Making continuity of midwife care implementable across health systems: A global qualitative study

Continuity of midwife care is associated with improved maternal and neonatal outcomes, reduced intervention, and better care experiences, yet implementation across health systems remains uneven. Existing research has largely identified barriers and facilitators, with less attention to how continuity is made implementable across different health system contexts.

To identify the recurring forms of contextual and system-level work required to make continuity of midwife care implementable across diverse global settings, from the perspectives of midwives and implementation scientists.

Global qualitative descriptive study using the Context and Implementation of Complex Interventions framework.

Participants described continuity of midwife care implementation across diverse health system settings in all six World Health Organization regions.

Twenty-two participants were interviewed, including midwives and implementation scientists with experience implementing continuity of midwife care or related maternal and newborn health-system change. Some participants brought both forms of expertise.

Semi-structured interviews were conducted between June and November 2025. Data were coded deductively using the Context and Implementation of Complex Interventions framework, including macro, meso, and micro system levels and legal, political, sociocultural, socioeconomic, geographical, epidemiological, and ethical domains. Inductive analysis was then used to identify recurring patterns and forms of implementation work.

Continuity of midwife care was implemented through four recurring and overlapping forms of work: authorizing midwives to hold clinical authority, institutionalizing continuity within stable service structures, configuring the model to local conditions, and legitimizing contested professional and organizational change. These forms of work involved interaction across system levels and contextual domains. A cross-cutting finding was a gap between formal implementation science and frontline implementation practice, with much of this work carried out through tacit, relational, and experiential strategies rather than explicit frameworks or tools.

Continuity of midwife care should be understood as complex health-system change rather than simple model adoption. Implementation required actors to reshape the legal, organizational, professional, workforce, and relational conditions that allowed continuity to function in practice. Earlier collaboration between frontline implementers and implementation scientists may strengthen scale-up, transferability, and sustainability.

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