Title: Predictors of modern contraceptive use among reproductive age women in high fertility
countries in sub-Saharan Africa: Evidence from Demographic and Health Surveys
Version: 1 Date: 08 Sep 2022
Reviewer's report:
Comments: Predictors of modern contraceptive use among reproductive age women in high
fertility countries in Sub-Saharan Africa: Evidence from Demographic and Health Surveys
In this manuscript, the authors highlight the prevalence and predictors of modern contraception
use in countries with high fertility rates in sub-Saharan Africa. Indeed, the use of contraceptives
is not only useful to curbing population growth but improving the physical and economic
wellbeing of women and their families. The methodology in this manuscript is statistical and
authors make relevant policy recommendations.  There are however several grammatical errors
in the manuscript that the authors will need to address.
COMMENTS BY SECTION
Background
The authors provide an insightful background to the research, highlighting the importance of
modern contraceptive use. Since the article is on the predictors of contraceptive use, it will be
useful to highlight what previous studies have identified as the various predictors of modern
contraceptive use. The authors acknowledge that individual studies exist in these countries. My
concern however is that the authors have not clearly indicated why a multi-country analysis
(the top ten high fertility countries in SSA) is necessary. Indeed, sociocultural and economic
variations exit across these countries and so my advice is that the authors provide a strong
justification for this analysis.
The use of contraceptives in SSA especially, is intricately linked to gender and/or household
power dynamics. Highlighting this in the background will help distinguish it from other health
behaviors such as ANC utilization. My appeal to the authors is to briefly discuss how gender
dynamics including other relevant factors shape contraceptives use.
The authors also mentioned that “In spite of the above-mentioned studies conducted on
contraceptive use, up to our knowledge, there is no study conducted to assess modern
contraceptive use to control high fertility in the world, particularly in top ten high fertility sub-
Saharan African countries.” I will like to draw the authors attention to a study by Ahinkora
(2020) titled: Predictors of modern contraceptive use among adolescent girls and young women
in sub-Saharan Africa: a mixed effects multilevel analysis of data from 29 demographic and
health surveys. I am curious how Ahinkora’s work differ from this current one.
Method
It appears Nigeria conducted a DHS in 2018. If correct, why did the authors use the 2012 data
set instead?
Under the section for the outcome variable (line 139), the authors categorised the “rest” as
“no”, coded as 1. Can you elaborate which specific categories constitute the “rest”? The authors
controlled for several variables, but do not justified why those variables were selected and
controlled for. Citing earlier studies will be helpful.
“Community-level poverty was created from household wealth index by recoding poorest and
poor as poor and then, categorized as low poverty level when the proportion of women from
households with poor household wealth index above the median value, and higher poverty level
when below the median value.” This sentence is quite confusing to me, and my advice is for the
authors to revise it and make it clearer.
Is there a variable on religious affiliation? There is literature that highlight the direct and indirect
effects of religion or religious affiliation on the use of contraceptives in SSA. I am curious why
religion was not controlled for. Could not controlling for it be a limitation to the study?
I don’t also see the variable “occupation” in table 5. Has occupation not been controlled for?
Are you using wealth quintile or wealth index? That is unclear
Results
In line 170, “median age” is reported suggesting that the variable “age” is treated as a continuous
variable. This contradicts what is in the table, which is categorical in nature.
Discussion
The authors do well by comparing their findings with earlier studies in this context. They also
highlight the policy implications of their results. My appeal is that the authors provide a bit
of context to some of these studies. Stating that this finding is similar to another study is not
enough. What did the study being compared to find?
“Another possible reason could be that as an income increases, exposure to different information
and financial accessibility of services will be improved.” Can the authors clarify what “financial
accessibility of services” mean?
“The study suggested that media exposure will reduce the barriers to accessing and using health
care services, including contraceptives.” This is an overstatement in my view.
Line 240, can you state some of the activities?
Lines 276 to 282, my understanding is that participants were asked if distance to the health
facility is a problem to them or not. Geographical distance is being conflated with difficulty
commuting to the health facility. Distance being a problem may also depend on access to
transportation services such as personal vehicle. Hence, individuals with means of transport may
be geographical far away from a facility but may not consider distance as an issue while those
near to these facilities may still consider distance as an issue. The authors may need to revise
this paragraph.
Minor comments
Be consistent with your description of variables  (dependent and outcome variable; independent
and explanatory).
The first “s” in Sub-Saharan Africa should be lower case.
Line 138, binary “variable” and not binary “outcome”.
Be consistent with your use of respondents and participants.
Table 2, add “place of” to residence.
Line 208,  “Women who attended secondary/higher education”, replace “attended” with “had”.
In your abstract, the variable names have not been appropriately reported. It is "wealth" is a
predictor and not "women in the rich wealth quintile". That appears to be a category and is
inconsistent with the others reported in your abstract.