title: What factors influence midwives' decision to perform or avoid episiotomies? A focus group study.
abstract: OBJECTIVE
  to explore midwives' reasons for performing or avoiding episiotomies and motivation to change episiotomy practice in a large tertiary maternity hospital.
  
  
  METHODS
  using purposive sampling, three focus groups were conducted to achieve theme saturation. Open-ended questions elicited personal reasons for performing or avoiding episiotomy, information sources, and opinions about past and future practice trends. Sessions were audiotaped, and transcripts independently examined by three researchers who coded for themes. An iterative process was used to achieve consensus. Grounded theory was used to interpret data and to derive a theoretical framework for understanding the reasoning that influences episiotomy practice.
  
  
  METHODS
  a high volume delivery unit in Singapore.
  
  
  METHODS
  20 of 79 licensed midwives, aged 28-70, who performed independent deliveries at the delivery unit.
  
  
  RESULTS
  participants recognised maternal, fetal and other factors affecting their own decision to perform episiotomies. Patient request, better healing, midwife's reputation and job satisfaction were cited as main reasons to avoid episiotomy. Key sources informing practice were past training, delivery experience, anecdotal learning and lack of a protocol. There was no consensus on current trends in episiotomy practice. There was an absence of recognition of individual roles in reducing episiotomy rates. Clinicians were perceived as having both positive and negative influence.
  
  
  CONCLUSIONS
  midwives' reasons for performing episiotomies were attributed to midwifery training, fear of doing harm and perceived clinician expectation, and were not consistent with current international practice guidelines. Reasons for avoiding episiotomies were associated with patient-centeredness and job satisfaction. Midwives agreed on the need to reduce episiotomy rates.
  
  
  CONCLUSIONS
  with reduction in episiotomy rates as a goal, a combination of guideline education, feedback, peer coaching and collaborative care with doctors may be needed to achieve desired outcomes. Views and experiences of midwives should also be incorporated into strategies to change episiotomy practice.
authors: Duke-NUS Graduate Medical School, 8 College Road, Singapore. linchiehwu@nus.edu.sg
authors: Lin Chieh
authors: LC
authors: Wu
authors: Désirée
authors: D
authors: Lie
authors: Rahul
authors: R
authors: Malhotra
authors: John C
authors: JC
authors: Allen
authors: Julie S L
authors: JS
authors: Tay
authors: Thiam Chye
authors: TC
authors: Tan
authors: Truls
authors: T
authors: Ostbye
mesh_terms: D000328:Adult; D000368:Aged; D001291:Attitude of Health Personnel; D003469:Culture; D004841:Episiotomy / Q000706:statistics & numerical data*; D005260:Female; D017144:Focus Groups; D006801:Humans; D008875:Middle Aged; D008880:Midwifery; D009721:Nurse Midwives / Q000523:psychology*; D057184:Practice Patterns, Nurses' / Q000706:statistics & numerical data*; D011247:Pregnancy; D012846:Singapore; D011795:Surveys and Questionnaires
keywords: Episiotomy practice; Focus group; Midwife beliefs; Singapore