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Table 5 Summary of program barriers and enablers related to the healthcare professionals and to the women and their families

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

DimensionsBarriers and enablersDimensionsBarriers and enablers
Factors related to the motivation and attitudes of healthcare professionals
Legal and medical pressure and professional prestigeBarriers
- Professionals end up doing Defensive Medicine or conservative clinical practice; the specific nature of obstetrics and gynecology mean the pressure is higher in this specialty.
- Doing a cesarean is considered a safe-conduct in the event of a legal dispute
- The responsibility falls more on medical professionals than on midwives
- Pressure due to professional prestige, and individual responsibility
Econ-omic incen-tives, compensationBarriers
- Absence of non-economic incentive system
- Questions regarding validity of individual evaluations of personnel. Suspicion that the audits do not take into account the causative factors
- The economic incentives are low and do not appear to be enablers
- Satisfaction gleaned from doing a good job, recognition by the patients of the care provided
- The audits, if they are positive, serve as positive reinforcement of an individual’s clinical practice and if they are negative they facilitate improvement.
Personal situation and clinical skillBarriers:
- Demotivation caused by changes related to the economic crisis and deterioration of working conditions.
- Practices sometimes based on convenience for the professional
- Some obstetric practices are no longer used, such as external version, and know-how is being lost because they are no longer taught. Some instrumental practices are not as well known as before, while providers continue to use and have a good command of cesarean deliveries.
Factors related to the women giving birth and their families
Pressure on professionalsBarriers
- Fear of pain
- Bad experiences in past or of close friends/family.
- Impatience in waiting for delivery to progress naturally
- Pre-conceived ideas about the “ideal delivery”.
- Improved information circuits for patients and their families
Trust in the professionalsBarriers
- Reduced prestige of hospital
- Distrust and fear of National Healthcare System and its professionals.
- The main fear for conquering fears and prejudices is communication.
- Communication and information exchange during entire gestation is fundamental: women in labor are less likely to assimilate new information.
- Misinformation based on confusion and myths
- Excess of information may overwhelm women
- Contradictions in information from the private system (used for care during pregnancy) and the public system
- Patients who have little decision-making capacity
- Women who want to have “too much” control
- Patients who are well-informed by midwife and gynecologist and do not have too many external influences
- Patients who know that birth is physiological and natural and the less intervention the better