-->PONE-D-25-08308-->-->Early contraceptive discontinuation and associated factors among married women initiating long-acting and short-acting contraceptives in humanitarian settings in Ethiopia:

A retrospective follow-up study-->-->PLOS ONE

Dear Dr. Alamdo,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Two experts have reviewed the manuscript noting the need to substantially revise it in terms of its placement on the literature, details on the setting and the methods, and a concern about the validity of the statistical analysis given the lack of testing of its assumptions. There are also many smaller suggestions.-->--> -->-->One further consideration that should be explicitly mentioned is the wealth index. It is a misleading term. The wealth index in the context of fertility surveys is an index constructed based on ownership of some products and characteristics of the house, not a self-declared perception. In order to avoid misinterpretation I suggest using "Self-declared wealth" or something along these lines.

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1. Is the manuscript technically sound, and do the data support the conclusions?

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Reviewer #1: Yes

Reviewer #2: Yes

**********

-->2. Has the statistical analysis been performed appropriately and rigorously? -->

Reviewer #1: I Don't Know

Reviewer #2: Yes

**********

-->3. Have the authors made all data underlying the findings in their manuscript fully available?

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Reviewer #1: Yes

Reviewer #2: Yes

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-->5. Review Comments to the Author

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Reviewer #1: Thank you for this important study. It is good to see studies on contraceptive discontinuation in humanitarian settings as there are so few. I have a few comments – some of which are substantive, but others are recommendation to make this a bit easier to read.

Abstract: is there a reason who switch between RH and SRH in the Background? Seems like you could just use SRH consistently.

Line 65-68: I believe these sentences need references. “Women in humanitarian settings are often unable to find contraceptive methods when only a small number would desire to become pregnant” and “In addition, as a strategy for war and conflicts, women and girls are at increased risk of early and forced marriage, sexual and gender-based abuse, sexual exploitation, and transactional sex.

Lines 71-73: Also needs a reference “Moreover, contraceptive provision can reduce maternal mortality and morbidity from unwanted pregnancies and unsafe abortions and help to prevent sexually transmitted infections from spreading within the population”

Lines 93-97: please add references for some of these statements.

Line 103: Isn’t reference 13 a study on contraceptive discontinuation in a humanitarian settings?

Introduction: would you please add a brief description of the selected refugee camps? For example, urban vs rural? Population size? Are contraceptive services available at health facilities in the selected camps?

Line 131: is FP provided only to married women? Is there a reason to limit your study population to only married women?

Line 197: what do you mean by ‘resumption of use at post-discontinuation’? Do you mean people who terminated method use without switching?

Methods: could you say a bit more about how you approached selected women for an interview – particularly since women gave no prior consent to be contacted about their contraceptive use? Presumably, women could feel that the services at the health facility were not confidential if a stranger showed up looking for them to talk about their contraceptive use. You specifically mention in Line 237 that the majority of participants kept their contraceptive use secret. How did you avoid breaking that confidentiality and making sure the fact that you interviewed them did not reveal their contraceptive use to others?

Results: I recommend that you reduce most % and ages to one decimal point (eg, 29.9 rather than 29.93 or 93.3% instead of 93.29%) as you present a lot of data. I also think it would be more clear if you present the %s in the narrative and only show the N’s in the table. I would recommend reducing the wordiness in the Results section. For example, you could also adjust text like in line 271 to say ‘42.1% of LARC and 40.0% of SAC acceptors…’ rather than write out ‘over forty percent’ and ‘nearly forty percent’

Line 265: what does 14.74 or 12.04 refer to? the mean number of years?

Line 269: all of the refugee camps were not rural? If not, please describe the context of the selected camps in the Introduction.

Tables: please reduce all % to one decimal place. It would be to indicate somewhere in the table that the number in parentheses is the % and the other number is the N (or just add the % sign after all numbers that are percents – the table is difficult to read as is).

Tables: To reduce the size of the tables, any variable with only Yes/No responses, you could report only the Yes.

Table 1: I don’t think you need to report mean age at initiation and mean age now since everyone in the sample initiated FP within the previous 12-18 months. It doesn’t really make sense that the mean age now is 3 years older than the age at initiation when only 12-18 months (should) have passed between the two dates. Can you explain this (or better yet, keep only one of these two age variables)?

Table 1: what is the difference between ‘Housewife’ and ‘Not working’ if everyone is married? Should these be collapsed into one category?

Line 292 and Table 2: was the desire for more children measured as within 2 years of now (time of interview) or of when they started using the method?

Line 302: could you say how partner approval was different? (Eg, higher or lower among LARC vs SAC acceptors?)

Line 307 and Table 3: were all participants asked about intention to use contraception in the future or only those who had terminated their contraceptive use? If all, what does that mean for women who were currently using a method?

Line 323: what is the difference between ‘experiencing side effects’ and ‘fear of side effects’? Seems like those could be combined.

Figure 3: Seems like the Y-axis could have a maximum of 100 given that is the highest number of women who gave a particular reason. Is there a reason you did not present this as %? Since you have so much going on in this chart, I recommend only presenting LARC vs SAC users. Or switch it to a table (could go into Table 4).

Line 328-329: ‘Among women who discontinued the baseline methods a substantial proportion of 32 (60.38%) LARC and nearly one-third of 56 (32.18%) SAC acceptors abandoned the method’ What did the rest who discontinued the method do? I’m not sure I understand this sentence.

Line 330-331: I just want to clarify – the question about method failure was for all women since it’s reported as ‘in their lifetime’ and not the reason for the current method discontinuation?

Lines 358-360: I’m still unclear about asking women who currently use FP about their intention to use in the future. I don’t think it makes sense to include in your regression model. If they are currently using, doesn’t that mean they’re likely to use in the future? Questions about intention to use FP in the future are usually asked of women who are NOT currently using FP.

Table 5: I am concerned about the number of categories you have in your regression models. Your N is not very large, so having 4-category variables in here (wealth index, husband occupation, no. of children) seems like it would reduce the power of the analysis. For example, would Husband occupation be more powerful to compare Not working vs Employed? There are only 62 people in the ‘private employee’ category and 12 in ‘Other’.

Table 5: I recommend using short acting and long acting rather than short term and long term to be consistent with how you’ve referred to the methods throughout the paper. Same for Line 374.

Line 380: I am familiar with this Congo study - these weren’t refugees, but rather conflict-affected populations.

Discussion: I would recommend that you report fewer % from your data in this section. You’ve already reported them in the Results. For example, lines 404-406, I recommend deleting the numbers by method.

Discussion: since side effects was a common reason for discontinuation, it may be good to reflect on how improvements to contraceptive counseling and information provided could potentially improve continuation. You sort of bring up quality of service delivery in your conclusion but seems like you could address this in the Discussion.

Lines 393-400: You mention multiple reasons for higher discontinuation among refugee women in your sample – do you know if any of these are true? For example, was there a lot of movement among the refugee populations in the selected camps?

Line 417-420: I’m a little confused by the statement here which seems to indicate that continuation should be higher in urban settings? That’s not what you found though?

Line 435: Here you contradict what you say in Line 397. Here you say the refugees may be more stable, but in Line 397 you say they’re less stable?

Lines 443-444: this statement needs a reference OR you should say they ‘may have’ to soften it since it is your inference, not necessarily a fact.

Line 479-480: do you have data on contraceptive prevalence among refugee populations in Ethiopia? This would be useful information to present in the Introduction. In general, I think there have been a number of studies on refugees in Ethiopia – could you reference some SRH data on refugees in Ethiopia in the Introduction or Discussion?

Lines 486-488: I’m not sure what you mean by ‘providers should place more emphasis on’ those specific categories?

Reviewer #2: 1. Is the manuscript technically sound, and do the data support the conclusions?

o Response: Yes, but only with major revisions.

The study addresses an important gap by examining contraceptive discontinuation among refugee women and has a clearly defined outcome. A moderate sample size (551 women) and use of survival analysis provide useful evidence. However, the design is essentially a retrospective cohort based on self reported dates, so recall bias is likely. Only married women were sampled; unmarried women and one camp were excluded, which limits generalisation. Stratifying short acting methods (injectables vs pills) is needed because discontinuation varies across methods. Despite these issues, the reported discontinuation rates and identified predictors broadly support the conclusions, but caution is warranted in interpreting causality.

2. Has the statistical analysis been performed appropriately and rigorously?

o Response: No, statistical methods need improvement.

The authors used Chi square tests and a Cox proportional hazards model. However, they do not report diagnostics for the proportional hazard’s assumption. Survival analysis literature emphasises that validating this assumption is crucial and that extended models should be used if it is violated. The hazard ratio cannot always remain constant, and tests such as log-minus log plots or goodness of fit measures are recommended. Furthermore, covariates were selected based on univariate p values, which may omit theoretical confounders; conceptual frameworks should guide confounder selection. The authors should also clarify whether they handled time varying covariates or conducted sensitivity analyses.

3. Have the authors made all data underlying the findings fully available?

o Response: Unsure / needs clarification.

In the submission form, the authors checked “Yes – all data are fully available without restriction”, but they did not provide a data repository link or accession number. PLOS policy requires depositing the de identified dataset in a public repository or including it in the supplementary files. The manuscript currently lacks details of where the data can be accessed. The authors should supply a data availability statement with a functional DOI or explicit explanation if data sharing is restricted.

4. Is the manuscript presented in an intelligible fashion and written in standard English?

o Response: Partially.

The manuscript is generally understandable, but grammatical errors and formatting problems impede readability. Several sentences in the abstract and abbreviations (LARC, SAC) are not defined on first use.

5. Review comments to the author

o Design and sampling: Clearly state that this is a retrospective cohort study. Describe how the 551 participants were identified and why 15 were excluded. Explain the characteristics of excluded camps and acknowledge that findings may not generalise to unmarried women or other refugee settings.

o Measurement of outcomes/exposures: Provide more detail on how discontinuation episodes were defined and handled. Consider stratifying short acting methods (pills vs injectables) to reflect their different adherence requirements. Explain how partner awareness, partner approval and wealth index were measured.

o Statistical analysis: Report tests for the proportional hazards assumption and, if violated, consider stratified or time dependent Cox models. Do not rely solely on univariate p values for confounder selection; include variables such as education, parity and fertility desire even if not significant in univariate analyses. Interpret hazard ratios correctly and specify the time units for continuous variables.

o Presentation and discussion: Improve table and figure formatting. Compare the discontinuation rates to other studies, including recent DHS analyses, and discuss why refugee settings may have higher rates. Expand the discussion of reasons for discontinuation, linking them to global evidence on fear of side effects, partner opposition and service quality. Provide a flow diagram showing participant selection.

o Ethics and data availability: Clarify how participants’ privacy was protected during interviews and provide information on any support mechanisms for women experiencing partner violence. Provide a clear data availability statement with a public repository link or justify why data cannot be shared.

**********

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Reviewer #1: No

Reviewer #2: No

**********

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-->PONE-D-25-08308R1-->-->Early contraceptive discontinuation and associated factors among married women initiating long-acting and short-acting contraceptives in humanitarian settings in Ethiopia: A retrospective cohort study-->-->PLOS One

Dear Dr. Alamdo,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Both reviewers were available. Reviewer 1 recommends acceptance, reviewer 2 suggests an additional editing and check of statistical results. In this respect, regarding the model in table 5, it is true that there might be too many variables in the model. It would help to carry out a likelihood-ratio test of joint significance for the categorical variables (together with the simple test already reported for dichotomous variables) and a strategy of eliminating from the model variables that are very far from being significant (you could choose the p-value threshold  eg: 0.25 or 0.10 (or even 0.05). Removing variables might make the estimation more precise for the rest of variables. You can include the results of both models or just the final model describing the variables that have been removed from the model.

Please submit your revised manuscript by Mar 18 2026 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org . When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

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-->If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

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We look forward to receiving your revised manuscript.

Kind regards,

José Antonio Ortega, Ph.D.

Academic Editor

PLOS One

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Reviewer #1: (No Response)

Reviewer #2: All comments have been addressed

**********

-->2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. -->

Reviewer #1: Yes

Reviewer #2: Yes

**********

-->3. Has the statistical analysis been performed appropriately and rigorously? -->

Reviewer #1: I Don't Know

Reviewer #2: Yes

**********

-->4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.-->requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.-->

Reviewer #1: Yes

Reviewer #2: Yes

**********

-->5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.-->

Reviewer #1: Yes

Reviewer #2: Yes

**********

-->6. Review Comments to the Author

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Reviewer #1: Thank you for your revisions. I have a last few very comments on clarification:

Line 310-311: I’m guessing the (p<.001) refers to the difference in country of origin for LARC and SAC acceptors - probably better to move the p-value closer to the country of origin, ie before ‘they were Muslim by religion’.

Line 312: please add ‘years’ if you are referring to 14.7 and 12.0 years as the length of stay in the camps. As written, the time period is unclear.

Table 1: would you please confirm that the p<.001 is correct for Occupation? The data don’t look that different, and I know you collapsed 2 categories into one so just want to double check this is correct.

Line 368-369: I’m a little confused about 15% of LARC users reporting discontinuation because of lack of/no access to services. Once they received the implant or IUD, they would need access to services to discontinue the method, so this doesn’t make much sense to me. (Lack of access does make a lot of sense for SAC.)

Figure 3: would you please change the Figure to show to % rather than numbers? % would be more meaningful, and would match the data in the narrative.

Line 462-465: In this sentence, how do counseling services and satisfaction influence discontinuation (ie do they generally increase or decrease discontinuation – or is it not consistent)?

Reviewer #2: I commend the authors for their careful and constructive response to the previous round of review. The revised manuscript demonstrates substantial improvement in methodological clarity, transparency of reporting, and coherence across sections. Key issues raised earlier particularly regarding study design classification, sample size justification, sampling procedures, interpretation of hazard ratios, and articulation of limitations have been addressed in a satisfactory manner.

Overall, the manuscript now presents a technically sound retrospective cohort analysis of contraceptive discontinuation among refugee women in Ethiopia. The analytical approach is appropriate for the research question, and the main conclusions are broadly supported by the data.

**********

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Reviewer #1: No

Reviewer #2: No

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<p>Early contraceptive discontinuation and associated factors among married women initiating long-acting and short-acting contraceptives in humanitarian settings in Ethiopia: A retrospective cohort study

PONE-D-25-08308R2

Dear Dr. Alamdo,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

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Kind regards,

José Antonio Ortega, Ph.D.

Academic Editor

PLOS One

Additional Editor Comments (optional):

One of the reviewers recommended acceptance on the previous draft. The remaining reviewer is satisfied with the change implemented to address their comments on the last version. The manuscript is ready for publication,

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Reviewer #1: All comments have been addressed

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-->2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. -->

Reviewer #1: Yes

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-->3. Has the statistical analysis been performed appropriately and rigorously? -->

Reviewer #1: I Don't Know

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-->4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.-->requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.-->

Reviewer #1: Yes

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-->5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.-->

Reviewer #1: Yes

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-->6. 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: (No Response)

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Reviewer #1: No

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