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


Objective: To assess the effectiveness and safety of task shifting for the delivery of injectable contraceptives,
contraceptive implants, intrauterine devices (IUDs), tubal ligation and vasectomy in low- and middle-income

Methods: Multiple electronic databases were searched up to 25 May 2012 for studies which had assessed the
delivery of contraceptives by health workers with lower levels of training, compared to delivery by health workers
usually assigned this role, or compared to no organized provision of contraceptives. We included randomized
controlled trials, non-randomized controlled trials, controlled before-after studies, and interrupted time series. Data
were extracted using a standard form and the certainty of the evidence found was assessed using GRADE.

Results: We identified six randomized controlled trials published between 1977 and 1995 that assessed the safety
and effectiveness of task shifting for the delivery of long-term contraceptives. Two studies assessed IUD insertion by
nurses compared to doctors, two assessed IUD insertion by auxiliary nurse-midwives compared to doctors, one
assessed tubal ligation by midwives compared to doctors, and one assessed the delivery of vasectomy by medical
students compared to doctors. In general, little or no difference was found in contraceptive outcomes between
cadres. Study design limitations and the low number of eligible studies, however, allow only limited conclusions to
be drawn.

Conclusions: The findings indicate that task shifting for the delivery of long-term contraceptives may be a safe and
effective approach to increasing access to contraception. Further research is needed because the certainty of the
evidence identified is variable.

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