Title: Knowledge, Attitudes, and Practices of Lebanese Women toward the Use of Oral
Contraceptive Pills
Version: 0 Date: 14 Nov 2023
Reviewer's report:
This was an ambitious project involving surveying women who came to pharmacies throughout
Lebanon. The underlying premise of this work seems to be that women need to be quite
knowledgeable about COCs to be motivated and able to use COCs to reduce unintended
pregnancy rates, but this is questionable. For example, why do all women need to know that oral
contraceptives can be used to treat some of the clinical problems posed by PCOS to want to use
pills to decrease unintended pregnancy rates? Technically, the authors are not correct; no COC
is “indicated” for many of the conditions displayed in Figure 1.
Why did the authors ask about “side effects”? Does knowledge of “side effects” promote further
COC use? Many of the side effects listed are wrong. Perhaps what the authors are trying to
demonstrate is that misinformation may be barriers to OC use, but they do not say that. Figure 2
does not represent “women’s knowledge”, since most epidemiologic studies and double-blind,
placebo-controlled studies have disproven that most of the listed “side effects” are attributable
to COCs. Most obviously, COCs reduce the risk of uterine cancer; uterine cancer is not a side
effect of OCs.
Why do random women need to know how to handle missed pills? Only 36.9% of those
interviewed were COC users and needed to know that. Maybe others had previously used pills
and might be expected to remember what they should have done when they forgot pills, but that
is not mentioned.
It would help if the authors described how OCs are accessed in Lebanon. Do users need
prescriptions? Do pharmacists provide access? Are they available over-the-counter? Are they
available free of cost from certain sources (free or public clinics)? If pills do not require
prescriptions, this may justify why the study was conducted in pharmacies. It may also explain
why the authors believe women would need to know this level of information about OCs.
The eligibility criteria are not specified. Are these women at-risk for pregnancy? Why should
they be expected to know this much about OCs?
How do the demographic characteristics of the study population compare to the general
population of Lebanon? There seems to be an excessive proportion of medically-related
professionals represented. Are there differences among the regions that could explain geographic
differences seen in COC use rates? This is not addressed but would seem to be significant. Have
there been similar findings in other studies? The authors state that their data set can be used for
“intra-study comparisons”, but it is not clear that the study is powered to accommodate these
subanalyses.
The authors use adjectives that are somewhat inflated, e.g., “invaluable guidance”, and
“imperative to conduct a survey”.
The failure rate of pregnancy (6%) does not represent a “high risk of failure”, but is exactly
what is expected in typical use during the first year of use. Unfortunately, the authors did not
ask about the duration of use to be able to accurately calculate the pregnancy rates.
The number of subjects in many of the analyses in this study are really quite modest. Many of
the analyses in Table 3 are based on 142 women. Were these analyses planned? Is this sample
size adequate to justify these sub-analyses? Was the survey beta-tested?
Much of the data in the background is unnecessary and/or incorrect (e.g., no method is 100%
correct and some of the mechanisms of action mentioned are not scientifically supported.
Do the authors attribute the “inadequate utilization of OCs” to a lack of knowledge? They need
to link a lack of knowledge to unintended pregnancies to justify their work.
The Discussion should be tightly edited.
The conclusion should be reconsidered. Do all “Lebanese women” need to know this level of
detail about COCs?  What types of educational programs are needed? What might work?
I would be happy to review any revisions the authors might decide to submit.