Barriers and facilitators when implementing midwifery continuity of carer: a narrative analysis of the international literature.
CFIR
Implementation
Maternity care
Midwifery
Midwifery continuity of carer
Policy
Journal
BMC pregnancy and childbirth
ISSN: 1471-2393
Titre abrégé: BMC Pregnancy Childbirth
Pays: England
ID NLM: 100967799
Informations de publication
Date de publication:
14 Aug 2024
14 Aug 2024
Historique:
received:
17
01
2024
accepted:
18
06
2024
medline:
15
8
2024
pubmed:
15
8
2024
entrez:
14
8
2024
Statut:
epublish
Résumé
Midwifery continuity of carer (MCoC) is a model of care in which the same midwife or small team of midwives supports women throughout pregnancy, birth and the postnatal period. The model has been prioritised by policy makers in a number of high-income countries, but widespread implementation and sustainability has proved challenging. In this narrative review and synthesis of the global literature on the implementation and sustainability of midwifery continuity of carer, we identify barriers to, and facilitators of, this model of delivering maternity care. By mapping existing research evidence onto the Consolidated Framework for Implementation Research (CFIR), we identify factors for organisations to consider when planning and implementing midwifery continuity of carer as well as gaps in the current research evidence. Analysing international evidence using the CFIR shows that evidence around midwifery continuity of carer implementation is patchy and fragmented, and that the impetus for change is not critically examined. Existing literature pays insufficient attention to core aspects of the innovation such as the centrality of on call working arrangements and alignment with the professional values of midwifery. There is also limited attention to the political and structural contexts into which midwifery continuity of carer is introduced. By synthesizing international research evidence with the CFIR, we identify factors for organisations to consider when planning and implementing midwifery continuity of carer. We also call for more systematic and contextual evidence to aid understanding of the implementation or non-implementation of midwifery continuity of carer. Existing evidence should be critically evaluated and used more cautiously in support of claims about the model of care and its implementation, especially when implementation is occurring in different settings and contexts to the research being cited.
Sections du résumé
BACKGROUND
BACKGROUND
Midwifery continuity of carer (MCoC) is a model of care in which the same midwife or small team of midwives supports women throughout pregnancy, birth and the postnatal period. The model has been prioritised by policy makers in a number of high-income countries, but widespread implementation and sustainability has proved challenging.
METHODS
METHODS
In this narrative review and synthesis of the global literature on the implementation and sustainability of midwifery continuity of carer, we identify barriers to, and facilitators of, this model of delivering maternity care. By mapping existing research evidence onto the Consolidated Framework for Implementation Research (CFIR), we identify factors for organisations to consider when planning and implementing midwifery continuity of carer as well as gaps in the current research evidence.
RESULTS
RESULTS
Analysing international evidence using the CFIR shows that evidence around midwifery continuity of carer implementation is patchy and fragmented, and that the impetus for change is not critically examined. Existing literature pays insufficient attention to core aspects of the innovation such as the centrality of on call working arrangements and alignment with the professional values of midwifery. There is also limited attention to the political and structural contexts into which midwifery continuity of carer is introduced.
CONCLUSIONS
CONCLUSIONS
By synthesizing international research evidence with the CFIR, we identify factors for organisations to consider when planning and implementing midwifery continuity of carer. We also call for more systematic and contextual evidence to aid understanding of the implementation or non-implementation of midwifery continuity of carer. Existing evidence should be critically evaluated and used more cautiously in support of claims about the model of care and its implementation, especially when implementation is occurring in different settings and contexts to the research being cited.
Identifiants
pubmed: 39143464
doi: 10.1186/s12884-024-06649-y
pii: 10.1186/s12884-024-06649-y
doi:
Types de publication
Journal Article
Review
Langues
eng
Sous-ensembles de citation
IM
Pagination
540Subventions
Organisme : National Institute for Health and Care Research
ID : NIHR151802
Organisme : National Institute for Health and Care Research
ID : NIHR151802
Organisme : National Institute for Health and Care Research
ID : NIHR151802
Organisme : National Institute for Health and Care Research
ID : NIHR151802
Organisme : National Institute for Health and Care Research
ID : NIHR151802
Organisme : National Institute for Health and Care Research
ID : NIHR151802
Organisme : National Institute for Health and Care Research
ID : NIHR151802
Organisme : National Institute for Health and Care Research
ID : NIHR151802
Organisme : National Institute for Health and Care Research
ID : NIHR151802
Informations de copyright
© 2024. The Author(s).
Références
Homer C, Brodie P, Sandall J, Leap N. Introduction. In: Homer C, Leap N, Brodie P, Sandall J, editors. Midwifery continuity of care. Second edition ed. Chatswood NSW: Elsevier; 2019. p. xxv-xxix.
Haggerty JL, Reid RJ, Freeman GK, Starfield BH, Adair CE, McKendry R. Continuity of care: a multidisciplinary review. BMJ. 2003;327:1219.
pubmed: 14630762
pmcid: 274066
doi: 10.1136/bmj.327.7425.1219
Saultz JW. Defining and measuring interpersonal continuity of care. Ann Fam Med. 2003;1(3):134–43.
pubmed: 15043374
pmcid: 1466595
doi: 10.1370/afm.23
McIntosh T. A social history of maternity and childbirth: key themes in maternity care. Abingdon, New York: Routledge; 2012.
Burau V, Overgaard C. Caseload midwifery as organisational change: the interplay between professional and organisational projects in Denmark. BMC Pregnancy Childbirth. 2015;15:121.
pubmed: 26013394
pmcid: 4493809
doi: 10.1186/s12884-015-0546-8
HSCNI Public Health Agency. Continuity of Midwifery Carer [Internet] Northern Ireland: Public Health Agency 2023 [ https://www.publichealth.hscni.net/directorates/nursing-midwifery-and-allied-health-professions/midwifery/continuity-midwifery-carer .
Mejia A, Shirazi R, Beech R, Balmer D. Planning midwifery services to deliver continuity of care. J Oper Res Soc. 1998;49(1):33–41.
doi: 10.1057/palgrave.jors.2600486
Symon A, Shinwell S, Craig J. Process lessons from evaluating a combined continuity of carer and home birth scheme. Birth. 2020;47(4):389–96.
pubmed: 33289141
doi: 10.1111/birt.12514
Farquhar M, Camilleri-Ferrante C, Todd C. Working with team midwifery: health visitors’ views of one team midwifery scheme. J Adv Nurs. 1998;27(3):546–52.
pubmed: 9543040
doi: 10.1046/j.1365-2648.1998.00554.x
Sandall J, Soltani H, Gates S, Shennan A, Devane D. Midwife-led continuity models versus other models of care for childbearing women. Cochrane Database Syst Rev. 2016;4(4):CD004667.
pubmed: 27121907
Taylor B, Cross-Sudworth F, Goodwin L, Kenyon S, MacArthur C. Midwives’ perspectives of continuity based working in the UK: a cross-sectional survey. Midwifery. 2019;75:127–37.
pubmed: 31100484
doi: 10.1016/j.midw.2019.05.005
Adcock JE, Sidebotham M, Gamble J. What do midwifery leaders need in order to be effective in contributing to the reform of maternity services? Women Birth. 2022;35(2):e142–52.
pubmed: 33931350
doi: 10.1016/j.wombi.2021.04.008
Prussing E, Browne G, Dowse E, Hartz D, Cummins A. Implementing midwifery continuity of care models in regional Australia: a constructivist grounded theory study. Women Birth. 2023;36(1):99–107.
pubmed: 35410848
doi: 10.1016/j.wombi.2022.03.006
Styles C, Kearney L, George K. Implementation and upscaling of midwifery continuity of care: the experience of midwives and obstetricians. Women Birth. 2020;33(4):343–51.
pubmed: 31474386
doi: 10.1016/j.wombi.2019.08.008
World Health Organization (WHO). WHO recommendations on maternal health: guidelines approved by the WHO Guidelines Review Committee. Geneva: World Health Organization; 2017.
International Confederation of Midwives (ICM). Position statement: Midwife-led Continuity of Care (MLCC) [Internet]: International Confederation of Midwives. 2021 [ https://www.internationalmidwives.org/our-work/policy-and-practice/icm-position-statements/ .
Grigg CP, Tracy SK. New Zealand’s unique maternity system. Women Birth. 2013;26(1):e59–64.
pubmed: 23107645
doi: 10.1016/j.wombi.2012.09.006
Maternity Services Review. Improving Maternity Services in Australia. The report of the Maternity Services Review. Canberra: Government of Australia Department of Health and Aged Care; 2009.
Dawson K, McLachlan H, Newton M, Forster D. Implementing caseload midwifery: exploring the views of maternity managers in Australia - A national cross-sectional survey. Women Birth. 2016;29(3):214–22.
pubmed: 26603016
doi: 10.1016/j.wombi.2015.10.010
Department of Health. Changing Childbirth Part 1: report of the Expert Maternity Group (Cumberlege Report). London; 1993.
NHS England. Better births: improving outcomes of maternity services in England - A five year forward view for maternity care. London: NHS England; 2016.
Department of Health and Social Care (DHSC). Women’s Health Strategy for England. London; 2022.
NHS. The NHS Long Term Plan. UK: National Health Service,; 2019. Contract No.: 11/12/23.
Scottish Government. The best start: five-year plan for maternity and neonatal care. Edinburgh: Scottish Government; 2017.
Independent Maternity Review. Ockenden Report - Final: findings, conclusions, and essential actions from the independent review of maternity services at The Shewsbury and Telford NHS Trust (HC1219) London: Crown. 2022 [ https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/1064302/Final-Ockenden-Report-web-accessible.pdf .
NHS England. Letter to NHS trusts in response to Ockenden final report. London: NHS England; 2022.
Wraight A, Ball J, Seccombe I, Stock J. Mapping Team Midwifery: a report to the Department of Health. London: Institute of Manpower Studies; 1993.
Hanley A, Davis D, Kurz E. Job satisfaction and sustainability of midwives working in caseload models of care: an integrative literature review. Women Birth. 2022;35(4):e397–407.
pubmed: 34257046
doi: 10.1016/j.wombi.2021.06.003
Brown M, Dietsch E. The feasibility of caseload midwifery in rural Australia: a literature review. Women Birth. 2013;26(1):e1–4.
pubmed: 23010666
doi: 10.1016/j.wombi.2012.08.003
Bradford BF, Wilson AN, Portela A, McConville F, Fernandez Turienzo C, Homer CSE. Midwifery continuity of care: a scoping review of where, how, by whom and for whom? PLOS Glob Public Health. 2022;2(10):e0000935.
pubmed: 36962588
pmcid: 10021789
doi: 10.1371/journal.pgph.0000935
Donnellan-Fernandez RE, Creedy DK, Callander EJ. Cost-effectiveness of continuity of midwifery care for women with complex pregnancy: a structured review of the literature. Health Econ Rev. 2018;8(1):32.
pubmed: 30519755
pmcid: 6755549
doi: 10.1186/s13561-018-0217-3
Hewitt L, Dahlen HG, Hartz DL, Dadich A. Leadership and management in midwifery-led continuity of care models: a thematic and lexical analysis of a scoping review. Midwifery. 2021;98:102986.
pubmed: 33774389
doi: 10.1016/j.midw.2021.102986
Leavy F, Leggett H. Midwives’ experiences of working in team continuity of carer models: a qualitative evidence synthesis. Midwifery. 2022;112:103412.
pubmed: 35780704
doi: 10.1016/j.midw.2022.103412
Pace CA, Crowther S, Lau A. Midwife experiences of providing continuity of carer: a qualitative systematic review. Women Birth. 2022;35(3):e221–32.
pubmed: 34253467
doi: 10.1016/j.wombi.2021.06.005
Homer CS. Models of maternity care: evidence for midwifery continuity of care. Med J Aust. 2016;205(8):370–4.
pubmed: 27736625
doi: 10.5694/mja16.00844
Fernandez Turienzo C, Rayment-Jones H, Roe Y, Silverio SA, Coxon K, Shennan AH, et al. A realist review to explore how midwifery continuity of care may influence preterm birth in pregnant women. Birth. 2021;48(3):375–88.
pubmed: 33749001
doi: 10.1111/birt.12547
Corrigan AE, Lake S, McInnes RJ. Normalisation process theory as a conceptual framework for continuity of carer implementation. Women Birth. 2021;34(2):e204–9.
pubmed: 32139185
doi: 10.1016/j.wombi.2020.02.017
Greenhalgh T, Thorne S, Malterud K. Time to challenge the spurious hierarchy of systematic over narrative reviews? Eur J Clin Invest. 2018;48(6):e12931.
pubmed: 29578574
pmcid: 6001568
doi: 10.1111/eci.12931
Damschroder LJ, Reardon CM, Widerquist MAO, Lowery J. The updated Consolidated Framework for Implementation Research based on user feedback. Implement Sci. 2022;17(75).
Damschroder LJ, Aron DC, Keith RE, Kirsh SR, Alexander JA, Lowery JC. Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science. Implement Sci. 2009;4:50.
pubmed: 19664226
pmcid: 2736161
doi: 10.1186/1748-5908-4-50
Page M, McKenzie J, Bossuyt P, Boutron I, Hoffmann T, Mulrow C, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2021;372:n71.
pubmed: 33782057
pmcid: 8005924
doi: 10.1136/bmj.n71
Braun V, Clarke V. Can I use TA? Should I use TA? Should I not use TA? Comparing reflexive thematic analysis and other pattern-based qualitative analytic approaches. Couns Psychother Res. 2020;21(1):37–47.
doi: 10.1002/capr.12360
King N, Brooks J. Thematic analysis in organisational research. In: Cassell C, Cunliffe AL, Grandy G, editors. The SAGE handbook of qualitative business and management research methods: methods and challenges. SAGE Publications Ltd,; 2018.
McInnes RJ, Aitken-Arbuckle A, Lake S, Hollins Martin C, MacArthur J. Implementing continuity of midwife carer - just a friendly face? A realist evaluation. BMC Health Serv Res. 2020;20(304).
Turner S, Crowther S, Lau A. A grounded theory study on midwifery managers’ views and experiences of implementing and sustaining continuity of carer models within the UK maternity system. Women Birth. 2022;35(5):e421–31.
pubmed: 34810140
doi: 10.1016/j.wombi.2021.10.010
Thorpe D, Neiman S, White J, Pezaro S. A midwifery team’s journey implementing and sustaining continuity of care. Br J Midwifery. 2022;30(9):518–25.
doi: 10.12968/bjom.2022.30.9.518
Newton M, Dawson K, Forster D, McLachlan H. Midwives’ views of caseload midwifery - comparing the caseload and non-caseload midwives’ opinions. A cross-sectional survey of Australian midwives. Women Birth. 2021;34(1):e47–56.
pubmed: 32653395
doi: 10.1016/j.wombi.2020.06.006
Dawson K, Forster DA, McLachlan HL, Newton MS. Operationalising caseload midwifery in the Australian public maternity system: findings from a national cross-sectional survey of maternity managers. Women Birth. 2018;31(3):194–201.
pubmed: 28964707
doi: 10.1016/j.wombi.2017.08.132
Tracy SK, Hartz DL, Tracy MB, Allen J, Forti A, Hall B, et al. Caseload midwifery care versus standard maternity care for women of any risk: M@NGO, a randomised controlled trial. Lancet. 2013;382(9906):1723–32.
pubmed: 24050808
doi: 10.1016/S0140-6736(13)61406-3
McLachlan HL, Forster DA, Davey M-A, Farrell T, Gold L, Biro MA, et al. Effects of continuity of care by a primary midwife (caseload midwifery) on caesarean section rates in women of low obstetric risk: the COSMOS randomised controlled trial. BJOG. 2012;119(12):1483–92.
pubmed: 22830446
doi: 10.1111/j.1471-0528.2012.03446.x
Forster DA, McLachlan HL, Davey M-A, Biro MA, Farrell T, Gold L, et al. Continuity of care by a primary midwife (caseload midwifery) increases women’s satisfaction with antenatal, intrapartum and postpartum care: results from the COSMOS randomised controlled trial. BMC Pregnancy Childbirth. 2016;16:1–13.
doi: 10.1186/s12884-016-0798-y
Walker SB, Moore HD, Eaton A. North Queensland midwives’ experience with a team model of midwifery care. Aust J Midwifery. 2004;17(1):17–22.
pubmed: 15079981
doi: 10.1016/S1448-8272(04)80020-8
Martin CJH, MacArthur J, Martin CR, McInnes RJ. Midwives’ views of changing to a continuity of Midwifery Care (CMC) model in Scotland: a baseline survey. Women Birth. 2020;33(5):e409–19.
pubmed: 31780253
doi: 10.1016/j.wombi.2019.08.005
Fernandez Turienzo C, Hull LH, Coxon K, Bollard M, Cross P, Seed PT, et al. A continuity of care programme for women at risk of preterm birth in the UK: process evaluation of a hybrid randomised controlled pilot trial. PLoS ONE. 2023;18(1):e0279695.
pubmed: 36634125
pmcid: 9836307
doi: 10.1371/journal.pone.0279695
Menke J, Fenwick J, Gamble J, Brittain H, Creedy DK. Midwives’ perceptions of organisational structures and processes influencing their ability to provide caseload care to socially disadvantaged and vulnerable women. Midwifery. 2014;30(10):1096–103.
pubmed: 24462188
doi: 10.1016/j.midw.2013.12.015
Newton MS, McLachlan HL, Forster DA, Willis KF. Understanding the ‘work’ of caseload midwives: a mixed-methods exploration of two caseload midwifery models in Victoria, Australia. Women Birth. 2016;29(3):223–33.
pubmed: 26631349
doi: 10.1016/j.wombi.2015.10.011
Stevens T, McCourt C. One-to-one midwifery practice part 4: sustaining the model. Br J Midwifery. 2002;10(3):174–9.
doi: 10.12968/bjom.2002.10.3.10207
Todd CJ, Farquhar MC, Camilleri-Ferrante C. Team midwifery: the views and job satisfaction of midwives. Midwifery. 1998;14(4):214–24.
pubmed: 10076316
doi: 10.1016/S0266-6138(98)90093-6
Jepsen I, Mark E, Nohr EA, Foureur M, Sorensen EE. A qualitative study of how caseload midwifery is constituted and experienced by Danish midwives. Midwifery. 2016;36:61–9.
pubmed: 27106945
doi: 10.1016/j.midw.2016.03.002
Bourgeault IL, Luce J, MacDonald M. The caring dilemma in midwifery: balancing the needs of midwives and clients in a continuity of care model of practice. Community Work Fam. 2006;9(4):389–406.
doi: 10.1080/13668800600924905
Lewis M. Midwives’ experience of providing continuity of care in a pilot project: findings of a prospective qualitative research study. Int J Childbirth. 2020;10(3):151–61.
doi: 10.1891/IJCBIRTH-D-20-00009
Sandall J. Midwives’ burnout and continuity of care. Br J Midwifery. 1997;5(2):106–11.
doi: 10.12968/bjom.1997.5.2.106
McAra-Couper J, Gilkison A, Crowther S, Hunter M, Hotchin C, Gunn J. Partnership and reciprocity with women sustain lead maternity carer midwives in practice. J N Z Coll Midwives. 2014;49:29–33.
doi: 10.12784/nzcomjnl49.2014.5.29-33
Wakelin K, Skinner J. Staying or leaving: a telephone survey of midwives, exploring the sustainability of practice as lead maternity carers in one urban region of New Zealand. J N Z Coll Midwives. 2007;37:10–4.
Fenwick J, Sidebotham M, Gamble J, Creedy DK. The emotional and professional wellbeing of Australian midwives: a comparison between those providing continuity of midwifery care and those not providing continuity. Women Birth. 2018;31(1):38–43.
pubmed: 28697882
doi: 10.1016/j.wombi.2017.06.013
Hartz DL, White J, Lainchbury KA, Gunn H, Jarman H, Welsh AW, et al. Australian maternity reform through clinical redesign. Aust Health Rev. 2012;36(2):6.
doi: 10.1071/AH11012
Fereday J, Oster C. Managing a work-life balance: the experiences of midwives working in a group practice setting. Midwifery. 2010;26(3):311–8.
pubmed: 18723257
doi: 10.1016/j.midw.2008.06.004
Collins CT, Fereday J, Pincombe J, Oster C, Turnbull D. An evaluation of the satisfaction of midwives’ working in midwifery group practice. Midwifery. 2010;26(4):435–41.
pubmed: 19781827
doi: 10.1016/j.midw.2008.09.004
Josif CM, Barclay L, Kruske S, Kildea S. No more strangers’: investigating the experiences of women, midwives and others during the establishment of a new model of maternity care for remote dwelling aboriginal women in northern Australia. Midwifery. 2014;30(3):317–23.
pubmed: 23676699
doi: 10.1016/j.midw.2013.03.012
Tran T, Longman J, Kornelsen J, Barclay L. The development of a caseload midwifery service in rural Australia. Women Birth. 2017;30(4):291–7.
pubmed: 27931780
doi: 10.1016/j.wombi.2016.11.010
McCaffery S, Small K, Gamble J. Rural Australian doctors’ views about midwifery and midwifery models of care: a qualitative study. Int J Childbirth. 2022;12(1):34–43.
doi: 10.1891/IJC-2021-0007
Cummins AM, Catling C, Homer CSE. Enabling new graduate midwives to work in midwifery continuity of care models: a conceptual model for implementation. Women Birth. 2018;31(5):343–9.
pubmed: 29217169
doi: 10.1016/j.wombi.2017.11.007
Jones A, Maben J, Adams M, Mannion R, Banks C, Blake J et al. Implementation of ‘Freedom to speak up guardians’ in NHS acute and mental health trusts in England: the FTSUG mixed-methods study. HSDR. 2022;10(23).
Haines HM, Baker J, Marshall D. Continuity of midwifery care for rural women through caseload group practice: delivering for almost 20 years. Aust J Rural Health. 2015;23(6):339–45.
pubmed: 26683716
doi: 10.1111/ajr.12232
Dixon L, Guilliland K, Pallant J, Sidebotham M, Fenwick J, McAra-Couper J, et al. The emotional wellbeing of New Zealand midwives: comparing responses for midwives in caseloading and shift work settings. J N Z Coll Midwives. 2017;53:5–14.
doi: 10.12784/nzcomjnl53.2017.1.5-14
Gilkison A, McAra-Couper J, Gunn J, Crowther S, Hunter M, Macgregor D, et al. Midwifery practice arrangements which sustain caseloading lead maternity carer midwives in New Zealand. J N Z Coll Midwives. 2015;51:11–6.
doi: 10.12784/nzcomjnl51.2015.2.11-16
Turnbull D, Reid M, McGinley MC, Shields NR. Changes in midwives’ attitudes to their professional role following the implementation of the midwifery development unit. Midwifery. 1995;11(3):110–9.
pubmed: 7565154
doi: 10.1016/0266-6138(95)90025-X
Callaghan F, Foley C, Olusile M. Setting up a home birth service in East London: lessons learned and reflections on the first year. Br J Midwifery. 2019;27(9):593–6.
doi: 10.12968/bjom.2019.27.9.593
Abbott A. The system of professions: an essay on the division of expert labor. Chicago, London: The University of Chicago Press; 1988. 315 – 26.
doi: 10.7208/chicago/9780226189666.001.0001
Perriman N, Davis DL, Ferguson S. What women value in the midwifery continuity of care model: a systematic review with meta-synthesis. Midwifery. 2018;62:220–9.
pubmed: 29723790
doi: 10.1016/j.midw.2018.04.011
Brigante L, Coxon K, Fernandez Turienzo C, Sandall J. She was there all the time. A qualitative study exploring how women at higher risk for preterm birth experience midwifery continuity of care. Women Birth. 2023.
Office for National Statistics. Families and the labour market, UK: 2021. UK: Office for National Statistics; 2021.
NHS Providers. Rising living costs: the impact of NHS, staff and patients [Internet] UK: NHS Providers. 2022 [ https://nhsproviders.org/rising-living-costs-the-impact-on-nhs-staff-and-patients .
Tracy SK, Hartz D, Nicholl M, McCann Y, Latta D. An integrated service network in maternity—the implementation of a midwifery-led unit. Aust Health Rev. 2005;29(3):332–9.
pubmed: 16053438
doi: 10.1071/AH050332
Edmondson MC, Walker SB. Working in caseload midwifery care: the experience of midwives working in a birth centre in North Queensland. Women Birth. 2014;27(1):31–6.
pubmed: 24148158
doi: 10.1016/j.wombi.2013.09.003
Davis SD, Bayes S, Geraghty S. Development of a tool to identify barriers and enablers to practice innovation in midwifery: a participatory action research study. Eur J Midwifery. 2023;7:1.
pubmed: 36761447
pmcid: 9885374
doi: 10.18332/ejm/157459