Reviewer ’s report  
 
Title: UNMET NEED FOR FAMILY PLANNING SERVICES AMONG YOUNG MARRIED  
WOMEN (15 -24 YEARS) LIVING IN URBAN SLUMS OF INDIA  
 
Version: 2 Date: 29 Oct 2019  
 
Reviewer: Research Square Reviewer 1  
 
Reviewer's report:  
 
PEER REVIEWER ASSESSMENTS:  
 
OBJECTIVE - Full research articles: is there a clear objective that addresses one or several 
testable research questions? (Brief or other article types: is there a clear objective?)  
No - there are minor issues  
 
DESIGN - Is the current approach (including controls and analysis protocols) appropriate for the 
objective?  
No - there are minor issues  
 
EXECUTION - Are the experiments and analyses performed with suff icient technical rigor to 
allow confidence in the results?  
No - there are major issues  
 
STATISTICS - Is the use of statistics in the manuscript appropriate?  
Not sure - I am not able to assess the statistics in this study  
 
INTERPRETATION - Is the current in terpretation/discussion of the results reasonable and not 
overstated?  
Yes - the author's interpretation is reasonable  
 
OVERALL MANUSCRIPT POTENTIAL - Has the author addressed your concerns sufficiently 
for you to now recommend the work as a technically sou nd contribution? If not, can further 
revisions be made to make the work technically sound?  
No - manuscript has some fundamental flaw(s)  
 
PEER REVIEWER COMMENTS:  
 
GENERAL COMMENTS: *  I have serious concerns about the ethics of this study. To 
quote "During the visits to the slums, the investigator approached and tried to convince all the 
young married women fulfilling the inclusion criteria to take part in the study" - this is clearly 
coercive and certainly brings in to question both the ethics of the study and the validity of the 
results.   
 
* Overall, there is very little that the authors do to address the "so what?" of this article. 
As written it has little value outside the "urban slums of Uttar Pradesh, India". Of course, this is 
not actually the case be cause some of the issues are global but the authors don't address that.  As 
it is written it is more of an internal report of collected than a journal article.  
 
REQUESTED REVISIONS:  
 
I carefully reviewed the author's responses to each of the reviewer's comments to assess whether 
they adequately addressed the concerns/suggestions.   
 
1. Please ensure that your manuscript adheres to STROBE guidelines for reporting 
observational studies (h ttp://www.equator -network.org/reporting -guidelines/strobe/).  
Please include a completed STROBE checklist as an additional file.  
* A completed STROBE checklist has been attached as an additional file. (As per 
modified manuscript BMC draft).  
* I am not sure which figure is the STROBE. The last figure is similar in style to a 
STROBE but instead presents the results. Typically, in a STROBE diagram you want to start 
with the population of interest, exclusion, approached, declined, included for analysis for 
examp le.  
 
2. In the paragraph before your objectives, you refer to "recently married young women" - 
this is the only place "recently" is included. Please clarify or correct this.  
* The word "recently" was a typographical error and it has been replaced by the w ord 
"currently" as per your comment. (page 4, line 22)  
* This was corrected.  
 
3. Please include a paragraph detailing the strengths and limitations of your study at the 
end of the Discussion.  
* Added as per comment. (page 22, line 7) The coverage of a larg e slum population and 
use of a strong methodology has enhanced the internal and external validity of the research work, 
thereby the limitations of the study are near about nil.  
* This did not adequately address the reviewer's comment, there are always lim itations, 
generalizability to other populations, self -report etc.  
 
4. The Conclusion section should be only 1 or 2 paragraphs which state clearly the main 
conclusions and provide an explanation of the importance and relevance of the study reported. 
Please  move all other text of the Conclusions section to the Discussion or remove it.  
* As per general protocol, conclusions form an important component of the research 
work. Apart from that the conclusive findings reflect the respective interventions which need  to 
be focused upon. The same has been added in the manuscript so as to provide the comprehensive 
inference of the manuscript and the key messages that could be intervened upon to improve the 
health care delivery by policy makers. However an attempt has be en made to reduce the size, so 
kindly accept the modification. More reduction of conclusive content will reduce the inferential 
quality of manuscript. Kindly accept the modification. (page 22 &amp; 23)  
* This was partially addressed - the first paragraph o f the conclusion could be removed or 
moved to Discussion as it essentially repeats the results.  
5. Please move the 'Declarations' heading to after the List of abbreviations.  
* Moved as per comment. (page 23, line 20)  
 
6. Please format the Availability of data and materials statement according to our 
guidelines.  
* Formatted as per comment. (page 24, line 5)  
 
7. Please remove figure titles and legends from the figure files. References should not be 
included in figure titles. These should be in figure legends , if necessary.  
* Removed as per comment.  
 
8. In your Additional files list, please include only the supplemental material - the 
questionnaire and the data file.  
* Only the questionnaire has been attached.  
 
9. If the questionnaire was not administered in English, please also include a copy of the 
original. Additionally, there appears to be a formatting error in the questionnaire file. Please 
check and correct.  
* Formatting error is due to use of different Micros oft word version by different user. It 
has been reviewed, kindly open document using Microsoft Word version 2007 and accept the 
same.  
* I don't see questionnaire in the files I received  
 
10. The data file format, .sav, cannot be opened. Please submit in a  different format.  
* The data set is not being submitted due to the topic of the study and concerns regarding 
the confidentiality of the data but is available from the corresponding author on reasonable 
request.  
* I leave this to the editors but it certain ly seems to me that de -identified data could be 
provided.  
 
11. Major language revision and editing in scientific language to be published.  
All authors have checked the manuscript twice for Typographical / Grammatical / Scientific / 
Language errors and made  the required modifications. Same has been given to independent 
literature reviewer and has been resubmitted after his approval.  
Kindly accept the modifications.  
While improvements were made from the original draft, issues remain. For example: "Attitude of  
the women and her husband towards family planning was assessed by the responses given by the 
respondents on the pertaining questions."  
 
12. Abstract: The unmet need for family planning in married women in Uttar Pradesh is 18.1% 
(urban -13.4% and rural -19.6%)". Is it the finding of this study? If not, please mention the data 
you are referring here?  
* Reference has been added to the cited information. It is not the finding of our study but 
is taken from National Family Health Survey -IV report of India. (page 2 , line 6 -8). 
* the reference was added, however this is still not typically how the background in an 
Abstract is written. Rather than data something like: "Among married women in the Uttar 
Pradesh region of India there remains a significant unmet need fo r Family planning".  
 
13. The objective doesn't look scientifically connected to the data? Why urban slums in UP?  
* As per author guidelines of BMC, there is limitation of words to be written in the 
abstract; therefore everything cannot be provided in the abstract section. However an attempt has 
been made to provide maximum reliable information in minimum words by rephrasing the 
background section of the abstract. The complete information has been included in the 
introduction section of the manuscript. Kind ly accept the modification.  
(page 2, line 6 -12). 
* This was partially addressed, I would add though that there needs to be more 
generalizability in the abstract, why would this study be of importance to those working or living 
outside of the slums of Uttar  Pradesh, India?  
  
14. "2 slums were"… I would request to start the sentence with words.  
* It is changed as per comment. (page 2 , line 15)  
 
15. In methods, the focus should be on statistical techniques used rather than SPSS.  
* As per author guidelines of BMC, there is limitation of words to be written in the 
abstract; therefore everything cannot be provided in the abstract section. However, it has been 
modified and an attempt has been made to provide maximum reliable information  in minimum 
words. The complete information has been mentioned in the data management section of the 
manuscript. (page 2 , line 18).  
 
16. In results, the multivariate results can be highlighted.  
* Due to the word limitation in guidelines for abstract, onl y the key findings conclusive 
of the result have been mentioned. Same has been explained in detail in the main manuscript. 
(page 2 , line 25).  
 
17. Language editing is required for the whole abstract. For example, cross sectional study was 
conducted (Not d one).  
* All authors have checked the manuscript twice for Typographical / Grammatical / 
Scientific / Language errors and made the required modifications. Same has been given to 
independent literature reviewer and has been resubmitted after his approval.Kin dly accept the 
modifications.  
* While improvements were made from the original draft, many issues remain. For 
example, in the Abstract Page 3 Line 10 "an association" vs. "association.  
 
18. Introduction: There many studies in India and elsewhere highlighti ng contraceptive use and 
unmet need, the authors may add few literatures from the slum areas and state how this study is 
different from other study.  
* Although many studies are available only the recent most, comprehensive and reliable 
national level findi ngs as best possible evidence of literature for the statement of study problem 
has been mentioned. This study is different from other studies as it primarily involved YMW 
(15-24 years) of Urban slums in Lucknow. The Sampling technique used, includes a larg e and 
representative sample of all slums, hence it is generalizable to all YMW. The same has been 
included in the introduction section. Kindly accept the  
modification. (page 3 -5). 
* I believe what the reviewers intended was for the authors to include studi es from areas 
of high poverty "slums" in other geographic areas across India and in other countries. This was 
not done  
 
19. Objectives are well defined.  
* I would suggest that for Objective 2 "understand" is not the correct term but rather 
"explore" or "id entify" because knowing what they are does not mean we understand the reasons  
 
20. Methods: I am not sure what is the format the journal follows, but the authors may follow the 
scientific writing style rather than highlighting every aspect with heading. I would request the 
authors to see a sample publication of the journal.  
* As per the recent scientific writing guidelines most of the worldwide journals suggest 
to write the method section of manuscript in a step wise manner to provide each and every 
informa tion specifically and completely. Apart from that highlighting every aspect with heading 
separately makes it easy to for the readers to understand.  
However, an attempt has been made to shorten the method section. Further reduction in content 
will reduce th e quality of manuscript so kindly accept the modifications made.(page 6)  
* This is an unusual way to present the Methods but I leave this to the editors.  
 
21. What types of slums were selected "notified / recognizable / identifiable"?  
* For the present stu dy slums notified by municipal corporation were selected (a local 
governing body for towns/cities) (page 6, line 21).  
 
22. Are "young married women (15 -24)" both inclusion and exclusion criteria? There may some 
error here.  
* The required corrections have b een made. (page 6, line 5 -8) 
 
23. In the definition/concept of "Unmet need for limiting", the authors have mentioned "who are 
not using any modern method" which should be not using any modern limiting methods. The 
author/s should clearly define, what are the modern methods that is cove red in the study.  
* The required corrections have been made and the operational definition along with the 
reference has been added in the revised manuscript. (page 8, line 8,9 &amp; 11). 
 
24. Like the dependent variables, the independent variables are also r equired to be explained for 
international readers. Like, for caste which list was used: state/centre list?  
How socio -economic status was calculated? Is it wealth based or income based?  
* The sub - group classification in independent variables are based on N ational Family 
Health Survey -4. If each and every Independent variable will be explained the manuscript will 
become too lengthy in nature. However an attempt has been made to elaborate new and rarely 
used independent variables and a reference has been made  for the commonly used variables to 
maximize the understanding of international readers. Kindly accept the modification. (page 9, 
line 13,16,18)  
* The point the reviewer was making, using the term "caste" is that some terms are not 
familiar to many outside  of India. The authors did not respond to this but rather made the claim it 
would make the manuscript too lengthy, however, other text can be taken out - for example 
"slum" need to be clearly defined but that does not mean essentially citing the Registrar of India.  
 
25. Results: The results are well structured, however, the interpretation of odds ratio are wrong. 
For example, "women of 20 -24 years are 0.36 times less likely….?" Here, 0.36 is the odds of 20 -
24 years women group with reference to 15 -19 years  women group (whose odd is considered as 
1). So women age 20 -24 are 64% less likely have unmet need in comparison to the reference 
groups and yes nobody writes 0.36 times. My apologies.  
* The results can be expressed in terms of percentages but the authors  believe that odds 
ratio is better method for representation as it is reader friendly and more conclusive of the 
findings. However corrections have been made as per your comment.  
Kindly accept the modifications. (page 12 -17). 
 
26. The CIs can be added whil e interpreting the results. For example, The women aged 20 -24 are 
significantly less likely to have unmet need for family planning ( OR: 0.36, CI:  
XX-XX).  
* It has been incorporated in the result findings as per your suggestion. Kindly accept the 
modificat ions. (page 12 -17) 
 
27. Please explain only the significant and key results.  
* The authors have tried to explain each and every thing in a detailed manner. Reducing 
the textual content of manuscript will compromise the reflectiveness and conclusiveness of the 
manuscript thereby affecting its quality. However certain  
changes have been made to reduce the content and make the result section more comprehensive 
as per the reviewer's comment so, kindly accept the modifications. (page 10 -17) 
* I agree with the rev iewer and suggest the Results section could be edited without 
compromise and this has not been done.  
 
28. Discussion: The discussion section is well written.  
 
29. There is inconsistency in referencing. For example, ref no. 16 and 32 are either insufficient  or 
not in proper format. This may be corrected.  
* It is corrected (page 26, line 12 &amp;  page 27, line 28)  
 
30. For global readers, abbreviations like SC/ST should be clearly defined in the foot note of the 
table.  
* The full form has been added in the li st of abbreviations and at the place of original 
text. (page 12, line 2)  
 
31. Finally, this manuscript requires language editing from a scientific writer to reduce 
inconsistencies and errors that the manuscript have and bring this into publishable format.  
* All authors have checked the manuscript twice for Typographical / Grammatical / 
Scientific / Language errors and made the required modifications. Same has been given to 
independent literature reviewer and has been resubmitted after his approval. Kindly a ccept the 
modifications.  
* While improvements were made from the original draft, many issues remain.  
 
32. Introduction: All three objectives of the study convey the same meaning. The objective/s 
should be compressed into one sentence.  
* The author is appre hensive as two different suggestions are given by two different 
reviewers regarding merging of objectives. However the current objectives are specific and 
reader friendly so kindly accept the same.  
* Objectives 2 and 3 are very similar (reasons vs. factors ) so the authors need to be 
clearer about the difference between the two  
 
33. Result: The result section is unnecessarily long, and references were not made to indicate 
tables being cited. Almost all information in the table were repeated in the result sec tion, thereby 
making it long and uninteresting. The proper thing to do is to report on important aspects of the 
table and cite the table in question.  
* The authors have tried to explain each and every thing in a detailed manner. Reducing 
the textual conten t of manuscript will compromise the reflectiveness and conclusiveness of the 
manuscript thereby affecting its quality. However certain changes have been made to reduce the 
content and make the result section more comprehensive as per the reviewer's comment  so, 
kindly accept the modifications.  
References have been added to indicate the tables being cited.  
* I agree with the reviewer and suggest the Results section could be edited without 
compromise and this has not been done  
 
34 .No table references were mad e for all these results. why?  
* Apart from the mean age of YMW, mean age of marriage, mean age of cohabitation, 
mean age at the birth of first child, mean no. of living children, mean no. of desired children and 
mean duration of stay in slum all the result s have been shown in table 1. (page 11). References 
have been added for the same. As the manuscript already has too many tables so, to prevent 
duplication, this data has been represented in textual form only and no separate table was made 
for the same. So kindly accept the modification.  
 
35. What do you mean by 'autonomy' here. It has been mentioned in the tools of data collection. 
(page 9, line 18)  
* Autonomy has been defined.  
 
36. Unnecessary statement. Delete.  
* It has been deleted. (page 12, line 3)  
 
37.  All age ?  
* This line has been rephrased. (page 12, line 3)  
 
38. Indicate table or figure for which this refers to.  
* The reference for this figure is table 2 , it has been already mentioned in between and at 
the end of paragraph.(page 12, line 6 &amp; 10) 
39.? table reference  
* The reference for this is table 2 , it has been already mentioned in between and at the 
end of paragraph. (page 12, line 6 &amp; 10). 
 
40. Statistical analysis: Statistical analysis was flawed. My observation is that 'Odds ratio' should 
not be used as effect measure for a cross -sectional design; rather it will be more appropriate to 
use 'Prevalence ratio'. Most of the assumptions in the d iscussion section may not be 
appropriate/valid. The odds ratio tends to overestimate the prevalence ratio when used for cross 
sectional study. were there any limitations to the study?  
* As per the current and most used statistical inferential methods the i nterpretation of 
results based on the conclusive findings by Crude and Adjusted Odds Ratio (COR &amp; AOR) is 
supposed to be more reflective in nature. As our study is crosssectional so, temporality cannot be 
established but odds ratio is the best and most a ppropriate method to represent the results in the 
current situation.  
The coverage of a large slum population and use of a strong methodology has enhanced the 
internal and external validity of the research work, thereby reducing the limitations of the study  
to near about nil.  
Limitation has been added as per your comment. Kindly accept the modifications. (page 22, line 
7) 
* This did not adequately address the reviewers' comment, there are always limitations, 
generalizability to other populations, self report  etc.  
 
41. What statistical method did you use to calculate the probabilities.  
* The data processing and analysis section has been reframed and rectified for easy 
understanding. Univariate analysis was performed using binary logistic regression and the fa ctors 
which were found significant during univariate analysis were forwarded to multiple logistic 
regression model in a step wise manner for calculation of Adjusted Odds Ratio. A p value &lt; 
0.05 was considered statistically significant. Kindly accept the  modification. (page 10, line 13 -
17) 
 
42. What effect measure did you use for the logistic regression?  
* The data processing and analysis section has been reframed and rectified for easy 
understanding. Univariate analysis was performed using binary logisti c regression and the factors 
which were found significant during univariate analysis were forwarded to multiple logistic 
regression model in a step wise manner for calculation of Adjusted Odds Ratio. Kindly accept 
the modification. (page 10, line 13 -17) 
 
43. This is a confusing statement. Consider revising it.  
* The statement has been deleted and the data processing and analysis section has been 
rephrased. (page 10, line 13 -17) 
 
44. Tables: There are so many tables, some of them are unnecessary. Table 3 is a repetition of 
table 1. Table 2 should be presented as a simple descriptive table with  
proportions/percentages. I wonder p -values for the different proportions were derived in table 2 
without cross tabulation or contingency tables? Review the statistical analysis.  
* Table 1 is different from Table 3. Table 1 shows stratification of Bio -social 
characteristics on the basis of age group of YMW, whereas table 3 shows sociodemographic 
determinants of unmet need among YMW. The age wise stratification has been do ne as the 
author wants to bring into the cognizance of readers/ policy makers the age -specific issues of 
family planning. This might help in delineating the age group appropriate interventions in a 
tailored manner to meet this huge unmet need for family pl anning, especially in this age groups 
(15-19&amp; 20-24 years).For table 2 in actual analysis cross tabs were made , but for the 
presentation part the big table in represented in small . As the row and column total and data for 
two cells has been mentioned so if anybody wants to calculate the other two cells it can be done 
by simple addition and subtraction. So, kindly accept the same.  
* I leave it to the editors to decide if they want to include all of the Tables. I do not see 
the value of the Figures. A pr oper STROBE diagram and perhaps this one but it needs more 
explanation - is it a Model built on the results from this study? I can't seem to find a reference to 
it in the Text.  
  
45. Discussion: Ambiguous statement. Revise.  
* The statement has been revised . (page 19, line 7)  
* Not sure if this was adequately addressed because I can't find the statement.  
 
46. Define what you mean by 'illiterate' in the definition of terms section.  
* The sub - groups in independent variables are based on National Family Health  Survey -
4. If each and every Independent variable will be explained the manuscript will become too 
lengthy in nature; so reference for the same has been added to maximize the understanding of 
international readers. (page 9, line 13)  
* If the other parts of  the manuscript were revised there would be room to define terms.  
 
47.Define these in the definition of terms.  
* The sub - groups in independent variables are based on National Family Health Survey -
4. If each and every Independent variable will be explained the manuscript will become too 
lengthy in nature; so reference for the same has been added to maximize  
the under standing of international readers. (page 9, line 13)  
* If the other parts of the manuscript were revised there would be room to define terms.  
 
48. Define  
* The sub - groups in independent variables are based on National Family Health Survey -
4. If each and e very Independent variable will be explained the manuscript will become too 
lengthy in nature; so reference for the same has been added to maximize  
the understanding of international readers. (page 9, line 13)  
* If the other parts of the manuscript were rev ised there would be room to define terms.  
 
49. Define  
* The word autonomy has been defined and referenced in the tools of data collection 
section. (page 9, line 18  
 
50. What is this?  
* Crude Odds Ratio, it has been mentioned in the table and list of abbrev iations.  
51. ...and this?  
* Adjusted Odds Ratio, it has been mentioned in the table and list of abbreviations.  
 
52. A change has been made in the order of authors.  
 Author no 4 is made author no 5 and vice versa. Page 1, line 14 &amp; 17. 
 
 
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 manuscript or would you recommend an  
additional statistical review?  
If an additional statistical review is recommended, please specify what aspects require further  
assessment in your comments to the editors.  
 
I recommend additio nal 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 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 o f 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.  
 
This reviewer has been recruited by a partner organization, Research Square. Reviewers with  
declared or apparent competing interests are not utilized for these reviews. This review er has  
agreed to publication of their comments online under a Creative Commons Attribution License  
attributed to Research Square and was paid a small honorarium for completing the review within 
a specified timeframe. Honoraria for reviews such as this are paid regardless of the reviewer  
recommendation.  
 
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which I do not wish to be included in my named report can  be included as confidential comments  
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I agree to the open peer review policy of the journal