title: The barriers and facilitators to evidence-based episiotomy practice in Jordan.
abstract: OBJECTIVE
  This paper examines the barriers to evidence-based episiotomy practice in Jordan and identifies strategies that may be effective in introducing evidence-based practice.
  
  
  BACKGROUND
  Episiotomy is routinely undertaken during birth in many parts of the world, including in the Middle East with little scientific evidence of benefit. There is a paucity of research examining the underlying drivers for episiotomy rates, and why they are higher in some countries.
  
  
  METHODS
  This study, conducted in Jordan, used a quality improvement approach and comprised three phases. In phase one, a retrospective file review of 300 births was conducted. In phase two, 15 face-to-face interviews were conducted with 10 midwives and five key stakeholders (managers and doctors). A feedback and discussion session using the audit and review model was conducted in phase three with 23 health professionals to identify strategies to reduce the episiotomy rate.
  
  
  RESULTS
  The episiotomy rate was 41.4% overall (91% of primiparous women and 24% of multiparous women). Six major themes emerged from the thematic analysis of data: 'Policy: written but invisible and unwritten and assumed'; 'the safest way'; 'doctors set the rules'; 'midwives swimming with the tide; 'uncooperative and uninformed women' and 'the way forward'.
  
  
  CONCLUSIONS
  Non-evidence based episiotomy practices are widely used during birth in this Jordanian hospital and numerous barriers to change exist. Medical professionals dictate childbirth practice and midwives fear recrimination if they go against the 'unwritten policy'. Strategies to change practice include development of evidence-based information for women, education of midwives and doctors, and policy review.
authors.affiliation: School of Nursing and Midwifery, Western Sydney University, Locked Bag 1797, Penrith South DC, NSW 2751, Australia. Electronic address: suhahussein@y7mail.com.
authors.forename: Suha Abed Almajeed Abdallah
authors.initials: SA
authors.lastname: Hussein
authors.affiliation: School of Nursing and Midwifery, Western Sydney University, Locked Bag 1797, Penrith South DC, NSW 2751, Australia. Electronic address: h.dahlen@westernsydney.edu.au.
authors.forename: Hannah G
authors.initials: HG
authors.lastname: Dahlen
authors.affiliation: School of Nursing and Midwifery, Western Sydney University, Locked Bag 1797, Penrith South DC, NSW 2751, Australia. Electronic address: m.duff@westernsydney.edu.au.
authors.forename: Margaret
authors.initials: M
authors.lastname: Duff
authors.affiliation: School of Nursing and Midwifery, Western Sydney University, Locked Bag 1797, Penrith South DC, NSW 2751, Australia. Electronic address: v.schmied@westernsydney.edu.au.
authors.forename: Virginia
authors.initials: V
authors.lastname: Schmied
mesh_terms: D001291:Attitude of Health Personnel; D036861:Delivery, Obstetric / Q000706:statistics & numerical data*; D004841:Episiotomy / Q000009:adverse effects* / Q000706:statistics & numerical data*; D055317:Evidence-Based Practice; D005260:Female; D006801:Humans; D007597:Jordan / Q000453:epidemiology; D008880:Midwifery / Q000379:methods; D057184:Practice Patterns, Nurses' / Q000706:statistics & numerical data*; D011247:Pregnancy; D012189:Retrospective Studies
keywords: Attitudes; Episiotomy; Evidence-based practice; Midwife