Title: A cross-sectional study of women’s Autonomy and Modern Contraception Use in Zambia
Version: 4 Date: 27 Jul 2022
Reviewer's report:
My main issues and comments with the manuscript center around the technical components
of modern contraception methods and women’s autonomy variable creation. Main comments
below with smaller comments to follow:
• The manuscript is almost 4500 words long. I believe it would benefit from being more precisely
and concisely written.
• There are multiple minor language issues and typos that needs to be addressed. In addition,
some words are used in the wrong way, hence making the sentence difficult to understand or
giving it a completely different meaning than expected based on the context. Please ask for help
in preparing your manuscript to increase readability.
• In the methods section, I would appreciate if the authors would clearly state that it is a survey
study directly in the beginning of the section, e.g. “In this survey study, we…”. I would also
provide comprehensive overview of the survey.
• The introduction is very generally written. I believe the manuscript would benefit from the
introduction being much shorter and focusing more on the aim of this particular study. Why is
your study question important? And what makes our setting and data valuable for your specific
study question?
• The authors note a few times in the manuscript that reducing unintended pregnancy by
increasing modern contraception use can improve maternal mortality and morbidity through
the reduction of abortion. This is  true with UNSAFE abortion. Safe abortion services result in
VERY low rates of mortality and morbidity, especially compared to childbirth (where the risk
is higher by several orders of magnitude). The main problems with an unwanted pregnancy are
the health risks to a woman forced to carry a fetus to term and postpartum, the socioeconomic
strain of a subsequent birth, and the health risks to a fetus/baby when parents are ill-equipped
to provide for them. Not to mention that the right to avoid a pregnancy is considered a human
right. I would recommend the authors re-tool their framing of this issue, to reflect this reality.
The purpose of offering a full range of family planning options is because the more methods
that are available, the more likely it is that a person will find something that works for their
current life and circumstances, and this improved choice and access is subsequently related to
more consistent and correct use (and thus, lower rates of unintended pregnancy). I would really
like to see this framed more consistently in the manuscript, as it is more representative of the
rights-based approach that the field has taken.
• The authors created a composite assessment of both long-acting methods and permanent
methods. This is not totally uncommon, but it is important to recognize that these methods are
wildly disparate from one another in key ways that may limit the interpretability of the authors'
findings. Permanent contraception, particularly female sterilization, occurs in an in-patient
setting because it involves surgery. Access to female sterilization is typically done immediately
following birth. Thus, the health system structures and supports will look very different for this
method vs. other methods, which are typically outpatient. The decisional pathways that lead
people to choose permanent methods are also very different than those that lead them to choose
long-acting reversible methods.
In a similar vein, injectable methods have been grouped together with IUDs and implants
as "long-acting reversible methods," in some studies, but again this is not typical. IUDs and
implants last for years, whilst injectable methods only last for 3 months. Further, injectables
can typically be done by lower cadres of providers (even pharmacists and community health
workers in some areas - or self injection, in places where subQ depo is available), while IUD
and implant services broadly require access to a clinic with various instruments and more
intensive training. Further, *removal* of IUDs and implants also requires access to the health
system, while injectables do not.  The decisional reasons for seeking IUDs and implants are also
divergent from people who want to use injectable methods (e.g., many people use injectable
methods as a way to maintain privacy from their partners because injectables cannot be detected
or observed). Thus, structural and individual characteristics that support these various methods
are also quite different.
My recommendation would be that the authors a) report in the sociodemographic table the
proportion of people who used the various different methods (female permanent methods,
vasectomy, intrauterine devices, implants, injectables), b) conduct a sensitivity analysis looking
at *at least* the differences between permanent methods and LARC methods in relation to the
larger analyses. If the purpose of this paper is to demonstrate key areas of need with respect to
these methods, this is important, given the major differences in how these methods are provided,
structured, funded, and chosen.
• I am happy with the 10 variables under the headings Women’s participation in decision making,
Women’s attitude toward wife beating should be included to make the autonomy variable.
However, it is not a good idea to consider whether women have own house or own land to be
considered in making the autonomy variable. Many women, particularly poor women, do not
have own land or house, but they still need contraception. Even many rich and educated women
do not have own house or land. This is very common in developing countries as well as the
developed countries.  Therefore, this is not right to add this variable to make women’s autonomy
variable.
• The ZDHS survey data is hierarchical and clustered, therefore, multivariate analysis is not
a best approach here. The authors need to use the multilevel mixed effect model to analysis
this study data. I would prefer multilevel missed effect Poission regression model for more
appropriateness.
• There are many blocks to improve the discussion section.