Reviewer's report
Title:Womens' preferences and values in contraceptive choice: a systematic
review of relevant attributes
Version:2Date:12 November 2013
Reviewer: Rebecca French
Reviewer's report:
This systematic review identifies attributes that are important to women’s
contraceptive decision-making. In addition to the research literature online
decision aids are also examined to identify contraceptive attributes used in these
tools. This paper provides a useful summary for those designing interventions,
for those delivering care and for contraceptive users.
Below I have some comments for the authors, which I feel need to be addressed
in the paper:
1) The search strategy is thorough and transparent although unless published in
an academic journal, paper-based decision tools would not have been included
(which are more likely to be used in resource-poor settings).
2) There were no limitations on study design and the authors explain that study
quality was not examined systematically as online decision tools were included.
However, I feel it would be useful to report more on the study designs of the
included studies and the possible effects design could have on the findings, e.g.
were all the surveys single cross-sectional studies? The authors comment in the
Discussion, “If we assume that the surveys/interviews reflect the true perspective
of women….” – given that little on study quality is provided in the paper, including
how the participants were sampled, the authors should be cautious about any
assumptions about representativeness of the findings.
3) Was there any information online on how the decision aids were developed,
e.g. any formative work with users, reviewing of the literature. This may explain
why more attributes were identified in decision aids than the surveys – and
perhaps those creating online tools need to be more transparent in how they
have developed them. I should disclose that I was involved in the development of
My Contraception Tool, and a paper on the development is to be published any
day now in the Journal of Family Planning and Reproductive Healthcare (so
obviously not within the search dates of this paper).
4) Many of the tools developed online had not been evaluated (or certainly these
evaluations had not been published). There are many problems in evaluating
interventions online, such as selection bias, validation of responses, etc. Again
this may be worth making reference to in the Discussion.
5) Social, cultural and geographical factors can shape women’s preferences and
values around contraception. Is it possible to do any subgroup analysis or at
least raise these issues in the Discussion? For example, cost is not an attribute
that is likely to affect decision-making in the United Kingdom as contraception is
freely available, while in other areas of the world it is likely to influence choice (or
lack of it). How women view menstrual change associated with contraceptive use
(e.g. amenorrhoea) can be influenced by age or cultural norms – and so on. So
information, whether it is through pamphlets, decision aids or face-to-face
counselling, should take account of the factors that may affect women (and
men’s) preferences.
6) The authors comment that a problem with some of the surveys is that the
attributes identified may have been investigator-driven. Given the point raised in
the paragraph above and the fact that only one qualitative study was identified in
the search strategy (which I am surprised about), perhaps more qualitative
research is required to better understand what influences women’s contraceptive
preferences. As the attributes that are important to women are unlikely to be
fixed do we also need prospective studies to better understand how preferences
change over time and with contraceptive experience?
Level of interest: An article of outstanding merit and interest in its field
Quality of written English: Acceptable
Statistical review: No, the manuscript does not need to be seen by a statistician.
Declaration of competing interests:
I declare that I have no competing interests