Abstract
ObjectiveAs part of a strategy to revitalize postpartum family planning services, Government of India revised its policy in 2013 to permit trained nurses and midwives to insert postpartum intrauterine contraceptive devices (PPIUCDs). This study compares two key outcomes of PPIUCD insertions — expulsion and infection — for physicians and nurses/midwives to generate evidence for task sharing. Study designWe analyzed secondary data from the PPIUCD program in seven states using a case–control study design. We included facilities where both doctors and nurses/midwives performed PPIUCD insertions and where five or more cases of expulsion and/or infection were reported during the study period (January–December 2013). For each case of expulsion and infection, we identified a time-matched control who received a PPIUCD at the same facility and had no complaints. We performed a multiple logistic regression analysis focusing on provider cadre while controlling for potential confounding factors. ResultsIn 137 facilities, 792 expulsion and 382 infection cases were matched with 1041 controls. Provider type was not significantly associated with either expulsion [odds ratio (OR) 1.84; 95% confidence interval (CI): 0.82–4.12] or infection (OR 0.73; 95% CI: 0.39–1.37). Compared with centralized training, odds of expulsion were higher for onsite (OR 2.32, 95% CI: 1.86–2.89) and on-the-job training (OR 1.23, 95% CI: 1.11–1.36), but odds of infection were lower for onsite (OR 0.45, 95% CI: 0.27–0.75) and on-the-job training (OR 0.31, 95% CI: 0.25–0.37). ConclusionTrained nurses and midwives who conduct deliveries at public health facilities can perform PPIUCD insertions as safely as physicians. ImplicationsInstitutional deliveries are increasing in India, but most normal vaginal deliveries at public health facilities are attended by nurses and midwives due to a shortage of physicians. Task sharing with nurses and midwives can increase women's access to and the acceptability of quality PPIUCD services.
Highlights
Our analysis compares the outcomes of insertions performed by physicians with those performed by nurses and midwives
We found that information on providers' years of experience in offering FP and postpartum intrauterine contraceptive devices (PPIUCDs) services are incomplete at many facilities
For each case of expulsion and infection, we identified a control who (1) received a PPIUCD at the same facility either during the 2 months preceding or 2 months following the month of the case's insertion and (2) had no complaints at 6-week follow-up (Fig. 2)
Summary
☆ Funding Source: Bill & Melinda Gates Foundation in collection of data and writing of the report. ☆☆ Conflicts of Interest: None. Proportion of deliveries taking place at health facilities increased from 41% in 2005–2006 [4] to 86.9% [10] This preference has emerged due to the government's flagship program — Janani Suraksha Yojana, a conditional cash transfer scheme for promoting institutional deliveries. Given high unmet need for birth spacing and the rise in institutional deliveries, the Government of India, with technical support from Jhpiego, has been working to reinvigorate and scale up the use of postpartum FP, with a focused effort on expanding the capacity to provide PPIUCD services. Evidence from several countries supports task sharing in the delivery of FP services [16,17], and studies have found that provision of interval intrauterine contraceptive devices (IUCDs) by nurse-midwives is effective and feasible in low-resource settings [18,19,20]. Our analysis compares the outcomes of insertions performed by physicians with those performed by nurses and midwives
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