Table 4 Studies related to HRH interventions: training and task shifting

Dusitsin [30] Thailand RCT

Tubal ligation in healthy women

–

–

Midlevel health workers

–

Operating theaters

–

No difference was found between the groups in postoperative complications (RR 2.43; 95% CI, 0.64–9.22).

–

Selection = UR

Performance and detection = UR

Attrition = UR

Reporting = LR

Eren [31] Philippines and Turkey controlled trial

Intrauterine device insertion by auxiliary nurse midwives

–

–

Auxiliary nurse midwives

–

Teaching hospitals

–

No difference was seen in those who were referred to a specialist after insertion of an intrauterine device (RR 0.93; 95% CI, 0.45–1.90).

Selection = UR

Performance and detection = UR

Attrition = UR

Reporting = LR

Warriner [32] South Africa and Viet Nam RCT

Manual vacuum aspiration performed by a midlevel health worker, with a follow-up 10 to 14 days later.

–

–

Midwives and doctor’s assistants

–

Primary care

–

Manual vacuum aspiration was significantly greater with auxiliary nurse midwives.

Selection = LR

Performance = LR

Detection = UR

Attrition = LR

Reporting = LR

Warriner [33] Nepal RCT

Administration of early medical abortion

–

–

Certified nurses and auxiliary nurses

–

Primary care

Midlevel health workers had full responsibility for the management of each case.

There was no significant difference in the likelihood of an incomplete abortion between groups of patients managed by auxiliary nurse midwives and those managed by doctors (RR: 0.93; 95% CI, 0.45–1.90). Nor was the likelihood of a complication during (RR: 3.07; 95% CI, 0.16–59.1)—or an adverse event after (RR: 1.36; 95% CI, 0.54–3.40)

-

Selection = LR

Performance = LR

Detection = UR

Attrition = LR

Reporting = LR

Mekbib [34] Ethiopia prospective (before/after)

This training focused on life-saving procedures in obstetric emergencies (C-sections, hysterectomies including management of incomplete abortion, post abortion scare, and ectopic pregnancy).

3 rounds of training were conducted. Each for 3 months period

Interventions began in 1999, and the results were analyzed in 2001.

GPs, midwives, and other service providers in EmOC

Department of obs/gyne and master trainers

Gandhi Memorial hospital in Addis Ababa and Ambo hospital

Management and coordination

The total number of deliveries at hospital increased by 39.7% from the baseline when compared with the year 2001. Instrumental deliveries increased from 6% in 1998 to 23% in 2001. The CFR for 1999 was 7.2% based on 18 deaths and for 2001 was 4.6% based on 20 deaths.

Almost $100 000 was used

1Y, 2Y, 3Y, 4Y, 5Y, 6Y, 7Y, 8Y, 9N, 10N, 11U, 12Y

Equipment, supplies, and drugs

Record keeping

Blood supply

Djan [35] Ghana prospective (before/after)

Midwife was trained in vacuum extraction, manual removal or retained placenta, and suturing of episiotomies and lacerations.

-MOs were trained to manage obstetric emergencies.

2 weeks training

Intervention implemented 1993 and 1994 and evaluated in 1995

Midwives and medical officers

Koforidua, Ghana, and tertiary hospital KATH

OT, blood bank

The number of women with complications coming increased from 26 in 1993 to 73 in 1995, and the proportion of these who were referred for treatment dropped 42–14%. Surgical obstetric procedures performed increased from 23 to 90. Midwives performed 32% manual removal, 58% vacuum extractions, and 98% episiotomy repairs. No death occurred.

US$ 30 000 but mostly for equipment and supplies

1Y, 2Y, 3Y, 4Y, 5Y, 6N, 7Y, 8Y, 9N, 10N, 11Y, 12Y

Maternity refurbished

Revolving drug fund. Running water supply

Improving access and reducing delay to care

Ifenne [36] Nigeria prospective (before/after)

In-house training of midwives and residents in principles and practices of EmOC

Intervention started in 1993, and results were analyzed on 1994 and 1995.

Midwives and residents

Ahmadu Bello University Teaching Hospital

-OT restored

-Maternity ward renovated

-Improved access and

-reduced delay to care

-Blood bank and drug pack system

Admission to treatment interval was reduced from 3.7 h to 1.6 h. Proportion of women treated in less than 30 min increased from 39% to 87%. CFR fell from 14% to 11%. The annual number of women with complication declined from 326 to 65.

US$ 135 000

1Y, 2Y, 3Y, 4Y, 5Y, 6U, 7Y, 8Y, 9N, 10N, 11U, 12Y

Kruk [37] Mozambique prospective (before/after)

2-year classroom-based instruction and 1-year internship

2–3 years

Training began in 1983/1984 and was evaluated in 2007

Nurses and medical assistants

Surgeons in Mozambique

Provincial hospitals

In 2002, 47 specialists and 53 AMOs performed 5 264 and 6 914 major obstetric surgeries, respectively.

The 30-year cost for obstetric surgery was $38.9 for AMOs and $144.1 for physicians. After doubling the salaries of AMOs lead to major difference in cost

1Y, 2Y, 3Y, 4Y, 5Y, 6U, 7Y, 8Y, 9Y, 10N, 11Y, 12Y

GHWA [38] Bangladesh prospective (before/after)

Training of MOs in obstetrics and anesthesia, nurses in midwifery, and laboratory technicians in safe blood transfusion. In 2003, a new 17-week competency-based training program, along with 1-year training on obs and gyne was introduced for MOs and nurses.

Training of MOs for 1 year. Training of nurses for 4 months. Laboratory technicians for 2 weeks.

Baseline figures were taken in 1999, and then, interventions were implemented and first evaluation took place ion 2003.

Medical officers, nurses and lab technicians

Maternal and Neonatal Health Care project personnel

Bangladesh Medical College Hospitals

Employment and retention

Natural deliveries increased by 63%, admissions of complicated cases increased by 135%, and cesarean deliveries increased by 70%.

Per trainee costs were approximately $1 550 for 1 year for MO, $1 020 for the 17-week competency-based team training, $340 for nurses, and $140 for laboratory technicians.

1Y, 2Y, 3Y, 4Y, 5Y, 6N, 7Y, 8Y, 9N, 10U, 11Y, 12Y

Management

Monitoring and evaluation

McCord [39] Tanzania prospective (before/after)

Trained AMOs to do cesarean sections and other emergency surgeries since 1963.

Tanzania started to train in 1963. Evaluation was done in 2006.

Assistant medical officers

Ministry of health

Among 1 134 complicated deliveries and 1 072 major obstetric operations, there was no significant difference between AMOs and MOs in outcomes, risk indicators, or quality.

1Y, 2U, 3U, 4Y, 5Y, 6Y, 7U, 8Y, 9N, 10Y, 11U, 12Y

Ohnishi [40] Paraguay prospective (before/after)

Comprehensive community-based ANC program

9 days. regarding maternal health care services, including comprehensive ANC programs, also involved hands-on practice

The pretest in 1997. Follow-up test in 1998. A post evaluation of follow-up test in June, 1999

Health care personnel (nurses, auxiliary midwives, and auxiliary nurses)

Physicians and nurses

Caazapa Regional Hospital

The average scores of the participants’ knowledge increased significantly from 41.0 before to 60.1 after training (P < 0.001). The enrollment rates of pregnant women in ANC increased from 2.2 times per pregnancy in 1996 to 3.4 times in 1998 (P < 0.001).

1Y, 2Y, 3Y, 4Y, 5Y, 6Y, 7Y, 8Y, 9N, 10Y, 11U, 12Y

Rana [41] Nepal prospective (before/after)

Comprehensive EmOC specifically for C-section and other surgical procedures was provided to junior doctors. BEmOC and post abortion care to nurses, as well as anesthetic services to nurses, health assistants, and senior auxiliary health workers

Varied from 5 days to 6 months depending on the type of training

Started in 2000 and the first assessment was done in 2001 and the program lasted for 4 years till 2004.

Doctors, nurses, AWH, ANM, medical officers, lab technicians, peons

Senior doctors used clinical training and curriculum for EmOC developed by JHPIEGO and AMDD

Hospitals

Infrastructure improvements

In 5 years, 3 comprehensive and 4 basic EmOC facilities were established in an area where adequate EmOC services were previously lacking. From 2000 to 2004, met need for EmOC improved from 1.9% to 16.9%; the proportion of births in EmOC project facilities increased from 3.8% to 8.3%; and the case fatality rate declined from 2.7% to 0.3%.

Technical training US$ 205 660

1Y, 2Y, 3Y, 4Y, 5Y, 6U, 7Y, 8Y, 9N, 10N, 11Y, 12Y

Data collection

Management training US$ 97 170

Equipment

Policy advocacy and community information activities

Population council [42] Ghana quasi-experimental

Self-paced learning (SPL) course and the 3-week residential course. Both courses covered theoretical and clinical training in life-saving skills, obstetric and infant care, family planning counseling, and post abortion care.

40 providers (midwives and physicians) in the experimental group received 6 months of SPL and a 1-week residential training course. In the comparison group, 35 providers attended the 3-week residential course.

Implantation started in 2001 and continued till 2004. Analysis was done during this period.

Midwives and physicians

2 administrative regions in northern Ghana

Knowledge improved in (SLP) group following the intervention, while clinical performance improved in both groups, with the residential group performing slightly better. Mean scores for management of obs complications, PAC, and pregnancy-related complications improved significantly in the SPL group.

The self-paced learning approach cost more per learner than the residential course (US$ 2 154 versus US$ 1 330).

Selection = UR

Performance and detection = UR

Attrition = UR

Reporting = LR

Vaz [43] Mozambique quasi-experimental

Assistant medical officers with previous experience of surgical work were trained for 3 years.

3 years

The AMOs were trained in 1992, and the evaluation took place in 1996.

Assistant medical officers

Ministry of health

No difference in indication for cesarean deliveries. The only significant difference was in the group of superficial wound separation which was slightly more (0.35% vs 0.05%) in AMO vs specialist group.

Selection = UR

Performance and detection = UR

Attrition = UR

Reporting = LR

Chilopora [44] Malawi prospective cohort study

COs were trained locally for 3 years.

3 years

The Government of Malawi has been training clinical officers since 1974.

Clinical officers

Government of Malawi

After a 1-year internship, they were licensed to practice independently.

No significant difference in postoperative maternal health outcomes, after emergency obstetric procedures performed by CO or by medical officers (RR 0.99; 95% CI, 0.95–1.03). No significant difference in stillbirth with procedures performed by CO (RR 0.75; 95% CI, 0.52–1.09) or in early neonatal death (RR: 1.40; 95% CI, 0.51–3.87). Although 22 maternal deaths occurred in 1 875 procedures performed by CO compared with 1 in 256 procedures performed by medical officers.

1Y, 2Y, 3Y, 4Y, 5U, 6U, 7Y, 8Y, 9Y, 10N, 11U, 12Y