***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
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    ***EXAMPLES*** 
    Input: Background  Clinical officers  perform much of major emergency surgery in Malawi , in the absence of medical officers . The aim of this study was to vali date the advantages and disadvantages of delegation of major obstetric surgery to non-doctors . Methods During a three month period , data from 2131 consecutive obstetric surgeries in 38 district hospitals in Malawi were collected prospect ively . The interventions included caesarean sections alone and those that were combined with other interventions such as subtotal and total hysterectomy repair of uterine rupture and tubal ligation . All these surgeries were conducted either by clinical officers or by medical officers . Results During the study period , clinical officers performed 90 % of all straight caesarean sections , 70 % of those combined with subtotal hysterectomy , 60 % of those combined with total hysterectomy and 89 % of those combined with repair of uterine rupture . A comparable profile of patients was operated on by clinical officers and medical officers , respectively . Postoperative outcomes were almost identical in the two groups in terms of maternal general condition – both immediately and 24 hours postoperatively – and regarding occurrence of pyrexia , wound infection , wound dehiscence , need for re-operation , neonatal outcome or maternal death . Conclusion Clinical officers perform the bulk of emergency obstetric operations at district hospitals in Malawi . The postoperative outcomes of their procedures are comparable to those of medical officers . Clinical officers constitute a crucial component of the health care team in Malawi for saving maternal and neonatal lives given the scarcity of physicians To assess whether trained nursing personnel could provide IUD services as safely and effectively as physicians in Brazil , an experimental study was conducted at the main clinic of the Center for Research on Integrated Maternal and Child Care in Rio de Janeiro . From November 1984 through April 1986 , a total of 1,711 women who requested IUD insertion at the clinic were r and omly assigned to have a Copper-T 200 IUD inserted by one of the clinic 's 11 physicians or 13 nurses . All of the physicians and nursing staff members who provided these services had taken the Center 's st and ard clinical family planning training course . Of 860 insertions attempted by the physicians and nurses , 1.3 % and 3.3 % , respectively , were unsuccessful . Statistically , this difference was very significant ( P < 0.01 ) . Also , mainly because the cervix was small and undilated , nulliparous women had a relatively high insertion failure rate of 8.0 % , as compared to 1.5 % for primiparas and 1.0 % for multiparas . The overall rate of complications at insertion was 1.8 % , these complications including diaphoresis , vomiting , syncope , cervical laceration , and one case of perforation of the uterus ; no significant difference was found between the complication rates for insertions performed by physicians as compared to nurses . However , 9.0 % of the study subjects reported severe pain during IUD insertion , with significantly higher percentages reporting pain if the IUD was inserted by a physician , or if the subject was nulliparous , had preinsertion symptoms , or had a history of pelvic inflammatory disease ( PID ) or sexually transmitted disease ( STD ) . It was also found that the nurses had a dramatically high insertion failure rate ( 11.6 % ) with nulliparous subjects , while the physicians ' failure rate with such subjects was a significantly lower 3.4 % . No significant difference was found in the groups served by nurses and physicians with regard to postinsertion complaints or termination of use within 12 months of insertion . These findings suggest that future training , besides preparing nursing personnel in IUD insertion , should emphasize preparation in taking the client 's medical history and diagnosing existing medical symptoms that could be associated with IUD insertion complications . In addition , if a nulliparous woman requests an insertion , it should be performed by a physician or more experienced nursing staff member with close medical supervision . Because of high rates of reported pain at insertion , such women , as well as those with medical symptoms associated IUD insertion complications and those with a history of PID or STD , should be considered c and i date s for extra care and counseling . ( ABSTRACT TRUNCATED AT 400 WORDS A shortage of doctors limits the provision of post-partum sterilisation services in rural areas of Thail and . To overcome this problem nurse-midwives with theatre experience were trained to perform post-partum tubal ligation by a mini-laparotomy incision under local anaesthesia . The performance of the nurse-midwives was compared with that of doctors in a controlled , r and omised clinical trial . Some operative difficulty was encountered by the nurses in 4.9 % of cases and by the doctors in 2.0 % of cases . This difference is not statistically significant and arose largely because the nurse-midwife cases were more obese . Nurse-midwives required a significantly longer operating-time ( 18.5 min ) than doctors ( 11.9 min ) . However , postoperative morbidity was similar in the two groups ( 7.0 % and 6.0 % , respectively ) . These results suggest that trained nurse-midwives with theatre experience can safely provide post-partum sterilisation services . A further field trial is underway BACKGROUND Tubal sterilization is an increasingly common method of contraception in the United States . Although pregnancy after sterilization is uncommon , it can occur and may be ectopic . We used data from the U.S. Collaborative Review of Sterilization to estimate the risk of ectopic pregnancy in women who had undergone the common types of tubal sterilization .  METHODS A total of 10,685 women undergoing tubal sterilization were followed in a multicenter , prospect i ve cohort study . We intended to follow all the women for 5 years by means of annual telephone interviews ; for women enrolled early in the study , we attempted an additional follow-up telephone interview 8 to 14 years after sterilization . To assess the risk of ectopic pregnancy in these women , we used cumulative life-table probabilities and proportional-hazards analysis . RESULTS There were 47 ectopic pregnancies in the 10,685 women ; the 10-year cumulative probability of ectopic pregnancy for all methods of tubal sterilization combined was 7.3 per 1000 procedures . The cumulative probability varied substantially according to the method of sterilization and the woman 's age at the time of sterilization . Women sterilized by bipolar tubal coagulation before the age of 30 years had a probability of ectopic pregnancy that was 27 times as high as that among women of similar age who underwent postpartum partial salpingectomy ( 31.9 vs. 1.2 ectopic pregnancies per 1000 procedures ) . The annual rate of ectopic pregnancy for all methods combined in the 4th through 10th years after sterilization was no lower than that in the first 3 years . CONCLUSIONS A history of tubal sterilization does not rule out the possibility of ectopic pregnancy , even many years after the procedure Several studies have shown that nurses , nurse midwives , and paramedical personnel can provide satisfactory IUD services , but restrictions are still placed upon their provision of these services . A r and omized trial of auxiliary nurse midwife and physician IUD services was conducted among 495 interval acceptors in Turkey and 510 postpartum acceptors in the Philippines between 1976 and 1979 to further evaluate this question . Discontinuations due to expulsion , removal , and pregnancy were comparable for physician and nurse midwife clients . Among Filipino women who experienced an early expulsion  , nurse midwives  reinserted a device in significantly more cases ( 54.5 % ) than physicians ( 31.3 % ) . The diagnosis of contraindications or complications were similar in the 2 groups . Turkish women frequently refused to have pelvic examinations by male physicians , and in the Philippines , nurse midwives provided better follow up than physicians . It is concluded that auxiliary nurse midwives can provide clinical services comparable to those provided by doctors , and may give better continuity of care because they are more accessible and acceptable to clients OBJECTIVE To compare the safety and quality of contraceptive injections  by community-based health workers with those of clinic-based nurses in a rural African setting . METHODS A nonr and omized community trial tested provision of injectable Depo Provera ( DMPA ) by community reproductive health workers and compared it with routine DPMA provision at health units in Nakasongola District , Ug and a. The primary outcome measures were safety , acceptability and continuation rates . FINDINGS A total of 945 new DMPA users were recruited by community workers , clinic-based nurses and midwives . Research ers successfully followed 777 ( 82 % follow-up ) : 449 community worker clients and 328 clinic-based clients . Ninety-five percent of community-worker clients were " satisfied " or " highly satisfied " with services , and 85 % reported receiving information on side-effects . There were no serious injection site problems in either group . Similarly , there was no significant difference between continuation to second injection ( 88 % among clients of community-based workers , 85 % among clinic-going clients ) , nor were there significant differences in other measures of safety , acceptability and quality . CONCLUSION Community-based distribution ( CBD ) of injectable contraceptives is now routine in some countries in Asia and Latin America , but is practically unknown in Africa , where arguably the need for this practice is greatest . This research reinforces experience from other regions suggesting that well-trained community health workers can safely provide contraceptive injections Insertion of IUDs by trained non-physicians is increasing . This secondary analysis of  TCu380A IUD acceptors collected at clinics in Nigeria , Turkey and Mexico involved 367 women ; 193 insertions were performed by physicians and 174 by non-physicians . Women having their IUD inserted by a non-physician were more likely to experience a pain-free insertion , but also likelier to have the IUD removed for bleeding and pain or to experience an expulsion than women who had their IUD inserted by a physician . Early discontinuation rates were similar between the two groups . Overall continuation rates were statistically higher for IUDs inserted by physicians only at the Mexico site . Trained non-physicians can probably safely insert the TCu380A IUD . Appropriate competency-based training is required to limit the number of expulsions and removals for bleeding and pain by non-physicians OBJECTIVE To assess safety associated with tubal ligation performed by trained clinical officers ( COs ) in rural Ug and a. METHODS Between March and June 2012 , 518 women in 4 regions of Ug and a were recruited into a prospect i ve cohort study and followed at days 3 , 7 , and 45 after undergoing tubal ligation performed by a trained CO . Intraoperative and postoperative adverse events ( minor , moderate , or major ) , and acceptability were assessed . RESULTS Mean age was 36 years ( range , 20 - 49 years ) and mean number of living children was 6.7 ( range , 0 - 15 ) . The overall rate of major adverse events was 1.5 % : 0.4 % intraoperatively ; 1.9 % at day 3 ; and 0.2 % at day 7 . The majority of women who underwent tubal ligation reported a good/very good experience at the facility ( range , 94%-99 % ) and would recommend the health services to a friend ( range , 93%-98 % ) . CONCLUSION In the present study , task sharing of tubal ligation to trained COs in private facilities was safe . Women reported high levels of satisfaction with the procedure . Training COs could be an effective strategy for exp and ing family-planning services to rural Ug and 
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CONCLUSIONS Well- design ed clinical trials , of adequate sample size , are urgently needed to establish the safety , efficacy and acceptability of task sharing tubal sterilization to midlevel providers