Author's response to reviews Title:Postpartum contraceptive use in Gondar town, Northwest Ethiopia: a community based cross-sectional study Authors: Yeshewas Abera (yeshiab57@gmail.com) Zelalem Birhanu Mengesha (zelalem78@gmail.com) Gizachew Assefa Tessema (agizachew@gmail.com) Version:2Date:16 May 2014 Author's response to reviews: see over
Author's response to reviews Contraceptive use and associated factors among postpartum women in Gondar town, Northwest Ethiopia: a cross-sectional study Authors: Yeshewas Abera (yeshiab57@gmail.com) Zelalem Birhanu Mengesha (Zelalem78@gmail.com) Gizachew Assefa Tessema (agizachew@gmail.com) Version: 1, Date: 07 May, 2013 Author's response to reviews: see over
To: Editorial manager BMC Women s Health From: Yeshewas Abera E- mail: yeshiab57@gmail.com, Subject: Submitting a revised version of the manuscript Ms ID: 2514789061238249 Contraceptive use and associated factors among postpartum women in Gondar town, Northwest Ethiopia: a cross-sectional study We would like to thank the reviewer for sharing their view and experience. The comments are very important which will improve the manuscript. The point-by-point responses for each of the comments and the revised manuscript are provided in the attached documents. During our revision we have described the quality control methods implemented in the study. Furthermore, the issue of multivariate analysis now checked and revised. With regards! Yeshewas Abera Corresponding Author
POINT BY POINT RESPONSES We would like to take this opportunity to thank the reviewers for sharing their view and constructive comments. The comments are very important which will further improve the quality of the manuscript. The point-by-point responses for each of the comments are provided in the following pages. Reviewer #1- Yohannes Adama Melaku Point by point Response 1. Is the question posed by the authors well defined? Yes 2. Are the methods appropriate and well described? Partially The method section has now been revised thoroughly 3. Are the data sound? Yes 4. Does the manuscript adhere to the relevant standards for reporting and data deposition? Yes 5. Are the discussion and conclusions well balanced and adequately supported by the data? Yes 6. Are limitations of the work clearly stated? No One paragraph limitation has been included 7. Do the authors clearly acknowledge any work upon which they are building, both published and unpublished? Yes 8. Do the title and abstract accurately convey what has been found? Partially 9. Is the writing acceptable? Needs some language corrections before being published 10. Level of interest - An article of importance in its field 11. Statistical review- No, the manuscript does not need to be seen by a statistician 12. Declaration of competing interest-i confirm that I have no competing interests 13. What do you advise should be the next step? Unable to decide on acceptance or rejection until the authors have responded to the major compulsory revisions The abstract section has been amended based on the comments given Language revision has been made by consulting an expert in the field.
Comments Abstract: Better to shorten the background of the abstract. Instead I recommend describing details on methods and results. This will enable the readers to know more about the paper. In the result section the phrase Nearly half. is bold. Please do some edition on this. In this section, mentioning the proportion of women using injectable will be important. Additionally, the direction of associations is important to mention. In the conclusion the authors have mentioned that contraceptive utilization is low. However, your finding indicates that almost of half of women were using some form of contraceptive and this figure is high compared to Ethiopian DHS 2011(27%). What is the reflection of Author s on this? Methods: Paragraph 1- The town is located 727 km away from Addis Ababa. In which direction Gondar found from the Addis? Paragraph 1- The total number of postpartum women was estimated to be 5,734 at the time of the study. -How do authors know this? It needs reference. Paragraph 2- The authors used single population proportion formula to calculate the sample size. This sample size calculation is used to estimate only proportion of an outcome (in this case proportion of postpartum women who were using contraceptive). However, the sample size calculation couldn t be used to Authors response We have now shorten the background section. Based on the reviewer s suggestion, we have emphasized on methods and results sections of the abstract. See the background of abstract section. Corrected! We have included data showing the proportion of women using contraceptive method. (68.5%) The direction of association has now been added in the abstract section. See result section of the abstract. As this study was done in urban set up, we tried to compare this finding with the EDHS 2011 report for urban women. However, when we see the 95% CI, it is more or less comparable. As a result, we have taken revisions accordingly. Comment considered and the direction is included. The town is located northwest of Addis Ababa. It is based on the assumption made by CSA that 2.77% of reproductive age women have children less than one years old meaning those women who have given one year prior to the data collection can be roughly estimated using this conversion factor. This data is obtained from the Amhara regional health bureau Woreda based plan in 2005E.c (2012/2013). We have calculated sample size considering both of our objectives. But we put the sample size calculated based on the proportion of the dependent variable because it gave us larger sample size than the one estimated using two population proportion.
identify factors associated with contraceptive utilization (appropriate sample size calculation method is double population proportion formula). Or the authors may compare the sample sizes from the two calculation methods and decided on the larger one. How do the authors see this? Paragraph 2- For sample size calculation the authors used proportion of 50%. I believe that this should be last option (if there are no existing related literatures on the topic). How do they comment on this? Paragraph 2- The sample size calculation finally comes up with 634. But, in the abstract, it was 703. Why this difference? Paragraph 3- The sampling procedure was not clearly described. They only tried to put geographic locations with their sampling procedures. How about the number of postpartum women in each cluster, ketene..? What are the sources of information on the number of postpartum women in each sample stage? I recommend the authors to display sampling procedures grammatically (with figure). They didn t also mention eligibility criteria. Paragraph 5- The sentence Descriptive and summary statistics were carried out. is not clear. Summary statistics could be part of descriptive statistics. Here the authors should describe.multiple logistic regression. is it to say multivariate? IN bivariate analysis, what was the cutoff point (p-value) a variable to be included to multivariate analysis? Dis the authors check for interaction and multi-collinearly? If yes, they have to mention this and how they did it. From our critical review of literatures, we didn t find a proportion done among postpartum women at local level. As a result, we assumed a proportion of 50%. It is clear that the primarily calculated sample size was 643. However, in the later stage of recruitment of the study participants, cluster sampling technique was employed. One of the recommendations of a cluster simpering technique is taking all the eligible individuals in the selected cluster. Hence, the final sample size will deviate from the calculated one. This is why it is different in our case. The steps we have followed to recruit the study participants are now clearly stated in the sampling size calculation and sampling procedure section. In fact, the actual number of postpartum women were not known. As a result, we have considered all eligible women in the selected clusters. Those women who were between 6week and one year of postpartum period, and not pregnant at the time of the data collection were included in the study. This eligibility criteria is now included in the manuscript. To avoid confusion, we have omitted the term summary statistics. We have used multiple LR. In doing so, we have done bivariate LR first for each of the independent variables and those variables having p-value of less than 0.02 have been fitted to multiple LR model in order to control the effect of confounding. We have now included one statement to clearly state this issue. See paragraph 2 under subtitle data collection and analysis
Ethical consideration: This part is not well described. Example if they get women less than 18 years, how did they manage the consent of these women? Result: Paragraph 1-They used mean to summarize age. Did they check for skewed distribution of age? If the age distribution is skewed, they have to use median and IQR. Paragraph 2- The mean number of living children was 2.1 per women (SD=1.2). In this sentence, I prefer and will be more meaningful if the authors use median and IQR. Factors associated with postpartum contraceptive use The sentences Those participants aged < 24 year were about 2.3 times more likely to use contraceptive as compared to those who were 35 years or more. And other similar sentences need corrections. The logistic regression model doesn t measure probability or risk (association) directly; rather the model measurements association of variables indirectly. So, the expression they used is not correct. The following expression may be appropriate one: Those participants aged < 24 year had 2.3 times higher odds to use contraceptive compared to those who were 35 years or more. All related sentences should be checked and corrected. Discussion: Putative explanations should be minimized. Limitations of the study are not presented in the manuscript. Conclusions: Specific applicable recommendations with detail explanations are very important to consider in this manuscript. Table 1-editorial problems are seen. (Exampleeducation) Figure 1-Bars are missed. Table 4- AOR for most of the variables were missed. It is important to put the findings even though they are not significantly associated. It is known that women aged 15-18 are consenting minor. Since the study is not sensitive we have taken informed consent from all the participants. This is a common practice in recent studies. The age of participants follows a normal distribution. As a result, we use mean to summarize. After checking the skewness of the data, we have now considered the reviewers comment. Hence, median with IQR is calculated. The manuscript is revised accordingly. This Comment is well accepted and revisions are made throughout. One paragraph has now been added to clearly describe limitations of the study. See paragraph ## We have now given a very specific and applicable recommendation to improve contraceptive use in the extended postpartum period in Ethiopia. Corrected! Corrected! Since we used stepwise LR (backward) model, those insignificant variables will not appear in the final step of the outputs. Thank you!!.
Reviewer #2 Zeleke Alebachew A Wagaw Point by point response Comments Major comments (Major Compulsory Revisions) 1. The proportion of mothers who initiated postpartum contraceptive use at the right time shall be described on both the result and discussion part. 2. This study did not address behavioral aspects of health service providers at health facility and accessibility of contraceptives. Contraceptive counseling and accessibility of contraceptive at health facility can affect the utilization of contraceptives. 3. The method section did not clearly show how variables selected for logistic regression model, which model is used, is it enter method or other? 4. The report did not indicate pregnancy status of mother (contraceptive user vs non user) at survey time. This information is important to show the proportion of mothers who get pregnant during one year time after birth. Minor Comment (Minor Essential Revisions) 1. Table 4. Author advised to include the type of analysis made on the title of the table. I think it is OR estimates for logistic regression analysis 2. In table 4, under variable age, the order of age category (>35, <24, 25-34) has no proper order. It shall be written as increasing order (<24, 24-35, >35). Regardless of the order author can choose the reference either the last or the first alternative from the logistic regression analysis model. 3. On the result section the third title< Contraceptive use in the post-partum period) correct the underlined word as postpartum. Authors response From the fact that women involved in the study were at different periods of time, it is difficult to comment whether they introduced contraceptive methods timely or not. However, we are learned that only 30 (8.8%) of contraceptive users were between 6 th week and 3 rd month. We have mainly focused on the individual level factors that affect postpartum contraceptive use. Since one study cannot address all the different level factors, additional studies that consider variables not addressed in this study (mainly facility based) are required. We have also described in the limitation part of the manuscript that facility level factors are not addressed in this study. The criteria for variable selection has been included in the recent manuscript. See### Measuring the prevalence of pregnancy in the postpartum period is not in the scope of this study. In addition, one of the exclusion criteria during recruitment of the study participants was pregnancy status because we cannot ask women about contraceptive use if they are pregnant. It is now included We have revised this variable accordingly. The order of the variables arranged in an increasing order. Corrected.
4. Citation and reference listing needs major revision and shall be written using a standard citation style (for articles in journal, reports, etc). 5. Figure1. If there is no additional figure there is no need to give figure number. 6. Why adjusted OR missed for most variable in table 4. There is a need to include adjusted OR for all variables. 7. Authors advised to explain including un expected results. Example number of live children greater than 4 Vs 1 has OR less than 1. 8. Why bivariate analysis was not performed before logistic regression analysis performed, which will be also useful to select variables for logistic regression analysis. Discretionary Revisions 1. If the result is available it will be good to compare contraceptive utilization practice among mother whose index child died and those whose index child alive. Quality of written English: Needs some language corrections before being published Referencing was made using endnote referencing software. We have checked for consistency according to the requirements of BMC Women`s Health journal. Since the revised manuscript has two figures, we numbered them in their order. The multiple LR analysis was done considering the backward LR model. As a result. After the iteration process, only those significant variable will remain in the last step. Those insignificant variables would be excluded in the final step. It is not worth to explain about the effect of parity on contraceptive use because this variable is not significant at multivariate level. We have done both bivariate and multivariate analysis and the outputs are clearly stated on Table 3. In the current study those women who have an alive index child were included. Due to its technical difficulty in recruiting women whose index child has died, we didn t yet included them. We have consulted expert in the field for language edition. Thank you!!!!!!