Reviewer’s report
Title: 
Association of race and ethnicity with postpartum contraceptive method
choice, receipt, and subsequent pregnancy
Version: 
0 
Date: 
24 Nov 2020
Reviewer's report:
Overview - Originality, Background, Methodology, Study Conclusions 
An interesting study in that while settling a question not many clinicians would
have hitherto thought of, it also raises many other, as important, questions.
The study is well written but there appear to be a few contextual issues in the
descriptions by the 
authors and some of the statements in the body of their text. 
These are possibly more related to sentence construction and how the average
reader would perceive them, as described in the itemised list.
The North American population studied prompts the question of what the study
authors want regarded as ethnicity - is there a classification that includes dual
heritage ? mixed race ? native Americans ? 
While it may be semantics but as stated in the study title is it truly choice or
selection ?
An explanation of precisely how the authors and other previous studies sought to
classify ethnicity. Was consideration given to self-determined ethnicity ? 
The definition of what is Black Ethnicity needs to be better clarified as this may
hold different meaning depending on the country/locale and could be termed to
include multiple heritage other than caucasian. 
Self defined ethnic grouping may be more appropriate given the distributions
described in this study.
Itemised Review
Line 28 Womens health ? (? care) 
Line 33 "are reported to have or "have higher reported rates" 
L39-40 
What is conception of pregnancy intendedness ? Are the authors
referring to an individual intention to conceive or seek pregnancy ? 
Line 45 - have not accounted for/ or did not take into account NOT largely did
not account for
Line 49 
Objectives are well defined 
1. assess racial/ethnic differences in choice of postpartum contraceptive method
after accounting for clinical and demographic influences (NOT mediators of
contraceptive use) 
2. sought to analyze racial/ethnic variation in postpartum contraceptive method
fulfilment 
3. Time to fulfilment 
4. Postpartum visit attendance 
5. Subsequent pregnancy rates in the main ethnic groups studied
L51 onwards - authors need to explain the basis for their a-priori hypotheses
based on ethnicity to eliminate any possibility that there has been an introduction
of personal bias
L51 Need to compare like with like - which ethnic groups were described in
prevous studies and how these groupings compare with the index study
L60 
Representative populations ?. An academic, urban, tertiary care teaching
hospital is far from representative of an overall regional or national population
L64 What is perinatal maternal death ?
Why exclude sterilisation and then IVF ?. This should be adequately explaned
L82 Notification or notation ?
L84-95 Please arrange statistical review as some of the statements are not quite
clear
Table 1 - influence of socio-economics and level of education seem quite
prominent 
For Non- North American readers what is the difference between Medicaid and
Medicare and how does this affect the study parameters ?
L352 What is meant by "referent" race here ?
Table 3 - Hispanics were significantly less likely to obtain their selected choice
of contraception yet failure rates were not worse than Blacks ? Authors need to
explain e.g. 
Were better methods selected by Hispanics 
e.g. Sterilisation in Table
1? The authors 
should show possible links and explain L154-156 more clearly.
L157 A very interesting observation. Ideally this should be referenced.
Overall View 
In summary, this is a secondary analysis of a previously studied cohort of
postpartum family planning choices among 8,649 women of different ethnicity.
The primary objective of the authors, to ascertain if ethnic differences in choice
persisted after accounting for other influencing demographic and clinical factors
was well demonstrated. While the authors are correct that clinicians should seek
a better understanding of intrinsic patient-level differences in contraceptive
preferences and respect these, the concluding statement regarding their
avoidance of biased counselling could incorrectly imply that this was an element
of their study. They could however suggest it should be a focus for further
studies.
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Is the study design appropriate to answer the research question (including the use
of appropriate controls), and are the conclusions supported by the evidence
presented?
Yes
Are the methods sufficiently described to allow the study to be repeated?
Yes
Is the use of statistics and treatment of uncertainties appropriate?
Yes
Is the presentation of the work clear?
Yes
Are the images in this manuscript (including electrophoretic gels and blots) free
from apparent manipulation?
Yes