Title: Discontinuation of family planning use among women of reproductive age in Rwanda:
Analysis from three Rwandan Demographic Health Survey (RDHS) 2010 – 2020
Version: 1 Date: 11 Aug 2024
Reviewer's report:
Title: Discontinuation of family planning use among women of reproductive age (15-49 years)
in Rwanda, Analysis from three Rwandan Demographic Health Survey (RDHS) 2010 – 2020
• Revise, consider - ‘Discontinuation of family planning use among women of reproductive age
in Rwanda: Analysis of three Rwanda Demographic and Health Survey (RDHS) 2010 – 2020’
Abstract
Background and aim
• Delete ‘aim’ from the heading
• Revise the first sentence, consider talking about FP first and then the SDGs.
o There are a lot of SDGs. So what SDG is FP fundamental to achieving?
Methods
You need to revise this section.
“Pooled data analysis of three consecutive demographic and health surveys of Rwanda (RDHS)
for the years 2010/2011, 2014/2015, and 2019/2020) was conducted using Stata Version 17.0.”
• How does Rwanda refer to these survey years, 2010/2011 or 2010-11; 2014/2015 or 2014-15;
2019/2020 or 2019-20?
• There is also lack of consistency in the entire document.
“Sampling weight svy command (v005/1000000) was used to take account of the complex
sampling procedure. P < 0.05 was declared as statistical significance.”
• This detail should be in the main document. Here simply say weighted analysis was conducted.
Results
• Replace ‘rates’ with ‘percentage.’
“Pooled multivariate analysis indicated that FP discontinuation was more than double folds
higher in the RDHS 2014/2015 (AOR: 2.17; 95 % CI: 2.01 to 2.35) and RDHS 2019/2020 (AOR:
2.71; 95 % CI: 2.49 to 2.93) as compared to RDHS 2010/2021.”
• You already stated that the study used data from the RDHS and the respective years. Therefore,
there's no need to keep mentioning 'RDHS' before the year.
• The last survey year in the sentence should be 2010-11 and not 2010/2021.
• Consider, “Pooled multivariate analysis indicated that FP discontinuation was more than
double folds higher in 2014-15 (AOR: 2.17; 95 % CI: 2.01 to 2.35) and 2019-20 (AOR: 2.71;
95 % CI: 2.49 to 2.93) as compared to 2010-11.”
Conclusions
• Ensure that the conclusion and recommendations are based on the study findings.
Background
“A study by Winfrey highlighted that about 25 million of the 75 million unintended births
happened in developing countries due to FP discontinuation [8].”
• Review and edit. You need to write this citation as done for others where no names are
mentioned.
“Furthermore, a study in six African countries stated that over 80% women with unintended
pregnancies had not used any FP method, and among the traditional method users, 83.8%
discontinued due to failure and among the modern method users 40.2% discontinued due to side
effect[13].”
• Add ‘of’ between 80% and women.
• effect = effects
“Majority of unwanted pregnancies and unsafe abortions happens”….
• happens = happens
Approximately 58 million women in African don’t = Approximately 58 million women in Africa
do not…
“Women’s average family size is 3.1 children, compared with the family size projection of 2.4
in 2050 [26].”
• Average family size in what year?
• Why compare with a projection for 2050?
“This rapid population growth, fueled by high fertility rates in Rwanda, is currently undermining
the government efforts on reducing poverty across the country [27].”
• There is no population growth stated in the previous sentence.
Check and revise sentence, “Each year, nearly half (47%) of all pregnancies in Rwanda are
unintended and an estimated 22% of unintended pregnancies end in induced abortion despite
legal restrictions. which often leads to unplanned births [28].”
“A national study by Rugigana Etienne [22] found that 74.6% of women discontinued FP use
and the latest RDHS report indicated that about 30% women in Rwanda discontinue FP.”
• The variation between the two studies is huge.
• Rugigana Etienne, conducted a study when and among who?
• You need to write this citation as done for others where there are no names are mentioned.
Check proposed revision, “Therefore, the purpose of this study was to assess FP discontinuation
and its associated factors among women of reproductive age in Rwanda, a secondary pooled
data analysis from RHDS of 2010-11, 2014-15, and 2019-20.”
What gap in literature has been identified? What's the study rationale?
Methods
This section needs to be reorganised and strengthened. There's a lot going in this one paragraph.
Please create key subheadings and provide the relevant information as per journal guidelines.
You need to have separate sections on, e.g. ‘Study design’, ‘sampling design and procedure’,
and ‘study variables’
Add ‘years’ after 15-49
“In this analysis, a woman’s Questionnaire was considered.”
• You didn’t analyse the woman’s questionnaire but women’s recode.
Before you begin to talk about variables, you have not explained:
• Which women were included in this study?
• What's your study’s sample size?
Variables
• With clear subheadings, begin first by explaining the dependent variable, then the independent
variables
• respondents = women
• number of born children = number of children ever born
• what is ‘information and source about FP’?
• I don’t think what is listed (women participation in decision-making for using FP, history
of terminated pregnancy, visited health facility in the last 12 months, discussed about FP with
healthcare worker, and fertility preference) qualifies to be classified as cultural factors.
• What measure of fertility preference was considered?
• There is need to explain in detail how the independent variables were categorised or coded
and/or defined (if applicable) in this study.
“We made use of the DHS calendar file and created the event file in order to analyze the FP
discontinuation events among women aged 15–49 who used contraception in 5 years before the
survey and discontinued within 12 months after beginning its use. Discontinued events were the
unit of analysis for further exploration.”
• This does not explain how the dependent variable was created including its categorisation.
• Add ‘years’ after 15-49
• Add ‘the’ before ‘5 years’
“Enhancing data usage for further analysis and exploration to find detail information is one of
the key goals of the DHS initiative.”
• detail = detailed
Data Analysis
“Three consecutive RDHS 2010/2011-2019/2020) were used for analysis.”
• One survey year is missing.
“Reference categories were informed by previous studies and a priori.”
• I think this should be in the description of independent variables.
Results
Distribution of socio demographic characteristics, information related factors and pattern of FP
discontinuation
“Table 1 displays the fundamental characteristics of the women.”
• Consider deleting ‘fundamental’
You need to rewrite some sentences here.
• For example, you already stated that the study used data from the RDHS and the respective
years. Therefore, there's no need to keep mentioning 'RDHS' before the year. Also, the results
obtained from the DHS for a given country are not about those interviewed but the entire target
population from which those were drawn. As such, you should also delete ‘participating’ or
‘participated’ used in some of your study results and discussion.
• Proportion = percentage.
• There are some missing words.
This sentence is not clear; “Household wealth index indicated that 22% to 23% of the DHS
participating women were from the highest wealth quantile.”
This sentence is not clear; “Similarly, the proportion of women who received information about
FP from Television increased from 5% -to -11% and FP use of any type has increased from 29%
to 39% in RDHS 2010/2011 and RDHS 2019/2020.”
“Similarly, women’s participation in the decision making of FP use has increased from 8% to
10% between during the same time period.”
• Consider; “Similarly, women’s participation in the decision making of FP use has increased
from 8% to 10% during the same time period.
Table 1. Distribution of socio demographic characteristics, information related factors and
pattern of FP discontinuation in the three RDHS 2010-2020 (weighted).
• Deleted ‘weighted’ from the title, to read “Table 1. Distribution of socio demographic
characteristics, information related factors and pattern of FP discontinuation, RDHS 2010, 2014,
and 2019”
• Women’s education attainment = Education attainment
• Currently/formerly/never in union = Marital status
o Never in union = Never married
o In union = Currently married
o Formerly in union = Formerly married
• Women participation in Family planning decision making = Participation in FP decision
making – use or non-use?
• Family planning use in the last 12 months – I didn’t see this one in the methodology.
• Fertility preference = measured by?
• Once the variable naming and description is clear in the methodology, ensure that you make
corrections in both the text and the tables (i.e. Tables 1 and 2).
Types of FP uptake discontinuation among the regions of Rwanda
Consider, “Pills were the most frequent method discontinued by the majority of the women in the
three different DHSs in Rwanda followed by male condom and periodic abstinence (Figure 1).
Furthermore, withdrawal was the fourth ranked practice on FP discontinuation among women
of reproductive age.”
• Percentages would be useful.
• Draw Figure 1 vertical scale to 100%
Factors associated with FP Discontinuation among Women of Reproductive age in Rwanda
participation in decision making for FP use or non-use?
maternal age = simply ‘age’
number of living children or children ever born?
educational level of the mother shouldn’t it be woman?
wontedness = wantedness
sources of information: information about?
Table 2
• Why does it have three columns for percentages?
• What percentage is the other column presenting?
o N (%) – shouldn’t this have been in table 1?
• The % discontinued plus not discontinued in a given category of an independent variable should
equal to 100%. But this is not what was done.
• The table can be made less crowded by removing the columns for those who discontinued FP,
and the N (%) (which should be in table 1). Full table with all results could be provided to enable
verification of the results.
• Other comments with regards to names of variables are same as observed on Table 1.
Multivariate analysis of predicting variables of FP Discontinuation among Women of
Reproductive age in Rwanda
Yet the table also has the crude odds ratios.
You need to rewrite some sentences here. There are some sentences with missing words, others
are unclear.
• Deleted ‘participated’
• Check and correct the sentence “..were more than two folds more experienced FP
discontinuation than women participated in the RDHS 2010/2011 (AOR: 2.17; 95 % CI: 2.01
to 2.35) and (AOR: 2.71; 95 % CI: 2.49 to 2.93), respectively.”
• mothers = women
• “women aged less than 20 years.” – state the age range.
• “gravida of less than three” – you have not used this term before.
•  Check and correct: “more likely to discontinue FP than women of > four or more children,
and the difference was significant (AOR: 1.38; 95 % CI: 1.28 to 1.49).”
Table 3:  Multivariate analysis of predicting variables of FP Discontinuation among Women of
Reproductive age in Rwanda
Yet the table also has the crude odds ratios.
Reasons of FP uptake discontinuation among women of reproductive age in Rwanda
• Check and revise the sentence.
• Figure 2 should be well labelled; the vertical and horizontal axis respectively.
Discussion
Overall, the discussion is inadequate and needs to be improved. The current version is a more
of a summary of statistical findings and mainly states how the study’s findings compare and
contrast with those of other studies.
• The reasons for most of the study’s findings hasn't been explained. Some of those, which have
been explained lacks relevant supporting literature.
• The section also has some typographical errors etc., making it difficult to understand the
message.
• There are many issues, as such, the write up below is not exhaustive.
Sentence one should be revised. “In the present study, FP discontinuation five years before the
survey was found 17%, 28%, and 29% in the three consecutive DHS surveys from 2010 to 2020
in Rwanda.”
• Also state the actual survey years.
Sentence two – ‘global average’ when?
Sentence four - “This large difference could be due to variation on unmet need among women of
Papua New Guinea as compred to Rwandan women, in which unmet needs is leading millions
of women of current users of FP to discontinue in the future.”
• unmet need for FP; check also the entire section
• compred = compared
• “leading millions of women” can we have the actual statistics here (% or number).
• Add reference (s)
“Pills were the most frequent method discontinued by majority of women participants in the
three DHS surveys from 2010 to 2020 in Rwanda followed by male condom and periodic
abstinence.”
• Check and revise by stating the actual survey years.
• Delete ‘participants’
“Overall, 11.65% and 11.17% of all respondents discontinued the use of FP methods because
of perceived they became pregnant and another more effective FP methods[13, 16].”
• Check and revise as the sentence aren’t clear.
• another = other
“By demographic factors, FP discontinuation was higher among young aged women, women
with no living children or just one child, and women who space births.”
• Did you analyse: children living or children ever born? women who space births?
• young aged women = young women
“This might be because older women have used their FP method for a longer period and are
more familiar with the method and hence more likely continue its use compared with younger
women.”
• You need to provide more reasons for the findings, and with supporting literature.
“Regarding the number of living children, women with more children might be more likely to
limit births and to realize that they are at higher risk of unwanted pregnancy than women with
lower parity, and hence more likely continue their use of contraception.”
• References needed.
“A small difference was highlighted by place of residence and regions in Rwanda, where the
highest percent of FP discontinuation was found in the Eastern province in the three consecutive
RDHSs from 2010 to 2020.”
• Check and revise by stating the actual survey years.
“Women respondents from the Western region, Kigali, South, North, and East were 1.33 times,
1.32 times, 1.30 times, and 1.27 times more likely to discontinue FP compared to women from
West and these differences were found significant (p<0.001) after adjusting.”
• Women respondents = delete ‘respondents’
• and these differences were found significant – delete
“The difference in FP discontinuation might be concerning for women in the Kigali and North
and this may be associated with women’s less autonomy in the high FP discontinuation regions
of Rwanda.”
• You need to provide reasons for the findings, and with supporting literature.
“Our finding also revealed that health facility attendance 12 months preceding the survey was
significantly associated with FP discontinuation by 1.56 times (AOR: 1.56; 95 % CI: 1.46 to
1.66).”
• What could be the reasons for the findings.?
“Women’s history of terminating pregnancy, were associated with FP discontinuation among
women of reproductive age in Rwanda.”
“In this analysis women participation in FP decision making had not association with FP
discontinuation. “The is different from other study stating male partners influences on FP and
FP use [31].”
• What could be the reasons for the findings.?
• What would you suggest?
“Furthermore, women with four and above parity were found more to discounted FP as compared
to less than three parities.”
• discounted = discontinue
• revise sentence
“This association was corresponding to a study among women reproductive age in Papua New
Guinea [30].”
• Check and revise sentence.
• What could be the reasons for the findings.?
“Women of in union during the data collection have reported more FP discontinuation than
women of who has never in union or formerly in union.”
• Revise sentence and give reasons for the findings.
Suggested revision, however, this sentence seems like a repetition. The paragraph before the
last two also has information on parity.; “Women with four or more parity were more likely to
discontinue FP use within the first 12 months. This was consistent with findings from studies
in other low-income countries [30].”
• This is a repetition. The paragraph before the last two also has information on parity.
“The present finding shows that FP discontinuation among women of reproductive age in
Rwanda is relatively common. This also reveals that, important determinants of FP which are
crucial for improving FP services in Rwanda to bring a change on unintentional/unnecessary
FP discontinuation. Further, this study suggests the FP counseling is needed about the different
choices of FP methods and potential side effects.”
• The conclusion and recommendations should be based on study findings.
Add separate sections on study conclusion; strengths and limitations of the study.
Declarations
• Review the journal author guidelines when preparing this section.
Abbreviations
Odd’s = Odds
Demographic Health Survey = Demographic and Health Survey
Acknowledgements
• “.. providing the data for analysis.” Consider: ‘approving the use of the RDHS 2010-11,
2014-15, 2019-20 women’s recode for use in this study.’
Authors’ contributions
• formal  = statistical
• data  = results
• report  = and manuscript
• This is not clear: ‘edited finally’
Ethics approval and consent to participate
• This section has two aspects (Ethics approval; and consent to participate), which you need to
ensure that you address in the write up.
• “The authorisation for using the data in the current analysis was granted from the DHS
programme: DHS, ICF international, Rockville, Maryland, USA office upon presenting the
research protocol and research plan aims.”
o Do requests for a dataset require one to submit a research protocol and research plan?
# Review the paragraph and correct accordingly.
o Use ‘Program’ since it is American English.
• There is no write up on “Consent to participate.”
Other suggestions
• Section headings should be in bold.
• Put spacing in between paragraphs.
• Also ensure to have well formatted tables and figures.
• Proofread your manuscript thoroughly.
• The manuscript could benefit from editing services.