Table 3

Summary of initial concepts, emergent themes and final themes

Initial concepts	Emergent themes/SoFs	Studies contributing to review finding	Final themes
Belief in a common approach to birth across obstetrics and midwifery	Beliefs about birth	44–46, 54, 57–62, 64–66	Underpinning philosophy of beliefs about birth informs both the importance health professionals attach to reducing unnecessary CS and the effectiveness of healthcare teams to do so with competing knowledge claims about what are clinically necessary and unnecessary CS across time, place and discipline used by health professionals to either endorse or dispute the value of CS per se.
Belief in value of physiological labour and vaginal birth
Belief in CS as progressive for birth
Doubts about the value of CS and concerns about comorbidities
Belief CS rate determined by factors beyond health professionals control	Beliefs about what constitutes necessary and unnecessary CS	47, 54–57, 63
Ambiguity surrounding medical indications for CS
Views and experiences of seeking a second opinion
Evidence as mechanism for change	Beliefs about the evidence base surrounding CS	54–55, 57–59, 61–64
Evidence as incomplete, unconvincing or not applicable
Views about guideline adherence and local audit
Belief CS rates are too high	Belief in need to reduce unnecessary CS and receptiveness to change	54–55, 57–59, 61–64
Belief unnecessary CS is unethical, negligent practice
Positive attitudes towards guidelines, second opinion, audit and feedback
Fear of blame in event of poor outcome of NVD	Fear of blame and recrimination (including medicolegal concerns)	45, 54–55, 57–58, 61, 63–64	Social and cultural context exerts an important influence on health professional’s commitment to reducing CS rates. This includes fear of blame and medicolegal concerns, financial incentives and health professionals perceptions of women.
Fear of threat to professional identify and career progression
Fear of litigation
Value greater monetary reward associated with CS	Value attached to financial rewards associated with CS	45, 47, 55, 57–58, 60–61, 63
Value scheduling CS and less time commitment compared NVD	Preferences for CS as convenient	46, 57–61, 63
Perception women are changing	Beliefs about women	45–47, 54–61, 63–66
Perceptions of what woman want
Belief women lack confidence in NVD
No team work within profession/not easy to listen to opinion of peers	Dysfunctional teamwork, within the medical profession and including the marginalisation of midwives	47, 55–63, 65
Little or no cross-professional working
Marginalisation of MWs
Concerns about the organisation of care	Organisation of care	47, 55–59, 61–63, 65	Health professionals may negotiate health system factors in accordance with their underpinning philosophy about birth, women and medicine, where the level of resource is sufficient to sustain necessary CS should a clinical need arise.
Insufficient human resource	Organisation of care	47, 55–59, 61–63, 65
Need 24 hours anaesthetic cover	Beliefs about need for high-level infrastructures
Need 24 hours consultant cover
Need for more equipment
Challenges to need for technology
Belief strategy/intervention would not be effective	Reluctance to change based on lack of training, skills or experience	45, 47, 55–57, 59, 61, 65–66
Preregistration and postregistration education does not prioritise NVD skills and training
Perception insufficient time to implement
Perception insufficient resources
Positive tone of intervention (reflective and facilitative)	Views about the format, content and delivery of interventions	55, 57, 59, 61–63
Without fear of blame or threat to professional identify
Use of language (ie, not conditional verb tense – should)
Women’s right to choose CS	Beliefs about the clinical encounter and autonomous decision making	44–47, 54–55, 57–59, 61–64, 66
Informed decision making too lengthy
Doctor’s decision takes precedence
Decision-making process with women

CS, caesarean section; MWs, midvives; NVD, normal vaginal delivery; SoFs, summary of findings.