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

From: Barriers and enablers in the implementation of a program to reduce cesarean deliveries

DimensionsBarriers and enablersDimens.Barriers and enablers
Factors related to healthcare policy and management  
Policy and macro-managementBarriers:
- 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
- National plans and policies aimed at reducing cesarean rates
Organization of center and personnel managementBarriers:
- 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
- Availability and disposition of anesthesiologists
- Good coordination with Pediatrics and Emergency Departments
Factors related to hospital characteristics
Characteristics of personnel and hospitalBarriers
- 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.
- The close communication in small hospitals can introduce more elements that push personnel to update their practice.
Training of personnelBarriers
- Taking days off work for training is now more difficult than before
- Personnel must assume cost of training
- 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 CareBarriers
- 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
- 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
- The PAC not being presented and explained to the staff
- Hospitals without leadership or with recently-established leadership
- 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 resourcesBarriers
- 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
- Having a pH meter available provides clinical and legal backing and facilitates adherence to the recommended time periods
- The remodeled dilation-delivery units facilitate care circuits, making work more fluid