Reviewer's report
Title:Covert contraceptive use among women attending a reproductive health
clinic in a municipality in Ghana
Version:2Date:25 July 2015
Reviewer: Lauren Ralph
Reviewer's report:
Major compulsory revisions
Methods/Tables
The methodology for both the quantitative and qualitative components needs
additional detail in order to sufficiently assess its rigor and the validity of findings.
Specifically:
- Quantitative component (bottom page 4/top page 5):
1. The definition of covert contraceptive use is unclear (p. 5, line 147-8). Suggest
revision to: “Covert contraceptive use was defined as reporting that their male
partner was not aware of the use of contraception” or something similar. Further,
was the question in reference to a specific male partner, or could women be
referring to any sexual partner? Given research documenting differential
contraceptive use patterns based on the type of relationship (e.g., spouse, casual
partner), it is important to clarify which partnership this question is getting at.
2. A description of all of the variables (covariates) considered needs to be
included here. For example, Table 2 includes “Willingness to recommend family
planning” and “Family planning conflict(s) with religious beliefs,” but it is unclear
how these variables were defined. This must be described somewhere in the
Methods or as a footnote in the table.
3. There needs to be a sentence in the methods describing the data/analysis
presented in Figure 1.
4. The authors do not mention what type of bivariate analysis is conducted to
arrive at the p-values assessed in determining which covariates would be
included in the final multivariate models (#2 tests?) – this information is critical
and must be included.
5. The presentation of two separate multivariate models predicting CCU is not
well motivated. Why separate sociodemographic (Table 1) and
method-/partner-/structural- predictors (Table 2)? I would argue that it is
important to adjust for salient confounders in all models.
6. Further, in the 2nd multivariate model (Table 2), why are certain methods
(IUD, implant) excluded? The fact that injectables and OCPs are the most
common methods used in this population does not seem sufficient, especially
since you have a non-negligible number of LARC users. You are likely losing
power by excluding these exposure groups, and since they are (fairly) discreet,
long term methods, they seem particularly salient to your research question (as
you note in the Discussion).
7. Page 5, line 152-3. - In order to make the statement “One the basis of the
literature,” the authors should either a) motivate this in the Introduction by
describing relevant literature, or, at a minimum b) cite this literature here.
- Qualitative component (page 5, lines 157-170). This section needs additional
detail, including:
8. Was the recruitment purposive in that women had to report CCU in order to
participate? If so, this must be explicitly stated.
9. Were some of the same inclusion criteria for the quant survey applied to select
women into the qualitative study (e.g., had to be using a modern FP method). If
so, this should be explicitly stated.
10. How were the number of IDIs and FGDs selected? Was the number chosen a
priori based on practical considerations (budget)? Was data collection continued
until saturation in themes was reached (the Discussion seems to suggest this
was not the case)?
11. Did all of the women participating in the qualitative study also complete the
quantitative instrument? If so, in what order did the data collection occur?
12. Re: analysis, how many researchers were involved in the coding process?
Did the process allow for identification of emergent themes (in addition to those
expected based on the survey)? Some additional description of what the authors
interpret as “content analysis” would be helpful here.
Results
This section is missing some critical information necessary to interpret study
findings.
13. What was the response rate for the quantitative survey? If the overall
response rate is not available (which should be noted as a limitation to
understanding generalizability of findings), it would be helpful to have a sense of
how representative these women are of women who attend care at this clinic or
of women in this region, perhaps by comparing to other data sources.
14. What was the range in age of participants (would suggest reporting as XX to
25 years, 26 to 33 (?) years in the table)? In the text, would present the median
age (and perhaps the SD). Currently, there is no indication of the lower age
range for participants.
15. For clarity, the authors should include more detail about the question
assessing women’s contribution to household income. This could be done in the
text of the methods, or in a footnote in the table. Additional detail on how all
covariates were coded would be helpful, but particularly for this question which is
a bit awkward to explain.
16. Page 6, lines 191-196 – Was this tested via inclusion of interaction terms in
the final multivariate model(s) or via stratified analyses? This must be specified in
the Methods section. The reason for this secondary (?) analysis should also be
justified in the Introduction (or elsewhere).
17. Page 6, lines 204-208 – It is unclear why the finding that OCP users are more
likely to report covert use than injectable users would be explained by the
preferential side effect or other profile of injectables. Women may choose
injectables more often than OCPs because they prefer their features (duration,
side effects, etc) or because the clinic staff told them it would be best, but how
this relates to covert use is not made clear. This transition/explanation needs to
be further elaborated or reconsidered.
18. Page 7, line 220-221 – I fear that the statement “Covert contraceptive use
was a statement that expressed their autonomy” may be reaching beyond the
data. It would be very helpful to have some specific quotes from women to
support this statement, or to have a sense of how often this response emerged.
The way it is currently presented suggests that this was a common or unanimous
response among women, which seems unlikely.
19. Page 7, lines 222-224. Similarly, some idea of the frequency with which
women expressed CCU as a means to “claim money from their partners” is
warranted. I fully recognize that this is qualitative data and am not necessarily
encouraging “response counting;” however, I would caution the authors to
provide some detail as to the commonality of this response (a minority of women,
a handful, etc.), otherwise you risk over interpretation of the data.
20. Page 8, line 253 – reconsider use of word “forced” – women are likely
perceiving a lack of control, whereas “force” suggest some overt influence.
21. Page 8, lines 258-9 – Were these experienced or feared consequences? It
would be helpful to have additional elaboration here.
Figure 1:
22. The legend for this figure is confusing. Would suggest editing to: “Covert use”
and “Non-covert use,” and using the title to describe how data are being
presented.
Tables 1 and 2 (which, as noted above, I would encourage be merged into one
table and one model) –
23. Levels of statistical significance should be presented for bivariate analyses
(CCU by each predictor).
24. Overall n’s for models must be included – how many women are contributing
to the analysis? As noted above, I worry that you are losing sample size because
of the exclusion of certain contraceptive users. Although there are 300 women in
the original sample, there cannot be 300 contributing to your analysis since a
significant minority of women were not using injectables or OCPs.
25. The titles for both tables should be revised to reflect that they include
univariate, bivariate, and multivariate analyses (the exact wording at the authors’
discretion). Currently, the titles for both tables are suggestive of a traditional
“Table 1” describing the study sample, which is confusing to a reader.
Throughout/big picture
- As you note, your study finds higher levels of CCU than previous research. A
few thoughts to consider/address:
26. Does the way in which the question was asked differ from other studies? As
others have found in qualitative work(1), there is a continuum of disclosure with
regard to contraceptive use, e.g., partners may not be aware of contraceptive
use because they are simply not interested or do not consider it their
responsibility, partners may presume contraceptive use (and support) while not
being aware of the specifics. If you used a validated/commonly used metric to
assess CCU, it would be helpful, at a very minimum, to hear if any of this sort of
distinction about levels of cohort use emerged in the qualitative interview. In
addition, as noted above, it would be important for the authors to report if they
used a standardized question to assess covert use (e.g. same as DHS).
27. Your sentence in the Discussion regarding potential explanations for higher
levels of CCU in this population is unclear (p. 9, lines 285-288).
Minor essential revisions
Page 3
28. Line 75 – Missing word. “…practice is common among women in
sub-Saharan…”
29. Line 77 – This sentence needs additional clarity and perhaps a citation. The
authors imply that CCU is “said to represent perceived or actual differences
between partners in the use of contraception.” Differences in contraceptive
intention? Attitudes toward contraception? Acceptance of FP/child spacing?
Line 78 – Missing word. “….to enable them to exercise….”
30. Line 97 – Misspelled word, replace “discrete” with “discreet”
31. Line 104 – missing “of” – “know of at least one…”
Page 4
32. Line 117 – I’m not sure that “middle belt” is a widely understood term;
consider deleting or replacing with something else.
33. Line 133 – replace “who were on” with “were using”
34. Line 136 – ensure that CCU has been previously defined in the text (versus
just the abstract)
Page 6
35. Line 185 – Sentence is unclear – while I understand the overall meaning (a
small minority of women contributed at least half of household income), the
current language is confusing; would also suggest removing “only.”
36. Line 188, Figure 1 – Were these differences statistically significant? Would
either state if significant or that levels of statistical significance were not
assessed.
37. Line 190 – Grammar, suggest revision to “Being single, including being
divorced or separated (n=6), was the strongest predictor..”
Page 9
38. Line 312 – replace convert with “covert”
Page 10
39. Lines 325-331 – This passage is challenging
a. “Among all methods, the OCP is the only one whose duration of use was
shortest.” This statement needs revision – women reported using OCPs for
shorter durations than other methods.
b. It is not clear that the data support the statement “It appears women initially
opt for OCPs and then later shift….” Was this a finding from the qualitative
study? If not, please appropriately cite with other research.
c. Since women generally experience comparable levels of side effects on
injectables and OCPs, it is not clear that the statement “Such disclosure may
have been due to the occurrence of side effects that necessitates the shift to
other methods” is well motivated.
40. Line 347-348 – meaning is unclear. I think the use of the word “attendant” is
misplaced. Please revise.
Page 11
41. Line 364-366 – It appears that the author information is missing for the
majority of authors?
References (pages 14-15)
42. Please check reference #17 – something appears off in the author
information.
Discretionary revisions
None, all revisions are considered essential.
References cited in review
1. Sahin-Hodoglugil NN, van der Straten A, Cheng H, Montgomery ET, Kacanek
D, Mtetwa S, et al. Degrees of disclosure: a study of women's covert use of the
diaphragm in an HIV prevention trial in sub-Saharan Africa. Social science &
medicine (1982). 2009;69(10):1547-55.
Level of interest: An article of importance in its field
Quality of written English: Needs some language corrections before being
published
Statistical review: Yes, and I have assessed the statistics in my report.
Declaration of competing interests:
I declare that I have no competing interests