2.1 Oxytocin administration to prevent PPH - standard syringe

Consider in context of rigorous research
Lay Health Worker
Consider in context of rigorous research
Should LAY HEALTH WORKERS administer oxytocin to (a) prevent and (b) treat postpartum haemorrhage using a standard syringe?
Recommendation
We suggest considering this option only in the context of rigorous research.
– For prevention of postpartum haemorrhage, we suggest evaluating this intervention where a well-functioning LHW programme already exists and where LHWs are already familiar with injection techniques and materials
For treatment of postpartum haemorrhage, we suggest evaluating this intervention where a well-functioning LHW programme already exists, where LHWs are already familiar with injection techniques and materials, and where referral to more specialised care is available or can be put in place.
Justification
There is insufficient evidence on the effectiveness and acceptability of using LHWs to administer oxytocin to prevent and to treat postpartum haemorrhage using a standard syringe. Possible undesirable effects include use that is not timely for prevention of haemorrhage; failure to diagnose a second foetus prior to administration; and inappropriate use for other purposes. However, the panel feels that the benefits probably outweigh the harms; that minimal clinical decision making is required; and that the intervention is probably acceptable and feasible. This intervention may also reduce inequalities by extending care to underserved populations.
Problem: Poor access to prevention and treatment of postpartum haemorrhage
Option: LHWs administering oxytocin using a standard syringe
Comparison: Care delivered by other cadres or no care
Setting: Community/primary health care settings in LMICs with poor access to health professionals

Recommend
Auxiliary nurse
Recommend
Should AUXILIARY NURSES administer oxytocin to prevent postpartum haemorrhage, using a standard syringe?
Recommendation
We recommend the use of auxiliary nurses to administer oxytocin to prevent postpartum haemorrhage, using a standard syringe. We suggest using this intervention where auxiliary nurses are already an established cadre.
Justification
There is insufficient evidence on the effectiveness of using auxiliary nurses to administer oxytocin to prevent postpartum haemorrhage using a standard syringe. Possible undesirable effects include use that is not timely for prevention of haemorrhage; failure to diagnose a second foetus prior to administration; and inappropriate use for other purposes. However, the panel feels that the benefits probably outweigh the harms; that minimal clinical decision making is required; and that the intervention is probably acceptable and feasible. In addition, the intervention may reduce inequalities by extending care to underserved populations.
Problem: Poor access to prevention of PPH
Option: Auxiliary nurses administering oxytocin to prevent PPH, using a standard syringe
Comparison: Care delivered by other cadres or no care
Setting: Community/primary health care settings in LMICs with poor access to health professionals

Scoped out (Recommend)
Auxiliary nurse midwife
Scoped out (Recommend)
This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

Scoped out (Recommend)
Nurse
Scoped out (Recommend)
This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

Scoped out (Recommend)
Midwife
Scoped out (Recommend)
This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

Scoped out (Recommend)
Associate clinician
Scoped out (Recommend)
This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

Scoped out (Recommend)
Advanced associate clinician
Scoped out (Recommend)
This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

Scoped out (Recommend)
Non specialist doctor
Scoped out (Recommend)
This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.
2.2 Oxytocin administration to treat PPH - standard syringe

Consider in context of rigorous research
Lay Health Worker
Consider in context of rigorous research
Should LAY HEALTH WORKERS administer oxytocin to (a) prevent and (b) treat postpartum haemorrhage using a standard syringe?
Recommendation
We suggest considering this option only in the context of rigorous research.
– For prevention of postpartum haemorrhage, we suggest evaluating this intervention where a well-functioning LHW programme already exists and where LHWs are already familiar with injection techniques and materials
For treatment of postpartum haemorrhage, we suggest evaluating this intervention where a well-functioning LHW programme already exists, where LHWs are already familiar with injection techniques and materials, and where referral to more specialised care is available or can be put in place.
Justification
There is insufficient evidence on the effectiveness and acceptability of using LHWs to administer oxytocin to prevent and to treat postpartum haemorrhage using a standard syringe. Possible undesirable effects include use that is not timely for prevention of haemorrhage; failure to diagnose a second foetus prior to administration; and inappropriate use for other purposes. However, the panel feels that the benefits probably outweigh the harms; that minimal clinical decision making is required; and that the intervention is probably acceptable and feasible. This intervention may also reduce inequalities by extending care to underserved populations.
Problem: Poor access to prevention and treatment of postpartum haemorrhage
Option: LHWs administering oxytocin using a standard syringe
Comparison: Care delivered by other cadres or no care
Setting: Community/primary health care settings in LMICs with poor access to health professionals

Recommend with monitoring and evaluation
Auxiliary nurse
Recommend with monitoring and evaluation
Should AUXILIARY NURSES administer oxytocin to treat postpartum haemorrhage, using a standard syringe?
Recommendation
We suggest considering this option with targeted monitoring and evaluation. We suggest using this intervention only where auxiliary nurses are already an established cadre and where a where a well-functioning referral system is in place or can be put in place.
Justification
There is insufficient evidence on the effectiveness of using auxiliary nurses to administer oxytocin to treat postpartum haemorrhage using a standard syringe. Possible undesirable effects include inappropriate use for other purposes. However, the panel feels that the benefits probably outweigh the harms; that minimal clinical decision making is required; and that the intervention is probably acceptable and feasible. In addition, the intervention may reduce inequalities by extending care to underserved populations.
Problem: Poor access to treatment of PPH
Option: Auxiliary nurses administering oxytocin to treat PPH, using a standard syringe
Comparison: Care delivered by other cadres or no care
Setting: Community/primary health care settings in LMICs with poor access to health professionals

Scoped out (Recommend)
Auxiliary nurse midwife
Scoped out (Recommend)
This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

Scoped out (Recommend)
Nurse
Scoped out (Recommend)
This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

Scoped out (Recommend)
Midwife
Scoped out (Recommend)
This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

Scoped out (Recommend)
Associate clinician
Scoped out (Recommend)
This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

Scoped out (Recommend)
Advanced associate clinician
Scoped out (Recommend)
This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

Scoped out (Recommend)
Non specialist doctor
Scoped out (Recommend)
This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.
2.3 Oxytocin administration to prevent PPH - CPAD

Consider in context of rigorous research
Lay Health Worker
Consider in context of rigorous research
Should LAY HEALTH WORKERS administer oxytocin to (a) prevent and (b) treat postpartum haemorrhage using a compact, prefilled, autodisable device (CPAD) such as Uniject?
Recommendation
We suggest considering this option only in the context of rigorous research.
– For prevention of postpartum haemorrhage, we suggest evaluating this intervention where a well-functioning LHW programme already exists
– For treatment of postpartum haemorrhage, we suggest using this intervention only where a well-functioning LHW programme already exists and where a well-functioning referral system is in place or can be put in place
Justification
There is insufficient evidence on the effectiveness of using LHWs to administer oxytocin to prevent and treat postpartum haemorrhage. However, this intervention may be an acceptable approach, may be feasible under certain conditions, and may reduce inequalities by extending care to underserved populations.
Problem: Poor access to prevention and treatment of postpartum haemorrhage
Option: LHWs administering oxytocin using a CPAD
Comparison: Care delivered by other cadres or no care
Setting: Community/primary health care settings in LMICs with poor access to health professionals

Recommend
Auxiliary nurse
Recommend
Should AUXILIARY NURSES administer oxytocin to prevent postpartum haemorrhage, using a compact, autodisable, prefilled injection device (CPAD) such as Uniject?
Recommendation
We recommend this option. We suggest using this where auxiliary nurses are already an established cadre.
Justification
There is insufficient evidence on the effectiveness of using auxiliary nurses to administer oxytocin to prevent postpartum haemorrhage using a CPAD. Possible undesirable effects include use that is not timely for prevention of haemorrhage; failure to diagnose a second foetus prior to administration; and inappropriate use for other purposes. However, this intervention is probably acceptable and feasible. In addition, the panel feels that the benefits probably outweigh the harms; that minimal clinical decision making is required, and that the intervention may reduce inequalities by extending care to underserved populations.
Problem: Poor access to treatment for prevention of PPH
Option: Auxiliary nurses administering oxytocin using a CPAD to prevent PPH
Comparison: Care delivered by other cadre or no care
Setting: Community/primary health care settings in LMICs with poor access to health professionals

Scoped out (Recommend)
Auxiliary nurse midwife
Scoped out (Recommend)
This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

Scoped out (Recommend)
Nurse
Scoped out (Recommend)
This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

Scoped out (Recommend)
Midwife
Scoped out (Recommend)
This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

Scoped out (Recommend)
Associate clinician
Scoped out (Recommend)
This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

Scoped out (Recommend)
Advanced associate clinician
Scoped out (Recommend)
This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

Scoped out (Recommend)
Non specialist doctor
Scoped out (Recommend)
This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.
2.4 Oxytocin administration to treat PPH - CPAD

Consider in context of rigorous research
Lay Health Worker
Consider in context of rigorous research
Should LAY HEALTH WORKERS administer oxytocin to (a) prevent and (b) treat postpartum haemorrhage using a compact, prefilled, autodisable device (CPAD) such as Uniject?
Recommendation
We suggest considering this option only in the context of rigorous research.
– For prevention of postpartum haemorrhage, we suggest evaluating this intervention where a well-functioning LHW programme already exists
– For treatment of postpartum haemorrhage, we suggest using this intervention only where a well-functioning LHW programme already exists and where a well-functioning referral system is in place or can be put in place
Justification
There is insufficient evidence on the effectiveness of using LHWs to administer oxytocin to prevent and treat postpartum haemorrhage. However, this intervention may be an acceptable approach, may be feasible under certain conditions, and may reduce inequalities by extending care to underserved populations.
Problem: Poor access to prevention and treatment of postpartum haemorrhage
Option: LHWs administering oxytocin using a CPAD
Comparison: Care delivered by other cadres or no care
Setting: Community/primary health care settings in LMICs with poor access to health professionals

Recommend with monitoring and evaluation
Auxiliary nurse
Recommend with monitoring and evaluation
Should AUXILIARY NURSES administer oxytocin to treat postpartum haemorrhage using a compact, autodisable, prefilled injection device (CPAD) such as Uniject?
Recommendation
We suggest considering this option with targeted monitoring and evaluation. We suggest using this intervention only where auxiliary nurses are already an established cadre and where a well-functioning referral system is in place or can be put in place.
Justification
There is insufficient evidence on the effectiveness of using auxiliary nurses to administer oxytocin to treat postpartum haemorrhage using a CPAD. . Possible undesirable effects include inappropriate use for other purposes However, this intervention is probably acceptable and feasible. In addition, the panel feels that the benefits probably outweigh the harms; that minimal clinical decision making is required, and that the intervention may reduce inequalities by extending care to underserved populations. As the assessment and diagnosis of postpartum haemorrhage requires some experience and judgement, the panel suggests that the option is considered with targeted monitoring and evaluation.
Problem: Poor access to treatment for PPH
Option: Auxiliary nurses administering oxytocin using a CPAD to treat PPH
Comparison: Care delivered by other cadre or no care
Setting: Community/primary health care settings in LMICs with poor access to health professionals

Scoped out (Recommend)
Auxiliary nurse midwife
Scoped out (Recommend)
This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

Scoped out (Recommend)
Nurse
Scoped out (Recommend)
This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

Scoped out (Recommend)
Midwife
Scoped out (Recommend)
This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

Scoped out (Recommend)
Associate clinician
Scoped out (Recommend)
This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

Scoped out (Recommend)
Advanced associate clinician
Scoped out (Recommend)
This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

Scoped out (Recommend)
Non specialist doctor
Scoped out (Recommend)
This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.
2.5 Misoprostol administration to prevent PPH

Recommend
Lay Health Worker
Recommend
Should LAY HEALTH WORKERS administer misoprostol to prevent postpartum haemorrhage?
Recommendation
We recommend the use of lay health workers to administer misoprostol to prevent postpartum haemorrhage. We suggest using this intervention where a well-functioning LHW programme already exists.
Justification
There is insufficient evidence on the effectiveness or acceptability of using LHWs to administer misoprostol to prevent postpartum haemorrhage. However, this intervention may be feasible under certain conditions and may reduce inequalities by extending care to underserved populations. In addition, a World Health Organisation guideline recommends that where skilled birth attendants are not present and oxytocin is not available, the administration of misoprostol (600mcg PO) by community health workers and lay health workers is recommended for the prevention of postpartum haemorrhage (Strong recommendation, moderate quality evidence).
Problem: Poor access to prevention of postpartum haemorrhage
Option: LHWs administering misoprostol
Comparison: Care delivered by other cadres or no care
Setting: Community/primary health care settings in LMICs with poor access to health professionals

Recommend
Auxiliary nurse
Recommend
Should AUXILIARY NURSES administer misoprostol to (a) prevent and (b) to treat postpartum haemorrhage before referral?
Recommendation
We recommend the use of auxiliary nurses to administer misoprostol to prevent and treat postpartum haemorrhage.
– For prevention of postpartum haemorrhage, we suggest using this intervention where auxiliary nurses are already an established cadre
For treatment of postpartum haemorrhage, we suggest using this intervention where auxiliary nurses are already an established cadre and where a well-functioning referral system is in place or can be put in place
Justification
There is insufficient evidence on the effectiveness of using auxiliary nurses to administer misoprostol to prevent and treat postpartum haemorrhage. However, the intervention is probably acceptable and feasible. In addition, the panel feels that the benefits probably outweigh the harms; that minimal clinical decision making is required; and that the intervention may reduce inequalities by extending care to underserved populations. A World Health Organisation guideline also recommends that where skilled birth attendants are not present and oxytocin is not available, the administration of misoprostol (600mcg PO) by community health workers and lay health workers is recommended for prevention of PPH (strong recommendation, moderate quality evidence).
Problem: Poor access to prevention and treatment of postpartum haemorrhage
Option: Auxiliary nurses administering misoprostol
Comparison: Care delivered by other cadres or no care
Setting: Community/primary health care settings in LMICs with poor access to health professionals

Scoped out (Recommend)
Auxiliary nurse midwife
Scoped out (Recommend)
This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

Scoped out (Recommend)
Nurse
Scoped out (Recommend)
This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

Scoped out (Recommend)
Midwife
Scoped out (Recommend)
This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

Scoped out (Recommend)
Associate clinician
Scoped out (Recommend)
This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

Scoped out (Recommend)
Advanced associate clinician
Scoped out (Recommend)
This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

Scoped out (Recommend)
Non specialist doctor
Scoped out (Recommend)
This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.
2.6 Misoprostol administration to treat PPH

Consider in context of rigorous research
Lay Health Worker
Consider in context of rigorous research
Should LAY HEALTH WORKERS administer misoprostol to treat postpartum haemorrhage before referral?
Recommendation
We suggest considering this option only in the context of rigorous research. We suggest evaluating this intervention where a well-functioning LHW programme already exists; where a well-functioning referral system is in place or can be put in place; and where the use of misoprostol can be monitored with appropriate indicators.
Justification
There is insufficient evidence on the effectiveness and acceptability of using LHWs to administer misoprostol to treat postpartum haemorrhage. However, this intervention may be feasible under certain conditions and may reduce inequalities by extending care to underserved populations.
Problem: Poor access to prevention and treatment of postpartum haemorrhage
Option: LHWs administering misoprostol before referral
Comparison: Care delivered by other cadres or no care
Setting: Community/primary health care settings in LMICs with poor access to health professionals

Recommend
Auxiliary nurse
Recommend
Should AUXILIARY NURSES administer misoprostol to (a) prevent and (b) to treat postpartum haemorrhage before referral?
Recommendation
We recommend the use of auxiliary nurses to administer misoprostol to prevent and treat postpartum haemorrhage.
– For prevention of postpartum haemorrhage, we suggest using this intervention where auxiliary nurses are already an established cadre
For treatment of postpartum haemorrhage, we suggest using this intervention where auxiliary nurses are already an established cadre and where a well-functioning referral system is in place or can be put in place
Justification
There is insufficient evidence on the effectiveness of using auxiliary nurses to administer misoprostol to prevent and treat postpartum haemorrhage. However, the intervention is probably acceptable and feasible. In addition, the panel feels that the benefits probably outweigh the harms; that minimal clinical decision making is required; and that the intervention may reduce inequalities by extending care to underserved populations. A World Health Organisation guideline also recommends that where skilled birth attendants are not present and oxytocin is not available, the administration of misoprostol (600mcg PO) by community health workers and lay health workers is recommended for prevention of PPH (strong recommendation, moderate quality evidence).
Problem: Poor access to prevention and treatment of postpartum haemorrhage
Option: Auxiliary nurses administering misoprostol
Comparison: Care delivered by other cadres or no care
Setting: Community/primary health care settings in LMICs with poor access to health professionals

Scoped out (Recommend)
Auxiliary nurse midwife
Scoped out (Recommend)
This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

Scoped out (Recommend)
Nurse
Scoped out (Recommend)
This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

Scoped out (Recommend)
Midwife details
Scoped out (Recommend)
This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

Scoped out (Recommend)
Associate clinician
Scoped out (Recommend)
This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

Scoped out (Recommend)
Advanced associate clinician
Scoped out (Recommend)
This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

Scoped out (Recommend)
Non specialist doctor
Scoped out (Recommend)
This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.
5.1 Continuous support for women during labour, in the presence of a skilled birth attendant

Recommend
Lay Health Worker
Recommend
Should LAY HEALTH WORKERS provide continuous support during labour (in the presence of a skilled birth attendant)?
Recommendation
We recommend the use of LHWs to provide continuous support during labour, in the presence of a skilled birth attendant. However, appropriate attention must be paid to the acceptability of the intervention to other health care providers.
Justification
The provision of continuous support by LHWs is probably effective and feasible, may have few undesirable effects and may reduce inequalities by extending care to underserved populations, although there may be acceptability issues. The role of the LHW in this context is to provide social support in the form of comfort and reassurance, and not to provide medical care
Problem: Poor support during labour
Option: LHWs providing continuous support (primarily social support in the form of comfort and reassurance) during labour
Comparison: Care delivered by other cadres or no labour support
Setting: Community/primary health care settings in LMICs, in the presence of a skilled birth attendan

Scoped out (Recommend)
Auxiliary nurse
Scoped out (Recommend)
This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

Scoped out (Recommend)
Auxiliary nurse midwife
Scoped out (Recommend)
This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

Scoped out (Recommend)
Nurse
Scoped out (Recommend)
This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

Scoped out (Recommend)
Midwife
Scoped out (Recommend)
This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

Scoped out (Recommend)
Associate clinician
Scoped out (Recommend)
This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

Scoped out (Recommend)
Advanced associate clinician
Scoped out (Recommend)
This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

Scoped out (Recommend)
Non specialist doctor
Scoped out (Recommend)
This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.
6.1 Puerperal sepsis management with intramuscular antibiotics - standard syringe

Consider in context of rigorous research
Lay Health Worker
Consider in context of rigorous research
Should LAY HEALTH WORKERS manage puerperal sepsis using intramuscular antibiotics, delivered by a standard syringe, before referral?
Recommendation
We suggest considering this option only in the context of rigorous research. We suggest evaluating this intervention where a well-functioning LHW programme already exists, where LHWs are already familiar with injection techniques and materials, and where referral to more specialised care is available or can be put in place.
Justification
There is insufficient evidence of the effectiveness, acceptability and feasibility of this intervention. However, it may reduce inequalities by extending care to underserved populations.
Problem: Poor access to treatment for puerperal sepsis
Option: LHWs using intramuscular antibiotics before referral
Comparison: Care delivered by other cadres or no care
Setting: Community/primary health care settings in LMICs with poor access to health professionals

Scoped out (Recommend)
Auxiliary nurse
Scoped out (Recommend)
This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

Scoped out (Recommend)
Auxiliary nurse midwife
Scoped out (Recommend)
This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

Scoped out (Recommend)
Nurse
Scoped out (Recommend)
This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

Scoped out (Recommend)
Midwife
Scoped out (Recommend)
This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

Scoped out (Recommend)
Associate clinician
Scoped out (Recommend)
This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

Scoped out (Recommend)
Advanced associate clinician
Scoped out (Recommend)
This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

Scoped out (Recommend)
Non specialist doctor
Scoped out (Recommend)
This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.
6.2 Puerperal sepsis management with oral antibiotics

Consider in context of rigorous research
Lay Health Worker
Consider in context of rigorous research
Should LAY HEALTH WORKERS manage puerperal sepsis, using oral antibiotics, before referral?
Recommendation
We suggest considering this option only in the context of rigourous research. We suggest evaluating this intervention where a well-functioning LHW programme already exists and where referral to more specialised care is available or can be put in place.
Justification
There is insufficient evidence of the effectiveness and acceptability of this intervention. However, it is probably feasible, and may reduce inequalities by extending care to underserved populations.
Problem: Poor access to treatment for puerperal sepsis
Option: LHWs using oral antibiotics before referral
Comparison: Care delivered by other cadres or no care
Setting: Community/primary health care settings in LMICs with poor access to health professionals

Scoped out (Recommend)
Auxiliary nurse
Scoped out (Recommend)
This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

Scoped out (Recommend)
Auxiliary nurse midwife
Scoped out (Recommend)
This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

Scoped out (Recommend)
Nurse
Scoped out (Recommend)
This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

Scoped out (Recommend)
Midwife
Scoped out (Recommend)
This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

Scoped out (Recommend)
Associate clinician
Scoped out (Recommend)
This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

Scoped out (Recommend)
Advanced associate clinician
Scoped out (Recommend)
This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

Scoped out (Recommend)
Non specialist doctor
Scoped out (Recommend)
This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.
6.3 Puerperal sepsis management with intramuscular antibiotics - CPAD

Consider in context of rigorous research
Lay Health Worker
Consider in context of rigorous research
Should LAY HEALTH WORKERS manage puerperal sepsis using antibiotics, delivered through a compact, prefilled, autodisable device (CPAD) such as Uniject, before referral?
Recommendation
We suggest considering this option only in the context of rigorous research. We suggest evaluating this intervention where a well-functioning LHW programme already exists and where referral to more specialised care is available or can be put in place.
Justification
There is insufficient evidence of the effectiveness of this intervention, although the use of Uniject by LHWs is probably acceptable. In addition, the intervention may be feasible and may reduce inequalities by extending care to underserved populations.
Problem: Poor access to treatment for puerperal sepsis
Option: LHWs delivering antibiotics using CPAD
Comparison: Care delivered by other cadres or no care
Setting: Community/primary health care settings in LMICs with poor access to health professionals

Scoped out (Recommend)
Auxiliary nurse
Scoped out (Recommend)
This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

Scoped out (Recommend)
Auxiliary nurse midwife
Scoped out (Recommend)
This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

Scoped out (Recommend)
Nurse
Scoped out (Recommend)
This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

Scoped out (Recommend)
Midwife
Scoped out (Recommend)
This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

Scoped out (Recommend)
Associate clinician
Scoped out (Recommend)
This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

Scoped out (Recommend)
Advanced associate clinician
Scoped out (Recommend)
This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

Scoped out (Recommend)
Non specialist doctor
Scoped out (Recommend)
This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.
9.1 Neonatal resuscitation

Consider in context of rigorous research
Lay Health Worker
Consider in context of rigorous research
Should LAY HEALTH WORKERS deliver neonatal resuscitation?
Recommendation
We suggest considering this option only in the context of rigorous research. We suggest evaluating this intervention where a well-functioning LHW programme already exists and where referral to a more specialised cadre is available or can be put in place.
Justification
There is insufficient evidence on the effectiveness of this intervention, and its acceptability is uncertain. However, it may be feasible and may reduce inequalities by extending care to underserved populations.
Problem: Poor access to neonatal care
Option: LHWs delivering neonatal resuscitation
Comparison: Care delivered by other cadres or no care
Setting: Community/primary health care settings in LMICs with poor access to health professionals

Consider in context of rigorous research
Auxiliary nurse
Consider in context of rigorous research
Should AUXILIARY NURSES deliver neonatal resuscitation?
Recommendation
We suggest considering this option only in the context of rigorous research. We suggest evaluating this intervention where auxiliary nurses are already an established cadre and where a well-functioning referral system is in place or can be put in place.
Justification
There is insufficient evidence on the effectiveness of auxiliary nurses delivering neonatal resuscitation. However, this intervention is probably acceptable, is probably feasible and may reduce inequalities by extending care to underserved populations.
Problem: Poor access to neonatal care
Option: Auxiliary nurses delivering neonatal resuscitation
Comparison: Care delivered by other cadres or no care
Setting: Community/primary health care settings in LMICs with poor access to health professionals

Recommend
Auxiliary nurse midwife
Recommend
Should AUXILIARY NURSE MIDWIVES deliver neonatal resuscitation?
Recommendation
We recommend this option. We suggest implementing this intervention where auxiliary nurse midwives are already an established cadre and where a well-functioning referral system is in place or can be put in place.
Justification
There is insufficient evidence on the effectiveness of auxiliary nurse midwives delivering neonatal resuscitation. However, this intervention is part of the core skills of skilled birth attendants, is probably acceptable, is probably feasible and may reduce inequalities by extending care to underserved populations.
Problem: Poor access to neonatal care
Option: Auxiliary nurse midwives delivering neonatal resuscitation
Comparison:Care delivered by other cadres or no care
Setting:Community/primary health care settings in LMICs with poor access to health professionals

Scoped out (Recommend)
Nurse
Scoped out (Recommend)
This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

Scoped out (Recommend)
Midwife
Scoped out (Recommend)
This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

Scoped out (Recommend)
Associate clinician
Scoped out (Recommend)
This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

Scoped out (Recommend)
Advanced associate clinician
Scoped out (Recommend)
This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

Scoped out (Recommend)
Non specialist doctor
Scoped out (Recommend)
This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.
11.1 Administration of intravenous fluid for resuscitation for PPH

Scoped out (Recommend against)
Lay Health Worker
Scoped out (Recommend against)
This task was accepted as outside the competency of this health worker category. No assessment of the evidence was therefore conducted.

Recommend
Auxiliary nurse
Recommend
Should AUXILIARY NURSES administer intravenous fluid for resuscitation as part of postpartum haemorrhage treatment?
Recommendation
We recommend this option. We suggest implementing this intervention where auxiliary nurses are already an established cadre and where a well-functioning referral system is in place or can be put in place. This intervention should be operationalised in the context of the WHO PPH guidelines, which outline a comprehensive approach to managing PPH.
Justification
There is insufficient evidence on the effectiveness and acceptability of auxiliary nurses administering intravenous fluid for resuscitation, as part of PPH treatment. However, the panel considered this intervention to be part of the core skills of auxiliary nurses. In addition, it is probably feasible and may also reduce inequalities by extending care to underserved populations.
Problem: Poor access to treatment for post-partum haemorrhage
Option: Auxiliary nurses administering intravenous fluid for resuscitation
Comparison: Care delivered by other cadres or no care
Setting: Community/primary health care settings in LMICs with poor access to health professionals

Recommend
Auxiliary nurse midwife
Recommend
Should AUXILIARY NURSE MIDWIVES (a) administer intravenous fluid for resuscitation as part of postpartum haemorrhage treatment, (b) perform internal bimanual uterine compression for postpartum hameorrhage, and (c) perform suturing for minor perineal / genital lacerations?
Recommendation
We recommend these options. We suggest implementing these interventions where auxiliary nurse midwives are already an established cadre and where a well-functioning referral system is in place or can be put in place. These interventions should be operationalised in the context of the WHO PPH guidelines, which outline a comprehensive approach to managing PPH.
Justification
There is insufficient evidence on the effectiveness of auxiliary nurse midwives delivering these interventions. However, the panel considered these interventions to be part of the core skills of auxiliary nurse midwives. In addition, they may be acceptable, are probably feasible and may also reduce inequalities by extending care to underserved populations.
Problem: Poor access to treatment for post-partum haemorrhage
Option: Auxiliary nurse midwives delivering a range of interventions to treat haemorrhage
Comparison:Care delivered by other cadres or no care
Setting:Community/primary health care settings in LMICs with poor access to health professionals

Scoped out (Recommend)
Nurse
Scoped out (Recommend)
This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

Scoped out (Recommend)
Midwife
Scoped out (Recommend)
This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.
Not considered by the guideline panel
Associate clinician
Not considered by the guideline panel
This question was not scoped for this guideline. No assessment of the evidence was therefore conducted.

Scoped out (Recommend)
Advanced associate clinician
Scoped out (Recommend)
This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

Scoped out (Recommend)
Non specialist doctor
Scoped out (Recommend)
This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.
11.2 Internal bimanual uterine compression for PPH

Scoped out (Recommend against)
Lay Health Worker
Scoped out (Recommend against)
This task was accepted as outside the competency of this health worker category. No assessment of the evidence was therefore conducted.

Recommend with monitoring and evaluation
Auxiliary nurse
Recommend with monitoring and evaluation
Should AUXILIARY NURSES perform internal bimanual uterine compression for postpartum haemorrhage?
Recommendation
We suggest considering this option with targeted monitoring and evaluation. We suggest implementing this intervention where auxiliary nurses are already an established cadre and where a well-functioning referral system is in place or can be put in place. This intervention should be operationalised in the context of the WHO PPH guidelines, which outline a comprehensive approach to managing PPH.
Justification
There is insufficient evidence on the effectiveness and acceptability of auxiliary nurses performing internal bimanual uterine compression for postpartum haemorrhage. However, the risk of significant harms is low, it may be acceptable, is probably feasible and may also reduce inequalities by extending care to underserved populations.
Problem: Poor access to treatment for post-partum haemorrhage
Option: Auxiliary nurses performing internal bimanual uterine compression for PPH
Comparison: Care delivered by other cadres or no care
Setting: Community/primary health care settings in LMICs with poor access to health professionals

Recommend
Auxiliary nurse midwife
Recommend
Should AUXILIARY NURSE MIDWIVES (a) administer intravenous fluid for resuscitation as part of postpartum haemorrhage treatment, (b) perform internal bimanual uterine compression for postpartum hameorrhage, and (c) perform suturing for minor perineal / genital lacerations?
Recommendation
We recommend these options. We suggest implementing these interventions where auxiliary nurse midwives are already an established cadre and where a well-functioning referral system is in place or can be put in place. These interventions should be operationalised in the context of the WHO PPH guidelines, which outline a comprehensive approach to managing PPH.
Justification
There is insufficient evidence on the effectiveness of auxiliary nurse midwives delivering these interventions. However, the panel considered these interventions to be part of the core skills of auxiliary nurse midwives. In addition, they may be acceptable, are probably feasible and may also reduce inequalities by extending care to underserved populations.
Problem: Poor access to treatment for post-partum haemorrhage
Option: Auxiliary nurse midwives delivering a range of interventions to treat haemorrhage
Comparison:Care delivered by other cadres or no care
Setting:Community/primary health care settings in LMICs with poor access to health professionals

Scoped out (Recommend)
Nurse
Scoped out (Recommend)
This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

Scoped out (Recommend)
Midwife
Scoped out (Recommend)
This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.
Not considered by the guideline panel
Associate clinician
Not considered by the guideline panel
This question was not scoped for this guideline. No assessment of the evidence was therefore conducted.

Scoped out (Recommend)
Advanced associate clinician
Scoped out (Recommend)
This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

Scoped out (Recommend)
Non specialist doctor
Scoped out (Recommend)
This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.
11.3 Suturing of minor perineal/genital lacerations

Scoped out (Recommend against)
Lay Health Worker
Scoped out (Recommend against)
This task was accepted as outside the competency of this health worker category. No assessment of the evidence was therefore conducted.

Recommend
Auxiliary nurse
Recommend
Should AUXILIARY NURSES perform suturing for minor perineal / genital lacerations?
Recommendation
We recommend this option. We suggest implementing this intervention where auxiliary nurses are already an established cadre. This intervention should be operationalised in the context of the WHO PPH guidelines, which outline a comprehensive approach to managing PPH.
Justification
There is insufficient evidence on the effectiveness and acceptability of auxiliary nurses performing suturing for minor perineal / genital lacerations. However, the panel considered suturing to be part of the core skills of auxiliary nurses. In addition, it is probably feasible and may also reduce inequalities by extending care to underserved populations.
Problem: Poor access to treatment for post-partum haemorrhage
Option: Auxiliary nurses performing suturing for minor perineal/genital lacerations
Comparison: Care delivered by other cadres or no care
Setting: Community/primary health care settings in LMICs with poor access to health professionals

Recommend
Auxiliary nurse midwife
Recommend
Should AUXILIARY NURSE MIDWIVES (a) administer intravenous fluid for resuscitation as part of postpartum haemorrhage treatment, (b) perform internal bimanual uterine compression for postpartum hameorrhage, and (c) perform suturing for minor perineal / genital lacerations?
Recommendation
We recommend these options. We suggest implementing these interventions where auxiliary nurse midwives are already an established cadre and where a well-functioning referral system is in place or can be put in place. These interventions should be operationalised in the context of the WHO PPH guidelines, which outline a comprehensive approach to managing PPH.
Justification
There is insufficient evidence on the effectiveness of auxiliary nurse midwives delivering these interventions. However, the panel considered these interventions to be part of the core skills of auxiliary nurse midwives. In addition, they may be acceptable, are probably feasible and may also reduce inequalities by extending care to underserved populations.
Problem: Poor access to treatment for post-partum haemorrhage
Option: Auxiliary nurse midwives delivering a range of interventions to treat haemorrhage
Comparison:Care delivered by other cadres or no care
Setting:Community/primary health care settings in LMICs with poor access to health professionals

Scoped out (Recommend)
Nurse
Scoped out (Recommend)
This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

Scoped out (Recommend)
Midwife
Scoped out (Recommend)
This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.
Not considered by the guideline panel
Associate clinician
Not considered by the guideline panel
This question was not scoped for this guideline. No assessment of the evidence was therefore conducted.

Scoped out (Recommend)
Advanced associate clinician
Scoped out (Recommend)
This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

Scoped out (Recommend)
Non specialist doctor
Scoped out (Recommend)
This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.
11.6 Maternal intrapartum care

Scoped out (Recommend against)
Lay Health Worker
Scoped out (Recommend against)
This task was accepted as outside the competency of this health worker category. No assessment of the evidence was therefore conducted.

Recommend against
Auxiliary nurse
Recommend against
Should AUXILIARY NURSES deliver maternal intrapartum care (including labour monitoring, e.g. using a partograph; foetal heart rate monitoring by auscultation; decision to transfer for poor progress; delivery of the baby)?
Recommendation
We recommend against auxiliary nurses delivering these maternal intrapartum interventions.
Justification
The effects of using auxiliary nurses to deliver maternal intrapartum care are uncertain. In addition, the delivery of intra-partum interventions requires considerable training and skills which auxiliary nurses do not generally have. Delivering this training would result in a different cadre.
Problem: Poor access to intrapartum care
Option: Auxiliary nurses delivering intrapartum interventions
Comparison: Care delivered by other cadres or no care
Setting: Community/primary health care settings in LMICs with poor access to health professionals

Scoped out (Recommend)
Auxiliary nurse midwife
Scoped out (Recommend)
This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.
Not considered by the guideline panel
Nurse
Not considered by the guideline panel
This question was not scoped for this guideline. No assessment of the evidence was therefore conducted.

Scoped out (Recommend)
Midwife
Scoped out (Recommend)
This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.
Not considered by the guideline panel
Associate clinician
Not considered by the guideline panel
This question was not scoped for this guideline. No assessment of the evidence was therefore conducted.

Scoped out (Recommend)
Advanced associate clinician
Scoped out (Recommend)
This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

Scoped out (Recommend)
Non specialist doctor
Scoped out (Recommend)
This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.
11.7 Vacuum extraction during childbirth

Scoped out (Recommend against)
Lay Health Worker
Scoped out (Recommend against)
This task was accepted as outside the competency of this health worker category. No assessment of the evidence was therefore conducted.

Scoped out (Recommend against)
Auxiliary nurse
Scoped out (Recommend against)
This task was accepted as outside the competency of this health worker category. No assessment of the evidence was therefore conducted.
Not considered by the guideline panel
Auxiliary nurse midwife
Not considered by the guideline panel
This question was not scoped for this guideline. No assessment of the evidence was therefore conducted.

Recommend against
Nurse
Recommend against
Should NURSES perform vacuum extraction during childbirth?
Recommendation
We recommend against the use of nurses to perform vacuum extraction.
Justification
There is insufficient evidence on the effectiveness of nurses performing vacuum extraction during childbirth, the intervention is outside of their typical scope of practice and its acceptability and feasibility are uncertain. We therefore recommend against the option.
Problem: Poor access to vacuum extraction
Option: Nurses performing vacuum extraction
Comparison: Care delivered by other cadres or no care
Setting: Community/primary health care settings in LMICs with poor access to health professionals

Recommend with monitoring and evaluation
Midwife
Recommend with monitoring and evaluation
Should MIDWIVES perform vacuum extraction during childbirth?
Recommendation
We suggest considering the option with targeted monitoring and evaluation of failure rates, complications and process measures such as frequency of use. We suggest using this intervention where midwives are already an established cadre and where a well-functioning referral system is in place or can be put in place.
Justification
There is insufficient evidence on the effectiveness of midwives performing vacuum extraction during childbirth and its acceptability is uncertain. However, it is probably feasible and may reduce inequalities by extending care to underserved populations.
Problem: Poor access to assisted delivery
Option: Midwives performing vacuum extraction
Comparison: Care delivered by other cadres or no care
Setting: Community/primary health care settings in LMICs with poor access to health professionals

Recommend against
Associate clinician
Recommend against
Should ASSOCIATE CLINICIANS perform vacuum extraction during childbirth?
Recommendation
We recommend against the use of associate clinicians to perform vacuum extraction during childbirth.
Justification
There is insufficient evidence on the effectiveness of associate clinicians performing vacuum extraction during childbirth, the intervention is outside of their typical scope of practice and its acceptability and feasibility are uncertain.
Problem: Poor access to obstetric care
Option: Associate clinicians performing vacuum extraction
Comparison: Procedure delivered by other cadres or no care
Setting: Health care facilities in LMICs

Recommend
Advanced associate clinician
Recommend
Should ADVANCED LEVEL ASSOCIATE CLINICIANS perform (a) vacuum extraction during childbirth and (b) manual removal of the placenta?
Recommendation
We recommend this option. We suggest implementing this intervention where advanced level associate clinicians with obstetric skills are already an established cadre and where a well-functioning referral system is in place or can be put in place.
Justification
There is insufficient evidence on the effectiveness of advanced level associate clinicians performing vacuum extraction during childbirth or performing manual removal of the placenta and acceptability is uncertain. However, advanced level associate clinicians are likely to have the necessary obstetric skills, the intervention is probably feasible and it may also reduce inequalities by extending care to underserved populations.
Problem: Poor access to obstetric care
Option: Advanced level associate clinicians performing vacuum extraction and manual removal of the placenta
Comparison:Procedure delivered by other cadres or no care
Setting:Health care facilities in LMICs

Scoped out (Recommend)
Non specialist doctor
Scoped out (Recommend)
This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.
11.13 Caesarean section

Scoped out (Recommend against)
Lay Health Worker
Scoped out (Recommend against)
This task was accepted as outside the competency of this health worker category. No assessment of the evidence was therefore conducted.

Scoped out (Recommend against)
Auxiliary nurse
Scoped out (Recommend against)
This task was accepted as outside the competency of this health worker category. No assessment of the evidence was therefore conducted.

Scoped out (Recommend against)
Auxiliary nurse midwife
Scoped out (Recommend against)
This task was accepted as outside the competency of this health worker category. No assessment of the evidence was therefore conducted.

Scoped out (Recommend against)
Nurse
Scoped out (Recommend against)
This task was accepted as outside the competency of this health worker category. No assessment of the evidence was therefore conducted.
Not considered by the guideline panel
Midwife
Not considered by the guideline panel
This question was not scoped for this guideline. No assessment of the evidence was therefore conducted.

Recommend against
Associate clinician
Recommend against
Should ASSOCIATE CLINICIANS perform caesarean sections?
Recommendation
We recommend against the use of associate clinicians to perform caesarean section.
Justification
There is insufficient evidence on the effectiveness of associate clinicians performing caesarean section. We are also uncertain about its acceptability and its feasibility in many settings as associate clinicians do not generally have surgical skills.
Problem: Poor access to caesarean section
Option: Associate clinicians performing caesarean section
Comparison: Caesarean section delivered by other cadres
Setting: Health care facilities in LMICs

Recommend with monitoring and evaluation
Advanced associate clinician
Recommend with monitoring and evaluation
Should ADVANCED LEVEL ASSOCIATE CLINICIANS perform caesarean sections?
Recommendation
We suggest considering the use of advanced level associate clinicians to perform caesarean sections with targeted monitoring and evaluation.
Justification
The available evidence of effectiveness of advanced level associate clinicians performing caesarean section is of very low certainty. We are also uncertain about the feasibility of this intervention in many settings. However, the intervention may reduce inequalities by extending care to underserved populations. We therefore suggest that this option be considered in the context of targeted monitoring and evaluation. We suggest that this intervention be used in settings where advanced level associate clinicians are working as the only cadre with surgical skills and it is not routinely possible to access cadres with higher levels of training.
Problem: Poor access to caesarean section
Option: Advanced level associate clinicians performing caesarean section
Comparison: Caesarean section delivered by other cadres
Setting: Health care facilities in LMIC

Scoped out (Recommend)
Non specialist doctor
Scoped out (Recommend)
This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.
11.14 Manual removal of the placenta

Scoped out (Recommend against)
Lay Health Worker
Scoped out (Recommend against)
This task was accepted as outside the competency of this health worker category. No assessment of the evidence was therefore conducted.

Scoped out (Recommend against)
Auxiliary nurse
Scoped out (Recommend against)
This task was accepted as outside the competency of this health worker category. No assessment of the evidence was therefore conducted.

Scoped out (Recommend)
Auxiliary nurse midwife
Scoped out (Recommend)
This question was not scoped for this guideline. No assessment of the evidence was therefore conducted.
Not considered by the guideline panel
Nurse
Not considered by the guideline panel
This question was not scoped for this guideline. No assessment of the evidence was therefore conducted.

Recommend against
Midwife
Recommend against
This task was accepted as outside the competency of this health worker category. No assessment of the evidence was therefore conducted.

Recommend with monitoring and evaluation
Associate clinician
Recommend with monitoring and evaluation
Should ASSOCIATE CLINICIANS perform manual removal of the placenta?
Recommendation
We suggest considering the option with targeted monitoring and evaluation. We suggest using this intervention where associate clinicians are already an established cadre and where a well-functioning referral system is in place or can be put in place.
Justification
The effects and acceptability of associate clinicians performing manual removal of the placenta is uncertain. We are also uncertain about its feasibility in many settings as associate clinicians do not generally have surgical and manual obstetric skills. However, this intervention has the potential to reduce inequalities by extending vital health care to underserved populations.
Problem: Poor access to obstetric care
Option: Associate clinicians performing manual removal of the placenta
Comparison: Procedure delivered by other cadres or no care
Setting: Health care facilities in LMICs

Recommend
Advanced associate clinician
Recommend
Should ADVANCED LEVEL ASSOCIATE CLINICIANS perform (a) vacuum extraction during childbirth and (b) manual removal of the placenta?
Recommendation
We recommend this option. We suggest implementing this intervention where advanced level associate clinicians with obstetric skills are already an established cadre and where a well-functioning referral system is in place or can be put in place.
Justification
There is insufficient evidence on the effectiveness of advanced level associate clinicians performing vacuum extraction during childbirth or performing manual removal of the placenta and acceptability is uncertain. However, advanced level associate clinicians are likely to have the necessary obstetric skills, the intervention is probably feasible and it may also reduce inequalities by extending care to underserved populations.
Problem: Poor access to obstetric care
Option: Advanced level associate clinicians performing vacuum extraction and manual removal of the placenta
Comparison:Procedure delivered by other cadres or no care
Setting:Health care facilities in LMICs

Scoped out (Recommend)
Non specialist doctor
Scoped out (Recommend)
This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.
2.7 Misoprostol distribution to pregnant women for self-administration after childbirth
Research about the effectiveness of the practice is needed before considering the cadres. Therefore no recommendation is made.
11.4 Antihypertensives for severe high blood pressure in pregnancy

Scoped out (Recommend against)
Lay Health Worker
Scoped out (Recommend against)
This task was accepted as outside the competency of this health worker category. No assessment of the evidence was therefore conducted.

Consider in context of rigorous research
Auxiliary nurse
Consider in context of rigorous research
Should AUXILIARY NURSES administer antihypertensives for severe high blood pressure in pregnancy?
Recommendation
We suggest considering this option only in the context of rigorous research. We suggest evaluating this intervention where auxiliary nurses are already an established cadre; where a well-functioning referral system is in place or can be put in place; and where care is delivered in the context of a standard protocol.
Justification
There is insufficient evidence on the effectiveness of auxiliary nurses administering these drugs. However, this may be acceptable and feasible, and may reduce inequalities in settings where access to more highly trained providers is limited.
Problem: Poor access to treatment for severe high blood pressure in pregnancy
Option: Auxiliary nurses administering antihypertensives for severe high blood pressure in pregnancy
Comparison: Care delivered by other cadres or no care
Setting: Community/primary health care settings in LMICs with poor access to health professionals

Recommend with monitoring and evaluation
Auxiliary nurse midwife
Recommend with monitoring and evaluation
Should AUXILIARY NURSE MIDWIVES administer antihypertensives for severe high blood pressure in pregnancy?
Recommendation
We suggest considering the option with targeted monitoring and evaluation. We suggest evaluating this intervention where auxiliary nurse midwives are already an established cadre; in an acute context prior to referral; and where following a standard protocol.
Justification
There is insufficient evidence on the effectiveness of auxiliary nurse midwives administering these drugs. However, this is probably acceptable, and they have the necessary clinical skills. The intervention may also reduce inequalities in settings where access to more highly trained providers is limited.
Problem: Poor access to treatment
Option: Auxiliary nurse midwives administering antihypertensives for severe high blood pressure during pregnancy
Comparison: Care delivered by other cadres or no care
Setting: Community/primary health care settings in LMICs with poor access to health professionals

Scoped out (Recommend)
Nurse
Scoped out (Recommend)
This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

Scoped out (Recommend)
Midwife
Scoped out (Recommend)
This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.
Not considered by the guideline panel
Associate clinician
Not considered by the guideline panel
This question was not scoped for this guideline. No assessment of the evidence was therefore conducted.

Scoped out (Recommend)
Advanced associate clinician
Scoped out (Recommend)
This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

Scoped out (Recommend)
Non specialist doctor
Scoped out (Recommend)
This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.
11.5 Corticosteroids to pregnant women in preterm labour to improve neonatal outcomes

Scoped out (Recommend against)
Lay Health Worker
Scoped out (Recommend against)
This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

Recommend against
Auxiliary nurse
Recommend against
Should AUXILIARY NURSES administer corticosteroids to pregnant women in the context of preterm labour to improve neonatal outcomes?
Recommendation
We recommend against the use of auxiliary nurses to administer corticosteroids to pregnant women in the context of preterm labour.
Justification
There is insufficient evidence on the effectiveness of auxiliary nurses administering these drugs; and they do not have the necessary clinical skills for diagnosis of preterm labour. We therefore recommend against the option.
Problem: Poor access to treatment in the context of preterm labour
Option: Auxiliary nurses administering corticosteroids
Comparison: Care delivered by other cadres or no care
Setting: Community/primary health care settings in LMICs with poor access to health professionals

Consider in context of rigorous research
Auxiliary nurse midwife
Consider in context of rigorous research
Should AUXILIARY NURSE MIDWIVES administer corticosteroids to pregnant womenin the context of preterm labour to improve neonatal outcomes?
Recommendation
We suggest considering the option in the context of rigorous research. We suggest evaluating this intervention where auxiliary nurse midwives are already an established cadre and where a well-functioning referral system is in place or can be put in place.
Justification
There is insufficient evidence on the effectiveness of auxiliary nurse midwives administering corticosteroids to pregnant women for the foetus in the context of preterm labour. However, auxiliary nurse midwives have the necessary clinical skills for diagnosis of preterm labour and for the administration of this drug and the intervention may be acceptable and feasible.
Problem: Poor access to treatment
Option: Auxiliary nurse midwives administering corticosteroids to pregnant women in the context of preterm labour
Comparison: Care delivered by other cadres or no care
Setting: Community/primary health care settings in LMICs with poor access to health professionals

Recommend against
Nurse
Recommend against
Should NURSES administer corticosteroids to pregnant women in the context of preterm labour to improve neonatal outcomes?
Recommendation
We recommend against the use of nurses to administer corticosteroids to pregnant women in the context of preterm labour to improve neonatal outcomes.
Justification
There is insufficient evidence on the effectiveness of nurses administering these drugs; they do not have the necessary clinical skills for diagnosis of preterm labour. We therefore recommend against the option.
Problem: Poor access to treatment
Option: Nurses administering corticosteroids to pregnant women in the context of preterm labour
Comparison: Care delivered by other cadres or no care
Setting: Community/primary health care settings in LMICs with poor access to health professionals

Consider in context of rigorous research
Midwife
Consider in context of rigorous research
Should MIDWIVES administer corticosteroids to pregnant women in the context of preterm labour to improve neonatal outcomes?
Recommendation
We suggest considering the use of midwives to administer corticosteroids to pregnant women in the context of preterm labour in the context of rigorous research.
Justification
We suggest considering the use of midwives to administer corticosteroids to pregnant women in the context of preterm labour in the context of rigorous research.
Problem: Poor access to treatment
Option: Midwives administering corticosteroids to pregnant women in the context of preterm labour
Comparison: Care delivered by other cadres or no care
Setting: Community/primary health care settings in LMICs with poor access to health professionals
Not considered by the guideline panel
Associate clinician
Not considered by the guideline panel
This question was not scoped for this guideline. No assessment of the evidence was therefore conducted.

Scoped out (Recommend)
Advanced associate clinician
Scoped out (Recommend)
This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

Scoped out (Recommend)
Non specialist doctor
Scoped out (Recommend)
This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.
11.12 Magnesium sulphate to women in preterm labour as a neuroprotective for the fetus

Scoped out (Recommend against)
Lay Health Worker
Scoped out (Recommend against)
This task was accepted as outside the competency of this health worker category. No assessment of the evidence was therefore conducted.

Scoped out (Recommend against)
Auxiliary nurse
Scoped out (Recommend against)
This task was accepted as outside the competency of this health worker category. No assessment of the evidence was therefore conducted.

Consider in context of rigorous research
Auxiliary nurse midwife
Consider in context of rigorous research
Should AUXILIARY NURSE MIDWIVES deliver magnesium sulphate to women in preterm labour as a neuroprotection for the foetus?
Recommendation
We suggest considering the option in the context of rigorous research. We suggest evaluating this intervention where auxiliary nurse midwives are already an established cadre and where a well-functioning referral system is in place or can be put in place.
Justification
There is insufficient evidence on the effectiveness of auxiliary nurse midwives delivering magnesium sulphate to women in preterm labour as a neuroprotective for the foetus. However, auxiliary nurse midwives have the necessary clinical skills for diagnosis of preterm labour and for the administration of this drug and the intervention may be acceptable and feasible.
Problem: Poor access to medical management of preterm birth
Option: Auxiliary nurse midwives delivering magnesium sulphate for preterm labour
Comparison: Care delivered by other cadres or no care
Setting: Community/primary health care settings in LMICs with poor access to health professionals

Recommend against
Nurse
Recommend against
Should NURSES deliver magnesium sulphate to women in preterm labour as a neuroprotective for the foetus?
Recommendation
We recommend against the use of nurses to deliver magnesium sulphate to women in preterm labour.
Justification
While the intervention may be acceptable and feasible, there is insufficient evidence on the effectiveness of nurses delivering magnesium sulphate to women in preterm labour as a neuroprotective for the foetus and the intervention is outside of their typical scope of practice.
Problem: Poor access to treatment for preterm birth
Option: Nurses delivering magnesium sulphate for preterm labour
Comparison: Care delivered by other cadres or no care
Setting: Community/primary health care settings in LMICs with poor access to health professionals

Consider in context of rigorous research
Midwife
Consider in context of rigorous research
Should MIDWIVES deliver magnesium sulphate to women in preterm labour as a neuroprotection for the foetus?
Recommendation
We suggest considering the option in the context of rigorous research. We suggest evaluating this intervention where midwives are already an established cadre and where a well-functioning referral system is in place or can be put in place.
Justification
There is insufficient evidence on the effectiveness of midwives delivering magnesium sulphate to women in preterm labour as a neuroprotective for the foetus. However, midwives have the necessary clinical skills for diagnosis of preterm labour and for the administration of this drug and the intervention may be acceptable and feasible.
Problem: Poor access to medical management of preterm birth
Option: Midwives delivering magnesium sulphate for preterm labour
Comparison: Care delivered by other cadres or no care
Setting: Community/primary health care settings in LMICs with poor access to health professionals
Not considered by the guideline panel
Associate clinician
Not considered by the guideline panel
This question was not scoped for this guideline. No assessment of the evidence was therefore conducted.

Scoped out (Recommend)
Advanced associate clinician
Scoped out (Recommend)
This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

Scoped out (Recommend)
Non specialist doctor
Scoped out (Recommend)
This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.