Introduction
Methods
Criteria for selecting studies
Types of studies
Types of interventions
Comparisons
Types of participants and settings
Types of outcomes
Outcome category
|
Contraceptive method
| |||
---|---|---|---|---|
Injectable contraceptive | Contraceptive implants | IUDs | Tubal ligation/vasectomy | |
Safety and effectiveness of contraceptive delivery
| Complication rates during provision of the injection | Complication rates during insertion/removal (e.g. damage of vessels, tissues) | Complication rates during insertion/removal (e.g. perforation, pain during insertion of IUD) | Complication rates during procedure |
Insertion/removal failure rates | Insertion/removal failure rates | Tubal ligation: Duration of operation* | ||
Post-procedure complications (e.g. haematomas, infection rate) | Post-procedure complications (e.g. removal rate, infection rate) | Post-procedure complications (e.g. expulsion rates, infection rates, removal rates) | Post-operative complications (e.g. infection rate) | |
Referral rates: during IUD insertion, or after IUD insertion* | For vasectomy: oligospermia rates* | |||
Unintended pregnancy rates | ||||
Coverage
| Uptake of contraceptives by intended recipients | |||
Contraceptive continuation rates | Not applicable |
Excluded studies
Search methods
Data collection and analysis
Results
Results of the search
Author Year | Study site | Study design | Intervention |
---|---|---|---|
Bunyaratavej et al. [25] | Hospital, Bangkok, Thailand | RCT | Vasectomy performed by medical students compared to doctors |
Dusitsin et al. [23] | Hospital, Khon Kaen Province, Thailand | RCT | Tubal ligation performed by midwives compared to doctors |
Einhorn et al. [24] | Hospital,Bogotà, Colombia | RCT | Insertion of IUDs by nurses compared to doctors |
Eren et al. [21] (Study A) | Primary health care setting, Cubuk District, north of Ankara, Turkey | RCT | Insertion of IUDS by auxiliary nurse-midwives compared to doctors |
Eren et al. [21] (Study B) | Hospital, Manila, Philippines | RCT | Insertion of IUDS by auxiliary nurse-midwives compared to doctors |
Lassner et al. [22] | Hospital, Rio de Janeiro, Brazil | RCT | Insertion of IUDs by nurses compared to doctors |
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Insertion of IUDs by nurses compared to doctors
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Insertion of IUDS by auxiliary nurse-midwives compared to doctors
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Tubal ligation performed by midwives compared to doctors
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Vasectomy performed by medical students compared to doctors
IUD insertion by nurses compared to doctors (2 RCTs)
What is the effectiveness of IUD insertion by nurses compared to IUD insertion by doctors?
| ||||||
---|---|---|---|---|---|---|
Patient or population: patients with IUDs | ||||||
Intervention: Nurses inserting IUDs | ||||||
Comparison: Doctors inserting IUDs | ||||||
Outcomes
|
Illustrative comparative risks* (95% CI)
|
Relative effect
|
No of Participants
|
Certainty of the evidence
|
Comments
| |
Assumed risk | Corresponding risk | |||||
Doctors inserting IUDs
|
Nurses inserting IUDs
|
(95% CI)
|
(studies)
|
(GRADE)
| ||
Continuation rates1 | 790 per 1000 | 782 per 1000 | RR 0.99 | 1786 | ⊕⊕⊝⊝ | |
(743 to 814) | (0.94 to 1.03) | (2 studies) | low2,3 | |||
Removal rates4 | 78 per 1000 | 71 per 1000 | RR 0.91 | 1632 | ⊕⊝⊝⊝ | |
(50 to 100) | (0.64 to 1.27) | (2 studies) | very low3, 5 | |||
Complication rates during insertion | 17 per 1000 | 18 per 1000 | RR 1.01 | 1711 | ⊕⊝⊝⊝ | |
(9 to 36) | (0.5 to 2.05) | (2 studies) | very low3,6 | |||
Unintended pregnancy rates7 | 12 per 1000 | 8 per 1000 | RR 0.66 | 1786 | ⊕⊝⊝⊝ | |
(3 to 20) | (0.25 to 1.7) | (2 studies) | very low2,3,6 | |||
Insertion failure rate, nulliparous women | 34 per 1000 | 117 per 1000 | RR 3.41 | 263 | ⊕⊕⊝⊝ | |
(40 to 337) | (1.18 to 9.85) | (1 study) | low2,6 | |||
Insertion failure rate, multiparous women | 9 per 1000 | 16 per 1000 | RR 1.66 | 1448 | ⊕⊕⊝⊝ | |
(6 to 40) | (0.65 to 4.25) | (1 study) | low2,6 | |||
Expulsion rates | 54 per 1000 | 50 per 1000 | RR 0.93 | 1195 | ⊕⊕⊝⊝ | |
(31 to 82) | (0.57 to 1.52) | (1 study) | low2,6 | |||
Pain during insertion | 108 per 1000 | 70 per 1000 | RR 0.65 | 1711 | ⊕⊕⊝⊝ | |
(52 to 96) | (0.48 to 0.89) | (1 study) | low2 | |||
Uptake of contraceptives - not measured | See comment | See comment | Not estimable | - | See comment | |
Referral rates - not measured | See comment | See comment | Not estimable | - | See comment |
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Both studies assessed contraceptive continuation rates. The studies suggest that there may be little or no difference in continuation rates when IUDs are inserted by nurses compared to doctors (RR 0.99, 95% CI 0.94 to 1.03, p = 0.4311, low certainty evidence).
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Both studies examined removal rates, complication rates during insertion, and unintended pregnancy rates. It is uncertain whether there are any differences between the performance of doctors compared to nurses for these outcomes because the evidence was of very low certainty.
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One study [22] examined insertion failure rates. The study reported different results according to the parity of the woman. For nulliparous women, insertion failure rates for IUDs may be higher if inserted by nurses compared to doctors (RR 3.41, 95% CI 1.18 to 9.85, p = 0.0237, low certainty evidence), whereas for multiparous women, there may be little or no difference in insertion failure rates if the treatment is provided by nurses compared to doctors (RR 1.66, 95% CI 0.65 to 4.25, p = 0.2939, low certainty evidence).
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One study [22] examined expulsion rates. This study suggests that there may be little or no difference for this outcome when IUDs are inserted by nurses compared to doctors (RR 0.93, 95% CI 0.57 to 1.52, p = 0.7786, low certainty evidence).
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One study [22] examined pain during insertion of the IUD and suggested that there may be lower rates of reported pain in the group receiving care from nurses compared to the group receiving care from doctors (RR = 0.65 95% CI 0.48 to 0.89, p = 0.0069; low certainty evidence).
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Neither of the studies measured the uptake of contraceptives or referral rates.
IUD insertion by auxiliary nurse-midwives compared to doctors (2 RCTs)
What is the effectiveness of IUD insertion by auxiliary nurse midwives compared to IUD insertion by doctors?
| ||||||
---|---|---|---|---|---|---|
Patient or population: patients with IUDs | ||||||
Settings: Primary health care setting in nine rural villages in Cubuk district, Turkey (Eren et al. [21] Study A) and Jose Fabella | ||||||
Memorial Hospital in Manila, Philippines (Eren et al. [21] Study B) | ||||||
Intervention: Auxiliary nurse-midwives inserting IUDs | ||||||
Comparison: Doctors inserting IUDs | ||||||
Outcomes
|
Illustrative comparative risks* (95% CI)
|
Relative effect
|
No of Participants
|
Certainty of the evidence
|
Comments
| |
Assumed risk | Corresponding risk | |||||
Doctors inserting IUDs
|
Auxiliary nurse-midwives inserting IUDs
|
(95% CI)
|
(studies)
|
(GRADE)
| ||
Continuation rates1 | 699 per 1000 | 727 per 1000 | RR 1.04 | 996 | ⊕⊕⊕⊝ | |
(671 to 783) | (0.96 to 1.12) | (2 studies) | moderate2 | |||
Removal rates | 107 per 1000 | 115 per 1000 | RR 1.08 | 996 | ⊕⊕⊕⊝ | |
(82 to 162) | (0.77 to 1.52) | (2 studies) | moderate2 | |||
Expulsion rates | 96 per 1000 | 81 per 1000 | RR 0.84 | 996 | ⊕⊕⊕⊝ | |
(54 to 121) | (0.56 to 1.26) | (2 studies) | moderate2 | |||
Unintended pregnancy rates | 20 per 1000 | 19 per 1000 | RR 0.95 | 996 | ⊕⊕⊝⊝ | |
(8 to 47) | (0.4 to 2.27) | (2 studies) | low2,3 | |||
Referral rate during IUD insertion4 | 65 per 1000 | 52 per 1000 | RR 0.80 | 1058 | ⊕⊕⊝⊝ | |
(33 to 84) | (0.50 to 1.29) | (2 studies) | low2,3 | |||
Referral rate after IUD insertion5 | 43 per 1000 | 64 per 1000 | RR 1.49 | 996 | ⊕⊕⊝⊝ | |
(38 to 109) | (0.88 to 2.54) | (2 studies) | low2,3 | |||
Uptake of contraceptives6 - not measured | See comment | See comment | Not estimable6 | - | See comment | |
Complication rates at insertion6 - not measured | See comment | See comment | Not estimable6 | - | See comment | |
Insertion failure rates6 - not measured | See comment | See comment | Not estimable6 | - | See comment |
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There is probably little or no difference in continuation rates (RR 1.04, 95% CI 0.96 to 1.12, p = 0.7227, moderate certainty evidence); removal rates (RR 1.08, 95% CI 0.77 to 1.52, p = 0.564, moderate certainty evidence); or expulsion rates after IUD insertion (RR = 0.84, 95% CI 0.56 to 1.26, p = 0.38, moderate certainty evidence) when IUDs are inserted by auxiliary nurse-midwives compared to doctors.
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There may be little or no difference in unintended pregnancy rates when IUDs are inserted by auxiliary nurse-midwives compared to doctors (RR 0.95, 95% CI 0.40 to 2.27, p = 0.927, low certainty evidence).
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There may be no or little difference in referral rates, either during IUD insertion (RR 0.80, 95% CI 0.50 to 1.29, p = 0.3731, low certainty evidence) or during follow-up after IUD insertion (RR 1.49, 95% CI 0.88 to 2.54, p = 0.1298, low certainty evidence), when IUDs are inserted by auxiliary nurse-midwives compared to doctors.
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The studies did not measure the uptake of contraceptives, complication rates at insertion or insertion failure rates.
Tubal ligation by midwives compared to doctors (1 RCT)
What is the effectiveness of tubal ligation performed by midwives compared to tubal ligation performed by doctors?
| ||||||
---|---|---|---|---|---|---|
Patient or population: patients with tubal ligation | ||||||
Settings: Hospital setting, Khon Kaen, Thailand1 (Dusitsin et al. [23]) | ||||||
Intervention: Midwives performing tubal ligation | ||||||
Comparison: Doctors performing tubal ligation | ||||||
Outcomes
|
Illustrative comparative risks* (95% CI)
|
Relative effect (95% CI)
|
No of Participants (studies)
|
Certainty of the evidence (GRADE)
|
Comments
| |
Assumed risk | Corresponding risk | |||||
Doctors performing tubal ligation
|
Midwives performing tubal ligation
| |||||
Complication rates during surgery2 | 5 per 1000 | 11 per 1000 | RR 2.12 | 1168 | ⊕⊕⊝⊝ | |
(3 to 34) | (0.64 to 6.88) | (1 study) | low3,4 | |||
Postoperative complications5 | 60 per 1000 | 70 per 1000 | RR 1.16 | 292 | ⊕⊕⊝⊝ | |
(29 to 161) | (0.48 to 2.66) | (1 study) | low3,4 | |||
Duration of operation | The mean length of operation in the intervention groups was 6.6 minutes higher (5.58 to 7.62 minutes higher) | 292 | ⊕⊕⊕⊝ | |||
(1 study) | moderate3 | |||||
Uptake of contraceptives6 - not measured | See comment | See comment | Not estimable6 | - | See comment | |
Unintended pregnancy rates6 - not measured | See comment | See comment | Not estimable6 | - | See comment |
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There may be little or no difference in complication rates during surgery when tubal ligation is performed by midwives compared to doctors, although the total number of events was very low (RR 2.12, 95% CI 0.64 to 6.88, p = 0.1895, low certainty evidence).
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There may be little or no difference between postoperative complications (such as mild pyrexia, respiratory infection, cystitis, and wound breakdown) assessed at five days and six weeks post procedure when tubal ligation is performed by midwives compared to doctors (RR 1.16, 95% CI 0.48 to 2.66, p = 0.7417, low certainty evidence).
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The duration of a tubal ligation operation is probably longer when performed by midwives compared to doctors. However, the time difference may not be clinically important (mean time = 18.5 minutes for midwives (SE 0.41) versus 11.9 minutes for doctors (SE 0.32), mean difference = 6.60, 95% CI 5.58 to 7.62, p < 0.0001, moderate certainty evidence).
-
The study did not assess uptake of contraceptives or unintended pregnancy rates.
Vasectomy by medical students compared to doctors (1 RCT)
What is the effectiveness of vasectomy performed by medical students compared to vasectomy performed by doctors?
| ||||||
---|---|---|---|---|---|---|
Patient or population: patients with vasectomy | ||||||
Setting: Chulalongkorn Hospital, Bangkok, Thailand (Bunyaratavej et al. [25]) | ||||||
Intervention: Medical students performing vasectomy | ||||||
Comparison: Doctors performing vasectomy | ||||||
Outcomes
|
Illustrative comparative risks* (95% CI)
|
Relative effect (95% CI)
|
No of Participants (studies)
|
Certainty of the evidence (GRADE)
|
Comments
| |
Assumed risk | Corresponding risk | |||||
Doctors performing vasectomy
|
Medical students performing vasectomy
| |||||
Complication rates during surgery1 | See comment | See comment2 | Not estimable | 463 (1 study) | ⊕⊕⊕⊝ moderate3 | |
Early post-operative complication rates (within 7 days)4 | 43 per 1000 | 33 per 1000 (13 to 85) | RR 0.78 (0.31 to 1.99) | 456 (1 study) | ⊕⊕⊝⊝ low,5 | |
Post-operative oligospermia rates (after 3 months)6 | 29 per 1000 | 76 per 1000 (25 to 225) | RR 2.59 (0.87 to 7.70) | 322 (1 study) | ⊕⊕⊝⊝ low4,7 | |
Unintended pregnancy rates8 - not measured | See comment | See comment | Not estimable8 | - | See comment |
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There is probably little or no difference in complication rates during surgery (no complications found in either group, moderate certainty evidence).
-
There may be little or no difference in early post-operative complication rates (within seven days after the procedure) (RR 0.78, 95% CI 0.31 to 1.99, p = 0.5536, low certainty evidence) or in oligospermia rates three months after surgery (RR 2.59, 95% CI 0.87 to 7.70, p = 0.0865, low certainty evidence) when a vasectomy is performed by medical students compared to doctors.
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The study did not measure unintended pregnancy rates.