Reviewer ’s report  
Title: Unfulfilled need for contraception among women with unmet  need but with the intention 
to use co ntraception in Rakai, Uganda: A longitudinal study  
 
Version: 2 Date: 09 Feb 2018  
 
Reviewer: Anita Nelson  
 
Reviewer's report:  
PleBMWH -D-17-00398R2  
 
Unfulfilled demand for contraception among women with unmet need but with the intention to 
use contracept ion in Rakai Uganda  
 
I appreciate the modifications the authors have made to improve this manuscript. It highlights an 
important distinction between 2 subgroups of women who desire not be become pregnant - those 
who do not desire to take any action to avoi d pregnancy and those who plan to use some form of 
contraception to prevent that pregnancy. This distinction is important in understanding the most 
important message of this study that unmet need for contraception does not reflect latent demand 
for contrac eption. However, the authors take quite a convoluted approach to defining those 2 
groups and use unnecessary terminology "a casual relationship between." As I understand it, 
"unmet need for contraception" includes all women who do not want to become pregna nt 
whether or not they had planned to use contraception. "Unfulfilled need for contraception" on the 
other hand, represents the women who said at baseline that they wanted to use contraception, but 
for some reason did not, whether or not they became pregna nt in the temporal interval between 
surveys.  
 
The authors attempt to use an available database of serial interviews of women over time. 
However, after I have read this several times, it is still not clear how dynamic the analysis was. 
Were women able to ch ange their status at different interview times? If so, were any changes in 
status between interviews captured? An example of the former would be the woman who at 
baseline had unmet need (did not want a pregnancy at this time) and wanted to use contraceptio n. 
If she was not using contraception at the time of the next interview, she was labeled as having an 
"unfilled demand." But what if she changed her mind by the time of the second interview and did 
not want to use contraception was she still an "unfulfille d demand" or was she now jus "unmet 
needs"? An example of the latter would be the woman who did use contraception during a 
significant proportion of the interval between interviews, but was not using it at the time of the 
second interview - was she classif ied as an "unfilled needs"? And what about the woman who, 
during the interval, decided she sought pregnancy (but did not yet achieve it) --- was she still 
unfulfilled? I suspect that the authors did not have enough information to be able to adjust for 
these contingencies. They had only static information at intervals the time points at which the 
woman were interviewed. This is certainly understandable but should be discussed as a limitation 
of the study design.  
 
Another limitation is that some of the tradit ional method of birth control were apparently not 
credited. For example, it was said that one common reason women gave for nonuse of 
contraception was that they were breastfeeding and had not had return of menses; that sounds an 
awful lot like lactational amenorrhea to me.  
 
From a policy standpoint, the women who have "unfilled demand" would appear to be low 
hanging fruit and constitute the highest priority group. They have the greatest potential to 
increase the cost effectiveness of any future expansion of  family planning programs. This might 
be an important conclusion from this analysis. Women over 40 certainly constitute a very high -
risk group with recognized higher mortality risks, so identifying them is important for policy 
makers to know. On the other hand, if you are trying to minimize women -years of life lost, then 
prevention of maternal mortality among younger women would be the focus. These conclusions 
would certainly strengthen the conclusion/discussion sections.  
 
I suggest the authors consider th ese changes so their manuscript will be more impactful and 
ready for publication. I would be happy to review any revisions the authors submit.  
 
 
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 controls?  
If not, please specify which controls are required in your comments to the authors.  
Unable to assess  
Are the conclusions drawn adequately supported by the data shown?  
If not, please explain in your comments to the authors.  
No 
Are you able to assess any statistics in the manus cript or would you recommend an 
additional statistical review?  
If an additiona l 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 salary from an  
organisation that may in any way gain or lose financial ly from the publication of this 
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2. Do you hold any stocks or shares in an organisation t hat may in any way gain or lose 
financially 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 organization 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 the above, write 'I declare th at I have no competing interests' 
below. If your reply is yes to any, please give details below.  
 
Grants/Researce:  Agile, ContraMed, Estetra SPRL, Evofem Inc, FHI (MonaLisa), Mathra 
Pharma, Merck  
Honoraria/Speakers Bureau:  Allergan, Bayer, Merck  
Consultan t/Advisory Board:  Agile, AMAG Pharma, Bayer, ContraMed, Merck, Pharmanest  
 
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