Title: Knowledge, Attitudes, and Practices of Lebanese Women toward the Use of Oral
Contraceptive Pills
Version: 2 Date: 05 Jul 2024
Reviewer's report:
Again, the authors have been quite responsive to reviewer comments and have greatly improved
their manuscript. However, there are still some confusing or misleading information and some
organizational issues.
Abstract
Still does not address the question of why it is important to investigate the knowledge,
attitudes and practices of Lebanese women. In your author’s response you mentioned something
about enhancing continuation rates and offering OCPs for noncontraceptive treatments. Closing
an educational gap is not in itself sufficient justification for such a study.
There really is no urgency to addressing this “need”, especially if it were a special carve out for
only OCP education. Other studies have shown women harbor significant misinformation and
ignorance about all contraceptive methods. Education is needed for all methods, for pregnancy,
for menopause, etc. What made OCP education more important and more urgent?
There are some definitional problems. Contraception is one specific approach to birth control and
family planning, but there are others. Contraception specifically works by blocking fertilization.
Therefore, you cannot say that contraception is also known as birth control or family planning.
There are not one million unplanned conceptions each year among OCP users. We cannot
detect conception. The majority o f conceptions do not end in established, clinically detectable
pregnancies. Even if you accept that what you are reporting is pregnancies, they are not
measuring unplanned pregnancies, but what you mean to say is “one million unintended
pregnancies”.
In the introduction, it would be useful to describe how oral contraceptives are obtained and who
pays for them in your setting? Are there subsidized governmental or NGO programs for those
who are low income? Does insurance cover the cost?
Didn’t Ghada report the prevalence of coitus interruptus?
Why should university students have to know the appropriate dosage regimen of contraceptives
and what does that mean? Hormonal IUDs have lower circulating hormonal levels than
injections.
There is a significant over-estimation of the importance of this work (page 7 “crucial”) or of
the “crucial” need for healthcare providers to educate comprehensively (page 28) and in the
Conclusion (page 29 “critical” need; “efforts are crucial”).
Table 1 really belongs in the Results section along with its discussion.
It is difficult to know from the Results section (page 15) if the authors believe that OCP use
increases the risks of mood swings, weight gain and uterine cancer. I agree with the other
reviewers that the first two not be categorized as “health risks”, even if they were attributable to
OCP use, but should be included under potential OCP side effects.
Since so few of the respondents had actual experience with OCPs, Table 3 should also contain
2 more columns to demonstrate the answers from those who should have detailed counselling
about the method – those who have used them.
I do not understand Figure 1. Did 54.0% of OCP users report family and neighbors provided
information but 55.8% of the entire study population reported this? Does the 1.8% include the
55.8% (that is mathematically impossible)?
The section on “attitudes towards OCPs” is wrong. According to Table 4, 7.8% said OCPs were
the safest contraception not that pills were safe. And, by the way, only 2.9% of the respondents
answered that question correctly, pills are not the safest contraceptive method (implants are).
Similarly, the 6% cited by the authors that pills were effective is another misinterpretation. The
statement in the survey was “oral contraception is the most effective contraceptive method”.
They were wrong. Only the 2.4% who totally disagreed with that statement were correct. Why
was “partially agreed” not combined with “totally agree” for those partner involvement questions
since both reflect that the respondent did not think she could make the decision herself.
The patterns of OCP use should also include analysis of those who have experience with pill use.
Women who do not use pills should not be expected to have this level of detailed knowledge.
It’s like asking people without diabetes about insulin dosing because many of them some day
will need to know about it.
The reasons for non-usage of OCPs seem quite reasonable. Seventy-five percent were using
another method or did not need pills (? Not sexually active?). This stresses the need to do the
separate analyses based only on the responses of those who had ever used OCPs.
Factors associated with OCP use. I believe the last sentence is not complete, the higher income
participants were significantly less likely to use oral contraception (not all contraception).
The 5th and 6th paragraphs in the Discussion really need to be tightly edited.
Once the additional data are provided and the editing changes are made, I would be happy to
review the manuscript again. I know that publishers often limit the number of revisions they
consider, but I believe that the authors are capable of completing these changes and making their
work acceptable for publication. I urge the editor to give them another opportunity to try.