Reviewer ’s report  
Title: Unfulfilled need for contraception among women with unmet  need but with the intention 
to use contraception in Rakai, Uga nda: A longitudinal study  
 
Version: 1 Date: 30 Nov 2017  
 
Reviewer: Anita Nelson  
 
Reviewer's report:  
BMWH -D-17-00398R1  
Major revisions  
Unfulfilled demand for contraception among women with unmet need but with the intention to 
use contraception i n Rakai, Uganda: A longitudinal study  
 
The authors are clearly working in a region of remarkable need and one that is undergoing rapid 
transformation. The introduction of modern methods of contraception often calls into question 
couples ideas about their r ole in controlling their own fertility. Gender roles are in transition. 
Economic pressures combined with HIV epidemics make this a very dynamic environment in 
which to do meaningful research. The authors have made good use of data from longitudinal 
surveys  to gain insights into women's behaviors compared to their declared plans. This 
manuscript has good potential, but would benefit from clarifying and refining the terminology 
used.  
 
1. The greatest problem with this analysis is it is not at all clear what wo men were actually 
asked in the survey - were they asked if they planned to use any method in the next 12 
months or were they asked if they would use "modern" methods? The methods section infers 
that only modern methods (which needs to be defined for intern ational readers) were 
included. It would certainly have been more appropriate to include all methods, including 
traditional methods, such as coitus interruptus on the principle that something is better than 
no method.  
2. It is not clear how it was establis hed that every pregnancy that occurred between surveys was 
unwanted. Were women who changed their minds about their reproductive plans and became 
pregnant also excluded?  
3. Even if the pregnancies were unintended, why were all such pregnancies counted as a n 
unmet need for contraception? Every method has known failure rates; none is perfect. This 
approach seems to strongly overestimate unmet need. Under this reasoning, there would 
always be unmet needs or, stated differently, it would be impossible to ever m eet all needs.  
4. Numbers are sometimes not placed into context. For example, in the abstract (line 26) and in 
the background (line 29), a figure of 26% is used to estimate unmet need, but it is not clear 
what that represents - 26% of sexually active women  not seeking pregnancy?  
5. More fundamentally, the premise that eliminating unmet need would eliminate unwanted 
pregnancies is either a tautology or it is an incorrect statement. It must assume (once again) 
that all methods provide perfect pregnancy protec tion and that all women are (or should be) 
fully committed to fertility control. But, as the authors point out, indifference and 
ambivalence as well as other cultural factors completely independent of access issues make 
significant contribution to unintend ed pregnancy rates. But the authors seem to set that 
thought aside and continue to press forward with their definition.  
6. The authors need to provide references for the factors they used as confounding variables 
they used in the multivariate analysis.  
7. In reality, only 1741 women could have provided data. These are the women who should be 
described in the baseline information. If a woman participated on only one survey, then there 
would be no outcome data for her.  
8. The authors should probably acknowled ge the biases in their data in the limitations section. 
Women with HIV probably had a higher rate than uninfected women - which might explain 
the proportion of HIV -negative women increasing over time. Also, was there something 
about the women who out -migra ted that was different from the women who stayed in the 
study community? Were they able to control for these factors?  
9. Philosophically, can it be said that a woman who does not intend to use contraception has 
any unmet need for contraception? But this is  the claim that is made in the results in lines 
184-87. It seems a strange play on words, unless you posit that the reason she does not plan 
to use contraception is that there are no methods she finds acceptable to use.  
10. References would also be helpful  to support the contention that most studies are cross -
sectional or restrict the women included.  
11. Table 2 - I would have expected that overall would represent the total of the 3 subcategories 
or that there would be a footnote explaining any differences.  
12. Table 3 - should clarify that intention is to use modern method or redefine unfilled demand 
(see above). Does "soon" mean in the next 2 years?  
I would be happy to review any revisions the authors wish to submit.  
 
Are the methods appropriate and well described?  
If not, please specify what is required in your comments to the authors.  
No 
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.  
No 
Are you able to assess any statistics in the manus cript or would you recommend an 
additional statistical review?  
If an additiona l 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:  
Acceptable  
Declaration of competing interests  
Please complete a declaration of competing interests, considering the following questions:  
1. Have you in the past five years received reimbursements, fees, funding, or salary from an  
organisation that may in any way gain or lose financial ly from the publication of this 
manuscript, either now or in the future?  
2. Do you hold any stocks or shares in an organisation t hat may in any way gain or lose 
financially from the publication  of this manuscript, either now or in the future?  
3. Do you hold or are you currently applying for any patents  relating to the content of the 
manuscript?  
4. Have you received reimbursements, fees, funding, or salary from an organization that 
holds or has applied for patents relating to the content of the manuscript?  
5. Do you have any other financial competing interests?  
6. Do you have any non -financial competing interests in relation to this paper?  
If you can answer no to all of the above, write 'I declare that I have no competing interests' 
below. If your reply is yes to any, please give details below.  
 
Grants /Research                  Agile, ContraMed, Estetra SPRL, Evofem Inc, FHI (MonaLisa), 
Mathra Pharma, Merck  
Honoraria/Speakers Bureau  Allergan, Bayer, Merck  
Consultant/Advisory Board          Agile, AMAG Pharma, Bayer, ContraMed, Merck, 
Pharmanest  
 
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