71 impacto ambiental al ecosistema que se esta invadiendo, se citan a continuación unos ejemplos de

To our knowledge this is the first review to synthesise midwife experiences of working in continuity of carer models. This systematic review has identified themes through synthesis of 17 qualitative studies on this topic. The overarching themes identified through this synthesis are 1) Joy of Practice, 2) Real Midwifery, 3) Counting the Personal Costs, 4) Working in a System, and 5) Strategies to Sustain. While there were a relatively small number of studies included in the review (n=17), the inclusion/exclusion criteria and quality appraisal process has ensured that the quality of data and relevance to the review questions were high. The GRADE CERQual ratings of the synthesis findings indicate that they are transferable to midwives working in similar contexts with high to moderate confidence.

The line of argument generated from the findings of the review surmises that while there are positives of working in this way, midwives must construct professional boundaries to protect their own personal needs. The strategies to sustain which the midwives created enable the positive elements of MCoCer practice whilst negating the challenges presented by working in this way. Support from colleagues and the wider multidisciplinary team enable the midwives to create and implement these strategies for enjoyable and sustainable practice.

The majority of the studies identified that continuity enabled meaningful relationships which were both rewarding and obligating. The paradoxical nature of the midwife-woman relationship is identified by Davies (2017) as,

A Nexus- Women need midwives and midwives need women. (p.139)

The findings in the included studies represented a continuum of midwife perception from predominantly positive experience of this relationship, to overly challenging. Previous studies have also reported that midwives become emotionally fatigued when the development of meaningful relationships with women were either not possible (Sandall 1997) or reciprocal (Deery and Hunter 2010; Deery 2009). The two studies which reported the most positively about continuity of carer practice (Hunter et al. 2016; Moore 2009) evidenced addressing the needs of the midwife, including reciprocal relationships with women, colleagues and support from the wider organisation. The studies which focused on the challenging aspects of MCoCer without the positives signified there was a lack of balance and reciprocity within the midwife-woman relationship (Donald et al. 2012; Cox and Smythe 2011; Engel 2003) which led to the midwives feeling exploited and burnt out. The midwives need for reciprocity in the midwife-woman relationship identifies with the concept of person centred, not simply woman centred practice.

Challenges experienced by the midwives centred around an inability to build meaningful relationships and a lack of work/life balance. Expectation setting with self (Hunter et al. 2016; Edmondson and Walker 2014; Donald et al. 2012; Engel 2003), midwife colleagues (Hunter et al. 2016; Newton et al. 2016; Cummins et al. 2015; Gilkison et al. 2015; Edmondson and Walker 2014; Moore 2009) and with women (Newton et al. 2016; Cummins et al. 2015; Gilkison et al. 2015; McAra- Couper et al. 2014; Edmondson and Walker 2014; Donald et al. 2012; Engel 2003) to create clear practice guidelines and establish professional boundaries helped the midwives negotiate and define their relationship with women, enabling the joy of practice and necessary personal freedom. The importance of this balance is summarised in McAra-Couper et al. (2014):

Although midwives are inspired and sustained by partnership and reciprocal relationships, they also need to negotiate boundaries and ensure their professional and personal lives are integrated and balanced. (p.30)

their own lives. Students highlighted the pressure to complete a certain number of continuity experiences and a lack of choice about how and when they worked as key factors in affecting their enjoyment of their caseloading experiences. Student midwives who were able to organise routine care with women and had supportive mentors enjoyed their experience, which directly reflects the experiences of qualified midwives in continuity of carer models.

The model of continuity which the midwives worked in ranged from mixed risk caseloading practice to team midwifery. Midwives working in low risk caseloading and midwifery group practice in midwife led units did not find working within the system a challenge compared with those who provided all risk caseloading, highlighting the tensions of low and high risk caseloading. The comments made by midwives working in all risk caseloading indicated that they were not supported to practice across the scope of midwifery care, which challenged their ideology and autonomy. Midwives working with low risk women did not experience the same challenges and felt supported and autonomous in their roles. This was described in Moore (2009) as,

None of us are fighting the establishment (p.85)

This finding indicates that while the current system may support midwives to provide care for women without complexities, it appears that the autonomous nature of MCoCer is potentially threatened when complexity and complications are present for women in their care. Both a medically organised model and a financially driven system were discussed in the studies which found the system challenging. A financially driven system is incongruent with the nature and practice of midwifery and therefore causes tension between the aims of the institution and midwives. Midwives who did not feel that they worked in a model which supported woman centred care and supported them as autonomous practitioners experienced frustration and disillusionment, which in turn could lead to burnout. This reflects the qualitative study by Hunter (2004) which highlighted the emotional implications for midwives working in an environment which had a conflicting ideology to their own.