Reviewer ’s report  
 
Title: Modern Contraceptive Use among Postpartum Women l iving with HIV Attending Mother 
Baby Care Points in Kabarole District, Ug anda  
 
Version: 1 Date: 01 May 2018  
 
Reviewer: Deborah Lynn Billings  
 
Reviewer's report:  
 
Review BMC Women's Health  
 
Modern Contraceptive Use, Women Living w ith HIV, Uganda  
 
Overall, this paper presents some interesting findings that are relevant to strengthening the 
arguments that contraceptive care services should be better integrated into postpartum services, 
including for women living with HIV.  My comment s that follow aim to strengthen the paper, 
both in terms of the clarity of the concepts that are used as well as in enabling readers to better 
understand the Ugandan context in which this study took place.  
 
 
Terms that need further clarification:  
 
* Mother -baby HIV care points (in the main text, they are referred to as mother -baby care 
points, without referring to HIV) - what are these exactly?  Are they specialty clinics?  
Are they Uganda -specific? What kind of care of provided to women and babies who 
access  services at these points?  When were they started in Uganda?  How 
useful/successful/effective have they been in achieving what they set out to offer?  
 
* Why is the term "mother" used throughout the paper instead of "woman" or "women"? 
The term "HIV positiv e women" is used in the Background section of the abstract but no 
where else in the paper.  To this reviewer, it is important to acknowledge that services, 
including contraceptive services, are important to women as women and not just as 
mothers.   
 
 
Overal l comments  
 
* Please explain in the abstract and early in the text, why estimating modern contraceptive 
prevalence, unmet needs, and factors associated with modern contraceptive use among 
postpartum mothers living with HIV is important to do?  And, in particular, why was this 
important to do in Kabarole District, Western Uganda.  Provide the reader with more 
context to show the importance of this study and its relevance to this particular part of 
Uganda.  And what does it teach us in general? Wh at lessons can be taken for those not 
living in that part of Uganda or Uganda overall?  
* It would be helpful to contextualize and compare the results for HIV+ women with 
women who are not HIV+ (but experiencing postpartum care).  While this comparison is 
made at some point, it comes at the end of the paper and is somewhat lost in the 
discussion.  Include this comparison up -front, including in the abstract.  
 
* Be consistent when referring to partners - sometimes the term "spouse" is used (implying 
marriage), sometimes "male partner".  Clarify that assumptions were made that all 
partners were male and that women with same -sex partners were not included or 
identified as such in the study.  
 
* Why was the period of 2 to 18 months postpartum chosen for inclusion?  Given that no 
justification is presented, this seems somewhat random and is actually quite a broad range 
of time, where a woman's life, sexual activity, and desire for another child can shift 
radically.  Please justify why this time period was chosen and h ow it makes sense to 
include data from all women in this broad time range.   
 
* Please describe from the outset of the paper whether and how / to what extent 
contraceptive counseling and methods are integrated into care points.  
 
 
Keywords: please add "anten atal" to the list of keywords  
 
 
Background:  
 
* Please define "unintended pregnancy" and cite the source of the definition used  
 
* Clarify that rates cited on p3, line 55, are for Sub -Saharan Africa, not Africa overall  
 
* P3: please clarify what "safe fertilit y decisions" refers to… what is meant by "safe" (here 
it would be important to clarify the authors' position on HIV+ women becoming 
pregnant)  
 
* P.4: it is not clear which countries or regions are being cited for the different rates given.  
Please note wher e studies were undertaken for citations 7 -15.  Citations 14 and 15 refer to 
women in Ohio (14) and women in Iran (15) and yet a very general statement about 
"postpartum women" is made.  These contexts and the women themselves are/can be very 
different and so citing these studies and then generalizing does not provide a strong basis 
for the statement made.  Instead, please cite global reviews that have been done to 
support statements made, eg p. 4, lines 69 -71 
 
* P4, line 79, citation 18: why is the document of WHO medical eligibility criteria serve as 
a reference for the statement made about determinants of postpartum contraceptive use 
among women living with HIV (instead, cite the original source that can support such a 
statement).  
 
Methods  
 
* P5, line 90: d oes 11.3% refer to women only, women and men together?  And what is the 
prevalence for pregnant women (the population of interest in this study)?  
 
* What does "very sick mothers" mean?  What defined "very sick" so as to exclude them 
from the study?  And wh o defined this?  
 
* Please define how many times a woman needed to attend the care point to be included in 
the study  
 
* The final sample size was 369.  What was the desired sample size?  How many women 
were recruited and what percentage (and number) refused t o participate?  
 
* Please define where the interviews were held and who conducted the interviews?  Were 
the interviewers staff at the care points?  (if so, this could compromise the quality of the 
data)  
 
* Please note how design effect was calculated  
 
* P 6, line 111: according to the PP to size sampling, how many participants should have 
been selected from each health facility and how many actually were recruited (and how 
many actually participated)?  
 
* How were "participants selected as they arrived for care "- describe in greater detail what 
was done, especially so that confidentiality was ensured and women had the opportunity 
to not participate if they didn't want to.  
 
* Were any incentives or compensation offered to women for their participation?  If so, 
note what that was; If not, state that and state why not.  
 
* What was defined as a "modern contraceptive method" for this study?  
 
* Use was defined as "yes" or "no" - was information also collected on the types and 
number of contraceptives being used (simultaneo usly)?  If not, why not?  
 
* P 7, line 139 - why was "access to contraceptives at the care points" included in a list of 
variables that are all women -specific?  In general, the question is, in the analysis, how 
were context/infrastructure specific variables included and understand as separate from 
but complementing women -specific variables?  
 
* Line 144: what does "partner intention to use a modern contraceptive" mean - does this 
refer to using a male condom?  If so, please state that.  
 
* Overall question:  please provide justification for the variables included in the analysis.  
What literature is the selection based on?  What were the hypotheses that guided the 
analysis? As it currently reads, a list of variables is presented to the reader but are 
decontext ualized in terms of the rationale and logic for their inclusion.  
 
 
Data Analysis  
 
* P8, line 155 -156: what is meant by "outcome variable was common, prevalence of 
39.8%?  
 
* Line 161 refers only to "married women" - were women in consensual union excluded 
from this analysis?  
 
* Line 165: what were the variables that were "dropped from the final model"?  
 
 
Results  
 
* About one -half of the women "had attained primary level education" - does this refer to 
primary education as the stopping point or that at least 53% had  attained a primary level 
education?  Please clarify  
 
* About 2/3 of births were unintended:  please define the term and how this was measured 
in the study  
 
* Use of modern methods:  what are the data for male condom use (so as to include the 
analysis for ma le partners in the results)?  
 
* P10, line 207:  the authors note, "in the adjusted analysis".  Please indicate, adjusted for 
what - what was done and why.  
 
 
Discussion  
 
* Please provide a citation for the statement on p12, lines 239 -240 about extra care being 
provided to women living with HIV.  What evidence exists to justify making this 
statement?  
 
* P12, lines 252 -253:  what do the percentages refer to (eg 68% to 15%, etc).  This is not 
clear at all.  
 
* P13, line 276: please add more detail about the "previous  study" being cited.  Where was 
that study conducted, when, and what was the finding?  
 
 
Conclusion  
 
* This section does not add to the paper. It is a rehashing of the results.  I suggest cutting 
this section.  
 
 
Ethics Approval  
 
* Please add detail about the literacy levels of women participants and how written 
informed consent was obtained, as well as where signed consent forms were stored.  
 
 
Availability of data  
 
* Please clarify that any data shared will be completely de -identified.  Please also note the 
format in which the data will be shared.  
 
Are the methods appropriate and well described?  
If not, please specify what is required in your comments to the authors.  
 
No 
 
Does the work include the necessary controls?  
If not, please specify which controls are required in your comments to the authors.  
 
No 
 
Are the conclusions drawn adequately supported by the data shown?  
If not, please explain in your comments to the authors.  
 
Yes 
 
Are you able to assess any statistics in the manus cript or would you recommend an 
additional statistical review?  
If an additional statistical review is recommended, please speci fy what aspects require further 
assessment in your comments to the editors.  
 
I recommend additional statistical review  
 
Quality of written English  
Please indicate the quality of language in the manuscript:  
 
Needs some language corrections before being published  
 
Declaration of competing interests  
Please complete a declaration of compe ting 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 manuscript, either now or in the future?  
 
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 relatin g 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 n o competing interests.  
 
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