Title: Unmet Need for Long Acting and Permanent Contraceptives and Associated Factors
among Married Women in Southern Ethiopia
Version: 4 Date: 08 Dec 2022
Reviewer's report:
General
The study by Abate et al reflects a relatively simple and straightforward assessment of unmet
need for long acting and permanent contraceptives in married women residing in a specific area
in Southern Ethiopia.
Overall the methods appear appropriate, however, I do have some specific comments and
concerns outlined below in terms of things that could be improved. In general the manuscript
is very lengthy and there is a lot of repetition of results presented in text and tables. This could
be shorted to improve readability.
With some minor revisions I would support publication.
Introduction:
The background is extremely long (1,000 words) and can be shortened and made more direct
to the point.
LAPM needs to be defined when first used. Needs to be clearly defined in figures as well.
Methods:
What does lottery method actually mean/involve from a methodological perspective?
Line 206, I assume 80 here refers to percentages (80%)?
What does seriously sick mean in the methods? More detail required here. How many people
were excluded from responding?
The study uses questionnaires to assess knowledge and attitudes. Neither of these appear to be
validated questionnaires? Some of the questions in attitudes such as “IUCD can disappear in
the abdomen after insertion” would appear more fitting as knowledge than attitudes. As they
currently stand, these questionnaires don’t feel very robust.
Line 208, classifying peoples attitudes based on them reporting above or below mean doesn’t
make sense. If the entire cohort had positive attitudes to LAPMs, by default half are
automatically coded as having a negative attitude by this method, even though they don’t possess
a negative attitude. This process should be revised.
Results:
Given a sample size calculation is provided based on desired level of precision of corresponding
prevalence estimate, it would be beneficial to include 95% CIs on the estimates generated from
this survey.
Line 231 – PCA is introduced here but should be part of the methods
Table 2 refers to abortions, please specify if these relate to spontaneous or induced abortions
It is unclear why certain factors were chosen for univariate analysis in Table 6. I can only assume
it is those where there was a significant association? But this is missing important variables like
impact of reproductive history on unmet need for LAPMs etc.
I don’t see much value in presenting AORs. These are overinterpreted as providing unbiased
estimates given the lack of a causal framework being used to structure the analysis. Many of
these variables would be correlated and in some cases measure the same concepts (i.e. attitude
and knowledge would be similar). You cannot accurately adjust for this many variables given
some variable subcategories have such small cell sizes.
Figure 1:
This doesn’t make sense as it says 245 and 230 were interviewed, with a total of 746. These
don’t add to 746. Further, the figure should reflect those actually responding to the survey (672).
Figure 2.:
Would be enhanced through improved formatting.
If all women in the survey are fecund, this doesn’t need to be mentioned in the figure.
It is not clear what the percentages are within each box, in some cases they appear of the total
population and in others as a subset of the number from the preceding box. This would benefit
from improved clarity.