Title: Pregnancy risk and contraception among reproductive-age women with rheumatic heart
disease attending care at a tertiary cardiac center in Tanzania: a hospital-based cross- sectional
study
Version: 2 Date: 29 Jan 2023
Reviewer's report:
This is an important topic and worthy of investigation; this manuscript provides a starting point
for further inquiry into contraceptive use amongst women with RHD (which may be relevant
for women with other cardiac diagnoses). This manuscript could be strengthened with revision
and could provide valuable data for both local and international researchers and clinicians.
Abstract
In the abstract and throughout the article it is important to clarify of the pregnancies were
unplanned or unwanted, as these are different in important ways. Further, it is unclear if the
assessment of the desirability of a pregnancy is that of the authors/medical practitioner, or the
women’s assessment, again, very different scenarios.
Language and grammar
In the abstract and throughout the article it would be beneficial to use a free tool such as
Grammarly to assist with diction and sentence structure. Please note in proper nouns such as
New York Heart Association, all words are capitalized.
“Contraception” is a noun, and you are interested in how many women with RHD use
contraception (i.e., you need the verb) and this needs to be included throughout the article.
For example, instead of “the proportion of contraception was …” becomes something like “the
proportion of women who were using contraception was …”.
In the results it would be useful to quantify “reduced ejection fraction”.
The authors make a valuable observation on page 12 that their cohort may not be representative
of all women with RHD, due to the recruitment strategy (hospital-based); this would be useful
to note in the abstract conclusion, or at least note something to the effect of “… in our hospital-
based cohort …”.
Background
It may not be worth including, but there are pockets of RHD in high-income countries,
specifically amongst indigenous populations, e.g. Katzenellenbogen, J. M., Bond-Smith, D.,
Seth, R. J., et al. (2020). https://doi.org/10.1161/JAHA.120.016851
There is definitely a paucity of research on contraception in women with cardiac disease,
including women with RHD, however there is some work that is available, and that is more
specific than the few lines in the Remedy study. These studies include issues such as risk
perception, motivations, desire to have children, and more.  Works include that by Matthew
Cauldwell, Mathias Kaemmerer, Sarah Holton and Kylie Ngu.  Issues for women with congenital
heart disease may be relevant for women with RHD and this data may help inform future research
on contraceptive use to inform the guidelines etc. as noted in the conclusion.
The last paragraph of the background
Do guidelines outline “management of reproductive age women” or do they describe managing
risk, providing education etc.?
Is the goal to ensure better pregnancy outcome or to avoid unplanned pregnancy, or both?  If
the discussion is about contraceptive use, then avoiding pregnancy needs to be at least one of
the intended outcomes.
It would be helpful to provide a brief synopsis of the poor pregnancy outcomes experienced by
women with RHD, rather than repeating that outcomes are poor without describing how.  That
is, maternal, foetal and neonatal morbidity and mortality.
Methods
• World Heart Federation needs to be capitalized.
• Consider re-writing the second sentence for improved clarity.
• Operational definitions – citations are required.
• I recommend referring to implants and injections as hormonal implants/injections.
Study procedures.
Consider re-wording the two sentences.  It would be helpful to clarify that when women received
the information and accepted the invitation to participate, that informed consent was given and
that there was no negative consequence of not participating (particularly as they were current
patients and as such, may feel vulnerable).
Who was the ECG read by?  Including the role of the reader is helpful (e.g. cardiologist).
Ethical considerations
Does the institutional ethics approval conform to the ethical principles for medical research on
human beings set out in the declaration of Helsinki (World Medical Association, 2013).
- If the project fulfills requirements on research: information, consent, confidentially and safety
of the participants and was guided by the ethical principles: autonomy, beneficence, non-
maleficence, and justice.
- If all participation and data collection were confidentially and with informed consent from the
participants.
- If the participants received both verbal and written information about the project and that they
could withdraw from the project at any time without any explanation.
Results
Noting that 65% of women were married, and that later it is commented that reproductive
decisions may be determined by the male spouse, it would be interesting to see the data analysed
by married/not married. Further, reporting on lesion severity and WHO risk classification by
age and marital status, contraception use by age and marital status, if sexually active, and if the
women already have children or not.
There is a high level of repetition between the first paragraph and Table 1 – this may be abridged
which would allow space for additional data above.
In table 2 please quantify normal/mildly reduced/reduced LVEF.
Reasons for choice – was this a single answer only?  For example, the women who nominated
safety as the reason for choice may have had that choice advised by their health worker based
on safety.
Consider rephrasing barrier methods being in “reliable hands”.
Is the goal to “ensure adherence”, or encourage, enable, support women to make informed
choices?
Women with RHD and other chronic health conditions may desire reversible contraception and
the option to have children, this is not specific to African countries (see authors above).
A key sentence in the results warrants elaboration and further research:
“… almost half of all participants were told by their attending doctor that they were not strong
enough to be pregnant but they were not specifically told to be on contraception.”
The reasons postulated are a good start and undertaking further research on this, as well as on
what women understand about their risks, desires for children, and decision-making processes
(and ownership or otherwise).
Conclusion
Comment regarding noting these results are specific to the study cohort and not necessarily
representative of all women with RHD as above.
Further research as above is required to inform the actions suggested in the discussion.