Contraceptive delivery

1.1-1.13 Promotion of maternal, newborn and reproductive health interventions

LHW | 1.1 - 1.13

Should LAY HEALTH WORKERS promote uptake of health-related behaviours and healthcare services for reproductive and sexual health including maternal, HIV, family planning and neonatal care?

Recommendation

We recommend the use of LHWs to promote uptake of maternal and newborn related healthcare behaviour and services

.

Justification

The use of LHWs to promote behaviours and services for maternal and child health is probably an effective, acceptable and feasible intervention and may also reduce inequalities by extending care to underserved populations

Problem: Low uptake of behaviours and services for maternal and neonatal health

.

Option: LHWs promoting uptake of behaviours and services for maternal and neonatal health

.

Comparison: No promotion

.

Setting: Community/primary health care settings in LMICs

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

12.1 Initiation and maintenance of injectable contraceptives - CPAD
Because the product is still in development and studies are ongoing, no recommendation was made by the panel.
12.2 Initiation and maintenance of injectable contraceptives - standard syringe
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LHW | 12.2

Should LAY HEALTH WORKERS initiate and maintain injectable contraceptives using a standard syringe?

Recommendation

We suggest considering the option with targeted monitoring and evaluation. We suggest implementing this intervention where a well-functioning LHW programme already exists.

.

Justification

There is insufficient evidence that met the criteria for this guideline on the effectiveness of this intervention. However, based on programme experience, the panel concluded that the intervention has the potential to improve equity by increasing access to family planning, and does not appear to have safety issues. In many settings, LHWs already deliver some contraceptive counselling and use injections for other conditions.

Problem: Poor access to contraception

.

Option: LHWs initiating and maintaining injectable contraceptives 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

AUX | 12.2

Should AUXILIARY NURSES initiate and maintain injectable contraceptives using a standard syringe?

Recommendation

We recommend the use of auxiliary nurses to deliver injectable contraceptives using a standard syringe with targeted monitoring and evaluation.

.

Justification

There is insufficient evidence on the effectiveness of this intervention. However, this intervention may be a cost-effective, acceptable and feasible approach to making injectable contraceptives available more widely. In addition, the delivery of injections is part of auxiliary nurse practice in a number of settings.

Problem: Poor access to contraception

.

Option: Auxiliary nurses initiating and maintaining injectable contraceptives 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

ANM | 12.2

Should AUXILIARY NURSE MIDWIVES initiate and maintain injectable contraceptives using a standard syringe?

Recommendation

We recommend the use of auxiliary nurse midwives to deliver injectable contraceptives using a standard syringe.

.

Justification

There is insufficient evidence on the effectiveness of this intervention. However, this intervention may be a cost-effective, acceptable and feasible approach to making injectable contraceptives available more widely. In addition, the delivery of injections is part of auxiliary nurse midwife practice in a number of settings.

Problem: Poor access to contraception

.

Option: Auxiliary nurse midwives initiating and maintaining injectable contraceptives 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

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

12.3 Insertion and removal of intrauterine devices

LHW | 12.3

Should LAY HEALTH WORKERS insert and remove intrauterine devices (IUDs)?

Recommendation

We recommend against the use of LHWs to insert and remove uterine devices (IUDs).

.

Justification

There is insufficient evidence on the effectiveness of this intervention. In addition, it is uncertain whether the intervention is cost-effective, feasible or acceptable; the intervention may be beyond the typical skills of this cadre; and there is potential for harm.

Problem: Poor access to contraception

.

Option: LHWs inserting and removing IUDs

.

Comparison: Care delivered by other cadres or no care

.

Setting: Community/primary health care settings in LMICs with poor access to health professionals

AUX | 12.3

Should AUXILIARY NURSES insert and remove intrauterine device (IUDs)?

Recommendation

We suggest considering using use auxiliary nurses to insert and remove IUDs only in the context of rigorous research.

.

Justification

There is insufficient evidence on the effectiveness of this intervention. In addition, auxiliary nurses do not have pelvic assessment competency within their scope and would require some training. However, this intervention may be a cost-effective, feasible and acceptable approach and may reduce inequalities by extending care to underserved populations.

Problem: Poor access to contraception

.

Option: Auxiliary nurses inserting and removing IUDs

.

Comparison: Care delivered by other cadres or no care

.

Setting: Community/primary health care settings in LMICs with poor access to health professionals

ANM | 12.3

Should AUXILIARY NURSE MIDWIVES insert and remove intrauterine device (IUDs)?

Recommendation

We recommend the use of auxiliary nurse midwives to insert and remove IUDs. This intervention may be used where auxiliary nurse midwives are already an established cadre.

.

Justification

This intervention is probably effective and may have few undesirable effects. It may also be cost-effective, feasible and acceptable, and may reduce inequalities by extending care to underserved populations.

Problem: Poor access to contraception

.

Option: Auxiliary nurse midwives inserting and removing IUDs

.

Comparison: Care delivered by other cadres or no care

.

Setting: Community/primary health care settings in LMICs with poor access to health professionals

NUR | 12.3

Should NURSES insert and remove intrauterine device (IUDs)?

Recommendation

We recommend the use of nurses to deliver IUDs.

.

Justification

While acceptability may vary, this intervention may be an effective, cost-effective and feasible approach to contraception and may also reduce inequalities my extending care to underserved populations.

Problem: Poor access to contraception

.

Option: Nurses inserting and removing IUDs

.

Comparison: Care delivered by other cadres or no care

.

Setting: Community/primary health care settings in LMICs with poor access to health professionals

MID | 12.3

Should MIDWIVES insert and remove intrauterine devices (IUDs)?

Recommendation

We recommend the use of midwives to deliver IUDs with targeted monitoring and evaluation. We suggest using this intervention where a well-functioning midwife programme already exists.

.

Justification

There is insufficient evidence on the effectiveness of this intervention, and acceptability may vary. However, there is evidence to suggest that auxiliary nurse midwives and nurses can effectively insert and remove IUDs. In addition, this intervention is probably be a cost-effective and feasible approach and may also reduce inequalities my extending care to underserved populations.

Problem: Poor access to contraception

.

Option: Midwives inserting and removing IUDs

.

Comparison: Care delivered by other cadres or no care

.

Setting: Community/primary health care settings in LMICs with poor access to health professionals

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

12.4 Insertion and removal of contraceptive implants

LHW | 12.4

Should LAY HEALTH WORKERS insert and remove contraceptive implants?

Recommendation

We suggest considering this option only in the context of rigorous research. We suggest evaluating the intervention only with LHWs who (a) have appropriate levels of training; and (b) deliver care within a facility or other setting with sterile conditions.

.

Note: Seven members of the panel dissented and indicated that they would prefer to recommend against the option. They noted that the cadre of LHWs, as defined for this guideline, includes a wide range of skills and training and it is not clear that those with lower levels of training have the necessary skills to deliver this intervention. The risk associated with delivering the intervention may therefore be higher.

.

Justification

There is insufficient evidence on the effectiveness of this intervention, which could be considered to be a minor surgical procedure. In addition, it is uncertain whether the intervention is cost-effective, feasible or acceptable.

Problem: Poor access to contraception

.

Option: LHWs inserting and removing contraceptive implants

.

Comparison: Care delivered by other cadres or no care

.

Setting: Community/primary health care settings in LMICs with poor access to health professionals

AUX | 12.4

Should AUXILIARY NURSES insert and remove contraceptive implants?

Recommendation

We suggest considering this option with targeted monitoring and evaluation. We suggest using this intervention where: (1) auxiliary nurses are already an established cadre; and (2) a well-functioning referral system is in place or can be put in place.

.

Justification

There is insufficient evidence on the effectiveness of this intervention. However, this intervention may be a cost-effective, feasible and acceptable approach and may reduce inequalities by extending care to underserved populations. In addition, the intervention would require minimal additional skills.

Problem: Poor access to contraception

.

Option: Auxiliary nurses inserting and removing contraceptive implants

.

Comparison: Care delivered by other cadres or no care

.

Setting: Community/primary health care settings in LMICs with poor access to health professionals

ANM | 12.4

Should AUXILIARY NURSE MIDWIVES insert and remove contraceptive implants?

Recommendation

We suggest considering the option with targeted monitoring and evaluation. We suggest using this intervention where auxiliary nurse midwives are already an established cadre and a well-functioning referral system is in place or can be put in place.

.

Justification

There is insufficient evidence on the effectiveness of this intervention. However, this intervention may be a cost-effective, feasible and acceptable approach and may reduce inequalities by extending care to underserved populations. In addition, this intervention would require relatively few additional skills.

Problem: Poor access to contraception

.

Option: Auxiliary nurse midwives inserting and removing contraceptive implants

.

Comparison: Care delivered by other cadres or no care

.

Setting: Community/primary health care settings in LMICs with poor access to health professionals

NUR | 12.4

Should NURSES insert and remove contraceptive implants?

Recommendation

We recommend the use of nurses to insert and remove contraceptive implants.

.

Justification

There is insufficient evidence on the effectiveness of this intervention, and acceptability may vary. However, there is evidence to suggest that nurses can effectively deliver other similar interventions. In addition, this intervention may be a cost-effective and feasible approach to contraception and may also reduce inequalities my extending care to underserved populations.

Problem: Poor access to contraception

.

Option: Nurses inserting and removing contraceptive implants

.

Comparison: Care delivered by other cadres or no care

.

Setting: Community/primary health care settings in LMICs with poor access to health professionals

MID | 12.4

Should MIDWIVES insert and remove contraceptive implants?

Recommendation

We recommend the use of midwives to insert and remove contraceptive implants. We suggest using this intervention where a well-functioning midwife programme already exists.

.

Justification

There is insufficient evidence on the effectiveness of this intervention and acceptability is uncertain. However, this intervention would require minimal additional skills. In addition, this intervention is probably a cost-effective and feasible approach to contraception and may also reduce inequalities by extending care to underserved populations.

Problem: Poor access to contraception

.

Option: Midwives inserting and removing contraceptive implants

.

Comparison: Care delivered by other cadres or no care

.

Setting: Community/primary health care settings in LMICs with poor access to health professionals

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

12.5 Tubal ligation

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

AUX | 12.5

Should AUXILIARY NURSES perform tubal ligation (post-partum and interval)?

Recommendation

We recommend against the use of auxiliary nurses to perform tubal ligation.

.

Justification

There is insufficient evidence on the effectiveness of this intervention. In addition, this procedure is beyond the skills of most auxiliary nurses and there is uncertainty regarding its cost-effectiveness, feasibility and acceptability.

Problem: Poor access to contraception

.

Option: Auxiliary nurses performing tubal ligation

.

Comparison: Care delivered by other cadres or no care

.

Setting: Community/primary health care settings in LMICs with poor access to health professionals

ANM | 12.5

Should AUXILIARY NURSE MIDWIVES perform tubal ligation (post-partum and interval)?

Recommendation

We recommend against the use of nurses to perform tubal ligation.

.

Justification

There is insufficient evidence on the effectiveness of this intervention. In addition, this procedure is beyond the skills of most auxiliary nurse midwives and there is uncertainty regarding its acceptability, feasibility and cost-effectiveness.

Problem: Poor access to contraception

.

Option: Auxiliary nurse midwives performing tubal ligation

.

Comparison: Care delivered by other cadres or no care

.

Setting: Community/primary health care settings in LMICs with poor access to health professionals

NUR | 12.5

Should NURSES perform tubal ligation (post-partum and interval)?

Recommendation

We suggest considering the option only in the context of rigorous research. This intervention should be evaluated where a well-functioning referral system is in place or can be put in place.

.

The panel acknowledges the different methods of tubal ligation that may be relevant in this context.

.

Justification

There is insufficient evidence on the effectiveness of this intervention. However, this intervention may be a cost-effective, acceptable and feasible approach to contraception and may also reduce inequalities by extending care to underserved populations.

Problem: Poor access to contraception

.

Option: Nurses performing tubal ligation

.

Comparison: Care delivered by other cadres or no care

.

Setting: Community/primary health care settings in LMICs with poor access to health professionals

MID | 12.5

Should MIDWIVES perform tubal ligation (post-partum and interval)?

Recommendation

We suggest considering this option only in the context of rigorous research. The intervention should be evaluated where:

.

- A well-functioning midwife programme already exists

.

- A well-functioning referral system is in place or can be put in place

.

The panel acknowledges the different methods of tubal ligation that may be relevant in this context.

Justification

This intervention may be effective, and may reduce inequalities by extending care to underserved populations. There is some uncertainty as to whether the intervention is an acceptable and feasible approach.

Problem: Poor access to contraception

.

Option: Midwives performing tubal ligation

.

Comparison: Care delivered by other cadres or no care

.

Setting: Community/primary health care settings in LMICs with poor access to health professionals

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

12.6 Vasectomy

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

AUX | 12.6

Should AUXILIARY NURSES perform vasectomy?

Recommendation

We suggest considering the option only in the context of rigorous research. Implementation in the context of research should be done where:

.

- Auxiliary nurses are already an established cadre

- A well-functioning referral system is in place or can be put in place

.

Note: Five members of the panel dissented and indicated that they would prefer to recommend against the option as they considered this procedure to exceed the typical scope of practice of auxiliary nurses

.

Justification

There is insufficient evidence on the effectiveness of this intervention. In addition, there is uncertainty regarding its cost-effectiveness, feasibility and acceptability.

Problem: Poor access to contraception

.

Option: Auxiliary nurses performing vasectomy

.

Comparison: Care delivered by other cadres or no care

.

Setting: Community/primary health care settings in LMICs with poor access to health professionals

ANM | 12.6

Should AUXILIARY NURSE MIDWIVES perform vasectomy?

Recommendation

We suggest considering this option only in the context of rigorous research. Implementation in the context of research should be done where:

.

- auxiliary nurse midwives are already an established cadre
- a well-functioning referral system is in place or can be put in place

.

Note: Five members of the panel dissented and indicated that they would prefer to recommend against the option as they considered this procedure to exceed the typical scope of practice of auxiliary nurse midwives.

.

Justification

There is insufficient evidence on the effectiveness of this intervention. In addition, there is uncertainty regarding its acceptability, feasibility and cost-effectiveness.

Problem: Poor access to contraception

.

Option: Auxiliary nurse midwives performing vasectomy

.

Comparison: Care delivered by other cadres or no care

.

Setting: Community/primary health care settings in LMICs with poor access to health professionals

NUR | 12.6

Should NURSES perform vasectomy?

Recommendation

We suggest considering this option only in the context of rigorous research. This intervention should be evaluated where a well-functioning referral system is in place or can be put in place.

.

Justification

There is insufficient evidence on the effectiveness of this interventions. However, this intervention may be a cost-effective, acceptable and feasible approach to contraception and may also reduce inequalities by extending care to underserved populations.

Problem: Poor access to contraception

.

Option: Nurses performing vasectomy

.

Comparison: Care delivered by other cadres or no care

.

Setting: Community/primary health care settings in LMICs with poor access to health professionals

MID | 12.6

Should MIDWIVES perform vasectomy?

Recommendation

We suggest considering this option only in the context of rigorous research. Implementation in the context of research should be done where:

.

- A well-functioning midwife programme already exists

.

- A well-functioning referral system is in place or can be put in place

.

Justification

There is insufficient evidence on the effectiveness of this intervention. However, this intervention may be a cost-effective, acceptable and feasible approach to contraception and may also reduce inequalities by extending care to underserved populations.

Problem: Poor access to contraception

.

Option: Midwives performing vasectomy

.

Comparison: Care delivered by other cadres or no care

.

Setting: Community/primary health care settings in LMICs with poor access to health professionals

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

During pregnancy (Antenatal care)

1.1-1.13 Promotion of maternal, newborn and reproductive health interventions

LHW | 1.1 - 1.13

Should LAY HEALTH WORKERS promote uptake of health-related behaviours and healthcare services for reproductive and sexual health including maternal, HIV, family planning and neonatal care?

Recommendation

We recommend the use of LHWs to promote uptake of maternal and newborn related healthcare behaviour and services

.

Justification

The use of LHWs to promote behaviours and services for maternal and child health is probably an effective, acceptable and feasible intervention and may also reduce inequalities by extending care to underserved populations

Problem: Low uptake of behaviours and services for maternal and neonatal health

.

Option: LHWs promoting uptake of behaviours and services for maternal and neonatal health

.

Comparison: No promotion

.

Setting: Community/primary health care settings in LMICs

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

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.
3.1, 3.3, 3,4 and 3.5 Oral supplement distribution to pregnant women

LHW | 3.1 - 3.2 - 3.3 - 3.4

Should LAY HEALTH WORKERS distribute oral supplements to pregnant women?

Recommendation

We suggest considering the use of LHWs to distribute oral supplements to pregnant women with targeted monitoring and evaluation.

.

Justification

The effects of using LHWs to distribute oral supplements to pregnant women may be mixed. However, it is probably an acceptable and feasible intervention, may have few undesirable effects, and may reduce inequalities by extending care to underserved populations.

Problem: Poor access to oral supplements for pregnant women

.

Option: LHWs distribution of oral supplements

.

Comparison: Care delivered by other cadres or no care

.

Setting: Community/primary health care settings in LMICs with poor access to health care

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

3.2 Low dose aspirin distribution to pregnant women at high risk of pre-eclampsia/ eclampsia

LHW | 3.2

Should LAY HEALTH WORKERS distribute low dose aspirin to pregnant women at high risk of developing pre-eclampsia/eclampsia?

Recommendation

We suggest considering this option only in the context of rigorous research. This research should focus on LHWs supporting taking the maintenance dose of aspirin after treatment has been initiated by a health worker with competency to assess the risk status of women.

.

Justification

There is insufficient evidence on the effectiveness of using LHWs to distribute low-dose aspirin to pregnant women at high risk of developing pre-eclampsia/eclampsia. In addition, the intervention requires the identification of pregnant women at high risk. However, it is probably an acceptable and feasible intervention and may reduce inequalities by extending care to underserved populations.

Problem: Poor access to low dose aspirin for pregnant women

.

Option: LHWs distribution of low dose aspirin

.

Comparison: Care delivered by other cadres or no care

.

Setting: Community/primary health care settings in LMICs with poor access to health care

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

4.1 Diagnosis and initial treatment of pPROM using injectable antibiotics

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

AUX | 4.1

Should AUXILIARY NURSES diagnose preterm pre-labour rupture of membranes (pPROM) and deliver initial treatment of injectable antibiotics, using a standard syringe, before referral?

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 this intervention. However, this intervention is probably acceptable and feasible and may reduce inequalities by extending care to underserved populations.

Problem: Poor access to injectable antibiotics for preterm PROM

.

Option: Auxiliary nurses delivering injectable antibiotics

.

Comparison: Care delivered by other cadres or no care

.

Setting: Community/primary health care settings in LMICs with poor access to health professionals

ANM | 4.1

Should AUXILIARY NURSE MIDWIVES diagnose preterm pre-labour rupture of membranes (pPROM) and deliver initial treatment of injectable antibiotics, using a standard syringe, before referral?

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 diagnosing preterm pre-labour rupture of membranes (PROM) and delivering initial treatment of injectable antibiotics using a standard syringe before referral. Possible harms include the overuse of antibiotics and misdiagnosis. Possible benefits include earlier access to treatment for preterm PROM, but it is unclear whether slightly earlier treatment, prior to referral, would have benefits. This intervention may be acceptable and feasible and may reduce inequalities by extending care to underserved populations.

Problem: Poor access to injectable antibiotics for preterm PROM

.

Option: Auxiliary nurse midwives delivering injectable antibiotics

.

Comparison:Care delivered by other cadres or no care

.

Setting:Community/primary health care settings in LMICs with poor access to health professionals

NUR | 4.1

Should NURSES diagnose preterm pre-labour rupture of membranes (pPROM) and deliver initial treatment of injectable antibiotics, using a standard syringe, before referral?

Recommendation

We suggest considering the option with targeted monitoring and evaluation. As there are questions about whether nurses have the skills and equipment to make the diagnosis, the intervention should be implemented where nurses are trained to give injections and in care for pregnant women.

.

Justification

There is insufficient evidence on the effectiveness of nurses diagnosing preterm pre-labour rupture of membranes (pPROM) and delivering initial treatment of injectable antibiotics, using a standard syringe, before referral. However, this is probably an acceptable and feasible approach to the management of preterm PROM. It may also reduce inequalities in settings where access to more highly trained providers is limited.

Problem: Poor access to injectable antibiotics for pPROM

.

Option: Nurses delivering injectable antibiotics for pPROM

.

Comparison: Care delivered by other cadres or no care

.

Setting: Community/primary health care settings in LMICs with poor access to health professionals

MID | 4.1

Should MIDWIVES diagnose preterm pre-labour rupture of membranes (pPROM) and deliver initial treatment of injectable antibiotics, using a standard syringe, before referral?

Recommendation

We suggest considering this option with targeted monitoring and evaluation. 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 and feasibility of midwives diagnosing preterm pre-labour rupture of membranes (pPROM) and delivering initial treatment of injectable antibiotics using a standard syringe before referral. However, this intervention may be acceptable and feasible and may reduce inequalities by extending care to underserved populations.

Problem: Poor access to injectable antibiotics for preterm PROM

.

Option: Midwives delivering injectable antibiotics

.

Comparison: Care delivered by other cadres or no care

.

Setting: Community/primary health care settings in LMICs with poor access to health professionals

This question was not scoped for this guideline. No assessment of the evidence was therefore conducted.

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

10.1 External cephalic version for breech presentation at term

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

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

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

NUR | 10.1

Should NURSES perform external cephalic version (ECV) for breech presentation at term?

Recommendation

We recommend against the use of nurses to perform external cephalic version.

.

Justification

There is insufficient evidence on the effectiveness of nurses performing external cephalic version, the intervention is outside of their typical scope of practice, and its acceptability is uncertain.

Problem: Poor access to ECV

.

Option: Nurses performing ECV

.

Comparison: Care delivered by other cadres or no care

.

Setting: Community/primary health care settings in LMICs with poor access to health professionals

MID | 10.1

Should MIDWIVES external cephalic version (ECV) for breech presentation at term?

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 performing external cephalic version and it has the potential to cause harm. However, this intervention is probably acceptable, is probably feasible and may reduce inequalities by extending care to underserved populations.

Problem: Poor access to ECV

.

Option: Midwives performing ECV

.

Comparison: Care delivered by other cadres or no care

.

Setting: Community/primary health care settings in LMICs with poor access to health professionals

ASC | 10.1

Should ASSOCIATE CLINICIANS perform external cephalic version (ECV)?

Recommendation

We recommend against the use of associate clinicians to perform external cephalic version.

.

Justification

There is insufficient evidence on the effectiveness of associate clinicians performing external cephalic version, the intervention is outside of their typical scope of practice and its acceptability and feasibility are uncertain.

Problem: Poor access to ECV

.

Option: Associated clinicians performing ECV

.

Comparison: Care delivered by other cadres or no care

.

Setting: Community/primary health care settings in LMICs with poor access to health professionals

ALAC | 10.1

Should ADVANCED LEVEL ASSOCIATE CLINICIANS perform external cephalic version (ECV)?

Recommendation

We suggest considering the option in the context of rigorous research in a hospital setting. We suggest using this intervention where advanced level associate clinicians 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 external cephalic version. It may be feasible and may reduce inequalities by extending care to underserved populations, but acceptability may vary.

Problem: Poor access to ECV

.

Option: Advanced level associate clinicians performing ECV

.

Comparison:Care delivered by other cadres or no care

.

Setting:Community/primary health care settings in LMICs with poor access to health professionals

NSD | 10.1

Should NON-SPECIALIST DOCTORS perform external cephalic version (ECV) for breech presentation at term?

Recommendation

We suggest considering the use of non-specialist doctors to perform ECV for breech presentation at term with targeted monitoring and evaluation.

.

Justification

The available evidence suggests that the use of non-specialist doctors to perform ECV has important benefits, and is likely to be acceptable and feasible.

Problem: Poor access to ECV

.

Option: Non-specialist doctors performing ECV

.

Comparison: Care delivered by other cadres or no care

.

Setting: Community/primary health care settings in LMICs with poor access to health professionals

11.4 Antihypertensives for severe high blood pressure in pregnancy

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

AUX | 11.4

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

ANM | 11.4

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

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

This question was not scoped for this guideline. No assessment of the evidence was therefore conducted.

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

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

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

AUX | 11.5

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

ANM | 11.5

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

NUR | 11.5

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

MID | 11.5

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

This question was not scoped for this guideline. No assessment of the evidence was therefore conducted.

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

11.8 Loading dose of magnesium sulphate to prevent eclampsia

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

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

This question was not scoped for this guideline. No assessment of the evidence was therefore conducted.

NUR | 11.8 - 11.10

Should NURSES deliver the loading dose of magnesium sulphate to (a) prevent eclampsia and refer to a higher facility, and (b) to treat eclampsia and refer to a higher facility?

Recommendation

We suggest considering the use of nurses to deliver the loading dose of magnesium sulphate to prevent and to treat eclampsia before referring to a higher facility with targeted monitoring and evaluation.

.

Justification

There is insufficient evidence on the effectiveness of nurses delivering a loading dose of magnesium sulphate to prevent and treat eclampsia and refer to a higher facility. However, a World Health Organization guideline recommends that for settings where it is not possible to administer the full magnesium sulphate regimen, the use of magnesium sulphate loading dose, followed by immediate transfer to a higher-level health facility, is recommended for women with severe pre-eclampsia and eclampsia (very low quality evidence, weak recommendation) (WHO, 2011).

Problem: Poor access to treatment for eclampsia

.

Option: Nurses delivering loading dose of magnesium sulphate for prevention and treatment of eclampsia

.

Comparison: Care delivered by other cadres or no care

.

Setting: Community/primary health care settings in LMICs with poor access to health professionals

MID | 11.8 - 11.10

Should MIDWIVES deliver a loading dose of magnesium sulphate to (a) prevent eclampsia and refer to a higher facility, and (b) treat eclampsia and refer to a higher facility?

Recommendation

We suggest considering the use of midwives to deliver a loading dose of magnesium sulphate to prevent or treat eclampsia and refer to a higher facility with targeted monitoring and evaluation.

.

Justification

There is insufficient evidence on the effectiveness of midwives delivering a loading dose of magnesium sulphate to prevent or treat eclampsia and refer to a higher facility. However, a World Health Organization guideline recommends that for settings where it is not possible to administer the full magnesium sulphate regimen, the use of magnesium sulphate loading dose, followed by immediate transfer to a higher-level health facility, is recommended for women with severe pre-eclampsia and eclampsia (very low quality evidence, weak recommendation) (WHO, 2011)..

Problem: Poor access to prevention of and treatment for eclampsia

.

Option: Midwives delivering loading dose of magnesium sulphate

.

Comparison: Care delivered by other cadres or no care

.

Setting: Community/primary health care settings in LMICs with poor access to health professionals

ASC | 11.8 - 11.10

Should ASSOCIATE CLINICIANS deliver a loading dose of magnesium sulphate to (a) prevent eclampsia and refer to a higher facility if appropriate; and (b) treat eclampsia and refer to a higher facility if appropriate?

Recommendation

We suggest considering the use of associate clinicians to deliver the loading dose of magnesium sulphate to prevent and treat eclampsia with targeted monitoring and evaluation.

.

Justification

There is insufficient evidence on the effectiveness of associate clinicians delivering a loading dose of magnesium sulphate to prevent or treat eclampsia and refer to a higher facility. However, a World Health Organization guideline recommends that for settings where it is not possible to administer the full magnesium sulphate regimen, the use of magnesium sulphate loading dose, followed by immediate transfer to a higher-level health facility, is recommended for women with severe pre-eclampsia and eclampsia (very low quality evidence, weak recommendation) (WHO, 2011).

Problem: Poor access to treatment for eclampsia

.

Option: Associate clinicians delivering loading dose of magnesium sulphate

.

Comparison: Care delivered by other cadres or no care

.

Setting: Community/primary health care settings in LMICs with poor access to health professionals

ALAC | 11.8 - 11.10

Should ADVANCED LEVEL ASSOCIATE CLINICIANS deliver a loading dose of magnesium sulphate to (a) prevent eclampsia and refer to a higher facility; and (b) treat eclampsia and refer to a higher facility?

Recommendation

We suggest considering the use of advanced level associated clinicians to deliver the loading dose of magnesium sulphate to prevent and treat eclampsia with targeted monitoring and evaluation.

.

Justification

There is insufficient evidence on the effectiveness of advanced level associated clinicians delivering a loading dose of magnesium sulphate to prevent or treat eclampsia and refer to a higher facility. However, a World Health Organization guideline recommends that for settings where it is not possible to administer the full magnesium sulphate regimen, the use of magnesium sulphate loading dose, followed by immediate transfer to a higher-level health facility, is recommended for women with severe pre-eclampsia and eclampsia (very low quality evidence, weak recommendation) (WHO, 2011).

Problem: Poor access to treatment for eclampsia

.

Option: Advanced level associate clinicians delivering loading dose of magnesium sulphate

.

Comparison:are delivered by other cadres or no care

.

Setting:Community/primary health care settings in LMICs with poor access to health professionals

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

11.9 Maintenance dose of magnesium sulphate to prevent eclampsia

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

This question was not scoped for this guideline. No assessment of the evidence was therefore conducted.

This question was not scoped for this guideline. No assessment of the evidence was therefore conducted.

NUR | 11.9 - 11.11

Should NURSES deliver the maintenance dose of magnesium sulphate to (a) prevent eclampsia and refer to a higher facility, and (b) treat eclampsia and refer to a higher facility?

Recommendation

We recommend against the use of nurses to deliver the maintenance dose of magnesium sulphate to prevent or treat eclampsia.

.

Justification

There is insufficient evidence on the effectiveness of nurses delivering a maintenance dose of magnesium sulphate to prevent or treat eclampsia and refer to a higher facility. In addition, the intervention is outside of their typical scope of practice and its acceptability is uncertain.

Problem: Poor access to treatment for eclampsia

.

Option: Nurses delivering loading dose of magnesium sulphate to prevent and treat eclampsia

.

Comparison: Care delivered by other cadres or no care

.

Setting: Community/primary health care settings in LMICs with poor access to health professionals

MID | 11.9 - 11.11

Should MIDWIVES deliver a maintenance dose of magnesium sulphate to (a) prevent eclampsia and refer to a higher facility, and (b) treat eclampsia and refer to a higher facility?

Recommendation

We suggest considering the option with targeted monitoring and evaluation. We suggest using this intervention in settings where midwives are working alone in primary care and it is not routinely possible to access more specialized cadres. Since appropriate care of a woman with pre-eclampsia and eclampsia requires a team effort, referral to higher care should be sought for such cases.

.

Justification

There is no direct evidence on the effectiveness of this intervention. However, this intervention may be a cost-effective and feasible approach and may be acceptable under certain conditions. The intervention may also reduce inequalities by extending care to underserved populations.

Problem: Poor access to initial and ongoing treatment for eclampsia

.

Option: Midwives delivering loading dose and maintenance dose of magnesium sulphate

.

Comparison: Care delivered by other cadres or no care

.

Setting: Community/primary health care settings in LMICs with poor access to health professionals

ASC | 11.9 - 11.11

Should ASSOCIATE CLINICIANS deliver a maintenance dose of magnesium sulphate to (a) prevent eclampsia and refer to a higher facility if appropriate; and (b) treat eclampsia and refer to a higher facility?

Recommendation

We recommend against the use of associated clinicians to deliver a maintenance dose of magnesium sulphate to prevent or treat eclampsia.

.

Justification

There is insufficient evidence on the effectiveness of associate clinicians delivering a maintenance dose of magnesium sulphate to prevent or treat eclampsia and refer to a higher facility, the intervention is outside of their typical scope of practice, and its acceptability is uncertain.

Problem: Poor access to treatment for eclampsia

.

Option: Associate clinicians delivering maintenance dose of magnesium sulphate

.

Comparison: Care delivered by other cadres or no care

.

Setting: Community/primary health care settings in LMICs with poor access to health professionals

ALAC | 11.9 - 11.11

Should ADVANCED LEVEL ASSOCIATE CLINICIANS deliver a maintenance dose of magnesium sulphate to (a) prevent eclampsia and refer to a higher facility if appropriate; and (b) treat eclampsia and refer to a higher facility if appropriate?

Recommendation

We suggest considering this option with targeted monitoring and evaluation. We suggest using this intervention in settings where advanced level associate clinicians are working alone in primary care and it is not routinely possible to access more specialized cadres.

.

Justification

There is insufficient evidence on the effectiveness and acceptability of advanced level associated clinicians delivering a maintenance dose of magnesium sulphate to prevent or treat eclampsia and refer to a higher facility. However, this intervention is probably feasible and may reduce inequalities by extending care to underserved populations.

Problem: Poor access to treatment for eclampsia

.

Option: Advanced level associated clinicians delivering maintenance dose of magnesium sulphate

.

Comparison:Care delivered by other cadres or no care

.

Setting:Community/primary health care settings in LMICs with poor access to health professionals

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

11.10 Loading dose of magnesium sulphate to treat eclampsia

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

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

This question was not scoped for this guideline. No assessment of the evidence was therefore conducted.

NUR | 11.8 - 11.10

Should NURSES deliver the loading dose of magnesium sulphate to (a) prevent eclampsia and refer to a higher facility, and (b) to treat eclampsia and refer to a higher facility?

Recommendation

We suggest considering the use of nurses to deliver the loading dose of magnesium sulphate to prevent and to treat eclampsia before referring to a higher facility with targeted monitoring and evaluation.

.

Justification

There is insufficient evidence on the effectiveness of nurses delivering a loading dose of magnesium sulphate to prevent and treat eclampsia and refer to a higher facility. However, a World Health Organization guideline recommends that for settings where it is not possible to administer the full magnesium sulphate regimen, the use of magnesium sulphate loading dose, followed by immediate transfer to a higher-level health facility, is recommended for women with severe pre-eclampsia and eclampsia (very low quality evidence, weak recommendation) (WHO, 2011).

Problem: Poor access to treatment for eclampsia

.

Option: Nurses delivering loading dose of magnesium sulphate for prevention and treatment of eclampsia

.

Comparison: Care delivered by other cadres or no care

.

Setting: Community/primary health care settings in LMICs with poor access to health professionals

MID | 11.8 - 11.10

Should MIDWIVES deliver a loading dose of magnesium sulphate to (a) prevent eclampsia and refer to a higher facility, and (b) treat eclampsia and refer to a higher facility?

Recommendation

We suggest considering the use of midwives to deliver a loading dose of magnesium sulphate to prevent or treat eclampsia and refer to a higher facility with targeted monitoring and evaluation.

.

Justification

There is insufficient evidence on the effectiveness of midwives delivering a loading dose of magnesium sulphate to prevent or treat eclampsia and refer to a higher facility. However, a World Health Organization guideline recommends that for settings where it is not possible to administer the full magnesium sulphate regimen, the use of magnesium sulphate loading dose, followed by immediate transfer to a higher-level health facility, is recommended for women with severe pre-eclampsia and eclampsia (very low quality evidence, weak recommendation) (WHO, 2011)..

Problem: Poor access to prevention of and treatment for eclampsia

.

Option: Midwives delivering loading dose of magnesium sulphate

.

Comparison: Care delivered by other cadres or no care

.

Setting: Community/primary health care settings in LMICs with poor access to health professionals

ASC | 11.8 - 11.10

Should ASSOCIATE CLINICIANS deliver a loading dose of magnesium sulphate to (a) prevent eclampsia and refer to a higher facility if appropriate; and (b) treat eclampsia and refer to a higher facility if appropriate?

Recommendation

We suggest considering the use of associate clinicians to deliver the loading dose of magnesium sulphate to prevent and treat eclampsia with targeted monitoring and evaluation.

.

Justification

There is insufficient evidence on the effectiveness of associate clinicians delivering a loading dose of magnesium sulphate to prevent or treat eclampsia and refer to a higher facility. However, a World Health Organization guideline recommends that for settings where it is not possible to administer the full magnesium sulphate regimen, the use of magnesium sulphate loading dose, followed by immediate transfer to a higher-level health facility, is recommended for women with severe pre-eclampsia and eclampsia (very low quality evidence, weak recommendation) (WHO, 2011).

Problem: Poor access to treatment for eclampsia

.

Option: Associate clinicians delivering loading dose of magnesium sulphate

.

Comparison: Care delivered by other cadres or no care

.

Setting: Community/primary health care settings in LMICs with poor access to health professionals

ALAC | 11.8 - 11.10

Should ADVANCED LEVEL ASSOCIATE CLINICIANS deliver a loading dose of magnesium sulphate to (a) prevent eclampsia and refer to a higher facility; and (b) treat eclampsia and refer to a higher facility?

Recommendation

We suggest considering the use of advanced level associated clinicians to deliver the loading dose of magnesium sulphate to prevent and treat eclampsia with targeted monitoring and evaluation.

.

Justification

There is insufficient evidence on the effectiveness of advanced level associated clinicians delivering a loading dose of magnesium sulphate to prevent or treat eclampsia and refer to a higher facility. However, a World Health Organization guideline recommends that for settings where it is not possible to administer the full magnesium sulphate regimen, the use of magnesium sulphate loading dose, followed by immediate transfer to a higher-level health facility, is recommended for women with severe pre-eclampsia and eclampsia (very low quality evidence, weak recommendation) (WHO, 2011).

Problem: Poor access to treatment for eclampsia

.

Option: Advanced level associate clinicians delivering loading dose of magnesium sulphate

.

Comparison:are delivered by other cadres or no care

.

Setting:Community/primary health care settings in LMICs with poor access to health professionals

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

11.11 Maintenance dose of magnesium sulphate to treat eclampsia

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

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

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

NUR | 11.9 - 11.11

Should NURSES deliver the maintenance dose of magnesium sulphate to (a) prevent eclampsia and refer to a higher facility, and (b) treat eclampsia and refer to a higher facility?

Recommendation

We recommend against the use of nurses to deliver the maintenance dose of magnesium sulphate to prevent or treat eclampsia.

.

Justification

There is insufficient evidence on the effectiveness of nurses delivering a maintenance dose of magnesium sulphate to prevent or treat eclampsia and refer to a higher facility. In addition, the intervention is outside of their typical scope of practice and its acceptability is uncertain.

Problem: Poor access to treatment for eclampsia

.

Option: Nurses delivering loading dose of magnesium sulphate to prevent and treat eclampsia

.

Comparison: Care delivered by other cadres or no care

.

Setting: Community/primary health care settings in LMICs with poor access to health professionals

MID | 11.9 - 11.11

Should MIDWIVES deliver a maintenance dose of magnesium sulphate to (a) prevent eclampsia and refer to a higher facility, and (b) treat eclampsia and refer to a higher facility?

Recommendation

We suggest considering the option with targeted monitoring and evaluation. We suggest using this intervention in settings where midwives are working alone in primary care and it is not routinely possible to access more specialized cadres. Since appropriate care of a woman with pre-eclampsia and eclampsia requires a team effort, referral to higher care should be sought for such cases.

.

Justification

There is no direct evidence on the effectiveness of this intervention. However, this intervention may be a cost-effective and feasible approach and may be acceptable under certain conditions. The intervention may also reduce inequalities by extending care to underserved populations.

Problem: Poor access to initial and ongoing treatment for eclampsia

.

Option: Midwives delivering loading dose and maintenance dose of magnesium sulphate

.

Comparison: Care delivered by other cadres or no care

.

Setting: Community/primary health care settings in LMICs with poor access to health professionals

ASC | 11.9 - 11.11

Should ASSOCIATE CLINICIANS deliver a maintenance dose of magnesium sulphate to (a) prevent eclampsia and refer to a higher facility if appropriate; and (b) treat eclampsia and refer to a higher facility?

Recommendation

We recommend against the use of associated clinicians to deliver a maintenance dose of magnesium sulphate to prevent or treat eclampsia.

.

Justification

There is insufficient evidence on the effectiveness of associate clinicians delivering a maintenance dose of magnesium sulphate to prevent or treat eclampsia and refer to a higher facility, the intervention is outside of their typical scope of practice, and its acceptability is uncertain.

Problem: Poor access to treatment for eclampsia

.

Option: Associate clinicians delivering maintenance dose of magnesium sulphate

.

Comparison: Care delivered by other cadres or no care

.

Setting: Community/primary health care settings in LMICs with poor access to health professionals

ALAC | 11.9 - 11.11

Should ADVANCED LEVEL ASSOCIATE CLINICIANS deliver a maintenance dose of magnesium sulphate to (a) prevent eclampsia and refer to a higher facility if appropriate; and (b) treat eclampsia and refer to a higher facility if appropriate?

Recommendation

We suggest considering this option with targeted monitoring and evaluation. We suggest using this intervention in settings where advanced level associate clinicians are working alone in primary care and it is not routinely possible to access more specialized cadres.

.

Justification

There is insufficient evidence on the effectiveness and acceptability of advanced level associated clinicians delivering a maintenance dose of magnesium sulphate to prevent or treat eclampsia and refer to a higher facility. However, this intervention is probably feasible and may reduce inequalities by extending care to underserved populations.

Problem: Poor access to treatment for eclampsia

.

Option: Advanced level associated clinicians delivering maintenance dose of magnesium sulphate

.

Comparison:Care delivered by other cadres or no care

.

Setting:Community/primary health care settings in LMICs with poor access to health professionals

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

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

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

ANM | 11.12

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

NUR | 11.12

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

MID | 11.12

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

This question was not scoped for this guideline. No assessment of the evidence was therefore conducted.

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

Giving birth (Intrapartum care)

2.1 Oxytocin administration to prevent PPH - standard syringe

LHW | 2.1 - 2.2

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

AUX | 2.1

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

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

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

LHW | 2.1 - 2.2

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

AUX | 2.2

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

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

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

LHW | 2.3 - 2.4

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

AUX | 2.3

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

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

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

LHW | 2.3 - 2.4

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

AUX | 2.4

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

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

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

LHW | 2.5

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

AUX | 2.5 - 2.6

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

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

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

LHW | 2.6

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

AUX | 2.5 - 2.6

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

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

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.
5.1 Continuous support for women during labour, in the presence of a skilled birth attendant

LHW | 5.1

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

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

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

LHW | 6.1

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

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

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

LHW | 6.2

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

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

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

LHW | 6.3

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

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

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

LHW | 9.1

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

AUX | 9.1

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

ANM | 9.1

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

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

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

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

AUX | 11.1

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

ANM | 11.1 - 11.3

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

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

This question was not scoped for this guideline. No assessment of the evidence was therefore conducted.

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

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

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

AUX | 11.2

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

ANM | 11.1 - 11.3

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

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

This question was not scoped for this guideline. No assessment of the evidence was therefore conducted.

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

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

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

AUX | 11.3

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

ANM | 11.1 - 11.3

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

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

This question was not scoped for this guideline. No assessment of the evidence was therefore conducted.

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

11.4 Antihypertensives for severe high blood pressure in pregnancy

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

AUX | 11.4

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

ANM | 11.4

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

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

This question was not scoped for this guideline. No assessment of the evidence was therefore conducted.

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

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

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

AUX | 11.5

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

ANM | 11.5

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

NUR | 11.5

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

MID | 11.5

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

This question was not scoped for this guideline. No assessment of the evidence was therefore conducted.

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

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

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

AUX | 11.6

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

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

This question was not scoped for this guideline. No assessment of the evidence was therefore conducted.

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

This question was not scoped for this guideline. No assessment of the evidence was therefore conducted.

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

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

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

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

This question was not scoped for this guideline. No assessment of the evidence was therefore conducted.

NUR | 11.7

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

MID | 11.7

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

ASC | 11.7

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

ALAC | 11.7 - 11.14

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

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

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

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

ANM | 11.12

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

NUR | 11.12

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

MID | 11.12

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

This question was not scoped for this guideline. No assessment of the evidence was therefore conducted.

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

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

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

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

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

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

This question was not scoped for this guideline. No assessment of the evidence was therefore conducted.

ASC | 11.13

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

ALAC | 11.13

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

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

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

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

This question was not scoped for this guideline. No assessment of the evidence was therefore conducted.

This question was not scoped for this guideline. No assessment of the evidence was therefore conducted.

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

ASC | 11.14

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

ALAC | 11.7 - 11.14

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

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

After delivery – Mother (Postpartum care)

1.1-1.13 Promotion of maternal, newborn and reproductive health interventions

LHW | 1.1 - 1.13

Should LAY HEALTH WORKERS promote uptake of health-related behaviours and healthcare services for reproductive and sexual health including maternal, HIV, family planning and neonatal care?

Recommendation

We recommend the use of LHWs to promote uptake of maternal and newborn related healthcare behaviour and services

.

Justification

The use of LHWs to promote behaviours and services for maternal and child health is probably an effective, acceptable and feasible intervention and may also reduce inequalities by extending care to underserved populations

Problem: Low uptake of behaviours and services for maternal and neonatal health

.

Option: LHWs promoting uptake of behaviours and services for maternal and neonatal health

.

Comparison: No promotion

.

Setting: Community/primary health care settings in LMICs

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

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

LHW | 6.1

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

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

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

LHW | 6.2

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

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

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

LHW | 6.3

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

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

11.4 Antihypertensives for severe high blood pressure in pregnancy

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

AUX | 11.4

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

ANM | 11.4

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

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

This question was not scoped for this guideline. No assessment of the evidence was therefore conducted.

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

After delivery – Baby (Neonatal care)

1.1-1.13 Promotion of maternal, newborn and reproductive health interventions

LHW | 1.1 - 1.13

Should LAY HEALTH WORKERS promote uptake of health-related behaviours and healthcare services for reproductive and sexual health including maternal, HIV, family planning and neonatal care?

Recommendation

We recommend the use of LHWs to promote uptake of maternal and newborn related healthcare behaviour and services

.

Justification

The use of LHWs to promote behaviours and services for maternal and child health is probably an effective, acceptable and feasible intervention and may also reduce inequalities by extending care to underserved populations

Problem: Low uptake of behaviours and services for maternal and neonatal health

.

Option: LHWs promoting uptake of behaviours and services for maternal and neonatal health

.

Comparison: No promotion

.

Setting: Community/primary health care settings in LMICs

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

7.1 Initiation of kangaroo mother care for low birth weight infants

LHW | 7.1 - 7.2

Should LAY HEALTH WORKERS (a) initiate and (b) maintain kangaroo mother care for low birth weight infants?

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 specialized care is available or can be put in place.

.

Justification

There is insufficient evidence on the effectiveness of using LHWs to initiate and maintain kangaroo care. However, the intervention is probably feasible and acceptable, and may reduce inequalities by extending care to underserved populations.

Problem: Low utilisation of kangaroo mother care for low birth weight infants

.

Option: LHWs initiating and maintaining kangaroo mother care

.

Comparison: Care delivered by other cadres or no care

.

Setting: Community/primary health care settings in LMICs

AUX | 7.1 - 7.2

Should AUXILIARY NURSES (a) initiate and (b) maintain kangaroo mother care for low birth weight infants?

Recommendation

We suggest considering this option with targeted monitoring and evaluation. We suggest using this intervention where auxiliary nurses are already an established cadre.

.

Justification

There is insufficient evidence on the effectiveness and feasibility of auxiliary nurses initiating kangaroo mother care for low birth weight infants. However, the intervention may have important benefits and is probably feasible and acceptable. It may also reduce inequalities by extending care to underserved populations.

Problem: Low utilisation of kangaroo mother care for low birth weight infants

.

Option: Auxiliary nurses initiating and maintaining kangaroo mother care

.

Comparison: Usual care

.

Setting: Community/primary health care settings in LMICs

ANM | 7.1 - 7.2

Should AUXILIARY NURSE MIDWIVES (a) initiate and (b) maintain kangaroo mother care for low birth weight infants?

Recommendation

We suggest considering the option with targeted monitoring and evaluation. We suggest using this intervention where auxiliary nurse midwives are already an established cadre.

.

Justification

There is insufficient evidence on the effectiveness and feasibility of auxiliary nurse midwives initiating kangaroo mother care for low birth weight infants. However, the intervention may have important benefits and is probably feasible and acceptable. It may also reduce inequalities by extending care to underserved populations. We therefore suggest considering the option with targeted monitoring and evaluation, with particular attention given to different birthweight subgroups.

Problem: Low utilisation of kangaroo mother care for low birth weight infants

.

Option: Auxiliary nurse midwives initiating and maintaining kangaroo mother care

.

Comparison:Usual care

.

Setting:Community/primary health care settings in LMICs

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

7.2 Maintenance of kangaroo mother care for low birth weight infants

LHW | 7.1 - 7.2

Should LAY HEALTH WORKERS (a) initiate and (b) maintain kangaroo mother care for low birth weight infants?

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 specialized care is available or can be put in place.

.

Justification

There is insufficient evidence on the effectiveness of using LHWs to initiate and maintain kangaroo care. However, the intervention is probably feasible and acceptable, and may reduce inequalities by extending care to underserved populations.

Problem: Low utilisation of kangaroo mother care for low birth weight infants

.

Option: LHWs initiating and maintaining kangaroo mother care

.

Comparison: Care delivered by other cadres or no care

.

Setting: Community/primary health care settings in LMICs

AUX | 7.1 - 7.2

Should AUXILIARY NURSES (a) initiate and (b) maintain kangaroo mother care for low birth weight infants?

Recommendation

We suggest considering this option with targeted monitoring and evaluation. We suggest using this intervention where auxiliary nurses are already an established cadre.

.

Justification

There is insufficient evidence on the effectiveness and feasibility of auxiliary nurses initiating kangaroo mother care for low birth weight infants. However, the intervention may have important benefits and is probably feasible and acceptable. It may also reduce inequalities by extending care to underserved populations.

Problem: Low utilisation of kangaroo mother care for low birth weight infants

.

Option: Auxiliary nurses initiating and maintaining kangaroo mother care

.

Comparison: Usual care

.

Setting: Community/primary health care settings in LMICs

ANM | 7.1 - 7.2

Should AUXILIARY NURSE MIDWIVES (a) initiate and (b) maintain kangaroo mother care for low birth weight infants?

Recommendation

We suggest considering the option with targeted monitoring and evaluation. We suggest using this intervention where auxiliary nurse midwives are already an established cadre.

.

Justification

There is insufficient evidence on the effectiveness and feasibility of auxiliary nurse midwives initiating kangaroo mother care for low birth weight infants. However, the intervention may have important benefits and is probably feasible and acceptable. It may also reduce inequalities by extending care to underserved populations. We therefore suggest considering the option with targeted monitoring and evaluation, with particular attention given to different birthweight subgroups.

Problem: Low utilisation of kangaroo mother care for low birth weight infants

.

Option: Auxiliary nurse midwives initiating and maintaining kangaroo mother care

.

Comparison:Usual care

.

Setting:Community/primary health care settings in LMICs

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

8.1 Injectable antibiotics for neonatal sepsis - standard syringe

LHW | 8.1

Should LAY HEALTH WORKERS deliver injectable antibiotics for neonatal sepsis, using a standard syringe?

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 cadre is available or can be put in place.

.

Justification

There is insufficient evidence on the effectiveness of this intervention. However, it is probably acceptable, may be feasible, and may reduce inequalities by extending care to underserved populations.

Problem: Poor access to treatment for neonatal sepsis

.

Option: LHWs delivering injectable antibiotics for neonatal sepsis, 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

AUX | 8.1

Should AUXILIARY NURSES deliver injectable antibiotics for neonatal sepsis, using a standard syringe?

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 clear clinical guidelines are available 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 injectable antibiotics for neonatal sepsis using a standard syringe, and its feasibility is uncertain. However, this intervention may be acceptable and may reduce inequalities by extending care to underserved populations. Also, giving intramuscular and intravenous injections are generally within the standard competencies of auxiliary nurses.

Problem: Poor access to treatment for neonatal sepsis

.

Option: Auxiliary nurses delivering injectable antibiotics for neonatal sepsis

.

Comparison: Care delivered by other cadres or no care

.

Setting: Community/primary health care settings in LMICs with poor access to health professionals

ANM | 8.1

Should AUXILIARY NURSE MIDWIVES deliver injectable antibiotics for neonatal sepsis, using a standard syringe?

Recommendation

We suggest considering this 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 injectable antibiotics for neonatal sepsis using a standard syringe, and its feasibility is uncertain. However, this intervention may be acceptable and may reduce inequalities by extending care to underserved populations. Also, giving intramuscular and intravenous injections are generally within the standard competencies of auxiliary nurse midwives.

Problem: Poor access to treatment for neonatal sepsis

.

Option: Auxiliary nurse midwives delivering injectable antibiotics for neonatal sepsis

.

Comparison:Care delivered by other cadres or no care

.

Setting:Community/primary health care settings in LMICs with poor access to health professionals

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

8.2 Antibiotics for neonatal sepsis - CPAD

LHW | 8.2

Should LAY HEALTH WORKERS deliver antibiotics for neonatal sepsis using a compact, prefilled, autodisable device (CPAD) such as Uniject?

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 cadre is in place or can be put in place.

.

Justification

There is insufficient evidence on the effectiveness of this intervention. However, it is probably acceptable, may be feasible and may reduce inequalities by extending care to underserved populations.

Problem: Poor access to treatment for neonatal sepsis

.

Option: LHWs delivering antibiotics for neonatal sepsis 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

AUX | 8.2

Should AUXILIARY NURSES deliver antibiotics for neonatal sepsis using a compact, prefilled, autodisable device (CPAD) such as Uniject?

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 clear clinical protocols are available 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 antibiotics for neonatal sepsis using a CPAD, and its feasibility is uncertain. However, this intervention may be acceptable and may reduce inequalities by extending care to underserved populations. Also, giving intramuscular and intravenous injections are generally within the standard competencies of auxiliary nurses. We therefore suggest considering the option in the context of rigorous research.

Problem: Poor access to treatment for neonatal sepsis

.

Option: Auxiliary nurses delivering antibiotics for neonatal sepsis 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

ANM | 8.2

Should AUXILIARY NURSE MIDWIVES deliver antibiotics for neonatal sepsis, using a compact, prefilled, autodisable device (CPAD) such as Uniject?

Recommendation

We suggest considering this option in the context of rigorous research. We suggest evaluating this intervention where auxiliary nurse midwives are already an established cadre, where clear clinical protocols are available 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 antibiotics for neonatal sepsis using a CPAD and its feasibility is uncertain. However, this intervention may be acceptable and may reduce inequalities by extending care to underserved populations. Also, giving intramuscular and intravenous injections are generally within the standard competencies of auxiliary nurse midwives.

Problem: Poor access to treatment for neonatal sepsis

.

Option: Auxiliary nurse midwives delivering antibiotics for neonatal sepsis 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

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

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

LHW | 9.1

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

AUX | 9.1

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

ANM | 9.1

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

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

This task was accepted as within the competency of this health worker category. No assessment of the evidence was therefore conducted.

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