title: Optimizing tubal ligation service delivery: a prospective cohort study to measure the task-sharing experience of Marie Stopes International Ethiopia.
abstract: The Ethiopian government implements a progressive task-sharing policy for health services as a strategy to address shortages of highly skilled providers and increase access to critical services, such as family planning. Since 2009, Marie Stopes International Ethiopia has trained health officers to provide tubal ligations, a permanent method of family planning, as part of its task-sharing strategy. The objectives of this research were to evaluate task-sharing tubal ligations to health officers at Marie Stopes International Ethiopia, specifically: (a) to investigate safety, as measured by the proportion of major adverse events; (b) to evaluate the feasibility, as measured by adherence to the standard tubal ligation procedure protocol and (c) to investigate acceptability to clients of the tubal ligation procedure provided by health officers. We established a prospective cohort of women aged  ≥18 years presenting for tubal ligation at Marie Stopes International Ethiopia sites in three regions in Ethiopia (March–May 2014). Data on adverse events (incomplete procedure, pain, bleeding, infection, perforation) were collected intra-operatively; peri-operatively (1-h post-procedure); and post-operatively (7 days post-procedure). To measure feasibility, 65% of procedures were selected for ‘audit’, where a nurse observed and scored health officers adherence to standard protocol using an 18-item checklist. To assess acceptability, women were asked about their satisfaction with the procedure. In total, 276 women were enrolled in the study. 97.5% of procedures took place in rural settings. All participants were followed up 7 days post-procedure (100% response rate). The overall proportion of major adverse events was 3% (95% CI 1–6%). The most frequent adverse event was ‘failure to complete the TL’ (2.2%, n = 6). The average score on protocol adherence was 96.9%. Overall, 98.2% (n = 271) of clients would recommend the procedure to a friend. Findings from this study, indicating safety, feasibility and acceptability, are consistent with the existing literature, which indicate safety and acceptability for task-sharing tubal ligations, and other methods of contraception with non-physician health providers. This study adds to scant literature on task-sharing tubal ligations in rural and low-resource settings.
authors.affiliation: Research, Monitoring and Evaluation Team, Health System Department, Marie Stopes International, London, UK.
authors.forename: Olivia
authors.initials: O
authors.lastname: Nuccio
authors.affiliation: John Snow Inc, Ethiopia.
authors.forename: Birhanu
authors.initials: B
authors.lastname: Sendek
authors.affiliation: London School of Hygiene and Tropical Medicine, London, UK.
authors.forename: Min Hae
authors.initials: MH
authors.lastname: Park
authors.affiliation: Research, Monitoring and Evaluation Team, Health System Department, Marie Stopes International, London, UK.
authors.forename: Tesfaye
authors.initials: T
authors.lastname: Mesele
authors.affiliation: Deputy Research Director, Abt Associates, Inc., Washington DC, USA.
authors.forename: Francis Ogojo
authors.initials: FO
authors.lastname: Okello
authors.affiliation: Global Oncology, Fred Hutch.
authors.forename: Cristin
authors.initials: C
authors.lastname: Gordon-Maclean
mesh_terms: D000328:Adult; D015331:Cohort Studies; D005002:Ethiopia; D005240:Feasibility Studies; D005260:Female; D006282:Health Personnel / Q000706:statistics & numerical data; D006801:Humans; D017060:Patient Satisfaction; D011446:Prospective Studies; D012424:Rural Population / Q000706:statistics & numerical data; D013246:Sterilization, Tubal / Q000009:adverse effects / Q000592:standards / Q000706:statistics & numerical data*; D013647:Task Performance and Analysis