What makes episiotomy rates change? : a systematic review of the literature

BACKGROUND: Episiotomy is still a commonly used surgical intervention during birth in some parts of the world, such as the Middle East and Eastern Europe. Evidence supports the restrictive use of episiotomy, and this is reflected in policy statements and clinical practice recommendations. Internationally, various strategies have been used to change and reduce the incidence of episiotomy. AIM: To identify and describe the strategies and practices that have been used internationally to effectively reduce the rate of episiotomy. METHOD: We searched CINAHL, Medline, Scopus, PubMed and Nursing Consultant from 1980 to 2010 by using the keywords episiotomy, change, practice, midwife, routine use and evidence-based. A review of the literature was undertaken, which examined factors that facilitate the reduction in episiotomy rates. RESULTS: Two hundred articles were found, and after examination, only nine provided relevant data and are included in this review. The findings of this review are discussed under the following headings: impact of practice change on episiotomy rates, continuous quality improvement, implementing clinical guidelines, practice change (system change), and the impact of health beliefs and organizational culture. Strategies for changing practice that were identified focused on challenging rationales for current practice and on creating a social and organizational environments that encourage motivation and, therefore, are more effective in reducing episiotomy rates. The literature identified the importance of clarifying critical success factors before trying to implement change with regards to episiotomy usage. CONCLUSION: Greater efforts to reduce episiotomy rates are currently needed, particularly in countries with high rates. Researchers need to continue to examine the barriers to change and investigate approaches that promote clinician behavior change.