Reviewer’s report
Title: Side Effect Concerns and their Impact on Women ’s Uptake of Modern Family Planning Methods
in Rural Ghana: A Mixed Methods Study
Version: 0 Date: 23 Nov 2019
Reviewer: Kwabena Appiah-Sakyi
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¹ the evidenced that women want smaller families ( in the Ghanaian context ) must be provided 
² how available are the various contraceptive methods in Ghana? Generalised statements to suggest
widespread availability is assumed and i think that is incorrect , particularly for suburban regions. very
few options are available
³ it is not clearly stated how many private and public factilities are in this district provide cobtraception,
and what kind of contraceptive methods they have. most private facilities are in the cities so at district
level , it is erroneous to assume most LARCs will be available there 
what is the rate of unmet in Ghana relative to other african states, as Ghana is described as one of the⁴
highest.
  i think, as stated earlier , one needs to clarify the availability of these methods in this  rural⁵
community. implants, IUDs & sterilization is not easily available so that should be made very clear 
 It needs to be made clear what the definition of marriage is here. In Ghana, village marriages may be⁶
more loosely defined than you would find in the west, so one needs to make clear how they are
defining a married person, distinguishing cohabitation, registered and traditionally arranged marriages -
all of which could be described in some settings as marriage.
 over 50% of the women with met needs  have DMPA and we know that DMPA is notorious for some⁷
of the bad press contraception has received. In the west very few women are on DPMA because we
have better methods with less side effects, if we promote DMPA in less resourced setting then much
more support and clinical oversight is required 
the  myths about menstral problem with use of modern contraception and its longterm effects have⁸
passed from one generation to the next without any active intervention to address them head on. This
finding is observed in many studies .... please discuss how to deal with this problem especially with full
understanding of what will work in the  local context 
education is good but may not be enough. actually providing mitigation steps for  women with⁹
abnormal  menstration  through  treatment  by  trained  health  practitioners  will  offer  women  more
confidence despite the side effects . Typically when these women have the side effect they have no
where to turn for reassurance or to discuss options. Their only option then is to stop using the methods
and thus be exposed to unwanted pregnancy.
¹ . what is the availability of this scheduled folow - up and clinical management in the district where⁰
study was conducted 
¹¹. how accessible and available were these LARC in the  Ghanaian district ? 
please see the attached highlighted comments in the article
I think much has been written about the myth surrounding challenges with contraception use in LMIC.
we cannot assume contraception is easily available to all women everywhere in Ghana , that's simply
untrue. those is district setting have real challenges eith access and continuity , not to mention the poor
counseling and treatment highlighted in the study. 
I think the authors should seek to beat a new path by going further than  what has received extensive
previous press, but dig into the real issues which is making women not engage which is : poorly trained
HW whi are unabke to support women when that have menstal side effects and eed clinical imput. we
also need to move away from DPMA and consider and more modern methods if we mean business with
family planning in LMICs
finally effort must be made to find the local availability of the different contraceptive methods  so as to
fully understand why more that 50% of women with met needs are on DPMA . it ti probably the only
method available there
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