Understanding the implementation of continuity-enhancing innovations as steps towards midwife-led continuity of care: A qualitative study using Normalization Process Theory

Objective: To examine how specific midwife-led continuity of care elements are implemented and sustained in a maternity care system where independent community midwives collaborate with hospital-based care professionals. Methods: An explanatory qualitative study was conducted, using the Normalization Process Theory as a conceptual framework. Maternity care networks that had implemented an innovation contributing to midwife-led continuity of care were included in the study. Stakeholders invited to participate in semi-structured interviews included community midwives, hospital-based midwives, obstetricians, managers, an obstetric nurse, and healthcare insurance company employees. Participants were recruited through an initial purposive sampling strategy. As data collection progressed, theoretical sampling was applied. Results: A total of 47 interviews were conducted with stakeholders from nine different maternity care networks. While many participants expressed strong conceptual support for midwife-led continuity of care (coherence), this did not always translate into aligned action in practice (collective action). Trust between stakeholders and financial feasibility were dominant themes across all four constructs of the Normalization Process Theory. Trust was found to develop incrementally through small collaborative steps but remained fragile in competitive or hierarchical networks. Financial structures shaped both engagement and resistance. Conclusion: The implementation process and normalization of midwife-led continuity of care elements are not only shaped by practical or organizational considerations but are also highly dependent on trust between stakeholders and financial feasibility. As dual preconditions, trust and financial alignment must be in place for stakeholders to consider new collaborative models and to be able to act in line with their beliefs. In systems with longstanding institutional divisions and fragmented funding, transformative change requires simultaneous investment in relational infrastructure and financial redesign.