Reviewer ’s report  
 
Title: Married Women's Autonomy and Post -Delivery Modern Contraceptive Use in the 
Democratic Republic of Congo  
 
Version: 0 Date: 11 Dec 2017  
 
Reviewer: Morounfolu Thompson  
 
Reviewer's report:  
 
Are the methods appropriate and well desc ribed? Yes.  
 
 
In reviewing the significance of the study question and assessing the background for the study, 
contemporary reading suggests that cost, availability, and socio -economic status are the major 
deterrents to successful modern contraceptive utilisa tion and family spacing. See references (1. 
Mukaba T, Binanga A, Fohl S, Bertrand JT. Family planning policy environment in the 
Democratic Republic of the Congo: levers of positive change and prospects for sustain ability. 
Glob Health Sci Pract. 2015;3(2):1 63-173. http://dx.doi.org/10.9745/GHSP -D-14-00244  and 2. 
Casey SE, Tshipamba M. Contraceptive availability leads to increase in use in conflict -affected 
Democratic Republic of the Congo: evidence from cross -sectional cluster surveys, facility 
assessments a nd service statistics. Conflict and Health. 2017 Mar 8;11(1):2.)  
 
  
The present study however challenges this thinking by questioning whether there may another 
important independent factor; the women's autonomy.  Autonomy implies well -informed 
independent i mportant lifestyle decision taking and as the authors pointed out, does not equate 
with socioeconomic balance in the home but with the more subtle power dynamics. This 
suggests that a woman's voice, level of involvement in domestic matters and negotiating ability 
may all be involved. These are difficult matters to assess and even more difficult to quantify, 
particularly from a retrospective databank. However, this was one of the issues raised from the 
national survey as an important aspect - that decision -making regarding reproductive health 
choices had more patriarchal influences.  
 
 
There were relevant questions asked by the national survey team, and the authors made good use 
of the pertinent questions in this case - as described on P6. The authors make a c ogent case 
overall, however, P5 , 30 -37 could have been better written to inform the reader as to the 
justification for this study.  In addition, decisions 2) making large purchases for daily needs, and 
4) household expenditures are possibly closely relate d to the couple's socioeconomic balance. 
The authors may wish to clarify this issue.  
 
 
The other influencing factors are described and interestingly, the high child mortality may be 
seen as an important contributor to the stated high national fertility rat e. In any case, that section 
with its descriptions may be better placed under the Discussion section of the paper.     
 
 
The authors may wish to discuss their choice of a retrospective approach rather than a 
prospective method as has previously been describ ed in search of the factors impeding 
contraceptive utilisation in DRC  (Mbadu Fidèle Muanda, Gahungu Parfait Ndongo, Lauren J. 
Messina & Jane T. Bertrand (2017) Barriers to modern contraceptive use in rural areas in DRC, 
Culture, Health & Sexuality, 19:9, 1011 -1023, DOI: 10.1080/13691058.2017.1286690). That 
study however was purely qualitative with a phenomenological approach, which may have its 
own drawbacks.  
 
 
Does the work include the necessary controls? Yes.  
 
This was a large population based survey comp rising 18,827 women of which 6,680 were 
appropriately selected for study. Principal Component Analysis (PCA) was utilised  and the 
authors' description and derivations appear well written (q.v. Vines SK, 2000. Simple principal 
components analysis, J R Soc Stat Applied Statistics 49(4):441 -451 DOI10.1111/1467 -
9876.00204)  
 
 
Are the conclusions drawn adequately supported by the data shown? Yes.  
 
The study objective was - to examine modern contraceptive use and its linkage to women's 
autonomy in the Congo Democr atic Republic based on a retrospective analysis of data from a 
national demographic and health survey. The study had a proportionally good sized sample of 
6,680 married women with a stated birth interval of less than 3 years in line with World Health 
Organ isation recommendations. The study conclusion was that it may not be enough to provide 
women with educational and employment opportunities to increase the uptake of modern 
contraception, but also to enhance women's assertiveness to make their own decisions  regardless 
of their partners' preferences within household settings, and this is in keeping with the study data. 
Logistic regression models were fitted to explore the relationship between women's autonomy 
and modern contraceptive use. After controlling fo r socioeconomic and demographic factors, the 
association between women's autonomy and modern contraceptive use remained positively 
significant.  
 
 
Statistical input has been requested simply to see if the statistics applied are appropriate  
 
 
Assessment Rat ings Overall  
 
Originality - 3/5. Previous qualitative studies .  
 
Study relevance - High 4/5 considering the background  
 
Significant contribution to scientific knowledge is limited in current form 2/5  
 
Significant contribution to women's healthcare practice - 3/5 
 
 
Overall Recommendation  
 
Accept if appropriate amendments made and statisticians report is good  
 
 
 
 
Are the methods appropriate and well described?  
If not, please specify what is required in your comments to the au thors.  
 
Yes 
 
Does the work include the necessary controls?  
If not, please specify which controls are required in your comments to the authors.  
 
Yes 
 
Are the conclusions drawn adequately supported by the data shown?  
If not, please explain in your comments to the authors.  
 
Yes 
 
Are you able to assess any statistics in the manus cript or would you recommend an 
additional statistical review?  
If an additional statistical review is recommended, please speci fy what aspects require further 
assessment in your comments to the editors.  
 
I recommend additional statistical review  
 
Quality of written English  
Please indicate the quality of language in the manuscript:  
 
Needs some language corrections before being published  
 
 
 
 
 
 
Declaration of competing interests  
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