BACKGROUND:
Maternal deaths and preventable perinatal harm persist in LatinAmerica—even in high-acuity facilities—when clinical decisions fall short of bestjudgement. Clinical reasoning (CR), the ability to interpret data, weigh risks and actswiftly, is therefore critical to obstetric safety. Marked variation in decision making withina high-complexity inpatient unit serving mainly low- to middle-income women promptedthis investigation.

OBJECTIVES:
To quantify CR levels and identify perceived facilitators and barriers amongmidwives in this unit (July 2023–July 2024), informing professional-developmentstrategies.

METHODS:
Sequential explanatory mixed-methods study. Quantitative phase: sixteenmidwives completed the 20-item Obstetric Script Concordance Test (OSCT), previouslyvalidated for Chile. Agreement with an expert panel was scored with weighted κ andmodelled by multiple linear regression (Stata v18) against age, years of experience andpostgraduate training. CR was classified as high (κ≥0.60), moderate (0.31–0.59) or low(≤0.30). Qualitative phase: two purposive focus groups (n=12) explored perceptions ofmidwives with high and low CR; inductive thematic analysis (NVivo 14) was triangulatedwith numerical findings.

RESULTS:
Fifty-six percent demonstrated high CR, 25% moderate and 19% low. Eachadditional year of clinical experience (β =0.06; p=0.02) and postgraduate study (β=0.041;p=0.01) increased κ; age showed no effect. Facilitators: intrinsic motivation, reflectivepractice, continuing education, mentorship and simulation of rare obstetric scenarios.Barriers: workload pressure, limited institutional and financial support, and insufficientclinical exposure during undergraduate training.

CONCLUSIONS:
CR variability depends more on educational trajectory than chronologicalage. Embedding the OSCT-20 with structured feedback, simulation and scholarship supportcould accelerate CR improvement, narrow safety gaps in vulnerable populations andadvance the ICM goal of “One Million More Midwives”.

KEY MESSAGE:
Sustained investment in evidence-based professional developmentstrengthens clinical judgement and, consequently, maternal–neonatal safety. Ethics & conflicts Approved by CEISH-University of Chile and the institutional ethicscommittee (January 2024). No conflicts of interest declared. Spanish - professional development (including three-minute presentation competition)