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Abstract
High rates of cesarean deliveries constitute an important public health problem. Audits, implementing best practices and giving feedback to the professionals have shown considerable promise in reducing rates of cesarean deliveries and mother-child morbidity. This study aims to identify the factors that facilitate change in practice and thus reduce the use of obstetric interventions. We analyzed the experiences of ob-gyns and nurse-midwives who work in Spain’s National Healthcare System and have been involved in the program. The interviews examined factors related to policy/management, hospitals, practitioners and patients.
The barriers identified were: 1) At the management level: limited influence of institutional policy and the scant political commitment perceived. 2) At the organizational level: separation of the hierarchical structure of doctors from that of nurse-midwives, few positive incentives and the strong threat of sanctions for malpractice, inappropriate reorganization of midwife/ob-gyns competencies, 3) Healthcare staff and facility level: reluctance to change accentuated by years of professional practice. 4) Physical resources: obsolete delivery rooms with a medical view, 5) At the professional level: medical and legal pressure, cesarean deliveries considered safe in the event of a legal claim, low motivation due to decline in working conditions, convenience-based practices. 6) Woman giving birth and her family: fear of pain, impatience while waiting for process to occur, misinformation. The enablers include: 1) At the organizational level: good coordination with paediatrics and emergency departments, 2) Training: skills updates for a less-interventionist approach, increased awareness, 3) Health professionals: satisfaction for a job well done, recognition by patients. 4) Woman giving birth: information circuits for patients and their families, trust in health professionals.
These results allow a better understanding of the problems that remain latent and that emerge in the day-to-day activity of the healthcare professionals attending births in public hospitals.