Table 1 Components of the intervention

   - Teams of 3–6 birth attendants per hospital

   - Selected by peer nomination

Interactive workshops

   - Opinion leaders teams will participate in a 5 day workshop

   - Objectives:

- To learn the need of an evidence based clinical practice

- To develop simple evidence based guidelines about episiotomy use and management of the third stage of labor

- To identify the barriers for the adoption of those guidelines at the hospital level

- To learn how to overcome barriers and to implement the guidelines

- To adapt and organize the dissemination and implementation of the guidelines in their hospitals

Academic detailing

   - Dissemination of the guidelines to hospital birth attendants in small groups and individual discussions

   - Identification of barriers to implement the guidelines

   - Adaptation and organization of implementation activities working closely with birth attendants.

Training on how to comply with the recommended practices

   - Training in manual abilities with videos, anatomical models and patients. One day workshop.

Reminders

   - Placing reminders of selective episiotomy and active management of the third stage of labor in labor and delivery wards, clinical records, and surgical packages.

Audit & feed back

   - Monthly reports of hospital episiotomy and active management rates to be distributed to every birth attendant.

Information technology

   - Each hospital in the intervention group will receive a computer with internet access

   - A specific web site will be developed to facilitate the access to study manuals and guidelines, sources of evidence-based health care literature (Reproductive Health Library, Cochrane Library), and communication among hospitals and study coordinators