title: A case study evaluation of an intervention aiming to strengthen the midwifery professional role in Morocco: anticipated barriers to reaching outcomes.
abstract: BACKGROUND
  In order to reduce the high maternal mortality ratio, Morocco is strongly committed to strengthen its midwifery professional role. This study aimed to identify barriers that could potentially hinder an action plan to strengthen the midwifery professional role from achieving desired outcomes. We used a conceptual framework, which is derived from Hatem-Asmar's (1997) framework on the interaction of educational, professional, and sociocultural systems in which a professional role evolves and from Damschroder et al's (2009) framework for the implementation analysis.
  
  
  METHODS
  This paper builds on a qualitative case study on the factors affecting the action plan's implementation process that also revealed rich data about anticipated barriers to reaching outcomes. Data were collected through training sessions, field observations, documents, focus groups (n=20), and semistructured interviews (n=11) with stakeholders pertaining to the three systems under study. Content analysis was used to identify themes related to barriers.
  
  
  RESULTS
  Seven barriers that may compromise the achievement of desired results were found. They relate to the legal framework, social representations, and media support in the sociocultural system and the practice environment, networks and communication mechanisms, and characteristics related to the role and the readiness in the professional system.
  
  
  CONCLUSIONS
  Disregarding sociocultural and professional system level, barriers may impede efforts to strengthen the midwife's role and to provide qualified midwives who can improve the quality of maternal care. Making changes in the educational system cannot be thought of as an isolated process. Its success is closely tied with multiple contextual factors pertaining to the two other systems. Activities recommended to address these barriers may have great potential to build a competent midwifery workforce that contributes to positive maternal and neonatal health outcomes.
authors.affiliation: IRSPUM, Université de Montréal, Montréal, QC, Canada ; Department of Social Preventive Medicine, Université de Montréal, Montréal, QC, Canada.
authors.forename: Sabina
authors.initials: S
authors.lastname: Abou Malham
authors.affiliation: IRSPUM, Université de Montréal, Montréal, QC, Canada ; Department of Social Preventive Medicine, Université de Montréal, Montréal, QC, Canada.
authors.forename: Marie
authors.initials: M
authors.lastname: Hatem
authors.affiliation: IRSPUM, Université de Montréal, Montréal, QC, Canada ; Department of Health Administration, School of Public Health, Université de Montréal, Montréal, QC, Canada.
authors.forename: Nicole
authors.initials: N
authors.lastname: Leduc
keywords: barriers; evaluation; maternal mortality; midwife; outcomes; professional role