Task shifting levonorgestrel implant insertion to community midwife assistants in Malawi: results from a non-inferiority evaluation

Abstract Background In 2013, Malawi began task shifting long acting reversible contraception (LARC) insertion from Nurse Midwife Technicians (NMTs), who undergo 3 years of training, to Community Midwife Assistants (CMAs), who undergo 18 months of training. However, there is no evidence on whether CMAs have the same competency as NMTs for LARC insertion. Therefore, we describe a non-inferiority evaluation to determine whether CMAs are non-inferior to NMTs for the insertion of levonorgestrel (LNG) contraceptive implants in Malawi. Methods One CMA and one matched NMT from 31 health centers across Malawi were selected for training in Malawi’s 1-week LARC insertion course in October 2016, and 31 CMAs and 30 NMTs completed the training. After the course, two Family Planning Master Trainers visited the nurses’ health centers over a 5-month period and used the Malawi LNG implant insertion checklist to evaluate the first five LNG implant insertions that each nurse performed during the monitoring visit. A non- inferiority margin of 10% was used to compare mean implant scores between CMAs and NMTs. Results We were able to fully evaluate 29 CMAs and 29 NMTs with the LNG implant insertion checklist. The CMAs and NMTs had mean scores of 90.2% and 89.7%, respectively, which were non-inferior (mean difference − 0.5%; 95% CI -3.4%, 2.4%), even when adjusted for the number of years post-graduation and the number of LNG implants inserted pre-training, during training, and since training (mean difference 1.3%; 95% CI -2.2%, 4.8%). Conclusions CMAs were non-inferior to NMTs with LNG implant insertion, and both cadres were generally observed to be competent with their insertions after completing their follow-up evaluations. During the evaluations, we generally saw an increase in scores with each insertion. Therefore, for both cadres, it is important to establish continued mentorship and evaluation for LARC insertion after the initial training