same amount of working hours, they will be motivated to transition to MLCC. 1 7 9 12 16 22-24 Midwives who depend on their salary, because they are the breadwinner or have arranged their lives on their current salary (for example with their mortgage), are not able to deal with a financial loss. Midwives will not be motivated to provide MLCC. Midwives who are not dependent on their salary, for example because they have a partner responsible for the main income, are able to deal with the financial loss. Midwives who are able to deal with the financial loss, will base the decision whether or not to transition to MLCC on other factors. 6
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