-->PONE-D-25-62366-->-->Understanding the Drivers of Modern Contraceptive Use Trend Change and Inequalities Among Sexually Active Women in Lesotho: A Decomposition Analysis (2004–2023)-->-->PLOS One

Dear Dr. Phiri,

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Academic Editor

PLOS One

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Reviewers' comments:

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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

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

Reviewer #1: Yes

Reviewer #2: Yes

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-->3. 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.-->

Reviewer #1: No

Reviewer #2: Yes

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Reviewer #1: No

Reviewer #2: Yes

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-->5. 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: Comment to authors

• The title and abstract emphasize "sexually active women," which is a crucial and relevant sample. However, the Introduction and parts of the Discussion frequently cite national mCPR statistics for "all women" or "married women" from the LDHS reports. This creates a slight disconnect. The manuscript would be strengthened by consistently framing the entire narrative around the specific population of interest (sexually active women) and clarifying how/why trends for this group might differ from national averages

• The paper’s aims are broadly stated but could be sharpened. At present, the Introduction mixes global FP trends, Lesotho programme context, and general SSA literature without clearly articulating the specific research questions. In the last paragraph of the Introduction, explicitly list 2–3 concrete objectives

• You classify covariates into “predisposing”, “enabling”, and “need” factors but do not explicitly cite or connect this to a conceptual framework (e.g., Andersen’s behavioral model). This weakens the health services / health economics framing. Explicitly state that you use Andersen’s model (or similar) to structure covariates, and briefly justify the classification (e.g. wealth as enabling, parity as need, etc.), with a reference.

• You repeatedly refer to “sexually active women”, but you do not define how sexual activity is operationalised (e.g. “had sex in the past 4 weeks”, “past 3 months”, or “past 12 months”). This is critical because DHS distinguishes between “ever had sex”, “had sex in last 4 weeks”, etc., and your choice affects both prevalence and comparability over time. In Methods, explicitly state the exact DHS variable(s) used (e.g. `v525` or `v536`) and the time window for “sexually active”, and confirm that the definition is comparable across all four surveys.

• The Introduction says: “contraceptive use among sexually active women… rose from 46.2% in 2004… to 72.1% in 2014… 66.5% in 2023/24 [15]”. But your results (Figure 1, Table 2) show 36.1% in 2004 and 62.7% in 2023. These cannot both be correct for the same population and outcome definition.

• The justification for using the Heckley et al. (2016) method over the more common Wagstaff decomposition is appreciated. However, the explanation is dense and could be more accessible. A clearer, concise summary of the key advantage ("it accounts for the covariance between health and socioeconomic rank") in the main text would be helpful.

• You list methods included in “modern contraception”, which is good. However, DHS definitions evolve over time (e.g. addition of emergency contraception; classification of Lactational Amenorrhea Method). You should state whether your classification is harmonized across survey waves and, if any recoding was done, how. Add a sentence clarifying whether the list of modern methods is identical in all four LDHS rounds and, if not, how discrepancies were addressed.

• In Table 3, the compositional (E) contributions of wealth categories are extremely small (on the order of ±0.0001–0.0014; less than 1% each), yet the Discussion states that “improvements in household wealth contributed significantly” to contraceptive use trends. In contrast, the major compositional contributors are education (especially secondary and higher) and visits to health facilities. Tone down claims about wealth composition driving the trend. Make clear that wealth appears more important in the coefficients component (C)—i.e. changes in the strength of association between wealth and contraceptive use—rather than in shifts in the wealth distribution.

• You list methods included in “modern contraception”, which is good. However, DHS definitions evolve over time (e.g. addition of emergency contraception; classification of Lactational Amenorrhea Method). You should state whether your classification is harmonized across survey waves and, if any recoding was done, how. Add a sentence clarifying whether the list of modern methods is identical in all four LDHS rounds and, if not, how discrepancies were addressed.

• The categorization of "Predisposing, Enabling, Need" factors is standard but not fully utilized in the interpretation. The decomposition results could be discussed through this lens to provide a more structured understanding of what types of factors (e.g., enabling vs. predisposing) drove changes.

• The Blinder-Oaxaca result that 90% of the increase is due to the "coefficients" component (labeled as "contraceptive behaviour change") is a central finding. This term requires more precise definition and interpretation. Does it reflect changes in the *effect* of characteristics (e.g., the impact of being rural changed over time), changes in unobserved factors (e.g., norms, program quality), or both? The discussion of this point (page 16) is good but should be expanded and linked more explicitly to potential drivers like policy changes, service integration (e.g., with HIV programs), and shifts in social norms.

• You report EI values of 0.2360, 0.1606, 0.0473, and –0.0164 for 2004, 2009, 2014, and 2023 respectively. You interpret 2023 as “pro poor” and as inequality having “disappeared”. Yet the magnitude is very small and no standard errors/95% CIs are given for the EI itself. Provide standard errors and 95% CI (or p values) for each EI estimate.

• Figure 3: The caption mentions "three concentration curves" but four are described (2004, 2009, 2014, 2023). Please correct. Ensure the figure is of publication quality with a clear legend.

• If the 2023 EI is not statistically different from zero, it is more precise to describe it as “no significant wealth-related inequality” rather than “pro-poor inequality”.

• The Discussion notes that in 2004 inequality was “significantly influenced” by age, education, and wealth, whereas in 2023 it was “influenced by district, sex of household head and number of living children”. This is consistent with Table 4 but should be interpreted carefully: RIF regression coefficients indicate association with EI, not necessarily causal contribution. Make clearer that these are associations with the index, and avoid strong causal language (“determine”, “cause”).

• There are several internal inconsistencies in descriptive tables that need careful checking.

• The Discussion is rich in cross country comparisons but could be more concise and more directly focused on implications for Lesotho’s policy-making: targeting districts with residual inequality, tailoring outreach to older, high parity women, strengthening community health worker programmes, etc.

• The discussion appropriately cites regional literature but would benefit from deeper integration of Lesotho's unique context. Brief mentions of HIV integration and community health workers are good starts. Elaborate more on specific national policies (e.g., National Strategic Development Plan II, RMNCAH strategy), programs, or health system changes that might explain the dramatic catch-up in rural areas and among poorer women between 2014 and 2023.

• The limitations section is adequate but should be expanded.

Minors:

• The manuscript is generally understandable but contains numerous grammatical errors, typographical errors, and long, sometimes repetitive paragraphs (especially in the Discussion).

• Phrases such as “coul dbe explained by” and “las 12 months” should be corrected.

• Several references are problematic. For example, reference [35] is a paper on dissolved organic matter (DOM) in boreal forest soils, which is clearly unrelated to inequality analysis and looks like a miscitation.

• Boadu (2022) appears more than once in the reference list.

• Some in text references (e.g. “WDW”) are not fully defined (presumably Wagstaff, van Doorslaer, Watanabe).

• Use consistent terms for wealth groups: e.g. “poorest, poorer, middle, richer, richest” throughout, both in text and tables

Reviewer #2: The article is original and meets academic writing requirements with clear statistics and description of findings. Only minor (typos) and deletion under the methodology are brought to the attention of authors.

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Reviewer #1: No

Reviewer #2: No

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Understanding the Drivers of Modern Contraceptive Use Trend Change and Inequalities Among Sexually Active Women in Lesotho: A Decomposition Analysis (2004–2023)

PONE-D-25-62366R1

Dear Dr. Phiri,

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.

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Kind regards,

José Antonio Ortega, Ph.D.

Academic Editor

PLOS One

Additional Editor Comments (optional):

From the two previous reviewers, reviewer 2 proposes to accept. Reviewer 1, who had provided very detailed comments, was not available. However, the academic editor has observed that all the comments have been addressed in the -also detailed- response and the new manuscript, therefore, the manuscript is much enhanced and ready for publication.

Reviewers' comments:

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1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.-->

Reviewer #2: 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 #2: Yes

**********

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

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.-->

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 #2: Yes

**********

-->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 #2: After the initial review, the manuscript looks good for publication. Grammatical and spelling errors and have been corrected with attention. The methodology, findings and flow of the paper are good.

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Reviewer #2: No

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