title: Skilled birth attendants in Mexico: how does care during normal birth by general physicians, obstetric nurses, and professional midwives compare with World Health Organization evidence-based practice guidelines?
abstract: BACKGROUND
  We evaluated the quality of basic obstetric care provided by Mexican general physicians, obstetric nurses, and professional midwives compared with World Health Organization (WHO) guidelines for evidence-based practices and national guidelines.
  
  
  METHODS
  Vaginal births were observed in 5 hospitals in 5 states from June 2006 until July 2007. We created 5 indices based on WHO guidelines and national standards for care during normal birth. These indices included 1) favorable practices at admission, 2) favorable practices during labor, birth, and immediately postpartum, 3) harmful or excessively used practices, 4) newborn practices, and 5) obstetric outcomes. We assessed each provider type's performance as high or low compared with the WHO standard and performed bivariate and multivariate logistic regression analyses to assess the association between indices, patient characteristics, and provider type, adjusting for standard errors for intragroup correlation.
  
  
  RESULTS
  We observed 876 independently managed vaginal births. Adjusted regression analyses compared with the general physicians standard revealed significant results for favorable care by obstetric nurses on admission (odds ratio [OR] 6.25; 95% confidence interval [CI], 2.08-18.84); for care by professional midwives (OR 21.08; 95% CI, 4.24-104.94) and obstetric nurses (OR 7.88; 95% CI, 2.76-22.52) during labor, birth, and postpartum; and for newborn practices by obstetric nurses (OR 4.14; 95% CI, 1.08-15.90). Professional midwives were least likely to perform harmful/excessively used practices during labor, birth, and the postpartum period (OR 0.06; 95% CI, 0.00-0.35).
  
  
  CONCLUSIONS
  Professional midwives and obstetric nurses perform equally or better than general physicians when assessed by use or misuse of evidence-based practices. Professional midwives are an underutilized resource in Mexico. If integrated into the mainstream Mexican health system, they may improve the quality of obstetric care.
authors.affiliation: University ofWashington,Department of Global Health, 325 9th Avenue, Seattle, WA 98104, USA. dilys@u.washington.edu
authors.forename: Dilys
authors.initials: D
authors.lastname: Walker
authors.forename: Lisa M
authors.initials: LM
authors.lastname: DeMaria
authors.forename: Leticia
authors.initials: L
authors.lastname: Suarez
authors.forename: Leslie
authors.initials: L
authors.lastname: Cragin
mesh_terms: D000293:Adolescent; D000328:Adult; D002983:Clinical Competence; D036861:Delivery, Obstetric / Q000009:adverse effects / Q000379:methods / Q000592:standards*; D005260:Female; D058006:General Practice / Q000379:methods / Q000592:standards*; D019983:Guideline Adherence; D006801:Humans; D016015:Logistic Models; D008297:Male; D008800:Mexico; D008880:Midwifery / Q000379:methods / Q000592:standards*; D015999:Multivariate Analysis; D009773:Obstetric Nursing / Q000379:methods / Q000592:standards*; D009774:Obstetrics / Q000379:methods / Q000592:standards*; D016017:Odds Ratio; D017410:Practice Guidelines as Topic; D011247:Pregnancy; D011787:Quality of Health Care; D059039:Standard of Care; D014944:World Health Organization; D055815:Young Adult