Reviewe r’s report  
 
Title: Gender norms and modern contraceptive use in urban Nig eria: a multilevel longitudinal 
study  
 
Version: 1 Date: 17 May 2018  
 
Reviewer: Brianna Magnusson  
 
Reviewer's report:  
 
Gender norms and modern contraceptive use in urban Nigeria: a multilevel longitudinal study  
The manuscript seeks to address an important question  regarding how changes in both individual 
and community -level attitudes affect use of contraception in Nigeria.  Although I believe the 
manuscript has potential, I do have a number of suggestions for improving the paper.   
 
 
 
Major Revisions:  
 
1. In general, I  find the manuscript to be excessively long.  Although I understand that 
BMCWH does not have a word limit, unnecessary length complicates reading the paper.  
I would suggest tightening the manuscript overall.  I have provided some specific 
recommendations below on places where this could be done.  
 
 
2. I have a number of questions regarding the analysis that are detailed below.  There may 
be valid reasons for the choices you have made, but I would appreciate a response 
explaining those decisions.  
 
 
 
Revisions by paper section:  
 
General Revisions  
 
1. I am unfamiliar with the word "endline".  I looked this up in the dictionary and although I 
understand, you mean the post -survey this does not appear to be the appropriate word.  I would 
suggest changing the  word endline throughout.  
 
 
2. The exposure variables in the analysis are individual and neighborhood level attitudes wife 
beating, household decision -making, family planning decisions, and family planning self -
efficacy. In the analysis the effect of each o f the four areas is examined separately.  Yet, it seems 
to be that these are likely correlated.  
a. What is the value of examining the four areas separately as opposed to creating a single 
score for individual level attitudes toward gender equality that i ncorporates all four areas?  
If my assumption that these attitudes are correlated is correct, a single score would 
greatly simplify the paper and make the results more easily interpretable.  I would also 
suggest a single score for the neighborhood exposure  variable.  
 
 
b. If there is a valid rationale for the four separate analyses, why not control for other 
attitudes? Again, my assumption is that these attitudes are correlated, so is it appropriate 
to look at the effect of attitudes toward wife beating witho ut controlling for attitudes 
toward family planning? etc.  
 
 
c. I have some concerns about the median split for attitudes.  It is not clear to me why this 
approach is used.  Further when comparing from high -low or low -high, it is hard for me 
to understand wh ether these are meaningful changes.  Perhaps some descriptive 
information on the mean change would be helpful.  
 
 
 
Abstract  
 
3. Line 27 -28 reads, "Evidence suggests that gender equality positively influences reproductive 
health outcomes. However the evidence f rom urban Africa is sparse."  - This background is too 
general for the abstract.  Assuming it is true, this should be specific to contraceptive use rather 
than all reproductive outcomes.   
 
 
 
Background  
 
4. The background is currently 7 pages. I find the backg round understandable and well written, 
but I would suggest critically assessing whether you could shorten this section without losing 
essential information.  
 
 
 
Methods  
 
5. The entire section could benefit from a reduction in text.  While I appreciate the deta iled 
explanation it could be written more succinctly.  
 
 
6. The study sample is well described.  In the paragraph beginning with line 249 please be more 
explicit on the reason for the loss of n = 26 women from 16,144 to 16,118.  I believe these were 
visitors  to the households at baseline?  
7. I am surprised at the inclusion of lactational amenorrhea as a modern contraceptive method.  Is 
there precedent for this? My opinion is that this is a traditional method.  
 
 
8. Beginning on line 296 you describe the exposu re variables. It seems that these attitudes toward 
wife beating, household decision -making, family planning decisions, and family planning self -
efficacy are likely correlated. In the analysis  
 
 
9. Beginning in line 346 you are describing a median split.  Ca lling it that is sufficient.  People 
will understand without the additional information.  
 
 
10. Line 371 "ever born" should be "ever birthed".  
 
 
11. Line 380; why is there not a "left -union" category? Was this not found in the data? Some 
other reason? Please e xplain in the manuscript.  
 
 
12. What is the rationale for including indigenous and non -religious with Christians? I know it is 
a small percent and they had to go somewhere. Is it a safe assumption that these people are more 
similar to Christians than Muslim s with respect to attitudes toward contraceptive use?  
 
 
13. There are many reasons that women discontinue use of contraceptive methods.  Certainly one 
would be a desire to conceive. Do you have any way of understanding what percentage of 
women who changed t heir contraceptive use status (adopters or discontinuers) did so due to a 
change in pregnancy desires?  
 
 
 
Results  
 
14. Please do no repeat things in the text that are given in the tables.  Removing duplicate 
information will greatly simplify the findings.   
 
 
15. Line 449 - Something is amiss in this line.  Although I think the entire line can be removed 
(as it's given in the table, if you retain, please fix the typo.  
 
 
16. Line 480 - attitudes toward what? Same line should it be 44% and 66%?  
 
 
17. Throughout the re sults when reporting exp(beta) call this the Odds Ratio or OR. This will 
help readers more easily determine the meaning of your values.  
 
 
18. As I mentioned in the major revisions section, I prefer a single measure of individual 
attitudes toward gender equa lity rather than presenting the four areas separately.  At minimum, it 
seems that these analyses should be controlled for other attitudes.  
 
 
 
Tables & Figures  
 
19. All tables should be independent of the text.  At present the tables are not interpretable 
without the accompany text.  
 
 
20. Table 1  
 
a. It would be useful to add the unweighted n's  
 
b. Rather than stating the proportions are weighted as a footnote, put this in the column 
heads  
 
c. That you are displaying percentages should be indicated in the column heads, not the 
rows.  
 
d. I would indicate the year of baseline and "endline" in the column heads rather than the 
table title.  
 
e. The final four rows (number of women etc.) should be reported in the text, rather than the 
table.  
 
f. Under parity should be 0 children, not child.  
 
g. Union status -if these are the results at baseline and "endline" wouldn't it be currently in a 
union or not currently in a union rat her than ever vs. never?  
 
 
21. Table 2  
 
a. This table could be improved by using four columns 1) Baseline Individual; 2) Endline 
Individual; 3) Baseline Neighborhood; 4) Endline Neighborhood.  
 
b. Add n and (%) to the column heads.  
 
c. Add unweighted n's to the cells 
d. Why present the means and standard deviations if you used a median split?  
 
e. Presenting the mean and the % high and low seems like a lot of information.  Not totally 
clear why it's all needed.  
 
f. Since all scores are dichotomous, you really don' t need to present the descriptive data for 
high and low.  As you know the other if one is given.  Perhaps present only the High 
gender equality attitudes.  
 
g. Alter the title to be more descriptive.  Exposure and outcome are not sufficient.  
 
h. Changing th e title should allow you to reduce the category labels removing "gender -
equitable attitudes" and sticking with just the substantive part.  This will improve 
readability of the table.  
 
i. Remove Modern Contraceptive use from this table and report in the tex t only.  It's a 
departure from the other data in the table so it hides there.  
 
 
 
22. Tables 3 through 6  
 
a. You could easily add the cell counts to the rows of these tables to provide the information 
the first reviewer requested without a supplementary tables .  Supplementary tables are 
often ignored, so if possible let's get that information in the main manuscript.  
 
b. For all tables, the use of both the CI and the p -value is redundant.  Please remove the 
asterisks indicating p -value levels of significance.  
 
c. Report exp(beta) as the OR  
 
d. For all analyses…thoughts on what explains the change in relative probability in the 
high-high group?  
 
 
 
23. Figure 1  
 
a. It would be useful to edit this figure to include your exposure measures, thus making this 
figure specific  to your study.  
 
b. Perhaps I missed them, but I did not see figure titles, please add.  
 
 
 
 
24. Figure 2  
 
a. A little more detail could be beneficial  
 
b. Perhaps I missed them, but I did not see figure titles, please add.  
 
 
25. Figure 3  
 
a. A pie chart might be better.  Since you are reporting percentages out of whole.   
 
b. Please include a title  
 
c. Please include an explanation of how the outcome variable is classified as a footnote to 
the figure.  
 
 
 
Discussion  
 
26. Overall, the discussion i s okay for now.  Depending on the decisions made in response to my 
suggestions, additional commentary (e.g. about the high -high findings) may be needed.  
 
 
 
Are the methods appropriate and well described?  
If not, please specify what is required in your comments to the authors.  
 
Yes 
 
Does the work include the necessary cont rols?  
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 statistic s 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 am able to assess the statistics  
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 salar y 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 
financ ially 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 organi zation 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 t he above, write 'I declare that I have  no competing interests' 
below. If your reply is yes to any, please give details below.  
 
I declare that I have no competing interests.  
 
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