Gates Open Research Open Peer Review RESEARCH ARTICLE Evaluation of a multi-level intervention to improve postpartum intrauterine device services in Rwanda [version 3; referees: 3 approved] Previously titled: Evaluation of a multi-level intervention to improve post partum intrauterine device services in Rwanda Rosine Ingabire , Julien Nyombayire , Alexandra Hoagland , Vanessa Da Costa , Amelia Mazzei , Lisa Haddad , Rachel Parker , Robertine Sinabamenye , Jeannine Mukamuyango , Julie Smith , Victoria Umutoni , Ellen Mork , Susan Allen , Etienne Karita , Kristin M. Wall 2,5 Projet San Francisco, Pathology & Laboratory Medicine, Emory University, Kigali, Rwanda Pathology & Laboratory Medicine, Emory University, Atlanta, GA, 30322, USA Gynecology and Obstetrics, Emory University, Atlanta, GA, 30322, USA Health Policy and Management, University of Michigan, Ann Arbor, MI, 48109, USA Epidemiology, Emory University, Atlanta, GA, 30322, USA Abstract The copper intrauterine device is one of the most safe, effective, Background. and cost-effective methods for preventing unintended pregnancy. It can be used postpartum irrespective of breastfeeding to improve birth spacing and reduce unintended pregnancy and maternal-child mortality. However, this method remains highly underutilized. We developed a multi-level intervention to increase uptake of the Methods. postpartum intrauterine device (PPIUD, defined as insertion up to six weeks post-delivery) in Kigali, Rwanda. High-volume hospitals and health centers were selected for implementation of PPIUD counseling and service delivery. Formative work informed development of a PPIUD counseling flipchart to be delivered during antenatal care, labor and delivery, infant vaccination visits, or in the community. Two-day didactic counseling, insertion/removal, and follow-up trainings were provided to labor and delivery and family planning nurses followed by a mentored practicum certification process. Counseling data were collected in government clinic logbooks. Insertions and follow-up data were collected in logbooks created for the implementation. Data were collected by trained government clinic staff and abstracted/managed by study staff. Stakeholders were involved from intervention development through dissemination of results. Two hospitals (and their two associated health centers) and two Results. additional health centers were selected. In 6-months prior to our intervention, 1 1 1 2 1 3 2 1 1 2 2 4 2 1 2,5 1 2 3 4 5 Referee Status: Invited Referees version 3 published 04 Feb 2019 version 2 published 10 Oct 2018 version 1 published 20 Aug 2018 1 2 3 report report report report report report , London School of Hygiene John Cleland & Tropical Medicine, UK 1 , FHI 360, USA Aurélie Brunie , FHI 360, USA Trinity Zan 2 20 Aug 2018, :38 ( First published: 2 ) https://doi.org/10.12688/gatesopenres.12854.1 10 Oct 2018, :38 ( Second version: 2 ) https://doi.org/10.12688/gatesopenres.12854.2 04 Feb 2019, :38 ( Latest published: 2 ) https://doi.org/10.12688/gatesopenres.12854.3 v3 Page 1 of 27 Gates Open Research 2019, 2:38 Last updated: 05 FEB 2019