{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,31]],"date-time":"2026-08-31T12:17:07Z","timestamp":1788178627298,"version":"build-2803163510"},"reference-count":89,"publisher":"BMJ","issue":"8","license":[{"start":{"date-parts":[[2026,8,31]],"date-time":"2026-08-31T00:00:00Z","timestamp":1788134400000},"content-version":"unspecified","delay-in-days":30,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/501100009130","name":"Programme Development Grants","doi-asserted-by":"publisher","award":["PDG - NIHR206404"],"award-info":[{"award-number":["PDG - NIHR206404"]}],"id":[{"id":"10.13039\/501100009130","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["BMJ Open"],"accepted":{"date-parts":[[2026,8,14]]},"published-print":{"date-parts":[[2026,8]]},"abstract":"<jats:sec>\n                    <jats:title>Objectives<\/jats:title>\n                    <jats:p>There has been considerable attention placed on \u2018failures\u2019 of maternity care in high-income countries, with little focus on the drivers of \u2018high-quality\u2019 care delivered at the organisational level. We conducted a realist review with this central focus and report on the first phase, initial programme theories (IPTs) generated from the literature, where a future phase will \u2018test\u2019 the IPTs.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Design<\/jats:title>\n                    <jats:p>A realist review methodology was employed, an interpretative, theory-driven approach designed to explore \u2018what works, for whom, in what circumstances\u2019 using context, mechanism and outcome (CMO) propositions.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Data sources<\/jats:title>\n                    <jats:p>The search strategy used a purposive database (MEDLINE) and hand searches, including peer-reviewed journals, grey literature and policy reports, to identify literature rich and relevant to the research question.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Eligibility criteria for selecting studies<\/jats:title>\n                    <jats:p>As per realist review approaches, we included any English-language literature from peer-reviewed journals, grey literature, policy reports, service guidance and public or professional commentary, from high-income countries, that provided explanatory insights to the operationalisation of \u2018high-quality\u2019 maternity care at the organisational level. Using an a priori definition, high-quality maternity care was defined based on four outcome criteria: higher service user and staff well-being, lower prevalence of complications\/adverse outcomes and optimal use of resources.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Data extraction and synthesis<\/jats:title>\n                    <jats:p>Data extraction configured evidence using the \u2018If, Then, Leading to\u2019 CMO heuristic. The IPTs were iteratively developed from the synthesised data and refined through consultation with a diverse 26-member core stakeholder group.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>The iterative search process included 17 index papers, which were a mix of systematic reviews, primary research studies, commissioned reports, evaluations and commentaries. These papers generated 292 initial CMO hypotheses, which were refined into 11 IPTs focusing on organisational-level mechanisms. The IPTs reflect a \u2018both-and\u2019 philosophy, balancing clinical excellence (safety) and values-based relational care (personalisation and staff environment). Key themes include visible and supportive leadership, responsiveness to workload assessments, ensuring operational fitness (system and workplace environment support) and broadening the definition of safety beyond physical safety to include psychological, emotional and cultural safety. The IPT related to \u2018A culture of equitable care\u2019 was identified as critical in underpinning all maternity service provision.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>The 11 IPTs offer crucial insights into the context and mechanisms that may produce desired outcomes in high-quality maternity care. Learning from high-quality services (safety II) provides a novel approach compared with focusing only on failings. These globally relevant IPTs can be applied to high-income contexts as a foundation for designing future improvement programmes.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>PROSPERO registration number<\/jats:title>\n                    <jats:p>CRD420251104996.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1136\/bmjopen-2026-119351","type":"journal-article","created":{"date-parts":[[2026,8,31]],"date-time":"2026-08-31T11:40:19Z","timestamp":1788176419000},"page":"e119351","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":0,"title":["Understanding the contexts and mechanisms that drive high-quality maternity care outcomes within organisations: generating 11 initial programme theories as phase 1 of a realist review"],"prefix":"10.1136","volume":"16","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-8013-0352","authenticated-orcid":false,"given":"Claire","family":"Feeley","sequence":"first","affiliation":[{"name":"Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King\u2019s College London, London, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ellen","family":"Thaels","sequence":"additional","affiliation":[{"name":"Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King\u2019s College London, London, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-4808-3880","authenticated-orcid":false,"given":"Andrew","family":"Booth","sequence":"additional","affiliation":[{"name":"SCHARR, The University of Sheffield, Sheffield, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Michelle","family":"Quashie","sequence":"additional","affiliation":[{"name":"King\u2019s College London, London, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Farrah","family":"Pradhan","sequence":"additional","affiliation":[{"name":"Royal College of Obstetricians and Gynaecologists, London, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kate","family":"Greenstock","sequence":"additional","affiliation":[{"name":"City University, London, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Alicia","family":"Burnett","sequence":"additional","affiliation":[{"name":"King\u2019s College London, London, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kate","family":"Walker","sequence":"additional","affiliation":[{"name":"University of Nottingham, Nottingham, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Yan-Shing","family":"Chang","sequence":"additional","affiliation":[{"name":"Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King\u2019s College London, London, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Gordon","family":"Prescott","sequence":"additional","affiliation":[{"name":"Lancashire Clinical Trials Unit, University of Lancashire, Preston, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Katrina","family":"Rigby","sequence":"additional","affiliation":[{"name":"Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Soo","family":"Downe","sequence":"additional","affiliation":[{"name":"University of Lancashire, Preston, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"239","published-online":{"date-parts":[[2026,8,31]]},"reference":[{"key":"2026083104402172000_16.8.e119351.1","doi-asserted-by":"publisher","DOI":"10.1016\/S0140-6736(16)31472-6"},{"key":"2026083104402172000_16.8.e119351.2","unstructured":"WHO . 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