OBJECTIVES:|To document facility-based practices for normal labour and delivery in Egypt, Lebanon, the West Bank (part of the Occupied Palestinian Territory) and Syria and to categorise common findings according to evidence-based obstetrics.|DESIGN:|Three studies (Lebanon, West Bank and Syria) interviewed a key informant (providers) in maternity facilities. The study in Egypt directly observed individual labouring women.|SETTING:|Maternity wards.|SAMPLE:|Nationally representative sample of hospitals drawn in Lebanon and Syria. In the West Bank, a convenience sample of hospitals was used. In Egypt, the largest teaching hospital's maternity ward was observed.|METHODS:|Shared practices were categorised by adapting the World Health Organization's (WHO) 2004 classification of practices for normal birth into the following: practices known to be beneficial, practices likely to be beneficial, practices unlikely to be beneficial and practices likely to be ineffective or harmful.|MAIN OUTCOME MEASURES:|Routine hospital practices for normal labor and delivery.|RESULTS:|There was infrequent use of beneficial practices that should be encouraged and an unexpectedly high level of harmful practices that should be eliminated. Some beneficial practices were applied inappropriately and practices of unproven benefit were also documented. Some documented childbirth practices are potentially harmful to mothers and their babies.|CONCLUSION:|Facility practices for normal labour were largely not in accordance with the WHO evidence-based classification of practices for normal birth. The findings are worrying given the increasing proportion of facility-based births in the region and the improved but relatively high maternal and neonatal mortality ratios in these countries. Obstacles to following evidence-based protocols for normal labour require examination.