Background
Methods
Study design and context
Sample selection
Task shifting intervention
Measurement
Statistical analysis
Ethics approval
Results
Sample characteristics
Nurse-midwives (n = 21) | Lay Nurse Aides (n = 27) | p-value | |
---|---|---|---|
Study Population | |||
Number of sites | 7 | 7 | - |
Total number of observations | 206 | 203 | - |
Group and individual counseling (%) | 79.1 | 73.9 | 0.15 |
Group counseling only (%) | 4.9 | 9.9 | |
Individual counseling only (%) | 16.3 | 16.0 | |
Provider characteristics | |||
Mean age (yrs) | 33.6 | 35.1 | 0.60 |
Completed secondary education (%) | 100 | 83.3 | 0.06 |
Years working in health field (yrs) | 10.1 | 10.9 | 0.73 |
Years working at health center (yrs) | 4.6 | 6.6 | 0.25 |
Patient characteristics | |||
Mean age (yrs) | 25.3 | 25.1 | 0.73 |
Mean gestational age (months) | 6.0 | 5.8 | 0.39 |
Educational status (%, >8 yrs) | 52.4 | 55.9 | 0.48 |
1st prenatal visit (%, in current pregnancy) | 24.3 | 23.2 | 0.79 |
Mean number of antenatal visits (in current pregnancy) | 2.7 | 2.7 | 0.99 |
Mean number of living children | 1.5 | 1.5 | 0.79 |
Content of communication
Mean % of messages provided | Nurse-midwives | Lay Nurse Aides | Differ-ence (β) | 95% CI | Inferencea
|
---|---|---|---|---|---|
No. of pregnant women (N = 409) | 206 | 203 | |||
Adjusted Scoresb
| |||||
Mean % of messages given (total) | 75.2 | 79.9 | 4.7 | -1.7, 11.0 | NI |
Mean % of messages given (by topicc) | |||||
Prenatal care | 74.6 | 90.3 | 15.7* | 7.0, 24.4 | S |
Birth preparedness | 82.9 | 82.9 | -0.0 | -9.0, 9.1 | NI |
Danger signs during pregnancy | 68.7 | 73.4 | 4.7 | -5.1, 14.6 | NI |
Clean delivery | 87.8 | 89.2 | 1.4 | -9.4, 12.3 | NI |
Newborn cared
| 69.0 | 61.7 | -7.3 | -23.1, 8.4 | U |
Mean % of communication techniques used | 95.2 | 97.6 | 2.4 | -0.2, 5.0 | NI |
Mean duration of antenatal consultatione
| 29.0 | 31.9 | 2.9 | -0.7, 6.4 | - |
Nurse-midwives | Lay Nurse Aides | Differ-ence (β) | 95% CI | |
---|---|---|---|---|
No. of pregnant women (N = 409) | 206 | 203 | ||
Prenatal care | ||||
Sleep under a mosquito net | 74.3 | 90.1 | 15.9* | 9.8, 22.0 |
Take anti-malarials | 71.4 | 89.2 | 17.8* | 11.5, 24.1 |
Take iron/folic supplements | 75.7 | 90.1 | 14.4 | 8.4, 20.4 |
Have at least four prenatal visits | 65.5 | 85.2 | 19.7* | 12.9, 26.5 |
Eat more and more varied | 73.3 | 86.7 | 13.4* | 7.0, 19.8 |
Birth preparedness | ||||
Identify place of delivery | 85.4 | 84.2 | -1.2 | -7.0, 4.6 |
Identify means of transport | 86.9 | 83.7 | -3.1 | -8.9, 2.6 |
Identify skilled attendant | 71.8 | 46.8 | -25.0* | -32.8, -17.3 |
Put money aside | 84.5 | 83.7 | -0.7 | -6.7, 5.2 |
Plan for emergency | 81.1 | 69.0 | -12.1* | -19.1, -5.1 |
Plan with family | 84.5 | 79.8 | -4.7 | -10.9, 1.6 |
Identify a blood donor | 68.9 | 70.0 | 1.0 | -6.5, 8.5 |
Danger signs during pregnancy | ||||
Vaginal bleeding | 71.3 | 75.4 | 4.0 | -3.2, 11.2 |
Convulsions | 53.4 | 43.4 | -10.0* | -18.1, -2.0 |
Fever | 71.4 | 73.9 | 2.5 | -4.7, 9.8 |
Water loss | 71.8 | 74.4 | 2.5 | -4.7, 9.7 |
Abdominal pains | 72.8 | 74.4 | 1.6 | -5.6, 8.7 |
Severe headaches | 67.5 | 72.9 | 5.4 | -2.0, 12.9 |
Blurred vision | 66.0 | 62.1 | -3.9 | -11.8, 3.8 |
Swelling of limbs | 58.3 | 65.0 | 6.8 | -1.1, 14.7 |
Diminished fetal movement | 57.3 | 50.2 | -7.0 | -15.1, 1.1 |
Clean Delivery | ||||
Bring plastic cloth | 67.0 | 62.6 | -4.4 | -12.2, 3.3 |
Bring five clean towels | 82.0 | 80.3 | -1.7 | -8.1, 4.6 |
Immediate newborn carea
| ||||
Skin-to-skin contact | 45.8 | 53.1 | 7.3 | -3.5, 18.0 |
Initiation of immediate breast feeding (BF) | 57.5 | 56.6 | -0.9 | -11.5, 9.8 |
Avoid prelacteal foods/exclusive BF | 54.2 | 60.2 | 6.0 | -4.6, 16.7 |
Delayed bathing | 41.7 | 45.1 | 3.5 | -7.2, 14.1 |
Clean cord care | 37.5 | 42.5 | 5.0 | -5.6, 15.5 |
Thermal protection | 47.5 | 52.2 | 4.7 | -6.1, 15.5 |
Communication technique | ||||
Presents the subject | 98.5 | 100.0 | 1.5 | 0, 2.8 |
Determines woman's current knowledge | 99.0 | 98.0 | -1.0 | -3.0, 0.1 |
Uses cards or other visual aids | 99.5 | 100.0 | 0.5 | -0.3, 1.3 |
Verifies understanding | 98.5 | 98.5 | 0 | -2.0, 1.9 |
Motivates to adapt behaviors | 96.1 | 99.0 | 2.9 | 0.4, 5.4 |
Asks woman if she has questions | 97.1 | 99.5 | 2.4 | 0.3, 4.5 |
Communication techniques and duration
Maternal knowledge
Percentage (%) of women with correct responses | Nurse-midwives | Lay Nurse Aides | Difference (β) 95% CI | Inferencea
|
---|---|---|---|---|
No. pregnant women (N = 409) | 206 | 203 | ||
Adjusted Scoresb
| ||||
≥3 messages in prenatal care | 56.0 | 79.8 | 23.8 (15.7, 32.0)* | S |
≥3 messages in birth preparedness | 39.3 | 52.0 | 12.7 (5.2, 20.1)* | S |
≥3 danger signs during pregnancy | 76.9 | 85.5 | 8.6 (3.3, 13.9)* | S |
= 2 messages in clean delivery | 54.7 | 52.6 | -2.1 (-14.1, 9.9) | U |
≥3 messages in newborn carec
| 63.1 | 73.0 | 9.9 (-0.3, 20.1) | NI |
Mean # correct responses | 11.4 | 12.6 | 1.2 (0.4, 2.0)* | - |
Provider perceptions
Task-shifting Statements: Percent (%) of providers responding 'Agree' | Nurse-midwives | Lay Nurse Aides | Total |
---|---|---|---|
No. of providers interviewed | n = 19 | n = 24 | N = 43 |
Holds role of counseling | Yes (prior to shift) | Yes (after shift) | |
Organization
| |||
The role of nurse aides can include counseling if they have the necessary support and supervision. | 94.7 | 100.0 | 97.7 |
Counseling should only be done by skilled providers. | 21.1 | 4.2 | 11.6 |
Counseling can be done by all maternity workers. | 94.7 | 100.0 | 97.7 |
Counseling can be done only by nurse aides. | 10.5 | 4.2 | 9.1 |
Task shifting is difficult and with challenges. | 36.8 | 29.2 | 32.6 |
Impact and Effectiveness
| |||
When the role of nurse aides was expanded, skilled workers had more time for clinical activities. | 100.0 | 87.5 | 93.0 |
Quality of counseling by nurse aides is less effective than that done by skilled providers. | 47.3 | 45.8 | 46.5 |
Quality of counseling by nurse aides is more effective than that done by skilled providers. | 52.6 | 25.0 | 37.2 |
Task shifting of counseling to nurse aides improves provider relationships. | 84.2 | 87.5 | 86.1 |
Shifting the role of counseling to nurse aides is more effective than the previous work organization. | 89.5 | 83.3 | 86.1 |
Comfort and Acceptability
| |||
Nurse aides are more comfortable counseling than the skilled providers. | 68.4 | 54.2 | 60.5 |
Skilled providers are more at ease if counseling is done by nurse aides. | 73.6 | 75.0 | 74.4 |
Counseling provided by nurse aides is accepted by women presenting at the maternity. | 89.5 | 100.0 | 95.4 |
Topic area: |
Advantages to task shifting:
|
Disadvantages to task shifting:
|
Suggestions to improve task shifting: |
---|---|---|---|
Skilled providers' responses
a (n = 19b) | - Skilled providers have more time for clinical tasks* - Facilitates the clinical work by enabling focus on clinical tasks that reduces fatigue - Allows skilled workers to attend to urgent cases as needed* - Improves the continuity of counseling even when the skilled provider is unavailable - Requires provider confidence - Increases/expands participation of all health workers in the provision of care* - Nurse aides speak the local language(s), so decreases language barriers | - Sometimes it's possible that the counseling could be poorly done by the unskilled worker - Difficult to implement in cases where there are severe shortages of both types of providers* - Aides prolong antenatal consultation as a result of counseling | - Increase circulation of the counseling task among the nurse aides - Post delegated task items for viewing - Expand task shifting to other health centers* - Improve site-level communication between cadres - Allow skilled workers to perform counseling also |
Lay nurse aides' responses
a (n = 24c) | - Provides more clarity on what are the tasks/role of nurse aides* - Have ability to conduct the counseling even in the absence of a skilled provider* - Women like counseling by aides - Improves the consultation - Allows aides to participate more in counseling activities - Aides received new knowledge* - Aides are more familiar/have more in common with the women from the community - Aides appreciated being promoted to new service* - Improved work relationship between providers | - Shortage of personnel makes it difficult to implement at times* | - Explore possibility of task shifting to nurse aides in other domains - Increase the number of nurse aides* - Improve supervision - Expand role of nurse aides at all sites* |
Operationalizing task shifting guidelines
Recommendation summary
a
,b
|
Study operationalization
|
---|---|
Endeavor to identify and involve appropriate stakeholders concerning aspects of task shifting approach (#2) | Study examined perceptions of both types of providers, including use of experience from a pilot test regarding acceptability among women. |
Examine extent to which task shifting is already taking place (#4) | Study found that informal task shifting occurred primarily in absence of skilled provider and that lay nurse aides regretted lack of training. Only a small proportion of counseling was provided by lay nurse aides prior to the shift. |
Adapt or create quality assurance mechanisms to support a task shifting approach that include processes and activities to monitor and improve quality of services. (#7) | The task shifting approach was adopted within a quality improvement collaborative that identifies improvement objectives and integrates site-level monitoring, coaching, and assessment of key indicators related to maternal and newborn care. Findings on effectiveness of tested changes are shared within learning sessions. |
Define role and quality standards that serve as the basis for establishing recruitment, training and evaluation criteria. (#8) | Lay nurse aides were trained and evaluated based on recommended communication goals during antenatal care for pregnant women. Lay nurse aides were recruited as candidates for the task shift given their existing integration within health system and local community. |
Provide supportive supervision and clinical mentoring within function of health teams that make certain that supervision staff have appropriate supervisory skills. (#11) | Task shifting approach included capacity building of nurse-midwives in supervision with emphasis on observation and feedback. Mentoring and supervision teams included technical personnel and regional trainers. |
Recognize that sustainable expansion of essential health services cannot not rely on volunteer cadre. Rather, trained workers should receive adequate wages or commensurate incentives. (#14) | Lay nurse aides are paid government health staff whose wages are lower than those of nurses-midwives. Lay nurse aides reported several non-monetary incentives resulting from task shift, but efforts are needed to explore appropriate remuneration for expanded role. |