Title: Early contraceptive implants removal and its associated factors among women using
implants at a National Referral hospital, Kampala Uganda
Version: 2 Date: 14 Mar 2021
Reviewer:  Megan Christofield
Reviewer's report:
Congratulations to this authorship team for collecting important data on women's experience
using contraceptive implants. These are valuable insights for providing high-quality, voluntary
family planning services to women and girls in Uganda and around the world.
I appreciate your exploration into the population of implant users seeking removal at this
hospital, particularly to learn the length of time they've used their implant and the reasons for
which they've sought removal.
I do, however, have some major concerns that have led me to suggest a "reject" decision by this
journal. I will share my thoughts here in hopes that the authorship team can continue refining
their analysis and report for submission to this or another journal once addressed. These include:
1. The definition of early removal: the authors have defined early removal as 18 months or
less from the time of insertion. The reason for this cutoff is of no clinical or population-
level relevance, and never explained. Thus, all the analyses that revolve around this unfounded
dependent variable are questionable. Furthermore, the actual analysis of this variable is never
included in the paper - only mentioned in text that 42% were early removers (before 18 months),
but we are never given a table that includes this distribution or range.
2. The premise that early removal is bad: Throughout this paper, the authors position early
removal as a negative outcome. However, removal at any time of a method's use is voluntary
and a choice. At a population level, removal is sometimes concerning when it occurs among
those who wish to avoid pregnancy and do not switch to another family planning method (e.g.
leaving them with unmet need for FP). But, the analyses presented in this paper do not account
for the proportion of women in the sample who removed the implant because of a desire to
conceive, nor those who switched to another method. We do not know, for example, how many
women removed the implant before 18 months, and among them, how many desired pregnancy
or a different method of contraception. Thus, concluding that all removals are bad outcomes is
misleading.
3. The citations used in the background section do not properly match the text being cited -
kindly look for more appropriate citations. For example, when citing the FP2020 goal you might
cite FP2020 itself. When presenting the medical attributes of the two implant products, you
might cite their manufacturers or the WHO. Lines 93-95 cite Bahamondes's study and yet the
information cited is not covered in his manuscript. And so on.
4. Some facts need updating. For example, line 85: there are 3 WHO prequalified implant
products in Uganda (Implanon NXT, Jadelle, and Levoplant). Please clarify this in the
manuscript, perhaps by mentioning all three and noting the two available at your study site.
Line 70 mentions "improper use of contraception" as a driver of the MMR, though this is not
mentioned in the UBOS DHS report. Lines 113-114 mention a clinical practice of using CoCs to
treat heavy bleeding, but are not sufficiently explained (and could be cut from this manuscript).
5. Method description is hard to follow: Consider streamlining your methods section, many
pieces of information are mentioned multiple times, while others are missing. Please clarify
how sampling was done - in the section starting with line 153 you mention that 253 women
were eligible for this study and those enrolled were every 1st and 3rd that entered the clinic. I
am unclear, then, how you arrived at 207 women? Does this mean you had recruited 2 women
per day for 46 days and all women recruited to the study consented? Please also explain the
questionnaire further and the data collection. This was a trained midwife. Did she use a paper-
based questionnaire? A tablet? Were participants consented? Were ethical protections granted
for this?
6. Tables and results: In Table 1, it is unclear why you've consolidated variables like "other
religion" - when "other" is the majority and you seem to have the data to present a more detailed
demographic table. Before table 4, please include a new table that describes the length of implant
use among your 207 women, and shows us the frequency and % of those who used less than 18
months. It would be great if you could disaggregate this by product (Implanon vs Jadelle) and
other factors too (e.g. desire to become pregnant, etc).  I think your current table 4 includes all
207 women, correct? Please include the 'n' for this table. Line 250 in your results section starts
to describe reasons for early removal, and yet it is unclear what women are included in figure 1
- how many women is this? could it be presented as a table since women were allowed multiple
responses, only presenting proportions may be inadequate. Table 5: what's the 'n' on this?This
table was hard to follow without knowing which women were included. Lines 283-285 describe
average months the implant was used but only calculate this among a sub-sample of users who
stopped using implants before 18 months, and thus are not clinically or population relevant.
7, Given the methodological gaps, I have not spent much time reviewing the discussion section.
I would suggest, however, that the authors avoid making guesses here (e.g. lines 373-377; 390;
394-397).
Thanks for the great work continuing to make contraceptive choices like implants available to
women who want them! I hope that your paper can be revisited with these comments in mind,
and submitted to another journal in the future.