title: Analyzing barriers and facilitators to the implementation of an action plan to strengthen the midwifery professional role: a Moroccan case study.
abstract: BACKGROUND
  As part of a national strategy for reaching Millennium Development Goals 4 and 5 in Morocco, an action plan covering three systems (sociocultural, educational and professional) was developed to strengthen midwives' professional role in order to contribute to high quality maternity care. This study aimed to understand the implementation process by identifying the characteristics of this intervention and the dimensions of the three-systems which could act as barriers to/facilitators of the implementation process. We used a conceptual framework that builds on Hatem-Asmar's model that describes change in a health professional role; and on the Consolidated Framework for Implementation Research for our analysis.
  
  
  METHODS
  An embedded case study with three levels of analysis was conducted during June and July 2010. Data were collected through 11 semi-structured interviews, 20 focus groups, training session observations and documents. A purposive sample of 106 multi-stakeholders from two Moroccan regions (health professionals, academic staff, students, medical administrative officers and health programmers) and one international consultant were recruited. A thematic analysis was conducted using QDA Miner.
  
  
  RESULTS
  Data showed a failure to carry out the plan as intended. Seventeen barriers and seven facilitators were identified. Misalignment of the values, methods, actors and targets of the sociocultural system with the values, methods and actors of the educational and professional systems, on one hand, and with the intervention, on the other hand, were likely the greatest impediments to implementing the plan. The bureaucratic structure and lack of readiness of the sociocultural system were among the most influential barriers to: dissemination of information, involvement of key actors in the process and readiness of the educational system. The main facilitators were the values promoted related to human rights, and the national and international policies to strengthen midwifery and reduce maternal mortality. The plan was perceived as beneficial, but complex and externally driven.
  
  
  CONCLUSIONS
  The findings suggest that successful implementation requires redesigning the implementation strategy to adapt to the factors identified in our study. The results would be very useful to health planners seeking the expansion of such an intervention to other developing countries looking to strengthen midwives' role and to improve maternity health care services.
authors.affiliation: IRSPUM, Université de Montréal, P.O. Box 6128, Centre-ville Station, Montreal, QC, H3C 3 J7, Canada. Sabina.abou.malham@umontreal.ca.|Department of Social and Preventive Medicine, School of Public Health, Université de Montréal, Montreal, Quebec, Canada. Sabina.abou.malham@umontreal.ca.
authors.forename: Sabina
authors.initials: S
authors.lastname: Abou-Malham
authors.affiliation: IRSPUM, Université de Montréal, P.O. Box 6128, Centre-ville Station, Montreal, QC, H3C 3 J7, Canada. Marie.hatem@umontreal.ca.|Department of Social and Preventive Medicine, School of Public Health, Université de Montréal, Montreal, Quebec, Canada. Marie.hatem@umontreal.ca.
authors.forename: Marie
authors.initials: M
authors.lastname: Hatem
authors.affiliation: IRSPUM, Université de Montréal, P.O. Box 6128, Centre-ville Station, Montreal, QC, H3C 3 J7, Canada. Nicole.leduc@umontreal.ca.|Department of Health Administration, School of Public Health, Université de Montréal, Montreal, Quebec, Canada. Nicole.leduc@umontreal.ca.
authors.forename: Nicole
authors.initials: N
authors.lastname: Leduc
mesh_terms: D005260:Female; D017144:Focus Groups; D006282:Health Personnel; D006801:Humans; D007407:Interviews as Topic; D007857:Leadership; D008297:Male; D008880:Midwifery / Q000193:education*; D009018:Morocco; D019982:Organizational Case Studies; D011247:Pregnancy; D024382:Professional Role; D016730:Program Development; D036301:Qualitative Research