Task shifting levonorgestrel implant insertion to community midwife assistants in Malawi: results from a non-inferiority evaluation

Abstract

BackgroundIn 2013, Malawi began task shifting long acting reversible contraception (LARC) insertion from Nurse Midwife Technicians (NMTs), who undergo 3 years of training, to Community Midwife Assistants (CMAs), who undergo 18 months of training. However, there is no evidence on whether CMAs have the same competency as NMTs for LARC insertion. Therefore, we describe a non-inferiority evaluation to determine whether CMAs are non-inferior to NMTs for the insertion of levonorgestrel (LNG) contraceptive implants in Malawi.MethodsOne CMA and one matched NMT from 31 health centers across Malawi were selected for training in Malawi’s 1-week LARC insertion course in October 2016, and 31 CMAs and 30 NMTs completed the training. After the course, two Family Planning Master Trainers visited the nurses’ health centers over a 5-month period and used the Malawi LNG implant insertion checklist to evaluate the first five LNG implant insertions that each nurse performed during the monitoring visit. A non- inferiority margin of 10% was used to compare mean implant scores between CMAs and NMTs.ResultsWe were able to fully evaluate 29 CMAs and 29 NMTs with the LNG implant insertion checklist. The CMAs and NMTs had mean scores of 90.2% and 89.7%, respectively, which were non-inferior (mean difference − 0.5%; 95% CI -3.4%, 2.4%), even when adjusted for the number of years post-graduation and the number of LNG implants inserted pre-training, during training, and since training (mean difference 1.3%; 95% CI -2.2%, 4.8%).ConclusionsCMAs were non-inferior to NMTs with LNG implant insertion, and both cadres were generally observed to be competent with their insertions after completing their follow-up evaluations. During the evaluations, we generally saw an increase in scores with each insertion. Therefore, for both cadres, it is important to establish continued mentorship and evaluation for LARC insertion after the initial training.Electronic supplementary materialThe online version of this article (10.1186/s40834-018-0077-6) contains supplementary material, which is available to authorized users.

Task Shifting and Task Sharing Implementation in Africa: A Scoping Review on Rationale and Scope

“…Fifty-four studies [ 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 , 60 , 61 , 62 , 63 , 64 , 65 , 66 , 67 , 68 , 69 , 70 , 71 , 72 , 73 , 74 ...…”

“…Forty studies [ 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 ] reported the rationale for task shifting and task sharing implementation to be due to a shortage of health workers. The cadres reported to be inadequate to inform task shifting and task sharing in the various countries included physicians [ 38 , 39 , 40 , 41 , 42 , 43 ], nurses [ 44 , 45 , 46 ], midwives [ 46 ], surgical specialists [ 47 , 48 ], eye care specialists [ 75 , 76 ], pharmaceutical staff [ 49 ], emergency care practitioners [ 27 ], psychiatrists [ 50 , 51 , 52 , 53 ], psychologists [ 51 ], and pathologists [ 54 ]. Insights on the reported shortages were provided in four studies.…”

“…The study in Madagascar [ 66 ] task-shifted the provision of injectable contraceptives and counselling of patients to community health workers. In a study in Malawi [ 46 ], the task of long-acting reversible contraception (LARC) insertion was shifted to community midwife assistants (CMAs). In a study in Nigeria [ 28 ], the provision of contraceptive implants was task-shifted to community health extension workers.…”

Factors Associated With Delayed Contraceptive Implant Removal in Ethiopia

“… 15 This effort is especially relevant in light of our findings, which demonstrate that even when implant introduction efforts try to build in safeguards to ensure timely removals (deploying higher-level providers to the community level and referring women to higher-level facilities for removals), they may not be sufficient to fulfill the removal needs of all women, particularly those living in rural areas who cite transportation or distance to the facility as barriers to care. Other projects piloting the “task-shifting” of implant provision have also demonstrated effective insertion skills by providers, 16 , 17 but information on removal services available to women through these efforts is still limited.…”

Is there any relationship between role stressors, job tasks, and job satisfaction among Health Surveillance Assistants in Malawi? A cross-sectional study

“…Previously, the HSAs were only performing a few preventive health tasks such as WASH, immunizations and growth monitoring [9]. With the increasing health demands at the community level and the critical shortage of health workers, has necessitated the addition of new roles the HSAs [32]. Evidence from the literature suggests role stressors among employees are likely to contribute to lower job satisfaction and poor job performance if mitigation measures are not put in place [9].…”