title: Optimizing the delivery of contraceptives in low- and middle-income countries through task shifting: a systematic review of effectiveness and safety.
abstract: OBJECTIVE
  To assess the effectiveness and safety of task shifting for the delivery of injectable contraceptives, contraceptive implants, intrauterine devices (IUDs), tubal ligation and vasectomy in low- and middle-income countries.
  
  
  METHODS
  Multiple electronic databases were searched up to 25 May 2012 for studies which had assessed the delivery of contraceptives by health workers with lower levels of training, compared to delivery by health workers usually assigned this role, or compared to no organized provision of contraceptives. We included randomized controlled trials, non-randomized controlled trials, controlled before-after studies, and interrupted time series. Data were extracted using a standard form and the certainty of the evidence found was assessed using GRADE.
  
  
  RESULTS
  We identified six randomized controlled trials published between 1977 and 1995 that assessed the safety and effectiveness of task shifting for the delivery of long-term contraceptives. Two studies assessed IUD insertion by nurses compared to doctors, two assessed IUD insertion by auxiliary nurse-midwives compared to doctors, one assessed tubal ligation by midwives compared to doctors, and one assessed the delivery of vasectomy by medical students compared to doctors. In general, little or no difference was found in contraceptive outcomes between cadres. Study design limitations and the low number of eligible studies, however, allow only limited conclusions to be drawn.
  
  
  CONCLUSIONS
  The findings indicate that task shifting for the delivery of long-term contraceptives may be a safe and effective approach to increasing access to contraception. Further research is needed because the certainty of the evidence identified is variable.
authors.affiliation: Institute for Medical Informatics, Biometry and Epidemiology, University of Munich, Munich, Germany. polus@ibe.med.uni-muenchen.de.|Department of Reproductive Health and Research, UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), World Health Organization, Geneva, Switzerland. polus@ibe.med.uni-muenchen.de.
authors.forename: Stephanie
authors.initials: S
authors.lastname: Polus
authors.affiliation: Global Health Unit, Norwegian Knowledge Centre for the Health Services, Oslo, Norway. simon.lewin@kunnskapssenteret.no.|Health Systems Research Unit, Medical Research Council of South Africa, Cape Town, South Africa. simon.lewin@kunnskapssenteret.no.
authors.forename: Simon
authors.initials: S
authors.lastname: Lewin
authors.affiliation: Global Health Unit, Norwegian Knowledge Centre for the Health Services, Oslo, Norway. claire.glenton@kunnskapssenteret.no.
authors.forename: Claire
authors.initials: C
authors.lastname: Glenton
authors.affiliation: Department of Community Medicine, University of Oslo, Oslo, Norway. priler@gmail.com.
authors.forename: Priya M
authors.initials: PM
authors.lastname: Lerberg
authors.affiliation: Institute for Medical Informatics, Biometry and Epidemiology, University of Munich, Munich, Germany. rehfuess@ibe.med.uni-muenchen.de.
authors.forename: Eva
authors.initials: E
authors.lastname: Rehfuess
authors.affiliation: Department of Reproductive Health and Research, UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), World Health Organization, Geneva, Switzerland. gulmezoglum@who.int.
authors.forename: A Metin
authors.initials: AM
authors.lastname: Gülmezoglu
mesh_terms: D003270:Contraceptive Agents / Q000592:standards*; D003695:Delivery of Health Care / Q000458:organization & administration* / Q000592:standards*; D003906:Developing Countries; D006801:Humans; D016032:Randomized Controlled Trials as Topic; D013647:Task Performance and Analysis
chemical_list: D003270:Contraceptive Agents