Table 4.

Barriers and enablers to the implementation or success of interventions to increase AVB use

Barrier categories	Barriers identified
Health professionals	Lack of skilled personnel (due to lack of training, high staff turnover, staff shortage) Lack of confidence Lack of supervision in general and especially in night shifts Fear of HIV transmission AVB perceived as a complicated and dangerous intervention Resistance to change, previous attitudes and beliefs not supportive of AVB Fear of malpractice litigation if complications arise
Environment	Lack of clarity on scope of midwifery practice and functions Power struggles in the maternity units Unsupportive work environment
Training	Lack of theoretical and formalised education on AVB Need to learn skills for correct AVB indications and when to stop trying and do a CS Lack of access to repeated opportunities to practice Teacher/mentor preference influence the type of instrument to use and exposure to learning opportunities Lack of access to or of willing clinical mentors Poor communication with mentors
Women – Healthcare provider relationship	Insufficient pain relief for women Lack of acceptance by the women (associated with negative interactions with staff, poor communication, little involvement in decision-making and mistrust of caregiver)
Equipment	Lack of equipment or maintenance of equipment Difficulties related to the need to sterilise instruments (unavailability of the material/equipment for this purpose)

Enabler categories	Enablers identified
Health professionals	Senior midwifery support Ownership of the initiative/strategy which is facilitated by Opinion Leaders Retention of trained staff
Environment	Provision of opportunities for staff to gain experience In areas where there is high population resistance to CS, AVB when indicated can be popular and acceptable Clarity on the scope of the midwifery practice and functions Establishment of task-shifting strategies Involving senior staff and hospital administrators at the planning stage Local stakeholders (Ministry of Health, hospital administrators) buy-in/endorsement Advocacy efforts Supportive environment including close supervision, proactive teaching by experienced colleagues enable the development of competencies
Training	Incorporating AVB training in the medical curriculum Training using a range of tools and modalities including videos and simulation (these do not replace hands-on clinical teaching) Training multidisciplinary teams Retraining (in-service)
Women–healthcare provider relationship	Good communication between healthcare providers and with the woman to foster trust Women’s and partners’ involvement in decision-making and satisfactory communication between women and providers Acceptance of intervention by the woman is facilitated by positive interactions with staff, respectful care and ongoing communication and trust
Equipment	Availability of functioning, user friendly equipment

AVB, assisted vaginal birth; CS, caesarean section.