title: Non-physician providers of obstetric care in Mexico: Perspectives of physicians, obstetric nurses and professional midwives.
abstract: BACKGROUND
  In Mexico 87% of births are attended by physicians. However, the decline in the national maternal mortality rate has been slower than expected. The Mexican Ministry of Health's 2009 strategy to reduce maternal mortality gives a role to two non-physician models that meet criteria for skilled attendants: obstetric nurses and professional midwives. This study compares and contrasts these two provider types with the medical model, analyzing perspectives on their respective training, scope of practice, and also their perception and/or experiences with integration into the public system as skilled birth attendants.
  
  
  METHODS
  This paper synthesizes qualitative research that was obtained as a component of the quantitative and qualitative study that evaluated three models of obstetric care: professional midwives (PM), obstetric nurses (ON) and general physicians (GP). A total of 27 individual interviews using a semi-structured guide were carried out with PMs, ONs, GPs and specialists. Interviews were transcribed following the principles of grounded theory, codes and categories were created as they emerged from the data. We analyzed data in ATLAS.ti.
  
  
  RESULTS
  All provider types interviewed expressed confidence in their professional training and acknowledge that both professional midwives and obstetric nurses have the necessary skills and knowledge to care for women during normal pregnancy and childbirth. The three types of providers recognize limits to their practice, namely in the area of managing complications.We found differences in how each type of practitioner perceived the concept and process of birth and their role in this process. The barriers to incorporation as a model to attend birth faced by PMs and ONs are at the individual, hospital and system level. GPs question their ability and training to handle deliveries, in particular those that become complicated, and the professional midwifery model particularly as it relates to a clinical setting, is also questioned.
  
  
  CONCLUSIONS
  Hospitals in the Mexican public health sector have a heavy obstetric workload; physicians carry the additional burden of non-obstetric cases. The incorporation of a non- physician model at the primary health center level to attend low-risk, normal deliveries would contribute to the reduction of non-necessary referrals. There is also a role for these providers at the hospital level.
authors.affiliation: Center for Population Health Research, Instituto Nacional de Salud Pública, Cuernavaca, Mexico. lcampero@insp.mx.
authors.forename: Lisa M
authors.initials: LM
authors.lastname: Demaria
authors.forename: Lourdes
authors.initials: L
authors.lastname: Campero
authors.forename: Marianne
authors.initials: M
authors.lastname: Vidler
authors.forename: Dilys
authors.initials: D
authors.lastname: Walker