Title: Utilization of modern contraception and determinants among HIV positive women in
Ethiopia: a systematic review and meta-analysis
Version: 1 Date: 27 Jan 2023
Reviewer's report:
Methods:
Did an informationist or librarian assist in the creation of the search strategy and choice of
information sources?
If study period not restricted, are results stratified by era? Prospero protocol says study period
would be restricted from 1995-search, whereas the manuscript says, “The study period was not
restricted”. Which is accurate?
Add mention of English-only restriction as limitation in discussion. The protocol registered
at Prospero states there will be no language restriction. Please justify this alteration from the
preregistered plan.
Could the authors clarify whether if a study included both sexes but provided results separated
by sex, was it still excluded?
What is considered a modern contraceptive or long-acting reversible contraception needs to be
either specified within the article or at least a citation to what is considered to belong in each
category. Was this following Hubacher & Trussell, 2015, WHO, some other classification?
On the last sentence of page 7, I recommend rephrasing from “The outcome of both tests with a
p-value greater than 0.05 was reported no publication bias.” to something like “P-values <0.05
on either test indicate potential publication bias.” Or “We considered p-values from both tests #
0.05 as no detection of publication bias.” Also, please add a citation for Begg’s and Egger’s tests.
Results:
It is preferred to include the number of studies excluded for each of the exclusion reasons, rather
than summing all of them. For instance, instead of 12 excluded articles for not matching the
eligibility criteria in Figure 1, saying "Excluded articles: HIV positive mothers not attending
ART clinics (3), men included studies (3), Publication without abstract or full text or editorials
(6)".
In the Figures, should all the author names (ex, woreke) be capitalized? If so, please do so.
The heading on page 10, “Pooled proportion of reversible long-acting contraception among
modern contraception users HIV positive women” does not make sense to me. Would it still
be accurate if it were rephrased to something like: “Pooled proportion of reversible long-acting
contraception among HIV positive, modern contraception using women”?
I understand if authors would like to focus on the positive, but I think it makes sense to point out
that Tigray region has both the lowest proportion of modern contraceptive use and long-acting
contraception among modern contraception users.
The Amhara region still has very high heterogeneity of the estimates in both Figure 2 and 3.
Does this bear further investigation or discussion?
Figure 5 axes titles need to be rewritten for clarity, for example, either in the axis or in a footnote
spell out Standard Error, and transform logodd into Log Odds.
Figure 7 has a typo: “Partener status HIV positive” should be “Partner status HIV positive”
The sentence on publication bias is confusing. I read it as saying there is an asymmetrical
distribution of studies (which would indicate publication bias—I think you mean that there is
no asymmetry?), Egger’s test has a p-value of 1.36 (I assume this is a type for 0.136, indicating
lack of evidence for publication bias), and no mention of the Begg’s test p-value. I suggest
rewriting this to something like, “Based on the symmetrical distribution of studies in a funnel
plot and the non-significant p-values for Egger’s test (0.136) or Begg’s test (??), we did not
detect publication bias.”
On page 12, “different articles” is insufficient information, please cite the studies that reported
sociodemographic factors as significant determinants of modern contraception use.
Discussion:
Given that the review and meta-analysis was only on HIV positive women attending ART
clinics, should these results be generalized to all HIV positive women in Ethiopia? If you think
all HIV positive women attend ART delivery sites, please expand on that in the Introduction;
their use and access to ART was unclear to me. If instead you think there could be selection bias,
either that bias should be discussed in the limitations section or phrases like “60% (95% CI:
52-68) of HIV positive women utilized modern contraception to prevent unintended pregnancy”
should be rewritten to something like “HIV positive ART using women”.
Please provide citations for the modern contraception use in Ghana and Uganda on page 14.
Given the magnitude of difference in use of modern contraception by region, there should be
some discussion of possible reasons for these differences.