Reviewer's report
Title:Prevalence of IUCD discontinuation and its associated factors: Findings
from a retrospective study with clients of a social franchising network in Pakistan.
Version: 2Date:8 December 2011
Reviewer: Ajmal Agha
Reviewer's report:
Major compulsory revisions
Title
In the title, instead of “prevalence”, the word “rate” or “frequency” should be used
as the study did not sample FP methods users in the general population.
Abstract
1. Objectives are written in methods in the abstract. Please put them in the
background.
2. Cross sectional is never a retrospective study. It is just capturing data at a
point in time or a period of time. I recommend that the word retrospective should
be removed.
3. Please mention how the percentage 81.7, which is mentioned in the last line of
findings on page 2, was calculated. What was the denominator?
4. The conclusions don’t address all the objectives set for the study. Also some
of the conclusions are not directly coming from the study findings.
Main article
1. Objectives
a. Rationale of the study, second last line: Use the word associated factors rather
than reasons. The latter is more a qualitative term. Also here, authors mention
that the study will capture the level of satisfaction and accessibility; however,
these objectives are not mentioned when objectives were phrased in the
abstract.
b. Italicize the word Suraj in the objectives on page 6
2. Methods
a. In methods section, sampling strategy has to be reviewed. Some of the
aspects are as below:
i. What was the list frame? Did that include only providers with healthy clients
flow? If yes, how many were they in each area? Also operational definition of the
word healthy client flow should be included.
ii. Again logic for 55% and 45% voucher and non voucher clients’ selection is not
given. Was that true in the overall sample? Why was the Probability proportional
to size (PPS) sampling technique not employed at each step of multistage
sampling? Also the reason given for choosing the higher number of voucher
scheme client is related more with the program than with the current study.
iii. No rationale is given for choosing six districts from Punjab and three from
Sindh. Where were the 18 districts from? Despite the use of random sampling
technique, three districts each were included from each major area - southern
Punjab, northern Punjab and Sindh. Authors should review if they stratified the
areas and choose the equal number of districts.
iv. Since the sample size was not calculated, post-hoc power analysis should be
done for the insignificant associations.
b. Why 6, 12 and 24 months cohorts were chosen and not 6, 12 and 18 months?
Does that have any link with the programmatic activities? Please mention
c. Was there any exclusion criterion?
d. In the section on statistical analysis, write about the cut off p-value that was
used include the variables from univariate to multivariate analysis
e. In data collection and management section, in the last two lines, the terms
intra and inter rater variability are mentioned. Please mention, how these were
measured and the statistical test used?
3. Findings
a. Socio-demographic characteristics: Husband’s education could be an
important factor. If captured should be included in the analysis
b. For the variables means are calculated, standard deviations should also be
mentioned
c. In the section on “Discontinuation of IUCD, reasons, accessibility and level of
satisfaction with services” the finding “No variation was found between the
responses among the women of three cohorts (2 in Punjab and one in Sindh)”
should be backed by the statistical test and CI.
d. Add the word univariate analysis in the caption of table 2. Use the term OR
instead of PR.
4. Discussion
a. Paragraph 3, instead of the terms directly proportional and relationship use the
term association. Similarly the word correlated should also be removed.
b. Paragraph 3: Please review the statement, “Insignificant association between
discontinuation and receiving service free of cost indicates the strong voucher
distribution mechanism”.
c. The finding that the clients living closer to the Suraj were more likely to
discontinue IUCD merits discussion. Similarly the possible reasons for the higher
odds of continuation of clients in Sindh should be discussed.
5. Conclusions
a. The conclusion, “Such interventions and strong counseling for promoting the
use of long term contraceptive methods are one solution to resolve the issue of
high unmet need for contraception in Pakistan [21]. In addition, the study
highlights the need to provide counseling to the women to switch to any suitable
contraceptive method of their choice, in case they get IUCD removed “ is not
based on the findings of the study.
6. Minor essential revision
a. Discussion paragraph 2: The term IUD is used instead of IUCD.
Level of interest: An article whose findings are important to those with closely
related research interests
Quality of written English: Acceptable
Statistical review: Yes, and I have assessed the statistics in my report.