Missed opportunity for family planning counselling along the continuum of care in Arusha region, Tanzania

Introduction Adequate sexual and reproductive health information is vital to women of reproductive age (WRA) 15 to 49 years, for making informed choices on their reproductive health including family planning (FP). However, many women who interact with the health system continue to miss out this vital service. The study aimed to identify the extent of provision of FP counselling at service delivery points and associated behavioral factors among women of reproductive age in two districts of Arusha region. It also determined the association between receipt of FP counselling and contraceptive usage. Methods Data were drawn from a cross-sectional survey of 5,208 WRA residing in two districts of Arusha region in Tanzania; conducted between January and May 2018. Multistage sampling technique was employed to select the WRA for the face-to-face interviews. FP counseling was defined as receipt of FP information by a woman during any visit at the health facility for antenatal care (ANC), or for post-natal care (PNC). Analyses on receipt of FP counseling were done on 3,116 WRA, aged 16–44 years who were in contact with health facilities in the past two years. A modified Poisson regression model was used to determine the Prevalence Ratio (PR) as a measure of association between receipt of any FP counseling and current use of modern contraception, controlling for potential confounders. Results Among the women that visited the health facility for any health-related visit in the past two years, 1,256 (40%) reported that they received FP counselling. Among the women who had had births in the last 30 months; 1,389 and 1,409 women had contact with the service delivery points for ANC and PNC visits respectively. Of these 31% and 26% had a missed FP counseling at ANC and PNC visit respectively. Women who were not formally employed were more likely to receive FP counselling during facility visit than others. WRA who received any FP counseling at PNC were significantly more likely to report current use of modern contraception than those who did not (adjusted PR [adj. PR] = 1.28; 95% Confidence Interval [CI]: 1.09, 1.49). Conclusion Overall, only 40% women reported that they received any form of FP counseling when they interfaced with the healthcare system in the past two years. Informally employed women were more likely to receive FP counselling, and women who received FP counselling during PNC visits were significantly more likely to use contraceptive in comparison to the women who did not receive FP counselling. This presents a missed opportunity for prevention of unintended pregnancies and suggests a need for further integration of FP counseling into the ANC and PNC visits.


Introduction Introduction
Adequate sexual and reproductive health information is vital to women of reproductive age (WRA) 15 to 49 years, for making informed choices on their reproductive health including family planning (FP). However, many women who interact with the health system continue to miss out this vital service. The study aimed to identify the extent of provision of FP counselling at service delivery points and associated behavioral factors among women of reproductive age in two districts of Arusha region. It also determined the association between receipt of FP counselling and contraceptive usage.
Methods Data were drawn from a cross-sectional survey of 5,208 WRA residing in two districts of Arusha region in Tanzania; conducted between January and May 2018. Multistage sampling technique was employed to select the WRA for the face-to-face interviews. FP counseling was defined as receipt of FP information by a woman during any visit at the health facility for, antenatal care (ANC), or for post-natal care (PNC). Analyses on receipt of FP counseling were done on 3,116 WRA, aged 16-44 years who were in contact with health facilities in the past two years. A modified Poisson regression model was used to determine the Prevalence Ratio (PR) as a measure of association between receipt of any FP counseling and current use of modern contraception, controlling for potential confounders.

Results
Among the women that visited the health facility for any health-related visit in the past two years, 1,256 (40%) reported that they received FP counselling. Among the women who had had births in the last 30 months; 1,389 and 1,409 women had contact with the service delivery points for ANC and PNC visits respectively. Of these 31% and 26% had a missed FP counseling at ANC and PNC visit respectively. Women who were not formally employed were more likely to receive FP counselling during facility visit than others. WRA who received any FP counseling at PNC were significantly more likely to report current use of modern contraception than those who did not ( Overall, only 40% women reported that they received any form of FP counseling when they interfaced with the healthcare system in the past two years. Informally employed women were more likely to receive FP counselling, and women who received FP counselling during PNC visits were significantly more likely to use contraceptive in comparison to the women who did not receive FP counselling. This presents a missed opportunity for prevention of unintended pregnancies and suggests a need for further integration of FP counseling into the ANC and PNC visits. Introduction L 12-19: I suggest taking above before the background reference status of FP situation in TZ We thank the reviewer for the comment, we have made the changes Page 4, L 13: the study also assesse'd' whether… We thank the reviewer for the comment, we have made the revision Materials and methods L 16: Please stay with the abbreviation WRA We thank the reviewer for the comment, we have made the editions in the revised manuscript L 19: reference the data source: e.g. ministry of health or other partners We thank the reviewer for the comment, we have added the reference L 21: I suggest to delete "the" We have made the deletion, thanks for the observation Page 5, L 15: Are these referring to the "other associated factors"? Thanks for the comment. Other associated factors include the demographics and other behavioral characteristics of the women. L 16, L17 and L19: keep to the abbreviation introduced "FP" We thank the reviewer for the comment, we have made the revisions L 21: the outcome of L18-21 did not also come out in the conclusion Thanks for the comment. The secondary outcome contraceptive usage was used to determine the association between receipt of FP counselling and current contraceptive usage. We found a significant association between receipt of FP counselling at any PNC visit and current usage of contraception (see Table 3). Conclusion was revised. L 22: I suggest to include 'as shown in fig 1'. We thank the reviewer for the important observation. We have placed the figure in the data collection section, where sample selection was described.
Sample selection description flow chart L 1: FP counselling of (1,256/3,116) is 40% not 38%. We thank the reviewer for the comment, we have made the revisions L7-10, please use a space before the opening bracket If the analysis is done up this category, the coverage should be 40% instead of 38%. We thank the reviewer for the comment, we have made the revisions Characteristic of the study participants L 7: This is confusing, if 462 was excluded then, does it mean analysis for coverage was done on "2,654" out of the 3,116, then coverage of 38% is still questionable. We thank the reviewer for the comment. The 462 women who were never pregnant in the past two years, were excluded in the separate analysis that looked on predictors of FP counselling at any ANC and PNC visits. The revisions are made in the revised manuscript. Predictor of receipt of family planning counselling along the continuum of care L 2: keep to the abbreviation "FP" We thank the reviewer for the comment, we have made the revision L 3: it is correctly stated here but in the Abstract, it is stated as 38%. Please don't use the word 'about' so the sentence needs reframing. We thank the reviewer for the comment, we have made the revision Discussion L 4: Staying with the abbreviation WRA We have made the revision, thanks for the comment. L 7: Please discuss further, as table 1 show combined % for poorest and poorer as 24.2%, does this mean low FP counselling coverage is found among the middle to richest category; this also goes for employment. We thank the reviewer for the comment, we have revised the discussion to include detailed information in the revised manuscript. L 10: here again the 38% instead of 40% We thank the reviewer for the comment, we have made the revision Strength and Limitations L 5: If these factors were not assessed, then why are they mentioned in the abstract "aim" to identify the associated factors.
Thanks for the comment. The study assessed the predictors of receiving FP counselling and determined to see if there is any association between receiving of FP counselling and Current contraceptive usage. However, the study did not look at the reasons why some women did not use contraception even after receiving FP counselling. Conclusion L 11: Here again the coverage is not consistent in the other section such as the conclusion in the abstract. We thank the reviewer for the comment, we have made the revision Reviewer #2: The title refers to continuum of care while only ANC and postpartum periods are considered! Thanks for the comment. The study assessed FP counselling at any health facility visit, at any ANC visit and at any PNC visit in the past two years.
It is not clear how 38% was calculated since 3115 women were included in the analysis "Overall, 1,256 (38%) women reported that they received FP counseling at any of the health facility visits in the past two years. We thank the reviewer for the comment, we have made the revision in the revised manuscript.
Of the 1,389 and 1,409 women who had contact with the service delivery points for ANC and PNC visits respectively; 27% and 26% had a missed FP counseling at ANC and PNC visit respectively." Calculations of 27 and 26% are also not clear! We thank the reviewer for the comment, we have made the revision in the revised manuscript after double checking the calculations.
"The data were originally collected for an impact evaluation of a community-based intervention on contraceptive information, counselling and referral." Are the results presented in this paper before the intervention or after the intervention? Thanks for the question. The results presented in the paper were for the baseline data before the intervention.
"A total of 3,116 women were included in the overall analysis; whereas 462 women who had no pregnancy were excluded for the ANC and PNC analysis." In figure 1, WRA included in the analysis was 3115, where did the extra participant come from to make them 3116? Thanks for the comment. Figure one shows a total of 3,116 WRA included in the analysis (see Fig 1) Where did the 462 women excluded come from since in figure 1, they are not shown and pregnancy was not mentioned as an exclusion criteria? We thank the reviewer for the comment. The 462 women who were never pregnant in the past two years, were excluded in a separate sub-analysis that looked on predictors of FP counselling at any ANC and PNC visits. The clarifications are made in the revised manuscript.
"Overall, among the women who had had births in the last 30 months more than seventy percent received FP counselling at ANC and PNC visits (73% and 74% respectively Review Board -RB17-1794 to conduct the household survey. A written participant consent was obtained before participation in the study for women aged 18 years and older. Participants who were aged 16 -17 an assent was requested. Consent for them to participate was sought from partners for those who were married/ cohabiting, and from parents/ guardians for those who were under parental care. The women included in this study were only the ones who consented to participate in the study. Adequate sexual and reproductive health information is vital to women of reproductive age (WRA) 15 to 3 49 years, for making informed choices on their reproductive health including family planning (FP). 4 However, many women who interact with the health system continue to miss out this vital service. The 5 study aimed to identify the extent of provision of FP counselling at service delivery points and associated 6 behavioral factors among women of reproductive age in two districts of Arusha region. It also determined 7 the association between receipt of FP counselling and contraceptive usage. 8

9
Data were drawn from a cross-sectional survey of 5,208 WRA residing in two districts of Arusha region 10 in Tanzania; conducted between January and May 2018. Multistage sampling technique was employed to 11 select the WRA for the face-to-face interviews. FP counseling was defined as receipt of FP information 12 by a woman during any visit at the health facility for, antenatal care (ANC), or for post-natal care (PNC). 13 Analyses on receipt of FP counseling were done on 3,116 WRA, aged 16-44 years who were in contact 14 with health facilities in the past two years. A modified Poisson regression model was used to determine 15 the Prevalence Ratio (PR) as a measure of association between receipt of any FP counseling and current 16 use of modern contraception, controlling for potential confounders. 17

18
Among the women that visited the health facility for any health-related visit in the past two 19 years, 1,256 (40%) reported that they received FP counselling. Among the women who had had 20 births in the last 30 months; 1,389 and 1,409 women had contact with the service delivery points 21 for ANC and PNC visits respectively. Of these 31% and 26% had a missed FP counseling at ANC and 22 PNC visit respectively. Women who were not formally employed were more likely to receive FP 23 counselling during facility visit than others. WRA who received any FP counseling at PNC were 24 significantly more likely to report current use of modern contraception than those who did not (

Conclusion 3
Overall, only 40% women reported that they received any form of FP counseling when they interfaced 4 with the healthcare system in the past two years. Informally employed women were more likely to receive 5 FP counselling, and women who received FP counselling during PNC visits were significantly more 6 likely to use contraceptive in comparison to the women who did not receive FP counselling. This presents 7 a missed opportunity for prevention of unintended pregnancies and suggests a need for further integration 8 of FP counseling into the ANC and PNC visits. 9 Introduction 1 Contraceptive counselling is a key intervention that could decrease unintended 2 pregnancies by increasing contraceptive uptake and enabling effective contraceptive use. 3 Contraceptive counselling has been shown to be associated with increased contraceptive use [1-  care (ANC) visit, 64% deliver at a health facility, and the child vaccination coverage was greater 1 than 95% in more than 90% of the districts [10]. This creates an opportunity for FP information 2 to be disseminated during pre-natal, post-natal, and maternal health service delivery. Provision of 3 FP information and counseling is an essential aspect of Tanzania maternal health plan and 4 provided free of charge [16][17][18]. During these visits women are expected to receive information 5 on FP methods that are available, possible side effects, and the importance of resuming the FP 6 after delivery [1].

7
There is limited information on the prevalence of contraceptive counselling in Tanzania   8 when women come into contact with health facilities (HFs). One study found that FP counselling 9 is more likely to be offered in private service delivery points compared to public ones [19]. In 10 response to the Tanzania FP 2020 commitment of reaching 45% modern contraceptive 11 prevalence rate by 2020, this study determines the extent of provision of FP counselling at 12 service delivery points, and its associated factors in Arusha. The study also assessed whether 13 being counselled during clinic visit increases the use of modern contraceptives.

15
Data collection 16 Data were drawn from a cross-sectional survey of WRA in two districts of Arusha region, 17 northeastern Tanzania. The household survey data were collected from January to May 2018.

18
The data were originally collected for an impact evaluation of a community-based intervention 19 on contraceptive information, counselling and referral [20]. The survey was conducted on a 20 representative sample of females aged 16-44 years, residing in the study area. A multi-stage 21 random sampling was employed to select 3,938 women of reproductive age from Arusha city 22 6 council and Meru district council. Further details on the study, participants and sampling strategy 1 are described elsewhere [20].Women who consented to participate in the survey were asked 2 questions relating to pregnancy history, use of FP services, and whether or not they had ever 3 received FP counselling at a health facility. Only women who were sexually active and had 4 visited a health facility in the last two years were included in the analysis (Fig 1). The outcome of interest in this analysis was whether or not a woman received FP counselling 3 during any visit to a health facility (HF), during a visit for ANC and visit for PNC within the past 4 two years. Women were included if they had any visit, and then a separate analysis was limited 5 to those women who had had a birth in the last 30 months and who visited for ANC or PNC. 6 Women were considered to have received FP counseling if, at any visit to the HF within the past 7 two years, they reported that they received and/or discussed any information about FP with a 8 health provider. The definition of counselling used was broad and did not specify the content of 9 what the woman and her provider discussed. A missed opportunity for FP counseling was 10 defined as a woman's ANC or PNC clinic visit at which a staff member did not provide any FP 11 counseling.

12
In this analysis, current use of modern contraceptive was the secondary study outcome and was 13 defined as currently using any of the following methods of FP to delay or limit pregnancy i.e. 14 female sterilization, intra-uterine device, injectables, implants, oral contraceptive pills, condoms 15 and emergency contraception. This variable was categorized as 1 if currently using any one of 16 the modern contraceptive methods, and 0 if otherwise.  Women's socio-demographic information (age as a continuous variable; marital status 21 categorized as Never married (0),Married or cohabiting (1) and Divorced/widowed/separated (2);

22
Occupation categorized as (0) for those employed or do any work and (1) otherwise; distance to 23 8 health facility was categorized as less than 2 km (0), 2-3 km (1) and 4 km and above (2) and 1 parity as a continuous variable were included in the analysis; with reference from other studies 2 done on FP Counselling [14,21]. To construct the wealth index, we identified variables in our 3 survey that are similar to the ones in the Tanzania Demographic and Health Survey (TDHS). It 4 was created as a composite, asset-based measure from a series of questions and 5 then standardized to quintiles. Using these common variables, we categorized using the same 6 cut-off points as the TDHS through principal components analysis. Hence, we ended up with five 7 categories or groups of wealth index namely, poorest, poorer, medium, richer, and richest.  RB17-1794 to conduct the household survey. A written participant consent was obtained before 5 participation in the study for women aged 18 years and older. Participants who were aged 16 -6 17 an assent was requested. Consent for them to participate was sought from partners for those 7 who were married/ cohabiting, and from parents/ guardians for those who were under parental 8 care. The women included in this study were only the ones who consented to participate in the 9 study.

11
Characteristics of the study participants 12 The sociodemographic, economic and health related characteristics of the study participants are 13 shown in Table 1. A total of 3,116 women were included in the overall analysis. The mean 14 (±standard deviation) age of the women was 30.3 (±6.9) years. Most of the women were between 15 20 and 29 years old (43%), had three or more children (40%) and were in the richer wealth 16 quintile (46%). Three-quarter of the study participants were currently married or living with a 17 partner (75%). Overall, among the women who had had births in the last 30 months, sixty nine 18 percent received FP counselling at ANC and 74% at PNC visits.

Association between receipt of any FP counseling and current use of modern contraception
3 Table 3 shows the results of analysis of association between receipt of any FP counselling 4 services and current use of modern contraceptive among women who visited a health facility in 5 the past two years. After adjusting for woman's age, marital status and parity; the women who 6 received any FP counselling services at a health facility visit, had a 4% higher current usage of 7 modern contraceptive in comparison to those who did not, although this association was not  Our study of missed opportunities for FP counseling among WRA along the continuum of care 5 highlights a few important findings. About 61% of the women in our sample who had an 6 interaction with the healthcare system in the past 2 years did not receive any form of 7 contraceptive counselling. Women not formally employed and those in the poorer wealth quintile 8 predicted receiving FP counseling during any health facility visit. Counseling during PNC period 9 increased the prevalence of modern contraceptive use. 10 We found that the receipt of FP counseling was 40% among the women who attended the 14 ANC visits provides an opportunity for health worker to advice and counsel on the importance of 15 FP. However, our study found that 31% of women were not counseled on FP at ANC and 26% at 16 PNC visit. Those who were counseled during postnatal care visit were more likely to currently 17 use modern contraceptive than those who were not counseled. This finding is similar to a study 18 done in Ethiopia which found that FP planning counseling increased the chance of using improve their own health and that of the new baby, hence higher prevalence of contraceptive use 2 after being counselled during postnatal period [16,19,30]. Improved uptake of maternal, newborn 3 and child health interventions after counseling during postnatal period have also been reported in 4 breastfeeding and vaccination [31]. 5 We also found that married or cohabiting women were 16% less likely to receive

20
Our study addressed one of the prominent areas in numerous efforts to achieve the FP 2020 21 commitment aiding in reducing the unmet need for FP among WRA. This study had some 22 limitations. Our study cannot infer a causal relationship between the association of FP 1 counselling and current usage of modern contraceptive. Also, some women might have some 2 recall bias about the content of what was discussed during ANC or PNC visits and thus under-3 report contraceptive counseling. In addition, the results cannot be generalized to the general 4 population in Tanzania. This is because WRA who interacted with the health care system, 5 attended ANC and PNC services could be different from those who do not utilize these services. 6 Another limitation is that counseling was reported by women, no observations were done. Further, health facility factors like providers knowledge and skills in counseling and FP as well 8 as availability of supplies was not assessed. We also cannot fully explain why some women did 9 not use contraception even after receiving FP counselling. The authors thank the Arusha Regional Medical Officer, District Medical Officers and other 11 administrative staff in Arusha city and Meru district; for their cooperation and support during the 12 study period. We also thank the study participants for their valuable participation in this study.       However, many women who interact with the health system continue to miss out this vital service. The 5 study aimed to identify the extent of provision of family planningFP counselling at service delivery points 6 and associated behavioral factors among women of reproductive age in two districts of Arusha region. It 7 also determined the association between receipt of FP counselling and contraceptive usage. any FP counseling and current use of modern contraception, controlling for potential confounders. 17

18
Among the women that visited the health facility for any health-related visit in the past two had contact with the service delivery points for ANC and PNC visits respectively; 27Of these 31% and 24 26% had a missed FP counseling at ANC and PNC visit respectively. Women who were not formally 1 employed were more likely to receive FP counselling during facility visit than others. WRA who received 2 any FP counseling at PNC were significantly more likely to report current use of modern contraception 3 than those who did not ( Overall, only 3840% women reported that they received any form of FP counseling when they interfaced 6 with the healthcare system in the past two years. Informally employed women were more likely to receive 7 FP counselling, and women who received FP counselling during PNC visits were significantly more 8 likely to use contraceptive in comparison to the women who did not receive FP counselling. This presents 9 a missed opportunity for prevention of unintended pregnancies and suggests a need for further the 10 integration of FP counseling into the continuum of care at allANC and PNC visits. 11 Contraceptive counselling is a key intervention that could decrease unintended 2 pregnancies by increasing contraceptive uptake and enabling effective contraceptive use. 3 Contraceptive counselling has been shown to be associated with increased contraceptive use [1-  Contraceptive counselling is a key intervention that could decrease unintended 20 pregnancies by increasing contraceptive uptake and enabling effective contraceptive use. 21 Contraceptive counselling has been shown to be associated with increased contraceptive use [7][8][9][10]. Several studies emphasize the importance of contraceptive counselling; it creates 1 opportunities for a woman to obtain necessary information to make an informed decision that is 2 appropriate for the reproductive needs and goals of the client [11-13]. Contraceptive counselling 3 has also been shown to increase method continuation, reduce contraceptive 4 switching/discontinuation and increase method satisfaction [14]. women are expected to receive information on family planningFP methods that are available, 14 possible side effects, and the importance of resuming the family planningFP after delivery [1]. 15 There is limited information on the prevalence of contraceptive counselling in Tanzania 16 when women come into contact with health facilities (HFs). One study found that family 17 planningFP counselling is more likely to be offered in private service delivery points compared 18 to public ones [19]. In response to the Tanzania FP 2020 commitment of reaching 45% modern  In this analysis, current use of modern contraceptive was the secondary study outcome and was 7 defined as currently using any of the following methods of family planningFP to delay or limit 8 pregnancy i.e. female sterilization, intra-uterine device, injectables, implants, oral contraceptive 9 pills, condoms and emergency contraception. This variable was categorized as 1 if currently 10 using any one of the modern contraceptive methods, and 0 if otherwise.  Women's socio-demographic information (age as a continuous variable; marital status 7 categorized as Never married (0),Married or cohabiting (1) and Divorced/widowed/separated (2); 8 Occupation categorized as (0) for those employed or do any work and (1) otherwise; wealth), 9 Formatted: Line spacing: Double Formatted: Heading 3, Left, Line spacing: single, Adjust space between Latin and Asian text, Adjust space between Asian text and numbers distance to health facility was categorized as less than 2 km (0), 2-3 km (1) and 4 km and above 1 (2) and parity as a continuous variable were included in the analysis; with reference from other 2 studies done on FP Counselling [14,21]. To construct the wealth index, we identified variables in 3 our survey that are similar to the ones in the Tanzania Demographic and Health Survey (TDHS).

4
It was created as a composite, asset-based measure from a series of questions and 5 then standardized to quintiles. Using these common variables, we categorized using the same 6 cut-off points as the TDHS through principal components analysis. Hence, we ended up with five 7 categories or groups of wealth index namely, poorest, poorer, medium, richer, and richest.  17 an assent was requested. Consent for them to participate was sought from partners for those 7 who were married/ cohabiting, and from parents/ guardians for those who were under parental 8 care. The women included in this study were only the ones who consented to participate in the 9 study.

12
Characteristics of the study participants 13 The sociodemographic, economic and health related characteristics of the study participants are 14 shown in Table 1. A total of 3,116 women were included in the overall analysis; whereas 462 15 women who had no pregnancy were excluded for the ANC and PNC analysis. The mean 16 (±standard deviation) age of the women was 30.3 (±6.9) years. Most of the women were between 17 20 and 29 years old (43%), had three or more children (40%) and were in the richer wealth 18 quintile (46%). Three-quarter of the study participants were currently married or living with a 19 partner (75%). Sixty-one percent had primary education and below. About half of women 20 resided in Arusha region for more than five years (52%). Overall, among the women who had had births in the last 30 months, more than seventysixty nine percent received FP counselling at 1 ANC and 74% at PNC visits (73% and 74% respectively).

Association between receipt of any FP counseling and current use of modern contraception
3 Table 3 shows the results of analysis of association between receipt of any FP counselling 4 services and current use of modern contraceptive among women who visited a health facility in 5 the past two years. After adjusting for woman's age, marital status and parity; the women who 6 received any FP counselling services at a health facility visit, had a 4% higher current usage of 7 modern contraceptive in comparison to those who did not, although this association was not  Our study of missed opportunities for FP counseling among women of reproductive age (WRA) 5 along the continuum of care highlights a few important findings. About 61% of the women in 6 our sample who had an interaction with the healthcare system in the past 2 years did not receive 7 any form of contraceptive counselling. Employment Women not formally employed and those in 8 the poorer wealth quintile predicted receiving FP counseling during any clinic health facility 9 visit. Counseling during PNC period increased the prevalence of modern contraceptive use. 10 We found that the receipt of FP counseling was 38.940% among the women who 14 ANC visits provides an opportunity for health worker to advice and counsel on the importance of 15 FP. However, our study found that nearly 2631% of women were not counseled on FP at ANC or 16 and 26% at PNC visit. Those who were counseled during postnatal care visit were more likely to 17 currently use modern contraceptive than those who were not counseled. This finding is similar to 18 a study done in Ethiopia which found that FP planning counseling increased the chance of using 19 postpartum family planning (PPFP) [27]. This is also similar to a study done in Kenya, where 20 they found that contraceptive usage was 35% higher among women who had FP counselling 21 during PNC [28,29]. Lack of association between FP counseling during ANC visits and current 22 usage of modern contraceptive has also been observed in other East African studies [16,19]. It maybe that after successful delivery, women are more receptive to the information that will 1 improve their own health and that of the new baby, hence higher prevalence of contraceptive use 2 after being counselled during postnatal period [16,19,30]. Improved uptake of maternal, newborn 3 and child health interventions after counseling during postnatal period have also been reported in 4 breastfeeding and vaccination [31]. 5 We also found that married or cohabiting women were 16% less likely to receive

20
Our study addressed one of the prominent areas in numerous efforts to achieve the FP 2020 21 commitment aiding in reducing the unmet need for FP among WRA. This study had some  Tanzania. This is because WRA who interacted with the health care system, 5 attended ANC and PNC services could be different from those who do not utilize these services. 6 Another limitation is that counseling was reported by women, no observations were done.

7
Further, health facility factors like providers knowledge and skills in counseling and FP as well 8 as availability of supplies was not assessed. We also cannot fully explain why some women did 9 not use contraception even after receiving FP counselling.

Review Comments to the Author
Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters) Reviewer #1: Missed opportunity for family planning counselling along the continuum of care in Arusha region, Tanzania. Abstract L 6&7: Associated factors of what: behavioral of the women or the health provider? What about health worker knowledge and skills, commodity supply, distance to the health facility, please clarify Please define women of reproductive age (15-49 years of age). We thank the reviewer for the observation, we have made the additions and defined the women of reproductive age. The authors acknowledge that apart from the women's behavioral factors studied in this paper, there could be other factors that could contribute. However, the Health worker and/or health facility related factors were not observed or studied at this time in this study project. Methods L 11: I suggest 'face-to-face' We thank the reviewer for the comment, we have made the revision L 11: Continue with to the abbreviation 'FP' after it has been introduced We thank the reviewer for the comment, we have made the revision L 13: The FP counselling: is it a group or one-on-one (confidential) counselling during the clinic visit? We thank the reviewer for this important comment. FP counselling is done on a one-on-one basis between health care worker and client. Although in some instances general information on FP can be provided as group, but later on detailed information and client is given time to ask any questions or concerns. L 16: Would contraceptive prevalence rate (CPR) or even modern CPR (mCPR) be more appropriate? We thank the reviewer for this comment. Contraceptive Prevalence Rate (CPR) or modern CPR (mCPR) will tell us the extent or current usage of contraceptive or modern contraceptive. To determine the association between contraceptive usage and receipt of FP counselling, we implored a modified poisson regression model, whereas Prevalence Ratio (PR) was estimated.

Results
L 18: The percentage is sometime cited as '38%' and sometime as "40%" Please clarify We thank the reviewer for the comment, we have made the revision Conclusion L 29: What about the other associated factors that is mentioned in the introduction. Were there any outcomes? We thank the reviewer for the comment, we have made the revision Introduction L 12-19: I suggest taking above before the background reference status of FP situation in TZ We thank the reviewer for the comment, we have made the changes Page 4, L 13: the study also assesse'd' whether… We thank the reviewer for the comment, we have made the revision Materials and methods L 16: Please stay with the abbreviation WRA We thank the reviewer for the comment, we have made the editions in the revised manuscript L 19: reference the data source: e.g. ministry of health or other partners We thank the reviewer for the comment, we have added the reference L 21: I suggest to delete "the" We have made the deletion, thanks for the observation Page 5, L 15: Are these referring to the "other associated factors"? Thanks for the comment. Other associated factors include the demographics and other behavioral characteristics of the women. L 16, L17 and L19: keep to the abbreviation introduced "FP" We thank the reviewer for the comment, we have made the revisions L 21: the outcome of L18-21 did not also come out in the conclusion Thanks for the comment. The secondary outcome contraceptive usage was used to determine the association between receipt of FP counselling and current contraceptive usage. We found a significant association between receipt of FP counselling at any PNC visit and current usage of contraception (see Table 3). Conclusion was revised. L 22: I suggest to include 'as shown in fig 1'. We thank the reviewer for the important observation. We have placed the figure in the data collection section, where sample selection was described.
Sample selection description flow chart L 1: FP counselling of (1,256/3,116) is 40% not 38%. We thank the reviewer for the comment, we have made the revisions L7-10, please use a space before the opening bracket If the analysis is done up this category, the coverage should be 40% instead of 38%. We thank the reviewer for the comment, we have made the revisions Characteristic of the study participants L 7: This is confusing, if 462 was excluded then, does it mean analysis for coverage was done on "2,654" out of the 3,116, then coverage of 38% is still questionable. We thank the reviewer for the comment. The 462 women who were never pregnant in the past two years, were excluded in the separate analysis that looked on predictors of FP counselling at any ANC and PNC visits. The revisions are made in the revised manuscript. Predictor of receipt of family planning counselling along the continuum of care L 2: keep to the abbreviation "FP" We thank the reviewer for the comment, we have made the revision L 3: it is correctly stated here but in the Abstract, it is stated as 38%. Please don't use the word 'about' so the sentence needs reframing. We thank the reviewer for the comment, we have made the revision Discussion L 4: Staying with the abbreviation WRA We have made the revision, thanks for the comment. L 7: Please discuss further, as table 1 show combined % for poorest and poorer as 24.2%, does this mean low FP counselling coverage is found among the middle to richest category; this also goes for employment. We thank the reviewer for the comment, we have revised the discussion to include detailed information in the revised manuscript. L 10: here again the 38% instead of 40% We thank the reviewer for the comment, we have made the revision Strength and Limitations L 5: If these factors were not assessed, then why are they mentioned in the abstract "aim" to identify the associated factors. Thanks for the comment. The study assessed the predictors of receiving FP counselling and determined to see if there is any association between receiving of FP counselling and Current contraceptive usage. However, the study did not look at the reasons why some women did not use contraception even after receiving FP counselling. Conclusion L 11: Here again the coverage is not consistent in the other section such as the conclusion in the abstract. We thank the reviewer for the comment, we have made the revision

Reviewer #2:
The title refers to continuum of care while only ANC and postpartum periods are considered! Thanks for the comment. The study assessed FP counselling at any health facility visit, at any ANC visit and at any PNC visit in the past two years.
It is not clear how 38% was calculated since 3115 women were included in the analysis "Overall, 1,256 (38%) women reported that they received FP counseling at any of the health facility visits in the past two years. We thank the reviewer for the comment, we have made the revision in the revised manuscript.
Of the 1,389 and 1,409 women who had contact with the service delivery points for ANC and PNC visits respectively; 27% and 26% had a missed FP counseling at ANC and PNC visit respectively." Calculations of 27 and 26% are also not clear! We thank the reviewer for the comment, we have made the revision in the revised manuscript after double checking the calculations.
"The data were originally collected for an impact evaluation of a community-based intervention on contraceptive information, counselling and referral." Are the results presented in this paper before the intervention or after the intervention? Thanks for the question. The results presented in the paper were for the baseline data before the intervention.
"A total of 3,116 women were included in the overall analysis; whereas 462 women who had no pregnancy were excluded for the ANC and PNC analysis." In figure 1, WRA included in the analysis was 3115, where did the extra participant come from to make them 3116? Thanks for the comment. Figure one shows a total of 3,116 WRA included in the analysis (see Fig 1) Where did the 462 women excluded come from since in figure 1, they are not shown and pregnancy was not mentioned as an exclusion criteria? We thank the reviewer for the comment. The 462 women who were never pregnant in the past two years, were excluded in a separate sub-analysis that looked on predictors of FP counselling at any ANC and PNC visits. The clarifications are made in the revised manuscript.
"Overall, among the women who had had births in the last 30 months more than seventy percent received FP counselling at ANC and PNC visits (73% and 74% respectively)." The reported percentage in the results section are different from those in the abstract, since it is reported that only 38% received FP counselling. We thank the reviewer for this important observation. Among the women that visited the health facility for any health-related visit in the past two years, 40% received FP counselling. Among the women who had had births in the last 30 months; 1,389 and 1,409 women had contact with the service delivery points for ANC and PNC visits respectively. Of these 68.8% and 73.6% received FP counselling at ANC and PNC visits respectively. Necessary revisions were made in the revised manuscript.
In the discussion, it is not clear what the authors are saying in this statement "These findings imply that 61% of the women missed FP counselling when they visited the facility for any health reason; while 26.8% and 26.2% missed FP counselling at 1 ANC and post-natal care (PNC) visits respectively." The discussion needs to be redone once the results have been revised. We thank the reviewer for this important observation. Among the women that visited the health facility for any health-related visit in the past two years, only 40% received FP counselling. This means that 60% of the women that visited the health facility for any health-related visit did not get FP counselling. Among the women who had had births in the last 30 months; 1,389 and 1,409 women had contact with the service delivery points for ANC and PNC visits respectively. Of these 31.2% and 26.4% missed FP counselling at ANC and PNC visits respectively. Necessary revisions were made in the revised manuscript.