A case study evaluation of an intervention aiming to strengthen the midwifery professional role in Morocco: anticipated barriers to reaching outcomes

Figures & data

Figure 1 Advanced version of the conceptual framework to evaluate the implementation of a complex intervention aiming to change a health professional’s role.

Table 1 Characteristics of the participants in the study

Job title/current position	Participants (N)	Sex		Work experience Mean (range)*	Rural setting experience yes	Urban setting experience yes
		Male n (%)	Female n (%)
Midwives practitioners	17	0	17	11.29 (1–25)	16	17
Nurses	5	1	4	20 (9–28)	2	5
Obstetricians	6	5	1	7.66 (1–16)	3	6
Physicians	2	1	1	24.5	1	2
Medical directors	2	2	0	23.5	1	2
Senior nurse managers	2	1	1	16	2	2
Midwife managers	2	0	2	26.5	2	2
Midwifery representatives	2	0	2	33.5	1	2
Midwifery educators	29	0	29	15.25 (6–32)	24	29
Midwifery students	15	0	15	N/A	N/A	N/A
Academic directors	2	1	1	32.5	1	2
Academic management staff	4	3	1	28.5 (24–37)	4	4
Medical administrative officers	7	6	1	19.85 (15–29)	7	7
Administrative nurse managers	2	0	2	23.5	1	2
Health programmer	1	1	0	16*	1	1
Women	8	0	8	N/A	N/A	N/A
Consultant	1	0	1	29*	N/A	N/A
Participants, n(%)	107	21 (19.63%)	86 (80.37%)	N/A	66 (79.52%)	100%

Note:

* Indicates data is expressed in years.

Abbreviation: N/A, not applicable.

Table 2 Qualitative codebook

Damschroder	Definition	Rules for identifying and mapping themes
CFIR’s constructs (Damschroder et al^Citation15)
Implementation process	How well the implementation is carried out according to plan, how well executing was done according to plan	Statements regarding the conceptual dimensions of the construct executing including the: – degree of fidelity of implementation to planned courses of action – intensity (quality) of implementation – timeliness of task completion – degree of engagement of key actors in the implementation process
Intervention’s effectiveness	Refers to the intervention’s performance	Statements regarding how the intervention might reach the outcomes as initially intended
External policy and incentives	A broad construct that includes external strategies to spread interventions including: local, state, or national policies, regulations, external mandates, guidelines and recommendations that influenced the decision to implement the intervention.	Codes relating to one or several elements of the definition
Networks and communications	The nature and quality of social networks and of formal and informal communications within an organization. Refer to general communication and relationships in the organization	Codes relating to one or several elements of the definition
Readiness for implementation: Available resources	Tangible indicators of organizational commitment to its decision to implement an intervention: – Level of resources dedicated for implementation including money, training, education, physical space, equipment, and information technology	Codes relating to one or several elements of the three sub-constructs of the definition
Other concepts not covered by the CFIR menu of constructs
Social representations	Representations (social values, ideas, beliefs) of midwives, their role held within the general social and cultural environment	Statements regarding the nature of representations held with the social and cultural environment regarding midwives, their role which may play a role in facilitating/hindering the attainment of the intervention’s outcomes
Media support	The nature of support provided by the media	Statements regarding how the media is supporting the Moroccan midwives which may play a role in facilitating/hindering the attainment of the intervention’s outcomes
Practice environment	The environment in which care is delivered and the characteristics of the work environment that facilitate or constrain the professional practice	Statements regarding how the work environment and conditions may play a role in the attainment of the intervention’s outcomes

Notes: The constructs of the CFIR that applied to our results are the only ones described in this table. Adapted from Damschroder LJ, Aron DC, Keith RE, Kirsh SR, Alexander JA, Lowery JC. Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science. Implement Sci. 2009;4:50. Creative Commons license and disclaimer available from: http://creativecommons.org/licenses/by/4.0/legalcode.¹⁵

Abbreviation: CFIR, consolidated framework for implementation research.

Table 3 Summary of results

	Mega codes	Sub-codes	Themes	Supplementary illustrative quotations
	Values	External policies and incentives/regulations	Archaic legal and regulatory framework	“When I find that there are statutes, legal texts that date back to 1950 and are still applied up till this day […], again we come back to the statute, to the legal framework which is problematic, and if the old law will not be changed, all is doomed to failure” (MedicalAdministrativeOfficer5)
Sociocultural System 3 Themes		Social representations	Poor image of the midwife and lack of public awareness of her role	“In addition to having a bad reputation, the midwife is regarded in society as the big lady slapping women, yelling at them, who doesn’t know how to communicate, who doesn’t behave properly” (AdministrativeNurseManager1)
	Methods	Media support	Disadvantageous media coverage for midwives and women	“Also, there is a problem, about mass media, they are not working in our favor [midwives], they know that there is a huge problem of maternal mortality. Who do they show on TV? They only show physicians or TBAs instead of midwives, which does not reflect properly the midwife in Morocco, so I think that the mass media are not on our side” (FG_MidwiferyEducators1)
Professional System 4 Themes	Methods	Midwifery practice environment	Poor working and living conditions	“The major problem, well, is particularly in the rural areas, this is the big problem, so for midwives, it’s about the living conditions that are devastating, it’s even going to create an impediment to this program, if you give a midwife a small house without enough electricity, without water for an entire year, it will affect her performance […] in your opinion is she going to perform well or apply her new competencies with no electricity?” (AcademicDirector1)
		Readiness for implementation/available resources	Inadaptability of human, material resources and training on the requirements of midwifery practice	“Lack of oxygen, unequipped ambulances, and lack of medical equipment, of supplies, will hinder our ability to work according to the new CBA” (FO_TTT_N7)
		Networks and communications	Inadequate communication and poor interdisciplinary collaboration	“For some [doctors], when the midwife calls the doctor, they say to me [the midwife] “why don’t you pass to me my friend” … because they find that the midwife is not qualified to transmit the complications of a woman, he says “I have to speak with the doctor, I do not want the midwife transmitting the patient’s complications”, even if the midwife was a good one” (FG_MidwivesPractitioners1) Quote that sums up many barriers: “The negative image of midwives in society, their relationship with anesthetists and physicians as a dominant/dominated relationship type, the difficult working conditions, regulations, all these elements might have an impact on the success of the intervention, on strengthening midwives’ role. Experience has shown that even if we change the training course or we revise it in a better way (to have more skills), it is not enough to strengthen nurses, health technicians and midwives given the barriers mentioned above. If the regulation does not change and does not give more space to midwives in decision-making, they would always remain subordinate and cannot gain autonomy, it is not at all motivating, […], so it is true that training can partially ensure strengthening the profession, but it is just a link in a chain that includes all the elements that I have mentioned earlier” (FG_MidwiferyEducators4)
	Actors	Role characteristics	Midwife’s role misunderstood and misused in the professional field	“Apart from education, there are several barriers, especially concerning the role of the midwife, which role we are talking about, tasks are not delineated, in maternity hospitals we do not know our job, tasks are not clear in the maternity hospitals, professional boundaries of midwives are not clear, they can function as a physician, […], dental assistant, even a cleaning person” (FG_MidwivesPractitioners2)
Educational System	No barriers reported

Abbreviations: FG, focus group; FO, field observation; TTT, train-the-trainers.

DamschroderLJAronDCKeithREKirshSRAlexanderJALoweryJCFostering implementation of health services research findings into practice: a consolidated framework for advancing implementation scienceImplement Sci200945019664226

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