Table 4 Example of how the qualitative evidence informed the final recommendations in the OptimizeMNH guidance (2): provision of vasectomy by trained midwives

The guidance panel was asked to consider whether midwives could perform vasectomies.

We were unable to identify any eligible studies that assessed the benefits or harms of midwives performing vasectomies. We did have indirect evidence from one systematic review of trials [52] that there may be little or no difference between midwives and doctors with regard to complications during surgery or postoperative morbidity for tubal ligation (low quality evidence).

Based on discussion in the technical team, we concluded that the intervention would require additional training, supervision and supplies and a functioning referral system for failed vasectomies or complications and might also require changes to norms and regulations.

Information regarding acceptability and feasibility came from one synthesis of qualitative evidence [20]. The synthesis did not identify any studies that evaluated the acceptability of vasectomy when performed by midwives. For other midwife-delivered interventions, the synthesis suggested that midwives and their trainers generally felt that midwives had no problem learning new clinical techniques (moderate confidence in the evidence) and might be motivated by being “upskilled” as this could lead to increased status, promotion opportunities and increased job satisfaction (moderate confidence in the evidence). However, midwives might be unwilling to take on tasks that moved beyond obstetric care, such as tasks related to family planning, possibly because this was not viewed as part of their role and might entail an increased workload (moderate confidence in the evidence). In addition, a lack of clarity in roles and responsibilities between midwives and other healthcare providers, as well as status and power differences, might also lead to poor working relationships and “turf battles” (moderate confidence in the evidence). Finally, the synthesis suggested that additional training and supervision were often insufficient in midwife task-shifting programmes.

This information was presented to the guidance panel in a summarised form using the DECIDE framework. More detailed versions were presented in appendices using summary of findings tables and full versions of each review were also made available to the panel.

Based on this evidence, the panel decided to recommend the intervention only in the context of rigorous research. The panel further specified that implementation in the context of research should only be done where a well-functioning midwife programme already exists and a well-functioning referral system is in place or can be put in place.