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 4 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 auxiliary nurse midwives compared to IUD insertion by doctors?
Patient or population: patients with IUDs
Settings: Primary health care setting in nine rural villages in Cubuk district, Turkey (Eren et al. [21] Study A) and Jose Fabella
Memorial Hospital in Manila, Philippines (Eren et al. [21] Study B)
Intervention: Auxiliary nurse-midwives 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	Auxiliary nurse-midwives inserting IUDs	(95% CI)	(studies)	(GRADE)
Continuation rates¹	699 per 1000	727 per 1000	RR 1.04	996	⊕⊕⊕⊝
Continuation rates¹	699 per 1000	(671 to 783)	(0.96 to 1.12)	(2 studies)	moderate²
Removal rates	107 per 1000	115 per 1000	RR 1.08	996	⊕⊕⊕⊝
Removal rates	107 per 1000	(82 to 162)	(0.77 to 1.52)	(2 studies)	moderate²
Expulsion rates	96 per 1000	81 per 1000	RR 0.84	996	⊕⊕⊕⊝
Expulsion rates	96 per 1000	(54 to 121)	(0.56 to 1.26)	(2 studies)	moderate²
Unintended pregnancy rates	20 per 1000	19 per 1000	RR 0.95	996	⊕⊕⊝⊝
Unintended pregnancy rates	20 per 1000	(8 to 47)	(0.4 to 2.27)	(2 studies)	low^2,3
Referral rate during IUD insertion⁴	65 per 1000	52 per 1000	RR 0.80	1058	⊕⊕⊝⊝
Referral rate during IUD insertion⁴	65 per 1000	(33 to 84)	(0.50 to 1.29)	(2 studies)	low^2,3
Referral rate after IUD insertion⁵	43 per 1000	64 per 1000	RR 1.49	996	⊕⊕⊝⊝
Referral rate after IUD insertion⁵	43 per 1000	(38 to 109)	(0.88 to 2.54)	(2 studies)	low^2,3
Uptake of contraceptives⁶ - not measured	See comment	See comment	Not estimable⁶	-	See comment
Complication rates at insertion⁶ - not measured	See comment	See comment	Not estimable⁶	-	See comment
Insertion failure rates⁶ - not measured	See comment	See comment	Not estimable⁶	-	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 calculated from the number of discontinuations at 12 months.
²Downgraded because of unclear but potential risk of contamination and inadequate blinding and because of statistical heterogeneity.
³Downgraded because of imprecision (i.e. the confidence interval indicates both benefit and harm).
⁴In one study, women were referred because the health worker decided that they were unable to insert the IUD because of postpartum conditions or because they made a failed attempt (i.e. insertion failure). In the other study reasons for referral included: suspected pregnancy, suspected pelvic inflammatory disease, cervicitis and erosion and conditions interfering with IUD insertion (e.g. prolapsed uterus, cervical incompetence).
⁵Where women with IUDs were referred at follow-up visits, because of pregnancy, bleeding problems, suspected pelvic inflammatory diseases (PID), a missing IUD tail, difficulty with insertion or postpartum conditions (anaemia, episiotomy).
⁶The studies did not measure uptake of contraceptives, insertion failure rates or complication rates at insertion.

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ISSN: 1742-4755

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