Optimizing the delivery of contraceptives in low- and middle-income countries through task shifting: a systematic review of effectiveness and safety

Polus, Stephanie; Lewin, Simon; Glenton, Claire; Lerberg, Priya M; Rehfuess, Eva; Gülmezoglu, A Metin

doi:10.1186/s12978-015-0002-2

Reproductive Health

Table 3 Summary of findings

From: Optimizing the delivery of contraceptives in low- and middle-income countries through task shifting: a systematic review of effectiveness and safety

What is the effectiveness of IUD insertion by nurses compared to IUD insertion by doctors?
Patient or population: patients with IUDs
Settings: Hospital setting, Brazil (Lassner et al. [22]) and Colombia (Einhorn et al. [24])
Intervention: Nurses inserting IUDs
Comparison: Doctors inserting IUDs
Outcomes	Illustrative comparative risks* (95% CI)		Relative effect	No of Participants	Certainty of the evidence	Comments
Outcomes	Assumed risk	Corresponding risk	Relative effect	No of Participants	Certainty of the evidence	Comments
	Doctors inserting IUDs	Nurses inserting IUDs	(95% CI)	(studies)	(GRADE)
Continuation rates¹	790 per 1000	782 per 1000	RR 0.99	1786	⊕⊕⊝⊝
Continuation rates¹	790 per 1000	(743 to 814)	(0.94 to 1.03)	(2 studies)	low^2,3
Removal rates⁴	78 per 1000	71 per 1000	RR 0.91	1632	⊕⊝⊝⊝
Removal rates⁴	78 per 1000	(50 to 100)	(0.64 to 1.27)	(2 studies)	very low^{3, 5}
Complication rates during insertion	17 per 1000	18 per 1000	RR 1.01	1711	⊕⊝⊝⊝
Complication rates during insertion	17 per 1000	(9 to 36)	(0.5 to 2.05)	(2 studies)	very low^3,6
Unintended pregnancy rates⁷	12 per 1000	8 per 1000	RR 0.66	1786	⊕⊝⊝⊝
Unintended pregnancy rates⁷	12 per 1000	(3 to 20)	(0.25 to 1.7)	(2 studies)	very low^2,3,6
Insertion failure rate, nulliparous women	34 per 1000	117 per 1000	RR 3.41	263	⊕⊕⊝⊝
Insertion failure rate, nulliparous women	34 per 1000	(40 to 337)	(1.18 to 9.85)	(1 study)	low^2,6
Insertion failure rate, multiparous women	9 per 1000	16 per 1000	RR 1.66	1448	⊕⊕⊝⊝
Insertion failure rate, multiparous women	9 per 1000	(6 to 40)	(0.65 to 4.25)	(1 study)	low^2,6
Expulsion rates	54 per 1000	50 per 1000	RR 0.93	1195	⊕⊕⊝⊝
Expulsion rates	54 per 1000	(31 to 82)	(0.57 to 1.52)	(1 study)	low^2,6
Pain during insertion	108 per 1000	70 per 1000	RR 0.65	1711	⊕⊕⊝⊝
Pain during insertion	108 per 1000	(52 to 96)	(0.48 to 0.89)	(1 study)	low²
Uptake of contraceptives - not measured	See comment	See comment	Not estimable	-	See comment
Referral rates - not measured	See comment	See comment	Not estimable	-	See comment

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: Confidence interval; RR: Risk ratio;
GRADE Working Group grades of evidence.
High certainty: We are very confident that the true effect lies close to that of the estimate of the effect.
Moderate certainty: We are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different.
Low certainty: Our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of the effect.
Very low certainty: We have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect.
¹Continuation rates were measured at 9 months in one study and 12 months in the other study.
²Downgraded because of differences in baseline characteristics, including differences in parity and history of pelvic inflammatory disease or sexually transmitted infections.
³Downgraded because of high risk of bias in sequence generation and allocation concealment.
⁴In one trial, the outcome was removal rate due to medical reasons and, in the other trial, termination rates due to side effects (including expulsions). Because further information was not provided, it was not clear whether these two outcomes were defined similarly.
⁵Downgraded because studies show different results, one showing no difference between nurses and doctors and the other one showing higher removal rates for nurses than for doctors.
⁶Downgraded because of imprecision (i.e. the confidence interval indicates both benefit and harm or because confidence interval is very wide).
⁷Pregnancy rates were measured at 9 and 12-month follow-ups.

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ISSN: 1742-4755

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