title: The promotion of intrauterine contraception in low- and middle-income countries: a narrative review.
abstract: BACKGROUND
  The contribution of copper-bearing intrauterine devices (IUDs) to overall contraceptive protection has declined in many countries, despite their well-known advantages. In response, initiatives to promote this method have been undertaken.
  
  
  OBJECTIVE
  To review and interpret the experience of interventions to promote use of IUDs in low- and middle-income countries in order to provide strategic guidance for policies and programs.
  
  
  METHODS
  We conducted a systematic search of Medline, Popline, Embase and Global Health electronic databases for relevant journal papers, reports and gray literature since 2010. Telephone interviews were held with two donors and six international family planning organizations.
  
  
  RESULTS
  We identified a total of 31 publications. Four reported the results of randomized control trials and three were derived from quasi-experiments. The majority were based on service statistics. Eight publications concerned interventions for HIV-positive women or couples, nine for postpartum or postabortion cases and 14 for general populations. Intervention approaches included vouchers, franchising of private practitioners, mobile outreach services, placement of dedicated staff in high-volume facilities and demand creation. Most publications adduced evidence of a positive impact and some reported impressively large numbers of IUD insertions. Results to date on the uptake of IUDs in postpartum interventions are modest. There is also almost no evidence of effects on IUD use at national levels. Implant uptake generally exceeded IUD uptake when both were offered.
  
  
  CONCLUSIONS
  The evidence base is weak and offers few lessons on what strategies are most effective. The overall impression is that IUD use can be increased in a variety of ways but that progress is hampered by persistent adverse perceptions by both providers and potential clients. Provider enthusiasm is a key to success. The lack of a population impact stems in part from the fact that nearly all interventions are initiated by international organizations, with limited national reach except in small countries, rather than by government agencies.
authors.affiliation: Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, Keppel Street, London WC1E 7HT, UK. Electronic address: John.cleland@lshtm.ac.uk.
authors.forename: John
authors.initials: J
authors.lastname: Cleland
authors.affiliation: Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland.
authors.forename: Moazzam
authors.initials: M
authors.lastname: Ali
authors.affiliation: Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, Keppel Street, London WC1E 7HT, UK.
authors.forename: Lenka
authors.initials: L
authors.lastname: Benova
authors.affiliation: Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, Keppel Street, London WC1E 7HT, UK.
authors.forename: Marina
authors.initials: M
authors.lastname: Daniele
mesh_terms: D000349:Africa; D001208:Asia; D003267:Contraception / Q000379:methods* / Q000706:statistics & numerical data*; D003270:Contraceptive Agents; D003906:Developing Countries; D005193:Family Planning Services / Q000193:education / Q000379:methods / Q000706:statistics & numerical data; D005260:Female; D006679:HIV Seropositivity; D006266:Health Education; D006801:Humans; D007434:Intrauterine Devices / Q000706:statistics & numerical data*; D007435:Intrauterine Devices, Copper / Q000706:statistics & numerical data; D007843:Latin America; D016912:Levonorgestrel / Q000008:administration & dosage; D016239:MEDLINE; D049590:Postpartum Period; D011203:Poverty
chemical_list: D003270:Contraceptive Agents; D016912:Levonorgestrel
keywords: Africa; Asia; Implants; Interventions; Intrauterine devices; Latin America