Midwifery leaders' views of the barriers and facilitators for implementing, sustaining and upscaling midwife-led continuity of care in Australia - a qualitative study.

PROBLEM: Despite national and global recommendations, most pregnant women in Australia do not receive midwife-led continuity of care (MLCoC). BACKGROUND: MLCoC improves health outcomes, yet its implementation has been slow. Supportive leadership is essential for upscaling, and insights from midwifery leaders across Australia can inform strategies to enhance national adoption. AIM: To explore midwifery leaders' views on barriers and facilitators to implementing, sustaining and upscaling MLCoC in Australia. METHODS: An exploratory-descriptive qualitative study design was used. Data were collected via semi-structured interviews with 16 midwifery leaders working in public hospitals in metropolitan, regional and remote areas throughout Australia, and analysed using thematic analysis. FINDINGS: The overarching global theme, Transforming maternity care through midwife-led continuity, comprises three themes and 11 sub-themes, which include facilitators and barriers at the system, organisational, and midwifery team levels. At the system level, facilitators for MLCoC models included the sub-themes 'Motivated by better outcomes', 'Policies, research, and service demand as drivers of change' and 'Increasing the reach of MLCoC', while 'Rigidity in complex systems' and 'Maternity care culture' were barriers. At the organisational level, facilitators were 'Leadership and management' and 'Collaboration and engagement', while barriers were 'Lack of support and low priority'. At the midwifery team level, facilitators consisted of 'Supporting midwives' and 'Optimising staffing', while 'Workforce strain and team instability' were important barriers. CONCLUSION: Expanding MLCoC models nationally requires maternity care structures and funding mechanisms that support implementation and scale-up, alongside strong midwifery leadership, interprofessional collaboration, balanced caseloads, reliable leave coverage, and dedicated government support.