Table 4 Summary of program barriers and enablers related to healthcare policy and management and to hospital characteristics

Policy and macro-management

Barriers:

- Institutional policy has limited capacity to influence real clinical practice

- Low commitment by the healthcare center to implement policy

- Lack of investment by upper management levels

- Distance between institutions and the day-to-day reality of healthcare centers

- High degree of centralization of the healthcare system and little collaboration among centers

Enablers

- National plans and policies aimed at reducing cesarean rates

Organization of center and personnel management

Barriers:

- The hierarchy of doctors and that of nurse-midwives is separate, with two different management lines

- Rigid structure makes it difficult to establish incentives for good clinical practice and sanctions for poor clinical practice

- The reorganization of competences between nurse-midwives and Ob-Gyns has created conflict

- Departments besides obstetrics/gynecology are not involved in or even aware of project

Enablers

- Availability and disposition of anesthesiologists

- Good coordination with Pediatrics and Emergency Departments

Characteristics of personnel and hospital

Barriers

- Resistance to change shown by some professionals and the difficulty of “unlearning” the way things are usually done.

- More years of professional practice perceived as a factor that heightens resistance to updating practices.

Enablers

- The close communication in small hospitals can introduce more elements that push personnel to update their practice.

Training of personnel

Barriers

- Taking days off work for training is now more difficult than before

- Personnel must assume cost of training

Enablers

- Training has allowed professionals to update their knowledge and skills for less interventionist deliveries, and it has also contributed to a change in the professionals’ mentality

Cooperation within the department and with Primary Care

Barriers

- Nurse-midwives describe themselves as more inclined to non-intervention than the medical personnel but it is the latter who make the final decision about the delivery

- Many primary care centers do not have nurse-midwives on staff

Enablers

- Efforts and initiatives to improve cooperation between nurse-midwives and Ob-Gyns

- The information and guidance provided by nurse-midwives on staff at primary care centers

Leader-ship

Barriers

- The PAC not being presented and explained to the staff

- Hospitals without leadership or with recently-established leadership

Enablers

- Managers who are actively involved: motivating, raising awareness about the program, facilitating access to the necessary resources, providing supervision and evaluation

- Managers who have capacity to negotiate, a good knowledge of the department and the staff, the ability to delegate, appropriate training, communication skills

Availability of human and material resources

Barriers

- Absence of monitoring equipment

- Obsolete delivery rooms with a medicalized appearance

- Distance between delivery room and operating room

- Shortage of nurse-midwives in deliveries without complications and shortage of medical personnel in deliveries with complications