WHO recommendations: Optimizing health worker roles for maternal and newborn health through task shifting

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.

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.

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.

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.

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.

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.

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.

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.

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).

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).

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.

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).

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

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.