Table 3. Initial concepts, emergent themes, final themes and supporting quotes.

Initial concepts	Emergent themes	Papers	Illustrative quotes	Final summary themes
Power of medical profession	Balance of power between stakeholders: Professional power, roles and relationships	42,46,47, 49,50,52–54,57,58, 60,61,62	“It is very difficult to work in this structure where doctors always have the first place.” (Binfa 2013:1155) “There were lots of people who had lots of doubts about it [normal labour pathway] for lots of reasons—whether this was appropriate for midwives?” (Hunter 2010a:229) “I just feel that we’ve [midwives and obstetricians have] got different agendas.” (Midwife, Cheyne 2015:336) “What I have witnessed in medical assemblies during these years was that we were the last; our efforts are not rewarded neither from financially or spiritually. And not recognising our profession and its hardships, takes all the encouragement away.” (Midwife, Janani 2015:1376, Iran). “The law does not protect midwives. Physicians are more protected by law.” (Midwife, Yazdizadeh 2011:6) The (fee reduction) policy was well-adopted by the hospital managers. Nurses and midwives in general perceived the policy as a positive one… doctors, and especially specialists were often found to use their power position to implement the policy half-heartedly or to change it to their advantage. (Witter 2016:12) “… to have the hierarchy of the doctors and nurses be less pronounced.” (Mother, Kennedy 2016:342)	Health system, organizational and structural factors
Power of midwifery profession
Relationships with women
Facilitator of access to CS for women and midwives	Fee exemption/reduction policies as mediators of access to necessary and unnecessary CS	28,43,44, 58,59,60	"There are more referrals thanks to the exemptions policy. Matrones no longer keep back in the cases women who lack the means‴ (Facility Key Informant, Witter 2008) You demand total non-charging, but it doesn’t happen like that at all. It’s not the state that is in charge of the health centres.’ (man, Witter 2009:6) “It has created too much robbery.” (Husband, Lange 2016:57) “Sometimes after the C-section, the sore can become infected…even when the sore heals… It reduces the strength and economic activities that you can do (” (Mother, Rishworth 2016:e123) L’argent des césariennes: une bouffée d’oxygène pour les hôpitaux: ('cesarean income; a breath of oxygen for the hospitals') (Mbaye 2011:216)
Short and long term costs of free for families
CS revenue as a means of income generation for facilities
Health insurance, women’s choice and/or clinicians’ indication	Health insurance reform as a mediator of access to necessary and unnecessary CS	27,29,47, 48	“The charge for CS was high. Under profit driving, CS rate increased.” (Zhu, 2013) “Proportional reimbursement may have some effect on the caesarean delivery rate. Caesarean delivery would cost 200 yuan and women could get nearly 1000 yuan back.” (Health Manager, Huang 2012:7) “In Iran, the insurance companies sign a contract with healthcare providers and pay them rather than compensating the service itself. Considering the fact that the service provided by the midwives is not covered by insurance companies, expectant moms prefer to go to a specialist. In this situation the rate of additional interventions and C-sections would increase.” (Yazdizadeh 2011:4)
Power of insurance companies
Built environment as barrier or facilitator to a positive labour and birth experience	Birth environment, efficiency concerns and organisational logistics	28,36,39, 40–42,46, 47,49, 51,55–58,61,62	Worked to improve birth environment–but beds got moved back. (Marshall 2015:336) They [the midwives] view the home setting and the presence of valued and welcomed friends and relatives as key elements… (Sakala 1993:1242) “…one labour room was shared between three mothers. One of them had given birth 30 minutes ago and the baby was in the Kangaroo position on the mother's chest, one of them was expected to be in full dilation, and one of them was in the early stages of labour". (Field note, Behruzi 2010:11) “Contrary to international standards, the size of our labor rooms have reduced and they have been converted into operating rooms over time. . . .” (Midwife) …“These facilities are old fashioned and designed for group labor rooms, and therefore should be modified.” (Physician) (Yazdizadeh 2011:9) “The Labor room lacked appropriate air-conditioning and adequate lighting… equipment and facilities for the use of non-pharmacological methods of pain relief were not enough.” (Janani 2015:1376)
Time and resource constraints on labour progress
Organisational policy priorities and use of room(s)
Type of hospital (independent/ private or public)	Role of hospital in acceptability of interventions to reduce unnecessary CS	36,42–44, 46,47,55	““…independent hospitals do anything to have higher incomes;” (Yazdizadeh 2011:7) “In the private sector, providers are reimbursed approximately $700 for normal childbirth and $1,500 for caesarean section.” (Colomar 2014:2388) “This hospital accepts trainees, and we cannot stay with mothers all the time.” [Behruzi 2010:12] “The big women’s and children’s hospitals are teaching hospitals, and are training sites for residents and specialists [who need surgical experience], and that is obviously going to increase the caesarean rate.” (Colomar 2014:2385) The absence of full-time specialists in teaching hospitals and the fact that 1st and 2nd year residents are responsible for the delivery…have contributed to an increase in the C-section rate in these hospitals.” (Yazdizadeh 2011:8) ‘Women living in urban areas benefit most from the policy as everything is centralized in the districts.” (Witter 2009:8)
Designation of hospital/facility (regional, teaching, district, rural)
Complexity of system (people, policies, place) as barrier to change	Apathy to change rooted in the interdependency of overall structure and complexity of healthcare system	28,43,46, 47,52–55,57–60	“It is not one thing, it’s the overall structure, which includes midwives, doctors, junior staff …” (Doctor, Hunter 2014:731) “Since the policy came into force we have not received a single cent in reimbursement. In any case, we do not really know what procedure to follow for reimbursement." (Witter 2008:98) “Patients do not receive the required care during pregnancy and therefore the high-risk cases are not detected;” “Whenever you try to modify the system you face a problem.” (Yazdizadeh 2011:9)
Complexity of clinical and non-clinical factors converging
Cross-disciplinary shared purpose and commitment to normal birth and/or CS rate reduction	Strength of multi-disciplinary collaboration, teamwork, communication, role demarcation and respect across maternity care system	40,42,46, 47,49,50–58,60–62	“I do think we’ve made good progress with it [multidisciplinary working].” (Marshall 2015:337) "This hospital provides more natural births. Many women choose this hospital for natural births… We believe that only some women need epidurals, for example, anxious women …". (Paediatrician, Behruzi 2010:11) “In this practice I have appropriate professional autonomy and respect… so I trust that my consultants are available and… otherwise in a normal situation appropriately disinterested.” (Midwife, Kennedy 2016:342). “The midwife can have the main role in the labor process unless the patient asks to have a physician at her bedside… In these situations, the physician only interferes if a problem occurs. The specialist can also ask a midwife to stay at the bedside of her own patient until it’s delivery time and thereafter the physician can carry out the process herself.” (Yazdizadeh 2011:8) Team working had suffered as a result [of implementation of normal labour pathway]; as a midwife commented: ‘‘It makes it ‘us and them”‘ (Hunter 2010b:233)	Human and cultural factors
Respectful team working
Antagonistic team working
CS as cultural norm	Attitudes towards risks, benefits and rates of CS	36,39,42, 46,47,50–56,59,61	Perception that CS is normal. (Kennedy 2016:340) “C-section is becoming more common and stylish these days” (p.11); “C-section for multiparous women is associated with limitations and various complications but if the mother intends to have a single or at the most two deliveries not many complications arise;” “Despite the reduced number of pregnancies, women undergo surgeries due to various other reasons in which the adhesions caused by previous C-sections might become troublesome.” (Yazdizadeh 2011:6) “Too many Caesareans is not nice.” (Doctor, Hunter 2014:731) “C-Sections are becoming too much.” (Woman, Rishworth, 2016:e122) “The truth is that we do not have statistics regarding caesarean complications, which could show a fatal outcome or anything like that.” (Physician, Colomar, 2014:2385)
CS rate and outcomes as cause for concern
Lack of knowledge about CS rates and outcomes
Women as key stakeholders to system change	Belief quality of care for women is compromised or enhanced by reducing unnecessary CS	27,39–42,46–55,57–62	There was no public consultation with maternity service users (client involvement depended solely on the service user group representative on the steering group) (Hunter 2010a:231) ‘‘It is requested a lot (cesarean)…” (Colomar 2014:2385) “Many women demand Caesarean section during admission even before entering the labor room…” (Janani 2015: 1377) “…we should assure mothers that C-section would be performed if needed, adding that vaginal delivery would not be our choice if its risks outweigh its benefits. In other words, we choose the method which is best for both the mother and baby.” (Yadizadeh 2011:11) “Belief that labour is a normal event.” (OWHC 2000:45)
Belief women want CS and/or it offers a more positive birth experience
Belief in labour and birth as normal
Attitudes towards 1:1 labour care	Value of human-to-human care during childbirth (including emotional labour, companionship and advocate for woman)	36,39,40, 41,46,47, 49,52–57,61,62	“Commitment to 1:1 labour support.” (44) “Philosophy of a natural experience; being a support person/ advocate rather than technician.” (OWHC 2000:45) “The companion talks with the patient and this reduces the patient’s stress. They go to the next step together gradually. But considering the fact that we don’t have enough human resources in the field, the quality of communication between the midwife and the mother has declined.” (Yazdizadeh 2011:8) ‘‘It is a facilitating factor that the companions are already immersed in the process of prenatal care and, therefore, care in labor…” (Colomar 2014:2388) “I was confused before she came to me. I was having a lot of pain, but when she came to me I was active and happy.” (Shelp 41:7) “Alone, I wouldn’t have known what to do.” (mother with doula) “I would have liked my mother or my husband to be there, to have some support, to feel someone’s affection, to feel I was important to someone.” (Mother without doula, Campero 1998:401).
Value of companion/support person
Belief too much unnecessary intervention in childbirth/concern cultural norm	Concerns about culture of intervention in childbirth	36,39,42, 46,47,49, 50,52–57,61,62	“An expectant mother who is being monitored… receiving IV-solutions…, catheterized… These unnecessary interventions increase the risk of C-section.” (Yazdizadeh 2011:8,Iran) Humanized birth is not a case without any medical intervention. Sometimes we need medication [. . .] we should marry humanized birth with medical intervention just by explanation, communication and the maintaining confidence". (Midwife, Behruzi 2010:9, Japan) “They’ve [doctors] got to be seen to be doing things. They get their hand in, rather than say ‘Hang on a minute, just step back. Let her be given a bit longer.’ (Manager, Hunter 2014, UK)
Intervention when necessary
Desirability of guidelines and clinical governance (audit)	Shifts to standardise care were widely desired but not universally acceptable in practice	40,42,50–55,57,58	“We are very clear on that… in Latin America and Central America the incidence [of caesarean births] decreased when a good protocol was established… “‘Despite being the directors of health we do not have much control over the private sector, and we have problems; even in overseeing our own units, we make a great effort but we have very few staff to monitor the private units” (Colomar 2014:2388) The majority of participants believed that some of the protocols relayed to the hospitals did not contain enough integrity and functionality and flaws in their implementation can cause problems. (Janani 2015:1376) “It’s a bit too dictatorial for me … You don’t need instructions telling you how labour progresses. Things like that should be part of your midwifery practice.” During observational fieldwork, no midwives were seen consulting the pathway as a decision-making guide. Use of clinical judgment was evident. (Hunter 2010b:232
Acceptability in practice
Embracing of evidence	Attitudes towards in-practice use of best-evidence	40,42,47, 50,52–54,55	“Embracing of evidence and the drive to continually improve.” (OWHC 2000:45) “It does give you a little bit of ammunition.” It’s written down and because it’s coming from research, you’ve got all the references in front of you as to what type of research has been used and it sort of … just backs you up;” “We’re swapping one lot of vague-ish evidence for another lot of vague-ish evidence–and wait and see if anything goes wrong or not.” (Hunter 2014:728–9) “Evidence-based medicine, which we are trying to follow in our practice, stresses that one of the vaginal delivery complications is the relaxation[of the vagina], but do we inform our patients about the complications associated with C-section as well? Never. Do we inform mothers about possible side effects of the anaesthetic agents, injuries sustained to the genitourinary system, more bleeding, higher infection rates and more infant-related problems associated with C-section? (Yazdizadeh 2011:10)
Scepticism of evidence
Selective use of evidence
Leadership	Effective leadership, stakeholder involvement and ownership	28,40,42, 47,50–58,60–62	“Commitment of the management team to true quality of care, i.e. the patient comes first.” “Support from management to deal with change, stress and conflict management;” “Institutional support for the program;” “Strong leadership role model within a shared governance model.” (OWHC 2000:45) ‘Hospitals that achieved success in reducing their rates identified nursing and medical leaders who endorsed and championed the project.” (Dunn 2013:310) “…the staff are briefed for ten minutes a day on what's on the board, so therefore everybody hopefully is buying in to providing better care, knowing our results and what we should be pursuing to make our results even better. There's also a section on the board which is called Bright Ideas, and staff are expected to contribute to a bright idea.” (Head of Midwifery: Marshall 2015:335) ““One of the problems we have is that by presenting a program, we cannot expect the program to be implemented in the best way. The managers should perceive the weaknesses and strengths of the program, personnel’s function, punish offenders, and reward good workers, which should not be necessarily financial. We become disappointed when we do not have these.” (Janani 2015:1376) “We kind of sit there waiting for the next step or for them to tell us what’s going on; and I think if we could change that culture.” (Mother, Kennedy 2016:341)	Mechanisms of effect for change factors
Buy in within and across professions, organisations and systems
Feelings of alienation, exclusion and exhaustion
Listening to mothers
Attitudes towards redefining professional role boundaries	Attitudes towards changing workloads, time and resource	42,46,47, 49,50–58,60,61	“There is a loss of that relationship [with women] and also the loss of being present with more normal deliveries… (Hunter 2014:733) ‘‘I don’t know if anybody. had any idea what it would involve or what a big project it was or how much time it would take you…” (p.230)… The audit had been “tagged on the end” No additional resources or budget were available (p.231) To be effective, time must be allocated for these [steering Group membership] roles rather than adding to existing workloads. (Hunter 2010a:232) Factors facilitating this [the success of the Toolkit] included: recognising the need for staff dedicated to the project with protected time and resources (Marshall 2015:338) “We have a lot of work to do and just don't have time [for humanised care during labour].” (Behruzi 2010:13) “…our center is too crowded and this is an important factor. We send expectant mothers who can be C-sectioned rapidly to the operation room in order to have more vacant beds.” (Yazdizadeh 2011:7) “The number of midwifes in each shift in proportion to the number of patients is really low…” (Janani 2015: 1376) “The physician goes to the hospital in the morning and to the clinic in the afternoon… I can’t revisit my patient in the hospital at 10pm to carry out a vaginal delivery.” (Yazdizadeh 2011:10)
Additional work involved as direct consequence of intervention
Pressures on everyday workloads
Fear, unpredictability and safety of vaginal birth	Fears about safely of reducing CS rates and skills and confidence to deliver normal birth amongst obstetricians, midwives and women	27,36,39, 40,42,46, 47,49, 50,52–55,57,61, 62	“We have to do [caesarean section] because pregnant women and their family think caesarean section can guarantee safety of both mother and baby.” (Liu 2010) “From what I understand, a normal care pathway means that this patient is presumed absolutely normal and will have absolutely normal labour, which I have a big reservation about because in labour, even if the patient had no problems before, you never know until the patient is delivered and the placenta is out… you see the problem with obstetrics is that some of them are very, very dicey and dangerous…” (Doctor) “…women will get on and do it themselves if you give them a chance to do it. “(Hunter 2014:732) “I know how to get [babies] out,” and “women are built to open up there” (Sakala 1993:1240)
Skills and confidence in normal birth
Training, education and experience of normal birth	Education and training that prioritises normal birth and continuous quality improvement	40,42,46, 47,55,56, 57,61	“‘ …their [obstetricians] view was that perhaps midwives weren’t using their professional judgement correctly, that they were leaving ladies too long without intervening, whereas our view was that maybe sometimes they were intervening too soon …” (Head of Midwifery) “I think that people are reluctant to change….Some of the consultants are very medicalised, and some of the midwives for that matter, quite tough to get on to side… Not everybody needs to be on CTGs… (Clinical midwife) (Marshall 2015:327) “In the past few years many obstetricians have never had the opportunity to do a vaginal delivery. The knowledge of a first year resident regarding the procedure is similar to that of an intern. Residents learn the process of natural delivery during the first year but by the time they have learned how to deal with physiologic labor, the year ends and a new unskilled group becomes responsible for the whole thing.” (Yazdizadeh 2011) “Education sessions were presented by paediatricians or obstetricians to communicate site-specific rates to the team, to discuss the evidence and the risks to neonates [of elective repeat CS before 39 weeks, and to garner buy-in for changes across the organisation. (Dunn 2013:311) “A commitment to continuous quality improvement such that great effort has been made to ensure that staff are aware of national standards and guidelines, and are encouraged to work collaboratively to decide how to get there.” (OWHC 2000:45)
Continued professional development and organisational commitment to continuous quality improvement
Extent practices already in place	Importance of understanding local context, culture and existing initiatives that influence how favourable an organisation, facility or system is to reducing unnecessary CS	27,40,42, 47–58,60–62	Most practices in relation to KCND were already in place. (Site B) [in contrast to a] Highly ‘medicalised’ model of care (Site C) (Cheyne 2013:1115) “We have always been interested in providing humanistic care, even before this guide was implemented.” (Midwife) “… to me this is the same assistance I received during my last delivery, nothing has changed.” (woman) (Binfa 2013:1153) These strategies were not effective… The model was initiated without acknowledging the socio-cultural characteristics of each regional context and ignoring local realities regarding the attitudes of each regional health team. (Binfa 2016:60) “For us to change… at first it was hard, but… we have begun to accept, we try…” (Colomar 2014:2388)
Professional opposition
Concurrent guidelines, policies and strategies
Opportunistic implementation factors	Adaptive, multi-faceted interventions with local ‘tinkering’ acknowledged as components in success (or failure)	28,39,40, 42,46,47, 50–54, 56,58–61	The idea for developing the clinical pathway appears to have been largely opportunistic. (Hunter 2010:228) The decision to expand the policy to the regional hospitals in the remaining regions was, according to one Kl, informed by budget under-spend (Witter 2008:97) Physicians document an "accepted" reason making accurate assessment of underlying reason rather impossible (Yazdizadeh 2011) Participation as a trial site provided opportunity to do things differently (Camperio 1998)
Local creativity and adaptation