Research aim

The aim of this structured rapid review was to identify potential factors that act as barriers and enablers for guideline implementation in maternity and neonatal settings. The research question was: What are the barriers and enablers for the implementation and adoption of clinical practice guidelines in maternal and neonatal settings related to pregnancy, labour, post-partum and neonatal services?

Design

The rapid review method was selected for timely evidence gathering for health policy and systems, and practice decisions for a rapidly changing clinical environment [11]. This form of knowledge synthesis “accelerates the process of conducting a traditional systematic review by streamlining or omitting specific methods to produce evidence for stakeholders in a resource-efficient manner” [12]. Our review procedures were informed by: Cochrane Rapid Reviews interim guidance recommendations [13]; the World Health Organization’s practical guide for rapid reviews [14]; and practical steps and activities for the review process [15]. Review reporting, tracking overall process and information flow was based on PRISMA 2020 guideline for reporting systematic reviews [16].

Aligned with the rapid review method [13], two post-hoc changes were made, which were updated in the published protocol in Open Science Framework (https://osf.io/q47dx/): (i) an updated PRISMA reporting guideline; and (ii) a decision to apply a single quality appraisal tool to screen diversity of included studies and consistency in quality assessment replacing multiple methodology-aligned tools. This research did not involve human participants, thus ethical approval was not required.

Search strategy and procedures

An iterative process within rapid review protocol parameters assisted a robust search for literature within project time constraints [14]. An Information Specialist and MeSH© (Medical Subject Headings) terms guided the refinement of included search terms (Table 1). The Peer Review of Electronic Search Strategies (PRESS) checklist [17] and the PRISMA-S checklist for literature search reporting [18] assisted search strategy optimisation. Four databases and article reference lists were searched simultaneously for three weeks during May and June 2023. An example of the search filter from PubMed is provided in Table 1.

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Table 1. Study eligibility and search terms.

https://doi.org/10.1371/journal.pone.0315588.t001

Inclusion and exclusion criteria

The scope of the review was defined by PICO elements (i.e., population, intervention, comparator, outcome), as well as setting, timeframe, and study design, which are recommended for a rapid review [14] (Table 1). Peer-reviewed, systematic reviews, qualitative, quantitative and mixed-methods studies published in English Language between January 2010 and 30 May 2023 were included. No geographical limits were applied. Project reports, unpublished and grey literature, study protocols without results, and conference abstracts were excluded.

Study selection and screening

Screening and study selection was undertaken in Covidence (Covidence systematic review software, Veritas Health Innovation, Melbourne, Australia. Available at www.covidence.org). Two authors independently recorded their decisions at each stage (titles/abstracts and full texts), with conflicts resolved by the third as required. Fig 1 presents PRISMA flow chart and study selection.

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Fig 1. PRISMA flow chart and study selection.

https://doi.org/10.1371/journal.pone.0315588.g001

Quality assessment

Risk of bias and quality appraisal of studies was assessed with the Quality Assessment with Diverse Studies (QuADS) tool which is an appraisal tool for methodological and reporting quality in systematic reviews of mixed- or multi-method studies [19]. The QuADS tool involved a scoring schema from 0 to 3 based on 13 criteria (maximum score of 39). Two authors independently evaluated the same five studies for inter-rater reliability, with discussion of quality assessment and resolution of scoring discrepancies through moderation, resulting in similar final scores. One author completed quality assessment for the remaining studies. Overall scores as percentages of the criteria were used to compare and critique the articles. Studies were not excluded based on quality appraisal.

Data extraction and synthesis

Relevant data were extracted from included documents, summarising the overall findings and forming conclusions to answer the research question [15]. Data were extracted by the first author, then independently verified by two other authors. Ritchie and Spencer’s [20] framework approach provided a structured method suited to qualitative data, and document analysis was used to identify barriers and enablers to guideline implementation and theme development. A general inductive and deductive approach was used to distil and condense extracted informational text (data) from the literature to generate themes [21]. This was managed through five iterative steps [20]: (i) familiarisation with the literature, (ii) generating overarching conceptual constructs, (iii) indexing and sorting coded data and concepts, (iv) summarising initial themes, and (v) mapping and interpreting data and final themes. Table 2 provides examples of theme development. Data were managed in Microsoft Word and Excel. Findings are presented in a descriptive narrative form as study characteristics and key themes related to barriers and enablers.

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Table 2. Example of coding and theme development.

https://doi.org/10.1371/journal.pone.0315588.t002

Study characteristics

A purposive database search and full-text screening yielded 49 papers for inclusion, of which a single paper was excluded by the reviewers jointly during data extraction since it did not meet the study design criterion (Fig 1). S1 File lists studies screened. In total, 48 papers were included for analysis and reporting, summarised in Table 3. (Also see S2 and S3 Files). Reports originated from different countries, including cross-regional research collaborations. More than half represented four countries, namely, Australia (n = 9), United States (US) (n = 6), United Kingdom (UK) (n = 6) and New Zealand (n = 4) (Table 3). Twenty-seven studies were published since 2018. Study methodology included quantitative (n = 31), qualitative (n = 7), mixed methods (n = 4), and systematic reviews (n = 6). Most studies considered guideline use in hospital settings (n = 35) and related to primarily medical, nursing and midwifery health professionals involved in maternity and neonatal care. Quality assessment for methodological and reporting quality indicated that all included studies individually scored more than 75% against the QuADS tool criteria (S4 File), which is acceptable evidence since different types of study designs were included in the review (Table 3).

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Table 3. Summary of studies reviewed.

https://doi.org/10.1371/journal.pone.0315588.t003

Barriers and enablers to guideline implementation

Key barriers and enablers related to guideline implementation in maternity and neonatal settings are summarised and grouped under five main themes, based on contextual level of impact or application, with some overlap between themes acknowledged (Tables 4 and 5). Also see S5 File.

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

https://doi.org/10.1371/journal.pone.0315588.t004

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Table 5. Summary of enablers or facilitators for guideline implementation and adoption related to maternal and neonatal care.

https://doi.org/10.1371/journal.pone.0315588.t005

Healthcare system factors

Healthcare system factors concern structural factors, including the scope of services, support infrastructure, and the socio-economic and policy environment of its geographical location. A key barrier impeding guideline uptake and adherence, particularly in low-income settings, were the lack of resources and economic factors which impacted scope of maternal services and quality of care as illustrated on Table 4. These affect both the healthcare system and the population (see patient and population factors). Other barriers related to models of care, such as fragmented maternity care that is not woman-centred. This affected the quality and consistency of services, such as provision of routine screening or a consistent schedule of pregnancy care visits [22, 23] and information flow across services at district and central levels, including limited access to current guidelines [24, 25].

Conversely, structural factors such as a well-planned healthcare system, policy priorities with resources and investment for maternal health facilitated practice change and guideline adoption at the system level (Table 5). For instance, national and local level government commitment and investment into public health initiatives were pivotal to improving maternity services and quality of care, particularly in low-resource settings [23–29]. Multiple studies (n = 13) (Table 5) identified that mechanisms for accountability through governance of healthcare practitioner regulators, incentivisation for practice change and positive outcomes facilitated guideline adherence and uptake by healthcare providers. Guideline uptake and adherence were also facilitated by centralised and standardised pregnancy care guidelines at state or national levels [23, 30].

Patient and population factors

Patient and population factors pertained to acceptance of guideline recommendations associated with maternity care among childbearing women, their support persons (and community), as well as parents of neonates as recipients of healthcare. Barriers included lack of influence or direct involvement in guideline development and shared decision-making, compounded by women’s previous poor experiences with healthcare systems, low health literacy, poverty, cultural and social influences and scepticism about the value and legitimacy of guidelines (Table 4). In some cultures, there was reliance on alternative faith-based care, or women could not attend a primary care clinic without the family’s or partner’s approval [26, 28]. Women’s willingness and ability to access pregnancy care were associated with service fees, a lack of health insurance, travel costs, and long distances to maternal health centres [23, 28]. Inefficiencies in healthcare system factors affected women’s perceptions of the cost effectiveness and acceptability of attending pregnancy visits, screening, treatments or medications recommended by guidelines [22, 23, 28, 29, 31–33]. These barriers ultimately affected maternal and neonatal health outcomes and quality of care [28, 29, 31, 32].

Conversely, as illustrated on Table 5, patient attributes and positive experiences and engagement with healthcare services facilitated guideline implementation. Elements such as establishing trust and rapport between women and healthcare providers, along with financial support to attend appointments [23, 27, 28, 34–38], promotion of autonomy and empowerment [36] and the availability of targeted and multilingual resources helped women with decision-making and care plan adherence [23, 27, 28, 34–38]. For example, pregnant women’s participation and decision-making within a program of antiretroviral medication was enhanced by improved monitoring, multilingual literature and support [37, 39]. This was critical to achieve national and global public health targets for antiretroviral therapy coverage in prevention of mother-to-child transmission of human immunodeficiency virus (HIV) among African women [39]. Similarly, the availability of multilingual and targeted educational material influenced uptake of screening for Group B Streptococcus (GBS) [31, 37, 40].

Guidelines and standards

Barriers associated with clinical guidelines themselves included a lack of, or poor: standardisation, quality, accessibility, feasibility of implementation across settings, and engagement with end users in their development (Table 4). Inconsistent or conflicting guidelines (i.e. that recommended different processes for the same condition) were unlikely to be followed [23, 29, 30, 41–44] and resulted in practice variations among clinicians and inconsistencies in care delivery [41–43]. For example, survey of maternity hospitals in Vietnam, identified the use of different international and national protocols for neonatal resuscitation among public maternity hospitals and the provincial and district level hospitals [30].

Guidelines that were difficult to access via the internet/intranet [44–46], considered to be too complex, or were inappropriate in the context of available resources or population diversity were also an issue [23, 43, 46, 47]. For example, the most commonly cited barrier to using a set of New Zealand maternity guidelines was locating them on the internet [44]. Guideline complexity, lack of clarity and lack of alignment with ‘common sense’ and the local context were cited as reasons for obstetricians’ low adherence to national guidelines for prevention of preterm birth in France [46]. Also, clinicians’ confidence to implement guidelines was undermined in the absence of a rigorous development process and lack of sufficient evidence-based recommendations [30, 43, 44].

By contrast, enablers at the guideline-level included quality, design, accessibility and usability of guidelines, clinician engagement and rigorous guideline development (Table 5). For instance, clinicians were more likely to view fetal surveillance and neonatal resuscitation guidelines as worthwhile and useful decision-making aids if there were clear unit policies and clinical indicators specific to the practice environment [30, 48]. Also, well-developed, standardised clinical practice benchmarks were important to improve confidence in guideline recommendations and supporting practice change [44, 45].

Organisational capacity

Guideline adoption is influenced by organisational factors at the facility or health centre level. These factors may be financial, human, technological and influenced by the presence or absence of robust quality improvement initiatives, implementation strategies, service culture and support, educational structures, data management systems and other work designs.

Various types of resource constraints at the service level impacted guideline adoption in practice (Table 4). For example, logistical and financial barriers limited the provision of supplies for pregnancy care in some countries [28, 29, 49]. Compliance with the national antenatal pertussis immunisation programs in some countries were affected by high vaccine costs, storage, and inventory requirements [50]. Other contextual examples include: lack of equipment affecting the provision of critical care for extremely premature infants [47]; lack of readily available essential equipment such as weigh scales causing practice discrepancies and poor milestone montioring of women’s gestational weight gain [35]; and inadequate human resources leading to a shortage of maternity and neonatal staff [28, 45].

Different work design issues within the organisation or health centre also impinged guideline adherence (Table 4). For instance, paper-based, rather than electronic medical records, and lack of reminders or in-built decision support aids and timely guideline alerts at point of care, affected guideline adherence and the ability to monitor quality of maternity and neonatal care [28, 51]. Environmental or contextual elements such as the organisation’s location and size also affected its ability to implement and support guideline use without the necessary mechanisms to bring about practice change [29, 46].

Deficits in organisational capabilities were linked to lack of human resources. These included shortages of well-trained healthcare workers and knowledge discrepancies among different levels of maternity staff affecting consistency and quality of care [24, 52]. Poor workplace culture additionally hampered guideline adherence. Examples included: lack of clinical leadership within maternity care [25, 27]; lack of quality improvement initiatives and lack of systems for monitoring guideline adherence and providing feedback to staff [24, 25, 29, 53].

Insufficient communication and collaboration between disciplines (i.e. doctors, midwives, nurses) was also a problem for guideline uptake (Table 4). For instance, Gu et al. [45] found that lack of multidisciplinary cooperation and working processes, as well as limited communication between doctors and nurses about infant nutrition, impeded efforts to implement a guideline for enteral nutrition risk screening for infants with congenital heart disease at a large tertiary hospital in China, with the nurses perceiving the screening task as being beyond their duties.

Other organisational barriers were inadequate guideline dissemination, insufficient planning, and lack of quality data monitoring systems (Table 4). For instance, Smith et al. [24] reviewed 10 countries at different stages of implementation of the World Health Organization Global Maternal Death Surveillance and Response and Maternal Death Review systems. They highlighted the lack of trained health workers to identify and collect data, poor quality of reporting, inaccurate reporting, poor data collection, use of handwritten reports (illegible and insufficient information, and lack of supervision or monitoring of reporting processes (weak registration systems) within services and the wider health system.

Several factors facilitated guideline adoption at the organisational level (Table 5). Targeted quality improvement initiatives, including well-planned implementation strategies, followed by periodic audit and monitoring of health professionals’ guideline adherence were the most widely reported initiatives by the studies (n = 17) (Table 5). Often organisations used distinct process models to inform practice change and guide implementation endeavours within the maternity services. For instance, systemic implementation science and research translation models [54] such as the Plan-Do-Study-Act (PDSA) cycles were used successfully to identify and implement evidence-based recommendations into healthcare and professional practice [38, 53, 55, 56]. Behaviour change models [54] such as the Theoretical Domains Framework [57] and the Theory of Change [26] specifically designed to address barriers and enablers to translating research into practice were also successfully applied to guide intervention activities and drive change effectively.

Ten studies highlighted organisational support, including championing change, the extent of stakeholder engagement in guideline development and implementation process as influential organisational factors for uptake of guidelines among health professionals. Several studies (n = 13) emphasised dissemination of information and promoting awareness of guideline content through training and education. Equally important were effective work design around guideline availability and decision support mechanisms for health professionals, including its integration into routine workflow at the point of care highlighted in 14 studies. Effective health data management systems and processes, including use of electronic data and health information management systems were also considered essential to effective guideline adoption [24, 25, 29, 45, 53].

Health professional practice

Various factors impeded guideline adoption at the level of the health professional (clinicians) (Table 4). Fourteen studies highlighted lack of awareness, knowledge, and skills in relation to guidelines. For instance, a recent US-based study [32] assessed compliance of clinicians with the American Academy of Paediatrics (AAP) guideline on recommendations for use of intravenous immunoglobulin (IVIG) in infants with haemolytic disease. They found that lack of understanding of the possible side effects, cost, and donor exposure related to IVIG and lack of awareness of current recommendations for practice were potential barriers to compliance in neonatal intensive care units. Other clinician-related barriers included a lack of motivation and engagement by maternity unit staff, especially without incentives to attend training [22, 25, 45, 58, 66]. Initial resistance to change [22, 38, 46, 52, 66] and loss of autonomy were also cited barriers [38, 44] For example, Trollope et al. [44] noted that poor compliance with the national women’s health maternity guidelines in New Zealand was associated with clinicians’ perceptions that the guidelines did not reflect current evidence and failed to acknowledge patient individuality. Moreover, the clinicians believed that guideline recommendations would not lead to desired outcomes in care and may reduce their autonomy to make appropriate decisions about care [38].

Health workers’ knowledge, attributes, beliefs, attitudes, and capability were prevalent barriers (Table 4). For example, there were differences in guideline adherence between disciplines. A UK-based study [59] examined nurses and doctors’ knowledge and reported practice regarding procedural pain assessment and management in a neonatal intensive care unit. They found guideline adherence was more consistent among nurses than doctors. Differences were also reported in individual practice, such as variation in referral practices for management of gestational weight gain within maternity settings by different clinicians [35] and variation in use of labour management triage checklists by staff to decrease caesarean birth [38].

Health workers’ knowledge and practice gaps were frequently reported (n = 16). For instance, a study assessing adherence of healthcare providers to hypertensive disorders of pregnancy guidelines in Jordan found nurses and midwives lacked sufficient knowledge about pathophysiology of the disease and their role in monitoring mothers to reduce the risk of complications [41].

Other health professional practice challenges are related to some of the barriers previously highlighted in the organisational environment, such as lack of interdisciplinary communication and collaboration [25, 27]; quality of reporting and documentation [24, 25, 28, 60]; and lack of education and training about guidelines and updates [22–24, 30, 66]. Challenges of time constraints and heavy workload are common in maternal and neonatal healthcare and were a major barrier in the use of guidelines [35, 46, 60–62, 66].

Universally, the critical enablers for guideline uptake among health professionals were education, training, and feedback to staff on guideline adherence and most widely reported (n = 21) (Table 5). Other enablers for practice change and guideline adherence were ensuring clinicians’ autonomy and ability to deviate from guidelines where person-centred care warranted change [44, 56]; interdisciplinary collaboration and communication [25, 27, 32, 36, 55, 60, 66]; and having established practice standards and expectations [27, 37, 42, 44, 45, 48, 52, 56, 60]. Additionally, more general factors playing an important part in supporting guideline adoption were related to health professionals’ involvement in guideline implementation, and positive perceptions about guidelines usefulness, along with being able to effect behaviour change (Table 5).

Limitations

Our rapid review of barriers and enablers for implementing CPGs in the maternal and neonatal clinical setting, had a narrow focus, a short timeframe, and limited database search. However, a robust and rigorous review methodology drawing on appropriate guidance documents were applied. Despite acknowledged limitations this review provides a comprehensive picture of the included studies and major contextual factors impacting CPG adoption. In considering these barriers and enablers, we acknowledge the authors’ underlying assumption (and thus a potentially biased view) that CPGs should reflect “best practice” and optimise maternity and neonatal care.