Title: Women’s sexual empowerment and utilization of long-acting reversible contraceptives
in Ghana: Evidence from the 2014 Demographic and Health Survey
Version: 1 Date: 27 Apr 2023
Reviewer:  Michael Boah
Reviewer's report:
The study explores the relationship between women's sexual empowerment and their use of
long-acting reversible contraceptives in Ghana. It draws data from the 2014 Demographic
and Health Survey. The results showed that age, parity, religion, and health decision-maker
had a significant relationship with LARC utilization, while sexual empowerment did not. The
authors suggested that lack of knowledge about LARC and its potential side effects might hinder
women's utilization. The study recommended interventions to educate women about the benefits
and side effects of LARC.
Find below my comments to help in improving the manuscript.
General comments
1. The authors must ensure consistency in their use of either British English or American English
throughout the text, and not alternate between the two.
Grammar
2. For example, in the abstract, we have the following: “Existing literature suggests that the use
of Long-Acting Reversible Contraceptives (LARC) are associated with a decline in unintended
pregnancies…” use of LARCs should go with “is” [associated with…] and not “are”
“On the other hand, the likelihood of utilization of LARC was lowest among women with high
level of sexual empowerment (aOR= 0.62; CI= 0.27 – 1.43)” utilisation should be replaced with
utilizing.
Comments specific to the various areas
Abstract
3. To make the abstract background more concise, consider rephrasing the sentence and reducing
its length.
4. Please verify the sentence describing the statistical analyses conducted.
5. The research aims to investigate the relationship between women's sexual empowerment and
the use of LARCs. However, the method section does not explain how the primary exposure
was assessed. Additionally, the results do not clarify the percentage of participants who were
considered sexually empowered, nor do they discuss, statistically, the association between the
primary exposure and the outcome.
6. It is recommended that you present the results of the primary exposure before reporting on
other variables.
7. After stating elsewhere that the use of LARCs was lower among women who reported high
levels of sexual empowerment, the authors concluded that there was no statistically significant
association between the two variables.
Main manuscript
Methods
8. The authors should include more comprehensive information regarding the sample used.
Merely specifying that the participants were married or cohabiting women is inadequate to
justify their sexual activity. At a minimum, the sample should include women who have
been pregnant or have given birth previously, as they are unlikely to deny sexual activity.
Furthermore, the 2014 GDHS dataset includes women who are currently pregnant and are either
married or cohabiting, which means that this group may not require contraception. Therefore,
the authors must provide a more detailed explanation of how they arrived at the final sample
of 5116 participants. Upon examining the dependent variable section later, I noticed that the
authors included certain sample information. Regrettably, that is not the appropriate location
for such reporting.
9. The content of lines 100-108 lacks clarity. At first, it seems as though the authors are providing
definitions for LARCs and other mothers. However, the passage appears to be incomplete or
missing important information, leading to confusion in the message being conveyed.
Main exposure variable
10. The information presented in lines 112-119 could benefit from being presented in a more
cohesive and comprehensive manner. The current structure lacks flow, making it difficult for
readers to follow and understand the content. Consider restructuring the passage to improve its
coherence and readability.
Statistical analysis
11. 1Should the analysis adjust for clustering?
Results
12. It is important for the authors to provide a clear and descriptive caption for Figure 1.
13. The authors should provide a detailed report of their findings regarding the relationship
between sexual empowerment and LARC use, as this is the primary research question. While
it is important to consider covariates in the analysis, the focus of the study should be on the
main exposure variable, and therefore the results related to sexual empowerment should be given
greater emphasis and detail in the report.
14. Title of table 3 reads multivariate… Although multivariable regression analysis and
multivariate regression analysis are used interchangeably in the literature, they refer to slightly
different concepts in statistics. The design in the study applies to the former. Authors should do
well to use multivariable throughout the manuscript.
Discussion
15. The authors should also look at the composite variable as an issue. If the authors created
the variable into three groups (low, medium, and high sexual empowerment) based on the sum
of scores from four dichotomous questions, they may have overlooked some important nuances
in the data that could have been relevant to the research question. Additionally, an arbitrary
grouping may not reflect the underlying distribution of the data.
Limitations
16. Given that the 2014 GHDS dataset is nearly a decade old, it is important for authors to
consider the implications of utilizing this dataset to convey present-day information.