This exploratory qualitative study explored clinician-reported reasons for the persistent underuse of vacuum-assisted birth (VAB) at a tertiary maternity hospital in Tanzania. The study identified two overarching categories of barriers: organizational factors that impede access to and effective use of equipment and systems, and individual clinician-level factors such as limited skills, experience, and fear of adverse outcomes.
The research used an exploratory qualitative design centered on in-depth interviews to obtain clinicians’ experiences and perspectives. The study site is a high-volume tertiary maternity hospital that manages approximately 9,000 deliveries per year, serves as a referral center for surrounding facilities, and had a high rate of emergency cesarean sections (reported as 75% of deliveries in the background data). Routine facility data showed very low use of VAB in recent years (DHIS2: ~2.0% in 2020, 2.2% in 2021, and 2.1% in 2022).
During the study period, VAB at the hospital was performed using reusable rigid stainless steel vacuum cups connected via tubing to an external hand-operated vacuum pump. Reusable cups were sterilized between cases following the hospital’s infection prevention protocols.
The study purposively recruited 12 clinicians—obstetricians and residents—who had experience in the labour ward. Inclusion criteria required obstetricians to have at least six months of post-specialist labour ward experience and residents to have completed a minimum of one year of residency training. The ward in charge identified potential participants; the principal investigator then explained the study and obtained written informed consent. Recruitment continued until data saturation was reached, with saturation achieved after ten interviews and the final two interviews confirming no new themes.
A semi-structured interview guide was developed from a structured literature review and organized using the socioecological model. The interview domains included individual-level topics (knowledge, skills, training exposure, confidence, perceived competence, and risk perception) and organizational-level topics (availability of functional equipment, guidelines and protocols, workload and staffing, and facility culture around operative vaginal birth).
Because interviews were conducted in Kiswahili, the guide was translated and iteratively reviewed by bilingual clinicians to ensure terminology matched local hospital language and practice. The Kiswahili version was validated with clinicians similar to study participants and adjusted for clarity and cultural relevance where necessary.
Interviews were held in private locations chosen by participants to ensure confidentiality. Each session lasted about 40–50 minutes, was audio-recorded with consent, and was supported by a trained research assistant with nursing and midwifery experience.
Interview recordings and field notes were analyzed inductively using thematic analysis to identify patterns and categories related to barriers in VAB use. The analysis focused on extracting themes aligned with the individual and organizational domains outlined in the interview guide.
Participants described multiple organizational impediments to routine VAB use. First, limited availability of functional VAB equipment was a recurrent concern: clinicians reported insufficient numbers of devices and reliance on reusable metal cups with a hand-operated external pump. Some available devices were perceived as ineffective or prone to malfunction, reducing clinicians’ willingness to attempt vacuum extraction.
Second, the study identified suboptimal team dynamics and communication as barriers. Poor collaboration and unclear roles during labour management were reported to hinder timely decision-making and the coordinated actions required for safe VAB. High workload and staffing pressures at a busy tertiary facility were contextual contributors to these team-based challenges.
Third, while sterilization practices for reusable cups were in place, the logistics of device processing and device turnover were implied challenges when device stocks were low, further constraining availability.
Clinicians reported several personal-level factors that limited VAB utilization. A prominent theme was apprehension about potential adverse maternal and neonatal outcomes associated with vacuum extraction, including concerns about scalp and head injuries and postpartum complications. These risk perceptions influenced clinicians’ preferences, sometimes leading them to favor cesarean section.
Limited hands-on experience and practical training was another key barrier. Many participants described insufficient exposure during training and a consequent lack of confidence and technical competence to perform VAB. These skill gaps reduced clinician readiness to attempt VAB, particularly in high-pressure or complex cases.
The combination of low confidence, fear of complications, and limited opportunity for supervised practice reinforced a cycle in which VAB was rarely attempted, further diminishing clinicians’ experience and comfort with the procedure.
Based on clinician perspectives, the study highlights actionable areas to increase appropriate VAB use. Strengthening the availability and maintenance of functional vacuum-assisted birth equipment, ensuring reliable device supply and processing, and improving team communication and defined roles during assisted vaginal birth were identified as organizational priorities.
At the individual level, the authors emphasize the need for enhanced practical training and competency-building initiatives—supervised hands-on practice and mentorship were suggested by participants as means to bolster clinician skills and confidence. These capacity-building strategies, combined with equipment support and better working conditions, are proposed as mechanisms to increase safe VAB use and potentially reduce unnecessary cesarean section rates.
The study’s exploratory qualitative approach enabled in-depth insight into clinician experiences at a high-volume tertiary facility where VAB use is persistently low. Recruitment continued until data saturation, and the interview tool was carefully adapted and validated for the Kiswahili-speaking clinical context.
Limitations reported in the manuscript include the focus on a single tertiary hospital; findings reflect clinician perspectives in that setting and may not capture all barriers across different facility levels or regions. The authors did not report additional quantitative measures or outcomes beyond thematic findings.
In conclusion, clinicians at the studied tertiary hospital identified both organizational (equipment availability and functionality, team dynamics) and individual (fear of adverse outcomes, limited skills and experience) barriers to the use of VAB. The authors suggest that addressing equipment supply and maintenance, strengthening hands-on training, and improving workplace conditions could increase appropriate VAB utilization and help reduce unnecessary cesarean deliveries.