To purchase or authenticate to the full-text of this article, please visit this link: http://onlinelibrary.wiley.com/doi/10.1111/birt.12245/abstract Byline: Holly P. Kennedy, Eleanor Doig, Stephanie Tillman, Amanda Strauss, Beth Williams, Christian Pettker, Jessica Illuzzi Keywords: cesarean prevention; qualitative research; vaginal birth Abstract Background One in three women will deliver by cesarean, a procedure that can be life saving, but which also carries short- and long-term risks. There is growing interest in preventing primary cesarean deliveries, while optimizing the health of the mother and infant. The primary aim of this study was to use participatory action strategies and ethnographic interview data collected from diverse stakeholders in birth (caregivers, women, policymakers) about facilitators and barriers to the achievement of primary vaginal birth in first-time mothers in hospital settings. The secondary aim was to use the findings to identify strategies to promote primary vaginal birth and future areas of research. Methods Individual and small group interviews were conducted with caregivers and policymakers (N = 79) and first-time mothers (N = 24) at a northeastern hospital. All interviews were audio-recorded, transcribed, and analyzed using Atlas.ti. Results Four broad themes were identified: 1) preparation for childbirth, 2) early labor management, 3) caregiver knowledge and practice style, and 4) birth environment (physical, cultural/emotional). The first two were closely linked from caregivers' perspectives. If the woman was not prepared for childbirth, it was perceived she would be more likely to present to the hospital in early labor. Once there, it was hard to prevent admission and interventions. A woman's knowledge and confidence were perceived as powerful mediators for vaginal birth. Conclusion Caregivers and first-time mothers identified early labor management and childbirth preparation as important factors to promote primary vaginal birth in hospital settings. Both deserve further inquiry as potential strategies to decrease rising cesarean delivery rates.