Reviewer’s report
Title: 
What are the prospects for the hormonal IUD in the public sector? A
mixed-method study of the user population in Zambia
Version: 
1 
Date: 
23 Nov 2021
Reviewer's report:
This paper provides useful insights into the use of hormonal IUDs through both
a quantitative and qualitative approach. 
There are many interesting results from
each component of the study that add to the evidence base as the hormonal IUD
is further scaled. 
However, I found myself wondering a few things and wonder if
your results can speak to these issues:
* The finding that hormonal IUD users tend to be older, wealthier, and more
employed was striking. 
Did anything in the IDIs provide any insight into why
this might be? 
While age and parity were not significant in the regression (but
see suggestion below about treating these as categorical variables), the profile
does appear to skew to older ages and higher parity for hormonal IUD users;
could this then be associated with some of the demographic differences? 
* Within the findings from the IDIs were you able to tease out differences in
motivation of method choice between implant and hormonal IUD users? Some
results from each are presented, but (if possible) it would be helpful to identify
where you see differences that might help to explain opting for one method
versus the others (especially given their many shared characteristics). 
This could
be useful in helping to inform SBC messaging, provider counseling tools, etc. 
Please find some more specific comments below: 
Could you say something about the choice in terminology of hormonal IUD vs
IUS? 
In the methodology section, can you please confirm (or discuss if not) if all of
the included facilities offered all of the included methods? 
Do you have client
data from the facilities to contextualize what share of overall FP clients select
one of the included methods? 
In the methodology section it would be helpful to provide a bit more context on
the survey sample. 
When was the data collected? How long was the recruitment
window to reach the desired sample size? To what degree does the sampling
approach represent a random selection of clients from the facilities? 
In results, when you point out differences between method users (e.g. lines 171-
173) it would be useful to indicate if these differences are significant given the
small sample sizes.
In the results, under Method Choice, the flow of the narrative may work better to
present the regression results after the results in Figures 1 & 2. 
Then you have
more descriptive results of differences, followed by a statistical analysis to
compare hormonal IUD to other method users. 
This could even become its own
sub-section on factors associated with method choice. 
Line 214-215; check these relative to Table 2. 
I see 52% for injectables, 78% for
implants, and 86% for copper IUD. 
In your regression, did you consider or experiment with using age and parity as
categorical variables, perhaps using the groupings show in Table 1? 
When discussing the results from the regression, I might be useful to point out
that beyond the variables discussed, results for all other variables were not
statistically significant. 
This in indicated in the table with bolding, but may help
to make this more apparent to the reader, especially as it is may be surprising
that some of these other variables did not show to be significant. 
Table 4: "Experienced problems when received method, %" consider rewording
this or adding a footnote with detail. 
The things listed in the text include some
expected effects (temporary pain, bruising) so would not necessarily classify
these as "problems". 
The comparison to injectable users is potentially
problematic for this indicator since the procedure is less invasive so would not
have similar expected effects. 
From the IDI did you get any indication of differences in choice drivers between
hormonal IUD, copper IUD, and implant users? 
It seems that many women
switched from injectables to one of these three methods, it would be helpful to
better understand what led to these different choices. 
Or for women who
switched from an implant to a hormonal IUD if they were included in the
sample. 
There is some method-specific information on method choice in the
qualitative results discussion but not really getting at the comparative differences
in choices. Perhaps including some more results/quotes from the 11 implant
users interviewed for comparison would be helpful? 
In the discussion, lines 370-373 I am a little unclear by the line of argument. 
You
note that a "sizeable minority" of clients were from lower educational or lower
quintiles, btu then go onto say this demonstrates that the public sector can
expand method choice for "traditionally underserved populations." 
Perhaps this
more says there is LARC demand across a range of different segments of
women, and the public sector is serving all of them, but maybe could do more to
reach the underserved groups? 
Though you would need to consider the relative
sizes of these groups, and their demand for contraceptives. 
Publons Reviewer Recognition
. Springer Nature can send verification of this
review directly to Publons (a subsidiary of Clarivate Analytics). If you would
like to take advantage of this service, please click on the “Yes” option below.
Your name, email address, title of the reviewed manuscript, name of the journal,
and date of your review submission (the “Review Data”) will then be transmitted
to Publons after the final decision on the manuscript has been made. If you have
already registered at Publons, they will notify you of the receipt of this review
and update your profile 
as per your settings and their policy. If you are not
registered with Publons, you will receive an email from them asking you to
register in order for them to be able to recognize your review on your new
profile page. Publons may use the Review Data to generate derivative metadata
for the benefit of Publons and you as a reviewer, carefully considering the
sensitivity of such information. For example, Publons may verify your record as
a reviewer by updating your profile published on its webservice if you have
registered for such service or help editors to identify candidate reviewers. Please
find the details of processing in Publons’ privacy policy
https://publons.com/about/terms
No
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 financially
from the publication of this manuscript, either now or in the future?
2
. 
Do you hold any stocks or shares in an organisation that 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 that I have no competing
interests' below. If your reply is yes to any, please give details below.
I declare I have no competing interests
Reviewer Publication Consent.
 I agree for my report to be made available
under an Open Access Creative Commons CC-BY License (
http://creativecommons.org/licenses/by/4.0
) if this manuscript is accepted for
publication. Any comments that I do not wish to be included in the published
report have been included as confidential comments to the editor, which will not
be published.
If you are not happy for us to publish this report, please contact the
editorial office before completing the review.
If you wish, you can include your
name in your published report. Please note you must decide whether to include
your name at the start of the process and confirm this decision whenever
prompted. If you change your decision later, we will not be able to publish your
name.
I agree to the terms of the CC-BY 4.0 license; please 
do not
 publish my name
with my report. (default)
Is the study design appropriate to answer the research question (including the use
of appropriate controls), and are the conclusions supported by the evidence
presented?
Yes
Are the methods sufficiently described to allow the study to be repeated?
Yes
Is the use of statistics and treatment of uncertainties appropriate?
Yes
Is the presentation of the work clear?
Yes
Are the images in this manuscript (including electrophoretic gels and blots) free
from apparent manipulation?
Yes