Reviewer ’s report  
 
Title: Successful Programmatic Approaches to Facilitating IUD Uptake: CARE's E xperience in 
DRC  
 
Version: 0 Date: 19 Mar 2019  
 
Reviewer: Dennis Matanda  
 
Reviewer's report:  
 
An interesting paper  that highlights the possibility of increasing uptake of IUD as a FP method in 
a context where its use has been limited. That said, the paper requires major revisions:  
 
#1. Line 42 -43, the authors mention that "A combination of purposive and random sampling  was 
used at two levels." This is confusing given that this study is purely qualitative. I'm aware that 
the implementation sites were randomly selected but the interest here is how the respondents 
were selected for IDIs and FGDs. I propose that they simply  state that the interviewees were 
purposively selected.  
 
#2. Line 61 -62, the authors state that "The study indicates that positive views about the IUD and 
family planning service quality can facilitate uptake of IUD use within a context of strengthened 
health services." Positive views about the IUD is an outcome rather than an activity that led to 
the observed increase in uptake. The authors should mention the key demand - and supply -side 
activities that were implemented which they think improved uptake of I UD. 
 
#3. Line 62 -64, "The technical elements required to sustain such a method mix are evidence -
based and likely to be replicable." This statement is too terse to make any sense. What do you 
mean by technical elements? Evidence -based of what? Likely to be r eplicable, how and where? 
In most cases, people read the abstract to find out whether the paper is worth reading in detail. 
The conclusion therefore should be self -explanatory and not leave questions to the reader.  
 
#4. Line 67 -68, "Advancing sexual and re productive health and rights requires breaking down 
remaining barriers to contraceptive uptake." See whether the term "breaking down" can be 
replaced with "overcoming".  
 
#5. Line 69, Avoid starting a sentence with an acronym. You could simply say: The use o f IUD 
across…rather than, IUD across…  
 
#6. Throughout the manuscript, always use past tense when reporting.  
 
#7. Line 76, "Among the projects new family planning users, about 30% chose an IUD." The 
30% IUD uptake needs to be contextualized i.e. what was the uptake in the study sites before the 
intervention? This will assist in interpreting the 30% uptake at the end of the intervention.  
 
#8. Line 67 -68, "Participants of this study expressed mainly positive views about the IUD and 
the quality of family planning services." I think the authors need to bring out the voices of those 
who did not use IUD. As the results show, 30% used IUD, what about the 70% who did not use? 
We need to hear their thoughts.  
 
#9. Throughout the manuscript, the authors keep using the term "described below" and yet the 
text that follows doesn't capture what they are referring to. For example, see text in line 130 -136 
and yet the text that follows talks about something else. This needs to be revised. Also, by saying 
"described below" and yet the text that follows is in the next page doesn't make sense.  
 
#10. Line 160 -161, "While there is disagreement over whether IUD use is more strongly affected 
by the attitudes of providers or clients [11]," I don't think these are disagreements but rather 
studies that showed contrasting findings.  
 
#11. Line 200 -205, the sentence is too long and winding. Please revise.  
 
#12. Throughout the manuscript, the authors mention that issues on sustainability of the project 
is beyond the scope of the paper. While this ma y be true, it is important that the authors highlight 
the issue of sustainability in their discussion. In the introduction, they explain some of the 
strategies that were used by the project to enhance sustainability; this needs to be put into 
perspective. They also talk of replicability of the project in other settings and provide a theory of 
change —how will this be replicated if there is no discussion on sustainability of the project? The 
project implemented an intervention that addressed both demand and s upply factors in order to 
increase IUD uptake. This scenario where most of the demand and supply issues are addressed is 
uncommon in the real world especially in many countries in the global south, DRC inclusive. 
Surely, the authors need to reflect on this  in their discussion which is currently very thin.  
 
#13. Line 267 -279, the authors keep referring to "unpublished project document". Consider 
simply describing the intervention rather than referring to a document that is publicly not 
accessible.  
 
#14. Genera l comment on the introduction: This section is quite long with many sub -headings. 
The authors should consider merging some of the sections e.g. the sub -section titled 'country 
context' and 'IUD use in DRC' can be merged and shortened; the sub -section 'IUD use in Africa' 
and 'Key technical aspects of service provision and…in Africa' can be equally merged.  
 
#15. The authors needs to mention whether data collectors were trained, for how long and on 
what. They also need to state their selection criteria for IDI  and FGD participants.  
 
#16. Line 349 -351, "Lists of sites in each health zone were used to randomly select four sites to 
be included in the sample. Sites that were not easily accessible were replaced by sites that were 
easy to access but with similar chara cteristics." This sounds more purposive than random 
sampling. Suppose the computer randomly selects four sites, then the researchers realize that 
these sites are not accessible, they then replace these sites with the ones with similar 
characteristics —this is not random sampling. Looks like the inclusion criteria here was 'sites that 
were easy to access' rather than random selection.  
 
#17. Line 368 -369, Insert the protocol number.  
 
#18. Line 376 -379, It looks like there were layers of translations (French, Kis wahili and English) 
before the final English version of findings presented in this paper. What measures were put in 
place to ensure that the message in the original interviews was not lost during translation. What 
approach was used in translating the scrip ts? Was it direct? Backward/Forward? This needs to be 
clearly stated.  
 
#19. Line 445 -450, the used quote was meant to show "a swift return to fertility upon removal". 
The problem here is that the quote is from a provider rather than a user. A quote from a user 
would make sense.  
 
#20. Line 453 -459, Similar to #19, the quote use d is from a community health worker who is 
male. Health providers/community health workers are likely to be biased given that they were 
part of the intervention. Consider using quotes from users.  
 
#21. Line 634 -637, The quote sounds similar to another one u sed earlier from the same 
respondent - see Line 489 -490. Consider quotes from other respondents.  
 
#14. General comment on the results: Similar to the introduction section, the section is quite 
long. The authors should consider making it more concise. For e xample, the intervention 
addressed demand and supply factors in order to increase IUD uptake and therefore it would 
make sense to tailor findings based on these factors i.e. they can begin by presenting findings on 
demand factors that facilitated/limited u ptake of IUD, move to supply factors that 
facilitated/limited uptake of IUD, then briefly present their proposed theory of change.  
 
#14. General comment on the discussion: The discussion section is very weak with no use of 
references and critical reflection s. This section should be scholarly written and not merely 
repeating study findings as currently presented. The authors need to step back and ask 
themselves, what are the key findings of this study? How do these findings compare with what is 
in the literat ure? What programmatic, policy or research implications do these findings have? 
The authors also prescribe a theory of change with no reflections on its sustainability and yet 
they argue it can be replicated. Apart from a critical reflection on sustainabil ity of the 
intervention, they need to scholarly compare their theory of change with other theories of change 
out there, which I guess are quite a number in the literature. They also need to clearly state the 
study limitations.  
 
Are the methods appropriate and well described?  
If not, please specify what is required in your comments to the authors.  
 
Yes 
 
Does the work include the necessary controls?  
If not, please specify which controls are required in your comments to the authors.  
 
No 
 
Are the conclusions drawn ade quately supported by the data shown?  
If not, please explain in your comments to the authors.  
 
No 
 
Are you able to assess any statistics in the manus cript or would you recommend an 
additional statistical review?  
If an additional statistical review is recomme nded, please speci fy what aspects require further 
assessment in your comments to the editors.  
 
Not relevant to this manuscript  
 
Quality of written English  
Please indicate the quality of language in the manuscript:  
 
Needs some language corrections before being published  
 
Declaration of competing interests  
Please complete a declaration of competing interests, considering the following questions:  
 
1. Have you in the past five y ears received reimbursements, f ees, funding, or salary from an 
organisation that may in any way gain or lose financial ly from the publication of this 
manuscript, either now or in the future?  
 
2. Do you hold any stocks or shares in an organisation that may i n any way gain or lose 
financially from the publication of this manuscript, either now or in the future?  
 
3. Do you hold or are you currently applying for any patents  relating to the content of the 
manuscript?  
 
4. Have you received reimbursements, fees, fund ing, or salary from an organization that holds 
or has applied for patents relating to the content of the manuscript?  
 
5. Do you have any other financial competing interests?  
 
6. Do you have any non -financial competing interests in relation to this paper?  
 
If you can answer no to all of the above, write 'I declare that I have  no competing interests' 
below. If your reply is yes to any, please give details below.  
 
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