Task Shifting to Save the Lives of Mothers and Children

Every day 800 mothers and 8,000 newborns die in pregnancy and childbirth, according to a World Health Organization (WHO) video. Most of these deaths could be prevented, states WHO, which blames a shortage of health workers in high burden countries as a key factor for the deaths.
This shortage means, “We are often unable to deliver … critical interventions to mothers and newborns,” says WHO’s Metin Gulemezoglu, Lead Specialist, Department of Reproductive Health and Research.
So what’s the answer? One possible solution is to shift tasks from one group of health workers to another who have less training but who can be trained to provide the lifesaving interventions.  Because these workers often live closer to the communities they serve, and may be more numerous, they may be able to save many lives.

This is the premise behind WHO’s recently released evidence-based guidelines: Optimizing health worker roles to improve access to key maternal and newborn health interventions through task shifting (pdf). The guidelines aim to facilitate universal access to key, effective interventions for maternal and newborn health. They cover lay health workers, auxiliary nurses, auxiliary health midwives, nurses, midwives, associate clinicians, and non-specialist doctors. These health workers have been and can be trained to provide such services as: contraceptive delivery, antenatal care, intrapartum birth (giving birth), postpartum care, and neonatal care. A useful interactive table summarizing the recommendations is available at the WHO website http://www.optimizemnh.org/, where you can also download the main Guidance Document and its annexes, as well as a comprehensive video explaining how the guidelines were formulated and the advantages and challenges for implementing task shifting.
Some major reasons why task shifting may or has worked include:

• Rural women have no money to pay for transport to far-away clinics.
• Lay or community health workers could take on tasks normally done by nurses, including health promotion or the prevention or treatment of some childhood illnesses.
• Nurses and other mid-level providers could engage in tasks normally carried out by doctors.
• People often prefer the opportunity of receiving health care closer to where they live and from health workers they know. (When one woman in Nepal went to the hospital with labor pain, she recounts: “The hospital staff scolded me! They used bad words. Their behavior was not good.”)
• Health workers are often pleased to be given the chance to expand their roles, particularly if they are given training and support.
• Many health workers who have delivered these tasks in the past appreciate the help they now receive from others.
• There will be shorter lines at the clinics.

WHO makes clear that that their recommendations are options rather than prescriptions or rules. Policy makers and program managers need to consider these recommendations in relation to information from their local setting regarding priority problems, the availability of different types of health workers, costs, etc., before making a decision on whether to implement.
The video also points out that there are a number of challenges:           

• Anything new meets resistance and often professionals don’t want to give responsibilities to someone who has less training.
• Practical problems such as poor access to training, supervision, or supplies, may make task shifting more difficult. There must be mechanisms in place to train, support, and monitor health workers who take on new tasks in case of any problems and for referrals. And this help should be continuous.
• Health workers who take on new tasks are sometimes dissatisfied with their new working conditions.
• Recipients may prefer more highly trained workers or may worry about confidentiality.
• Task shifting could be perceived as a cheap solution and that can create some rejection from consumers.

The Guidelines are all evidence-based recommendations and provide the optimum solution for the delivery of these interventions, according to WHO. An international panel of stakeholders systematically reviewed the evidence, with representation from the south. The work was carried out by a team from the WHO and the Norwegian Knowledge Centre for the Health Services , with participation from an international panel and support from a number of organizations, including HIFA2015.
WHO hopes the Guidance may encourage governments and organizations to formalize task shifting initiatives that might otherwise be done in an informal way, giving health workers “better protection and support.”
Senendra Raj Upreti Director, Family Heath Division, Ministry of Health and Population, Nepal says there was some resistance from doctors about transferring tasks to nurses and compromising the quality of the service. Doctors told him, “We have trained for such a long time and we are not able to do it efficiently, how will they (nurses) do?” He adds that in Nepal, they started training nurses in ultrasonic examinations, despite the doctors’ cynicism, “We found that they diagnosed correctly on more than 95% of instances.”
As with many health interventions, if the task shifting idea is to be successful, a major information communication effort needs to be launched to persuade skeptical doctors, nurses, health care providers, and the public that these efforts will benefit everyone. Once that is in place perhaps many more lives of mothers and newborns will be saved.