Reviewer's report
Title:Prevalence And Determinants Of Unintended Pregnancy Among Pregnant
Woman Attending ANC At Gelemso General Hospital, Oromiya Region, East
Ethiopia: A Facility Based Cross-Sectional Study
Version:2Date:18 September 2015
Reviewer: Melissa L Harris
Reviewer's report:
Comments to the authors
The purpose of this article was to assess the prevalence of unintended
pregnancy among a group of women at the Gelemso General Hospital in
Ethiopia. Overall, this article can make an important contribution to the area,
however there is a lack of detail particularly around the methods. Please find
below specific points that may improve the quality of the manuscript.
Major revisions
1. Abstract: The authors have a number of spelling and formatting errors in the
abstract that need to be addressed.
2. Introduction: In the introduction, the authors should:
a) Provide contextual information regarding the sexual and reproductive health
services available for Ethiopian women. This should include any barriers to
accessing contraception, abortion and prenatal care, as well as more discussion
about unintended pregnancy in Ethiopia.
b) Provide the rates of infant mortality and maternal mortality in paragraphs 5 and
6 respectively.
3. Methods: The statistics appear to be sound, however much more detail is
required.
a) Please provide information regarding how the authors measured unintended
pregnancy, as well as justification for this. Ideally, the interview/survey questions
used should be included as a supplementary file.
b) Please provide details about each variable you tested in the bivariate logistic
regression, including the demographic variables. Please also justify the inclusion
of these variables.
c) In paragraph 3, the authors indicate that the sociodemographic information
and obstetric factors were collected using a pre-tested and structured
questionnaire. Can the authors please clarify what this means (i.e. was the
questionnaire piloted on your participants and if so when and how?).
d) More detail about when the surveys were administered (i.e. before, during or
after pregnancy) is needed as research has shown that perceptions of
unintended pregnancy change after birth.
e) Information about the setting in which women completed the survey is needed.
For example, how the women were approached? Did they complete the
interview/survey alone or with their partner present? Did the researchers assist
them to complete it? What were the participants doing when they were
surveyed? (i.e. waiting for their antenatal appointment?)
f) Information about the length of the interview/survey, as well as how long it took
participants to complete it is needed.
g) The authors need to be consistent about what their research instrument is: is it
a survey or a questionnaire or an interview?
h) Please specify whether the authors checked that their variables met the
assumptions of the statistical test, in particular the cell counts of some of these
variables are small (more detail under the subheading Table 3).
4. Results: The results section needs to be clearer. The following information
needs to be added:
a) Is the sample demographically representative of the broader population?
b) Is media exposure used to assess socio-economic status?
c) Please define ANC in text before using the acronym.
d) Please refer to the tables and figures in text.
e) Please explain the difference between pregnancy interval and birth interval in
paragraph 1, underneath the heading “Obstetric characteristics of the
respondents”.
f) In the 3rd paragraph under the heading “Obstetric characteristics of the
respondents”, the author’s state that “the most frequently mentioned reason for
getting conceived was found to be not considering self as fertile”. This has also
been found among women experiencing an unintended pregnancy in developed
countries, and would be an interesting point for discussion.
g) Under the heading “Determinants of unintended pregnancy among
respondents” please delete about when referring to the odds ratio
h) Please check your reporting of confidence intervals, frequencies and p-values,
often the authors have left out a % or other information.
5. Discussion: The discussion section would be greatly improved with the results
placed in context with the existing literature. For example, in paragraph three
under the discussion section, the authors propose that women who are divorced
or widowed were more likely to engage in sexual activities for reasons other than
child bearing, or that they are less likely to access contraceptives due to stigma.
This paragraph would be greatly improved with some references which back up
this argument.
6. Limitations: The authors require further discussion of their limitations. In
particular:
a) The authors state that “…a majority of clients with unintended pregnancy has
less likely chance to visit maternal health care service including ANC.” Please
provide references for this statement.
b) The authors need to provide some discussion about the limitations of their
sample. In the introduction the authors note that unintended pregnancy greatly
contributes to maternal mortality as a consequence of unsafe abortion, and that
this is a significant problem in Ethiopia. However, the authors only
interview/survey women with unintended pregnancies that lead to birth, and not
abortion. This means that the authors are unable to capture the
socio-demographic and reproductive characteristics of women who have an
unintended pregnancy but do not carry it to term.
7. Conclusion: The authors conclude by noting that increased awareness and
access to contraception may reduce rates of unintended pregnancy. This may be
true, but overly simplifies the complexity of unintended pregnancy and the
reasons why it occurs. In fact research has shown that, at least in developed
countries, unintended pregnancy often occurs due to contraceptive misuse,
rather than as a consequence of a lack of contraception. It is recommended that
the authors amend their conclusion to take into account some of these
complexities. Additionally, please provide some indication of what the potential
next steps are in light of your findings.
8. Figure 1: please amend the horizontal label to “Reason given for unintended
pregnancy” rather than “Reason for failure to avoid unintended pregnancy.”
9. Table 1: Please make the following changes:
a) Under marital status, please explain what “other” is, and why it is grouped with
divorced and widowed.
b) Under ethnicity, please explain what “other” is.
c) Under occupation, the authors give 3 options. Please explain in text why these
occupations were chosen (are they the top three that the participants indicated?)
d) Please give the total number of missing responses for each variable.
e) Please move the columns pregnancy status and crude OR to Tables 1 and 2
and add all p values for the univariate analyses. There is no need to have the
column for overall frequencies as you are interested in looking at unintended vs
intended pregnancies.
10. Table 2: Please make the following changes:
a) Under parity, please make your labels consistent. Suggest changing them to
“no children, 1-2 children, 3-4 children, 5 or more children”.
b) Please change the heading “Wanted numbers of child” to “Desired number of
children”, or similar.
c) Please specify the number of missing responses for each variable, rather than
giving the total number of participants (for example, “Interval between the last
two delivery (n=264)”.
d) Please make changes to this table as in 9e.
11. Table 3: Please make the following changes:
a) Under the heading “parity” please make your headings consistent, as
suggested above for Table 2. Why are these headings different to those under
“parity” in table 2? In particular, why is there a category for women with no
children in Table 2 but not in Table 3?
b) You have very wide confidence intervals in Table 3. Please address this in the
results section.
c) This table should only present the adjusted odds ratios for the included
variables.
Minor essential revisions
1. All spelling, grammar and formatting errors need to be fixed.
2. Throughout the text the authors refer to “parity”. I think this should be replaced
with “women with x number of children” as this will increase readability. This
needs to be consistent throughout the text. If you choose the keep using the
word parity, please do not abbreviate to “para” (see paragraph four in the
discussion section for an example).
3. Ensure that acronyms are placed after the name, place or thing i.e.
Demographic and Health Survey (DHS), not DHS (Demographic and Health
survey) as in paragraph 3 of the introduction.
Discretionary revisions
None
Level of interest: An article whose findings are important to those with closely
related research interests
Quality of written English: Not suitable for publication unless extensively edited
Statistical review: No, the manuscript does not need to be seen by a statistician.
Declaration of competing interests:
Melissa Harris was previously employed as a Project Coordinator on a funded
Australian Research Council Linkage grant that received some cash and in-kind
support from Family Planning NSW and Bayer Australia Ltd.
Jacqueline Coombe has no conflict of interest to disclose.