The barriers and facilitators of introducing evidence-based practices around the use of episiotomy in Jordan

Abstract

The practice of episiotomy is frequently undertaken during birth in many parts of the world, including several countries in the Middle East and Eastern Europe, with no scientific evidence of its benefits. There is a paucity of research examining the underlying reasons or drivers for episiotomy rates, and why they are higher in some countries. Recent evidence supports the restrictive use of episiotomy and this is reflected in policy statements and clinical practice recommendations internationally. In recent years, various strategies have been adopted internationally with a view to shifting opinion and reducing the rate of episiotomy. This thesis has two main purposes. Firstly, it will examine the facilitators and barriers to evidence-based episiotomy practice in Jordan, including an exploration of the perceptions and beliefs of health practitioners around the use of episiotomy. Secondly, this thesis will identify the strategies that may be effective in introducing evidence-based practice in relation to the use of episiotomy. The study was undertaken in Jordan in 2012 and 2013 and was conducted in one of the major maternity hospitals in Irbid. A quality improvement approach was selected as the most appropriate framework to guide this study. The study was conducted in three phases; in phase one, a retrospective file review of 300 births was conducted using an audit and review model. In phase two, 15 face-to-face, in-depth semi-structured interviews were conducted with 10 midwives and five key stakeholders (managers and doctors). Interviews were audio-recorded and transcribed verbatim. A feedback and discussion session using a review model was conducted in phase three to present the findings of the previous phases of the study to staff and to discuss with the participants (23 midwives and nurses) potential strategies to reduce the episiotomy rate in the hospital. Data from this feedback session were also included in the analysis. All quantitative data from the case files were analysed using descriptive statistics to report the percentage of women having an episiotomy. Qualitative data from the field notes, interviews and the feedback and discussion session were analysed using thematic analysis. The rate of episiotomy is still high for primiparous women in this maternity unit in Jordan. This was confirmed by participating staff in the interviews and the feedback and discussion session. Six major themes emerged from the thematic analysis: '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'. Episiotomy is routinely conducted for all primiparous women in Jordan. This non-evidence-based policy has been handed down over time and appears as an unwritten 'rule' that governs the health professionals' practice of episiotomy. The analysis demonstrated that doctors direct maternity care practices, dictate policy, and determine and perpetuate the 'rules' in the maternity unit. Midwives, while at times doubting the spoken policy, were reluctant to modify practices or try to implement change. They did not want to 'rock the boat', believing it was better for them to 'keep the peace' with doctors and senior staff. Consequently, they would typically opt for the path of least resistance, or in other words 'swim with the tide'. Moreover, the participating midwives and doctors alike appeared to blame birthing women for not taking part in decision-making processes in relation to the administration of episiotomy: they described birthing women as 'uncooperative' and lacking in knowledge related to labour and birth. Strategies for change included: running educational programs for both the health staff and to keep their knowledge up to date, building local libraries and providing internet access. Participants suggested that women could be provided with information regarding relevant websites, or offered a telephone hotline or helpline through which to obtain information. Some emphasised that managers needed to be leaders to facilitate change and to offer support to midwives to practise in a different way. Despite these promising suggestions, it was nonetheless apparent that effecting change would be difficult without also addressing the power relationship between midwives and doctors. Similarly, and most importantly, professionals' perceptions of women as passive and uniformed must be challenged and subverted for change to occur.

Date of Award	2014
Original language	English