Title: Changes in Canadian Contraceptive Choices: Results of a National Survey on Hormonal
Contraceptive Use
Version: 2 Date: 03 Jul 2024
Reviewer's report:
This is a well written article with importance to the field of contraceptive research. The
author's should be commended for the clear and concise language, making reading through the
manuscript easy.
Background:
The flow of the background section could be improved.  The abstract clearly states the reason
the research was conducted, however, this is lost in the text and the manuscript would benefit
from this section being "tightened", with more references to why Canadian women might have
changed their contraceptive use patterns over the last 15 years (e.g. finacial, change in practice
(IUD for nulliparous etc).
- Lines 28-31 are fascinating, but link to the historical use and changing patterns of contraception
(which I think is what you are trying to say) is not 100% clear
- Lines 35-41 are not relevant to the article; or at least you cannot answer this question with your
research.  The last two sentences (from line 43) are highly relevant and could be expanded
- Lines 48-80 are good and really build out reasoning for this research; however, here you talk
at length about non-contraceptive reasons for contraceptive use (i.e. off-label use) and you do
not ask about this in your questionnaire (!!!) This is a huge limitation to your research, which I
think needs more discussion at a later point in the manuscript
- Not all readers will be familiar with the Canadian health system and it would be helpful to
understand a bit about the cost structure - is there a difference in reimbursement of LARC,
SARC? What about uninsured access? Or access for minors/students?
Methods:
Study was conducted during Covid-pandemic and potential lockdown period; do you think this
might have influenced your research?  I would not emphasise this, but potentially have a sentence
somewhere acknowledging this.
Statistical analysis:
- Would be interesting to know how was missingness handled? It is not discussed (only in line
109 mentioned)
- Profile of lifetime HC use: you mention a significant relationship was found between age and
lifetime HC use (isn't this by default i.e. the older you are, the more time you have had to use
a contraceptive (a 20 year old has "maximum" 5 years of potential contraceptive use period
available, as opposed to a 40 year old who has 25 years)
- Line 122: you mention employed and unemployed; how were full-time students clasified?
I am not familiar with the Canadian health system; do they have free access to contraception, or
it their access dependent potentially on their family insurance/wealth?
- Profile of lifetime HC use strongly follows sociodemographic lines (insurance, education,
employment, income, race); I would suggest to simplify this section and state is from the
beginning; and then provide a breakdown of individual sociodemographic parameters
Discussion:
- Did the respondents know the name of the contraceptive they were using (not only the drug
preparation?)
- Not asking reason for non-contraceptive use is a major limitation that should be discussed
in more detail (particularly as you spend a large paragraph in the background discussing the
improtance of knowing this)
- Financial considerations: As previously mentioned, understanding reimbursement of
contraception in Canada will help to understand why/how sociodemographics are influencing
use patterns. Who is likely to have extended health coverage?
- Line 213 mentions changes to British Columbia law; understanding the situation before the
law changed in Canada would provide better context for this statement
- Line 224-228; was there a relationship between LARC and previous pregnancy?
Limitations:
- Line 277; if the reason for the research was descriptive, you could have still asked about
reasoning for HC use (or reasoning for non-contraceptive HC use).  It is okay to have this
limitation, but it slightly contradicts the efforts that you made in the background to explain why it
is important to know this information.  This incongruence is the biggest limitation of the current
manuscript currently.