Title: “It was my own decision”: The transformational shift that influences a woman's decision
to use contraceptives covertly
Version: 2 Date: 23 Mar 2022
Reviewer's report:
General
This is a very well written account of qualitative research on covert use in four African countries,
and  the process by which women make the decision to use contraception covertly.
Background
Page 6, line 127: Please edit “Cruicially” to read, “Crucially”.
Methods
Page 9, line 193: The authors referred to immunization and contraceptive services being
provided by “different health providers”. Were the services delivered at the same geographical
location at the same time (same visit for women), or did the women have to make a separate trip
to access contraceptive services? This needs to be clearly explained in the text.
Results
Page 15, line 334: The authors describe bypassing negotiations with the participants’ husbands.
Were all situations a “bypass of negotiations”? Is this a reflection of the data or of the way
the authors have conceptualized “exercise of choice”? Authors should consider and address
the possibility of actual negotiations taking place between women and their husbands with the
women exercising her choice to use covertly due to failed negotiations. Basically, more nuance
is needed here.
Is additional information on age, number of living children, and level of education available
for the quotes shared, to better put the quotes in context? If the authors are concerned about
the possibility of this additional information making it easier to identify respondents, I fully
understand the need to maintain the anonymity of respondents.
Page 18, lines 399-400
The authors say, “Some women described initial attempts to discuss contraceptive use with their
husband but opted to avoid future negotiations once a refusal was voiced." This gets at my
earlier point. Were questions framed to refer to the current method being used covertly? If not,
it appears a discourse of “bypassing negotiations” projects an incomplete story. Authors should
revisit this thinking and provide a more balanced report.
Page 18, Line 401
“Other women felt that speaking with their husband would be difficult…” Did the women
explain why they felt such conversations would be difficult? If so, it would be good to include
such information here.
Page 18, line 409
The authors refer to a “difficult man”. Did this woman or someone else describe what “difficult”
means to them? Do you think this is “difficult” with regard to being mean, and possibly violent,
or “difficult” with respect to not being open to the wife trying to take control of her fertility, and
becoming involved in decision making?
Discussion
Page 24, lines 544 – 555
The authors wrote, “Women engaged in CCU when their fertility choices were not supported
within their relationship.” The nuance is missing from this statement as the results suggest that
some women do not discuss contraceptive use with their partners, especially if he is perceived
to be “difficult”. Would it be appropriate to say her fertility choices are not supported when in
fact, she has not discussed her fertility with her partner? A response to this is needed in the body
of the paper. The concept of reflexivity should be woven into the discussion.