Table 4. Summary of barriers related to guideline implementation and adoption to related to maternal and neonatal care.

Healthcare system factors
Lack of resources: predominantly low- and middle-income countries (LMICs)	Low resource settings and LMIC’s lack of capacity to train and update their staff in management of maternal and neonatal care [24, 26, 28, 30]. Lack of financial capacity, lack of equipment and poor quality of facilities for maternal services [22]. Lack of critical clinic and laboratory supplies and essential medicines impacted service delivery, quality of care and practice change [29, 36, 62]. Lack of human resources including lack of trained or qualified health professionals to provide maternity/neonatal care, with flow-on affect for service delivery [36, 45]. Resource limitations also compounded by environmental factors and geographical limitations; women may be unable to travel to health centres, unable to pay for service; lack of access to clean water affecting quality of maternal and neonatal care at a time of vulnerability to infection [49].
Models of care	Lack of woman-centred and comprehensive care, and fragmentation of maternity care in the public health system [22, 23]. Haphazard nature of offering routine screening and consistency of antenatal visits [27, 28, 33]. Challenges to introduce interventions (including preterm birth prevention and management guidelines) in the context of existing substandard intrapartum, birth and newborn care [36].
Poor communication and coordination	Poor information flow between district and central committees, and across the health system with healthcare providers being unaware or not able to access these guidelines [24, 25]. For example, Maternal Death Surveillance and Response requires government commitment for training, maternal death classification and formulating recommendations [24].
Macro-micro level factors	Contextual factors and internal and external environment of the organisation [53]. Political and economic environment, organisational status and culture, regulatory frameworks, resource allocation and system-level support [23, 24, 36, 37, 46].
Overburdened health system	Overburdened national health system, lack of resources, materials and staff shortages, poor accessibility (functional), supply chain bottlenecks [22, 23, 26].
Conflicting priorities and lack of policies	Conflicting healthcare investment priorities, resistance from government, political disinterest [22]. Lack of targeted healthcare policies [22, 24, 27, 49].
Patient and population (Women and community)
Costs and financial resource limitations	Cost effectiveness and acceptability of screening, treatments or medications recommended by guidelines ultimately affecting patient outcomes and quality of care [28, 29, 31, 32]. Lack of access to health insurance or financial constraints hindered women’s abilities to follow guideline recommendations, especially when expensive treatments or medications are recommended [23, 26–28, 50, 63]. Financial constraints were more pronounced for low-resource settings with geographic disparities that made access and follow-up care difficult for woman [23, 29].
Social and cultural influences	Reliance on alternative faith-based care [26, 28], and social vulnerabilities [50, 63]. Women’s real-life constraints [33]. Stigma associated with sexually transmitted disease and need for partner consent to seek healthcare [23].
Lack of health literacy	Low level of health literacy and awareness of services; lack of knowledge about consequences and intervention benefits among the women (and parents) [23, 27, 28, 34, 36, 50].
Patient factors (belief, preferences, practices)	Women’s belief and personal preferences for healthcare and fear of side effects and treatment legitimacy [23, 27, 33, 36, 50, 64].
Lack of stakeholder involvement	Lack of patient and population involvement and joint decision-making opportunities about their care [27].
Guidelines and standards
Multiple or different guidelines in use	Presence of different international and national guidelines [29, 30, 44]. Different clinical protocols and conflicting recommendations across health settings causing practice variations and inconsistencies [23, 41–43].
Guideline availability and access	Lack of guideline availability; difficult to locate; lack of accessibility at the point of care for decision support [44–46].
Complexity and guideline applicability	Complexity, lack of clarity and length of guidelines [43, 46]. Lack of contextualisation and relevance; did not fully account for local variations aligned to resources, or diversity of patient populations or the operating healthcare environment [23, 43, 44, 46, 47, 60].
Variability in guideline development and quality	Lack of a rigorous development process; lack of sufficient evidence-based recommendations [43, 44, 47]. Oversimplified; credibility and applicability concerns undermining clinicians’ confidence in recommendations [30, 43, 44, 46].
Lack of clear benchmarks or standards for practice	Inconsistent clinical guidelines and protocols used to guide practice decisions [36]. Different guidelines used to inform practice (national and international) [27, 35, 44].
Contextual implementation challenges	Lack of planning and insufficient impact monitoring systems [24]. Delays and changes in services resulting in multiple guideline changes over the implementation timeline affecting desired outcomes [29].
Organisational capacity (healthcare organisation, service, or facility level)
Resource constraints	Lack of necessary resources (financial, human, and technological) to support implementation of guidelines at the service level; limited access to essential equipment, technology updates and tools; inability to provide needed training to support health professionals [22, 28–30, 35, 45, 47, 49, 50].
Practice variations in organisations	Different protocols and practices at individual centres or facilities within the health service [24, 28, 30, 35, 36, 46, 48, 52, 53]. Variations in referral practice; variable practice opinions of clinicians [35]. Lack of consensus about interventions and measures to apply in settings [42].
Workflow organisation	Inefficient point of care workflow processes, paper-based documentation rather than electronic tracking systems and alerts [28]. Lack of triggers or reminders as decision support aids integrated with routine clinical workflow into the electronic medical record system for clinicians at the point of care [28, 51]. Poorly designed electronic decision alerts at point of care [65]. Outdated diagnostic tools and algorithms [39]. Lack of automated communication reminders for pregnant woman to adhere to scheduled appointments [28].
Environmental and contextual factors	Organisational status of maternal health services (public-private, non-university, small centres) and resources available to support guidelines implementation [29, 46]. Location-rural maternal centres spread geographically; frequent reassignment of maternal staff between services; diversity of facilities and populations served; large distances to travel and difficulties with follow-up maternity care; inadequate transportation systems to deliver supplies [29].
Organisations’ capabilities	Shortage of well-trained healthcare workers and knowledge discrepancies among different levels of staff [24, 52]. Lack of clinical leadership [25, 27]. Lack of quality improvement initiatives and systems for monitoring guideline adherence and providing feedback to staff [24, 25, 29]. Variation in quality improvement capabilities across centres and culture [53].
Lack of team communication and collaboration	Limited communication and collaboration among different healthcare disciplines [24, 25, 37, 45, 51, 66]. Professional indifference to innovative strategies [51]. Traditional medical hierarchies; lack of stakeholder consensus; blaming exercise culture; poor communication of audit meeting feedback to clinicians [25].
Inadequate dissemination of guidelines	Inadequate communication or restricted dissemination of guidelines [22, 25, 27, 46].
Quality of data and data management systems	Lack off or missing data; poor quality of data collection [24, 25, 39]. Untrained and inexperienced staff and un-motivated data collection [24, 25]. Inadequate response monitoring and data management systems in use [29].
Guideline implementation challenges	Lack of planning around implementation [24]. Lack of guideline adherence and monitoring systems in place [24, 25, 29, 31].
Health professional practice (clinicians)
Lack of guidelines awareness	Lack of current guideline awareness; minimal familairity with guideline content or recommendations for practice; current knowledge and skills deficit [23, 26, 32, 35, 37, 41, 45–47, 49, 57, 60, 62, 66].
Lack of professional motivation and engagement	Professional indifference; lack of motivation (without incentives) to attend training [22, 25, 45, 51, 58, 66].
Resistance to change	Health professional resistance to change; loss of autonmy [22, 38, 44, 46, 48, 52, 66].
Health workers’ attributes and attitudes	Variations in guideline adherence between disciplines [59]. Variations in individual practice [35, 38, 46]. Variable knowledge and health workers’ practice knowledge and skill gaps [24, 26, 27, 30, 32, 36, 41, 44, 45, 48, 51, 52, 60, 66, 67]. Lack of awareness of the degree of noncompliance [42, 60]. Personal beliefs and attitudes (beyond or outside their scope of duties); longstanding or entrenched practices; clinician perceptions [36, 44–46, 48, 49, 51, 60, 67].
Lack of interdisciplinary collaboration	Poor collaboration between health disciplines and units or clincial settings [27, 45, 66]. Traditional health profession hierarchies [25].
Time constraints and workload	Time constraints; heavy workload; busy units [35, 46, 60–62, 66].
Poor quality of reporting	Poor recording; inaccurate and inconsistent reporting; poor documentation quality [24, 25, 28, 60].
Lack of education and training about guidelines	Lack of education and training about guidelines and updates [22–24, 30, 66].