Peer Review History

Original SubmissionJuly 27, 2020
Decision Letter - Mohammad Rifat Haider, Editor

PONE-D-20-23298

Pooled prevalence and determinants of modern contraceptive utilization in East Africa: A Multi-country Analysis of recent Demographic and Health Surveys.

PLOS ONE

Dear Dr. Tadesse,

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.

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Please take care of the reviewers' comments. Edit the English language and grammar of the paper. Also justify the pooling of data from different East African countries, while there are so many papers already published. What new knowledge it is contributing to the body of literature? Also, update the analysis with including recent datasets.

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Please submit your revised manuscript by Nov 20 2020 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.

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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,

Mohammad Rifat Haider, MBBS, MHE, MPS, PhD

Academic Editor

PLOS ONE

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. 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: Partly

Reviewer #2: No

Reviewer #3: Partly

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

Reviewer #1: No

Reviewer #2: No

Reviewer #3: 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: Yes

Reviewer #2: Yes

Reviewer #3: Yes

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4. 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: No

Reviewer #2: Yes

Reviewer #3: 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: This is an interesting paper; however, requires major revision and English editing. Please consider addressing the given below points:

Abstract

Background:

- Please be consistent in writing east African vs. East African.

- Why was pooled prevalence required?

Methods:

- Line 35: Make the initial letter of ‘for’ an uppercase.

- Line 37: How was determinants estimated using Stata? It could help in estimating the strengths of determinants rather than estimating determinants itself.

Results:

- Consider specifying only the key findings of the study rather than listing all the determinants. Also, use the breakdown of the sentences rather than writing one long sentence that is hard to follow.

Conclusion:

- Line 56-58: Do not repeat the study findings under this section.

Plain English Summary

- Consider paraphrasing the sentences rather than repeating it same under each section.

- You could replace ‘Living country’ with ‘Country of residence’.

Background

- There are multiple typos throughout the manuscript. Authors are suggested to proofread them carefully.

- Need to define modern contraceptives.

- Authors have already listed most of the determinants of contraceptive use already under the background section, which weakens their rationale of determining the determinants.

- If effective strategies need to be country-specific, what was the rationale behind estimating pooled prevalence? The rationale part needs to be strengthened.

Methods

- Line 163: Residence is mentioned twice.

- Variables of the study: Good to specify how the variables were coded in the dataset, and whether the authors used the same coding or recoded them.

- Line 177: Need citation.

- Line 199: Once defined, no need to re-define the abbreviations. For e.g., MOR

- Need to define modern contraceptives under the methods section and cite it.

Results

- Line 208: Specify age in years. IQR should be presented in range.

- How are rural residents defined in this study?

- Line 222: Provide 95% CIs for the estimates.

- Results section is too long with many repetitive findings. Consider shortening it by only highlighting the key findings.

Discussion

- Authors started to compare and contrast study findings, which should have been followed after stating the key findings and justification for those findings.

- There is a repetition of most of the findings that are already stated under the results section.

- Justification for all the discordant results are presented same i.e., due to differences in sample size, study design, setting, and study population. This needs to be study specific rather than a mere generalization.

Conclusion

- Clearly and concisely state the conclusions of the study in relation to the key question it sought to answer and the contribution that the paper would make.

Reviewer #2: Dear Editor,

Thank you for the opportunity to review the manuscript titled Pooled prevalence and determinants of modern contraceptive utilization in East Africa: A Multi-country Analysis of recent Demographic and Health Surveys.

Overall, the manuscript is fairly well written and has clear aims. It also focuses on a topic of deep interest to the reproductive health community and is backed by an extensive body of research. However, I find that the justification for the study and its relative contribution to the existing literature is very weak. As the authors have noted, there is an expansive literature on correlates of modern contraceptive use among women in sub-Saharan Africa, and the conclusions on the reported associations between socio-demographic factors and modern contraceptive use are largely consistent these studies. As such, the unique contribution of these pooled analyses is unclear to me. I think the authors can make a stronger case if they could point out which variables have not been examined, whether is consensus and variables that have inconsistent results.

Introduction

Overall – clear and well written.

• Consider reporting on how east Africa compares in relation to regional estimates of modern contraceptive use.

• Also, how is the east Africa country grouping determined? UNFPA, WHO, World Bank, AU?

Page 5, line 128 – consider revising “Even though, different individual studies are there”. The first comma is redundant and the use of “are there”

Methods

Data sources and sampling techniques – could benefit from better organization structure – information seems randomly placed. Also, expand on stratification and provide a reference for a more elaborate description for the DHS sampling strategy.

Sample – Most studies on contraceptive use focus on married women. There is no problem in focusing on all reproductive age women but it’s important to provide a justification for your sample selection and highlight this difference to readers since there can be differences between your estimates and the “official estimates” of modern contraceptive use.

Variables – the variable “current modern contraceptive use” does not exist in the DHS. How this was variable derived? Which methods are included? How were the other variables selected? For purposes of research reproducibility, it would be helpful if you included the actual variable numbers used to derive these indicators, clearly indicating where these variables were computed. Your tables suggest that you computed several variables and you have to be transparent about your methods and decisions that went into collapsing these variables.

Data management and analyses

- Which sampling weight and strata id were used and was the weight normalized?

- Also, did you create unique cluster ids for each country before appending the data?

Model building

- It would be helpful if you specified these variable categorizations in the section “Study variables”. I am not which what community-level variables are”

- Also not clear is what is measured under fixed effects vs random effects. I didn’t see any reference to country or time. These surveys are not conducted at the same time so it’s important to account for this variation.

Parameter estimation methods – need to be more clear about which variables are measured under fixed effects vs random effects. Also, what if any covariates are included in the model.

Results

Figure 1 – Don’t think you need the non-modern contraceptive users bar; consider adding confidence intervals to the modern contraceptive user bars. Also, not sure of whether this graph is necessary since the same information is represented in Figure 2.

Figure 2: Define labels – study ID (country??); ES??

Table 2- typos e.g. “not bog problem”

Page 11, line 239 – what variables defines clusters? What is the role of the country? I would recommend using country as the clustering variable because from a programmatic perspective – this is the grouping that makes the most sense. As presented, I have no idea what the cluster intuitively represents here because these were not defined earlier (to they represent countries, regions?). Also, based on your modeling, you community level which you have not commented about – this is the cluster level?

Page 12, Line 259 – “After controlling for other individual and community level factors, the odds of modern 260 contraceptive utilization among women in the age groups 25-34 and 35-49 were decreased by 21%”. The use of “decreased by” suggests a time components, which is not modeled in this time and these are cross-sectional studies (with each country represented at a single time point). Do you mean were odds were lower…. Same comments applies to all other variables where this language is used.

Page 13 – font variations and formatting issues (e.g. Line 282). Presentation of results needs to be revised.

Discussion

Page 15, line 299: “The pooled prevalence of modern contraceptive utilization in East African countries was 21.95%. It was smaller when compared with a study conducted using a systematic analysis (21), a study conducted in 73 low and middle-income countries (16), and studies conducted in Ethiopia, Burkina Faso, and Nigeria (15) (22,23).

1. There are several data sources that can give you better estimates for comparison e.g. FP2020: http://www.familyplanning2020.org/data-dashboard

2. Second, this goes back to my point about indicating which samples you are using – all women or ever married women only because these estimates can differ substantially depending on the sample you use.

On the relationship between modern contraceptive utilization and health facility delivery, consider using variables – health worker talked to you about contraceptive use to elaborate on these findings. I think this may be more relevant than just a health facility delivery. In fact, across many countries- health workers teach about family planning during antenatal care and immunization of children. A hospital delivery does not necessarily mean that the woman attended ANC and utilization of post-natal care remains low in SSA.

Reviewer #3: Thank you for the opportunity to review the manuscript entitled “Pooled prevalence and determinants of modern contraceptive utilization in East Africa: A Multi-country Analysis of recent Demographic and Health Surveys”. This is a well-executed study. However, I will urge the authors to consider the most recent data set(2010 and above) and also they should not forget to include the new data from Zambia. Please see below my specific comments that could further improve the manuscript.

Abstract

1. Line 31-32 should read “Therefore, this study, aimed to estimate the pooled prevalence and determinants of modern contraceptive utilization in East African Countries”

2. The conclusion section of the abstract and main conclusion, Page 2 and page 18, line 55-56 and line 390 “We found that modern contraceptive utilization in the 12 East Africa countries was low”. The authors can decide to qualify it with the word ‘relatively low’. This is because how low is low if there is no benchmark to measure the level.

3. Please specify the study period or the years you considered. E.g Surveys from 2008-2017. However, I have a concern with the authors using data that is more than a decade that is those before 2010. The authors consider only those that are a bit current. I acknowledge the fact that Madagascar’s most recent Standard DHS was conducted around 2008-2009, this is more than a decade and I am sure a lot of changes have occurred as far as contraceptive usage is concerned. The authors can decide to take this out or acknowledge it as one of their key limitations.

4. Line 43, Please add the confidence interval for the overall prevalence

5. The authors can add determinants to their keywords.

6. I am not too sure about PLOS one’s guidelines, but it is allowed the authors can still keep the plain English summary. If not then this section can be taken out of the manuscript. I know for BMC Reproductive health it is a requirement.

Background

7. Please replace developing with low and middle-income countries throughout the manuscript

8. The authors have done a great job by situating their study within the SDGS.

Methods

9. At the methods section, the authors should kindly provide the countries, the survey year, the sample size and the numbers they excluded from their study in a table. With the data, I expect that the authors revise their analysis to consider the most recent ones. I inferred from the study period that Zambia’s current data (2018) was excluded

a. (Burundi 2016-17)

b. Ethiopia 2016,

c. Comoros 2012,

d. Uganda, 2016,

e. Rwanda, 2014-2015

f. Tanzania(2015-2016)

g. Mozambique (2015),

h. Madagascar(2008-2009),

i. Zimbabwe(2015),

j. Kenya(2014),

k. Zambia(2018),

l. Malawi(2015-2016)

10. Any reason why the authors considered women who have given birth 5 years preceding the survey but not sexually active women. This should be specified

11. Line 158, please indicate the specific modern contraceptive methods you used to create modern contraceptive usage and support the categorisation with an evidence.

12. Please provide another Table and give how each of the independent variables were derived or recoded from the original dataset. This can either be in the manuscript or attached as a supplementary file.

13. What informed the inclusion or selection of the independent variables?

14. Any reason why wealth index was collapsed into three categories instead of the original 5. This can be kept as it is due to the fact that the sample size is large enough.

15. At the analysis section, although the authors have vividly explained why they used multilevel analysis they should specify the levels (i.e whether 2 level or three level). By this I also expect the authors to group their variables into the various levels.

16. Please specify the model equation

17. What informed the choice of the reference categories

18. Did the authors check for multi-collinearity, the results should be provided

19. Please use the STROBE guidelines and present it as an appendix or a supplementary file

Results

20. The results are well presented. That notwithstanding, at the fixed effects analysis results section, they author have elaborately presented their results. I will urge them to present the key ones and make reference to the Table.

21. Table 2, please indicate as a footnote the meaning of AOR. The authors should also specify the exact p-values with different stars e.g *p < 0.05, ** p < 0.01, *** p < 0.001

Discussion

22. The authors have generally discussed their results very well. Nonetheless, it might be inappropriate to compare the pooled prevalence with country level studies. Comparing the average prevalence of all countries found in your study to specific countries in other studies is inappropriate when your own analysis included an analysis of prevalence in individual countries. It would be more appropriate to discuss the relative differences among countries included in your own study if you wanted to have this discussion here.

23. At the strength and limitation section, line 380-388, what about recall and social desirability biases?

Conclusion

24. The conclusion is well presented. However, the policy implications are not well discussed. The authors can consider beefing them up.

Kudos to the authors

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Reviewer #1: No

Reviewer #2: No

Reviewer #3: Yes: Abdul-Aziz Seidu

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Revision 1
Decision Letter - Mohammad Rifat Haider, Editor

PONE-D-20-23298R1

Pooled prevalence and determinants of modern contraceptive utilization in East Africa: A Multi-country Analysis of recent Demographic and Health Surveys.

PLOS ONE

Dear Dr. Tadesse,

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.

==============================

Take care of the comments made by the reviewers.

==============================

Please submit your revised manuscript by Feb 12 2021 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.

Please include the following items when submitting your revised manuscript:

  • A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
  • A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
  • An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

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.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols

We look forward to receiving your revised manuscript.

Kind regards,

Mohammad Rifat Haider, MBBS, MHE, MPS, PhD

Academic Editor

PLOS ONE

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

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 #1: All comments have been addressed

Reviewer #2: (No Response)

Reviewer #3: 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

Reviewer #2: Yes

Reviewer #3: Yes

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

Reviewer #1: Yes

Reviewer #2: I Don't Know

Reviewer #3: Yes

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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.

Reviewer #1: Yes

Reviewer #2: No

Reviewer #3: 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

Reviewer #2: (No Response)

Reviewer #3: 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: Authors have addressed all the comments provided by the reviewer. I do not have any further comments.

Reviewer #2: Dear Editor,

Thank you for the opportunity to review this manuscript. I commend the authors for the effort that they put into addressing the reviewer comments. However, I still feel that there is more work to be done before the manuscript is ready for publication. The biggest issue for me is that I am still not convinced with the justification for the pooled analyses. Even within the East African region, countries are progressing at different rates; the context varies markedly especially in times of method mix and factors underlying non-use of modern contraceptives. Cultural factors – among the major drivers also play out differently. Therefore, it is difficult to develop a uniform approach for the entire region.

Also, there are several places in the author’s response where they simply copy and paste comments, without necessarily addressing my comments. Rather than refer me back to the manuscript, I would appreciate if the authors could clarify those comments and provide actual samples of the in-text revisions. For example, what country grouping classification was used? What are the implications of focusing on both married and unmarried women – particularly when you are comparing your findings to the existing literature that typically focuses on married women only? [see response to my query in discussion] How was the weight normalized? These details should be added to the manuscript and not simply addressed in the response to reviewers.

Other comments

- Not necessary to describe modern methods of contraception as the first paragraph in the introduction. Putting this in methods section would suffice.

- Could summarize the benefits of modern contraception – not necessary to be long and paragraph is too wordy.

- Data management – still no mention of approach to create country specific PSU ids and strata. Authors mentioned this in reviewer comments but I don’t see these details in the manuscript.

Reviewer #3: I sincerely appreciate the effort the authors have used to revise their manuscript. At this point I do not have any major comment. However, I will till urge the authors to critically read through their manuscript to correct grammatical errors. And again, please do not start a sentence with numbers. E.g see page page 4 line 108 ". 11 East African

109 countries (Burundi, Ethiopia, Comoros, Uganda, Rwanda, Tanzania, Mozambique, Zimbabwe,

110 Kenya, Zambia, and Malawi) were included in this study.

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7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #2: No

Reviewer #3: Yes: Abdul-Aziz Seidu

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

PLOS ONE

Point by point response for editors/reviewers comments

The manuscript title “Pooled prevalence and determinants of modern contraceptive utilization in East Africa: A Multi-country Analysis of recent Demographic and Health Surveys.”

Manuscript: PONE-D-20-23298

Dear editor/reviewer.

Dear all,

I would like to thank you for this constructive, building, and improvable comments on this manuscript that would improve the substance and content of the manuscript. We considered each comment and clarification questions of reviewers on the manuscript thoroughly. My point-by-point responses for each comment and questions are described in detail on the following pages. Further, the details of changes were shown by track changes in the supplementary document attached.

Editor’s comment.

1. Please take care of the reviewers' comments. Edit the English language and grammar of the paper.

Author response: - Thank you very for comment. We gave our manuscript to English editor and we corrected grammatical and punctuation errors.

2. Also justify the pooling of data from different East African countries, while there are so many papers already published. What new knowledge it is contributing to the body of literature?

Author response: - Thank you very much for your concern. The data were pooled together to create a large sample size and to generalize the modern contraceptive utilization among reproductive-age women in East African countries. To our search, there is no study in East Africa that represents the entire WHO East Africa region. This method of analysis (both meta-analysis and multilevel analysis). The meta-analysis generates a pooled prevalence of modern contraceptive utilization reported using a forest plot that includes country-specific prevalence and overall East Africa region prevalence. If any interested NGO or governmental organization is interested to intervene in the uptake of modern contraceptives in the East Africa region, they can find country-specific as well as overall East Africa region prevalence and determinants of it. The other method of analysis for this study multilevel logistic regression analysis, which considers hierarchal nature of the dataset (considers variability within and between countries). The model identified determinants of modern contraceptive utilization in the East Africa region. The dataset used in this study was obtained from a nationally representative in the 11 East Africa DHS dataset. The study was population-based with a response rate of > 90%. Findings from this study are supported by large datasets covering 11 countries in the East Africa region. The data were gathered following a common internationally acceptable methodological procedure. Due to the representative nature of the survey, the findings are representative of included countries and generalizable to the reproductive age women East Africa Region. Studies review in this manuscript had an inconsistent result and fit the model without considering the hierarchal nature of the dataset.

3. Update the analysis with including recent datasets.

Author response: - Thank you very much for your comment. We accept your comment and corrected accordingly. The third review recommended us to include Zambia's new dataset (2018) and he recommends us to exclude Madagascar in which its DHS conducted in 2008. We accept his recommendation and we exclude Madagascar, and we included updated Zambia DHS data in the revised document (see-revised manuscript).

Response to Reviewers comments

Reviewer #1

1. Abstract

Background:

- Please be consistent in writing east African vs. East African.

- Why was pooled prevalence required?

Author’s Response: - Thank you very much for your comment. For the first bullet, we accept your comment and corrected accordingly. For the second bullet “Why was pooled prevalence required”. To have large sample data that represent the East African country and to generalize modern contraceptive utilization in the region. In addition, To our search, there is no study in East Africa that represents the entire WHO East Africa region. This method of analysis (both meta-analysis and multilevel analysis). The meta-analysis generates a pooled prevalence of modern contraceptive utilization reported using a forest plot that includes country-specific prevalence and overall East Africa region prevalence. If any interested NGO or governmental organization is interested to intervene in the uptake of modern contraceptives in the East Africa region, they can find country-specific as well as overall East Africa region prevalence and determinants of it.

2. Results:

- Consider specifying only the key findings of the study rather than listing all the determinants. Also, use the breakdown of the sentences rather than writing one long sentence that is hard to follow

Author’s response:-Thank you very much for your comment. We accept your comment and corrected accordingly (see the revised manuscript).

Conclusion:

3. Line 56-58: Do not repeat the study findings under this section.

Author’s response:-Thank you very much for your comment. We accept your comment and corrected accordingly.

4. Plain English Summary

- Consider paraphrasing the sentences rather than repeating it the same under each section.

- You could replace ‘Living country’ with ‘Country of residence’.

Author response: - Thank you very much for your comment. This is not the format of the journal.

5. Background

- There are multiple typos throughout the manuscript. The authors are suggested to proofread them carefully.

- Need to define modern contraceptives.

- Authors have already listed most of the determinants of contraceptive use under the background section, which weakens their rationale for determining the determinants.

- If effective strategies need to be country-specific, what was the rationale behind estimating pooled prevalence? The rationale part needs to be strengthened.

Author’s response:-Thank you very much for your comment. For the first bullet, we included definitions of modern contraceptives in the background session (see revised manuscript line 56-60). For the second bullet, we are reviewing the literature that was done before. To our search, there is no regional (East African countries) study that shows the magnitude and determinants of modern contraceptive utilization. Most studies used simple logistic regression that does not consider the hierarchal nature of the dataset and there are inconsistency findings from the literature. For the third bullet, we reported the overall pooled prevalence of the region and as well as country-specific prevalence using forest plot (figure 1). Therefore, for anyone interested to intervene at country-specific or at region level the magnitude is reported.

6. Methods

- Line 163: Residence is mentioned twice.

- Variables of the study: Good to specify how the variables were coded in the dataset, and whether the authors used the same coding or recorded them.

- Line 177: Need citation.

- Line 199: Once defined, no need to re-define the abbreviations. For e.g., MOR

- Need to define modern contraceptives under the methods section and cite it.

Author’s Response:- Thank you very much for your comment. For bullet one, we cite it. For bullet two, we included coding of the variable using the table(Table 1). For bullet three, we corrected it. For bullet three we included the definition and we site it(see the revised manuscript ).

7. Results

- Line 208: Specify age in years. IQR should be presented in range.

- How are rural residents defined in this study?

- Line 222: Provide 95% CIs for the estimates.

- Results section is too long with many repetitive findings. Consider shortening it by only highlighting the key findings.

Author’s response:-Thank you very much for your comment. A rural resident or countryside is a geographic area that is located outside towns and cities. We corrected it accordingly (see the revised manuscript).

8. Discussion

- Authors started to compare and contrast study findings, which should have been followed after stating the key findings and justification for those findings.

- There is a repetition of most of the findings that are already stated under the results section.

- Justification for all the discordant results are presented same i.e., due to differences in sample size, study design, setting, and study population. This needs to be study specific rather than a mere generalization.

Author’s Response: - Thank you very much for your comment. We accept your comment and corrected accordingly (see the revised manuscript).

9. Conclusion

- Clearly and concisely state the conclusions of the study in relation to the key question it sought to answer and the contribution that the paper would make.

Author’s response:-Thank you very much for comment. We accept your comment and corrected accordingly (see the revised manuscript).

Reviewer #2

1. Unique contribution of this pooled analysis is unclear.

Author’s response:- To have large sample data that represent the East African country and to generalize modern contraceptive utilization in the region. In addition, To our search there is no study in East Africa that represent the entire WHO East Africa region. This methods of analysis (both meta-analysis and multilevel analysis). The meta-analysis generate pooled prevalence of modern contraceptive utilization reported using forest plot that includes country specific prevalence and overall East Africa region prevalence. If any interested NGO or governmental organization interested to intervene on the uptake of modern contraceptive in East Africa region, they can find country specific as well as overall East Africa region prevalence and determinants of it.

2. Consider reporting on how east Africa compares in relation to regional estimates of modern contraceptive use.

• Also, how is the east Africa country grouping determined? UNFPA, WHO, World Bank, AU?

Page 5, line 128 – consider revising “Even though, different individual studies are there”. The first comma is redundant and the use of “are there”

Author’s Response: - Thank you very much for your comment. We accept your comment and corrected accordingly (see the revised manuscript)

3. Data sources and sampling techniques – could benefit from better organization structure – information seems randomly placed. Also, expand on stratification and provide a reference for a more elaborate description of the DHS sampling strategy.

Author’s Response: - Thank you very much for your comment. We accept your comment and corrected accordingly (see the revised manuscript)

4. Sample – Most studies on contraceptive use focus on married women. There is no problem in focusing on all reproductive-age women but it’s important to provide a justification for your sample selection and highlight this difference to readers since there can be differences between your estimates and the “official estimates” of modern contraceptive use.

Author’s response:-Thank you very much for your comment. For this study, we include both married and unmarried women. We exclude infertile women in our analysis because it underestimates. We believe that all sexually active women were eligible for this study. As you mentioned some studies focus on married women. Our study focus is on both married and unmarried women in the region. Our findings showed that unmarried women were highly likely to use modern contraceptive utilization. The reason might be unmarried women may have multiple sexual partners.

5. Variables – the variable “current modern contraceptive use” does not exist in the DHS. How this was variable derived? Which methods are included? How were the other variables selected? For purposes of research reproducibility, it would be helpful if you included the actual variable numbers used to derive these indicators, clearly indicating where these variables were computed. Your tables suggest that you computed several variables and you have to be transparent about your methods and decisions that went into collapsing these variables.

Author’s response:-Thank you very much for your comment. The modern contraceptive variable exists in the DHS dataset with code v364 (Use modern method, Use traditional method, Non –use, intend to use later, and Do not intend to use) we recoded this variable (1=modern contraceptive use, 0= otherwise). We included this coding variable in the revised manuscript (see revised manuscript Table 1 page 6-8 line 146)

6. Data management and analyses

- Which sampling weight and strata id were used and were the weight normalized?

- Also, did you create unique cluster ids for each country before appending the data?

Author’s response:-Thank you very much for the comment. We used sampling weight (v005), primary sampling unit (v021), and strata (v022) for this analysis. Complex survey design were set before any statistical analysis. Was weight normalized? Yes, it was normalized. Did you create unique cluster ids for each country before appending the data? Yes, a unique code was given for each country to appended the data together. We included this coding in the revised manuscript (Table 1)(see revised manuscript)

7. Model building

- It would be helpful if you specified these variable categorizations in the section “Study variables”. I am not which what community-level variables are”

- Also not clear is what is measured under fixed effects vs random effects. I did not see any reference to the country or time. These surveys are not conducted at the same time so it’s important to account for this variation.

Parameter estimation methods – need to be clearer about which variables are measured under fixed effects vs random effects. Also, what if any covariates are included in the model.

Author’s response:-Thank you very much comment. For the first bullet, I included the variable coding in table 1. For the second bullet, our fixed effect variables are level one and level to variables. Our random variables was cluster (Enumeration Area(EAs)). Cluster (EAs) is a geographic area covering on average 181 households. The sampling frame contains information about the EA location, type of residence (urban or rural), and the estimated number of residential households. Actually, we tried to make the country as a cluster variable and it was not significant that’s why we used two-level variables.

Figure 1 – Don’t think you need the non-modern contraceptive users' bar; consider adding confidence intervals to the modern contraceptive user bars. Also, not sure of whether this graph is necessary since the same information is represented in Figure 2.

Figure 2: Define labels – study ID (country??); ES??

Author’s Response: - Thank you very much for your comment. We accept your comment and corrected accordingly figure 1 (see revised manuscript).

8. Page 11, line 239 – what variables define clusters? What is the role of the country? I would recommend using the country as the clustering variable because from a programmatic perspective – this is the grouping that makes the most sense. As presented, I have no idea what the cluster intuitively represents here because these were not defined earlier (to they represent countries, regions?). Also, based on your modeling, you community level which you have not commented about – this is the cluster level?

Author’s response:- Cluster (Enumeration Area(EAs)) is a geographic area covering on average 181 households. The sampling frame contains information about the EA location, type of residence (urban or rural), an estimated number of residential households. Actually, we tried to make the country a cluster variable and it was not significant that’s why we used two-level variables. The role country in this study is as an independent variable. We tried as a cluster variable but it was not significant. That is why we used two-level variable in our analysis. Our plan was to use three-level variables but the country as a cluster variable was not significant. We included the level one and level two variables in the revised manuscript (see the revised manuscript).

9. Page 12, Line 259 – “After controlling for other individual and community level factors, the odds of modern 260 contraceptive utilization among women in the age groups 25-34 and 35-49 were decreased by 21%”. The use of “decreased by” suggests a time component, which is not modeled in this time and these are cross-sectional studies (with each country represented at a single time point). Do you mean were odds were lower…. The same comments apply to all other variables where this language is used.

Author’s Response: - Thank you very much for your comment. We accept your comment and corrected accordingly. That was to mean that lower and higher. We appreciate your comment and included the revised document (see the revised manuscript).

10. Page 13 – font variations and formatting issues (e.g. Line 282). The presentation of results needs to be revised.

Author’s Response:- Thank very much for your comment. We accept your comment and correct accordingly(see revised manuscript).

11. Discussion

Page 15, line 299: “The pooled prevalence of modern contraceptive utilization in East African countries was 21.95%. It was smaller when compared with a study conducted using a systematic analysis (21), a study conducted in 73 low and middle-income countries (16), and studies conducted in Ethiopia, Burkina Faso, and Nigeria (15) (22,23).

1. There are several data sources that can give you better estimates for comparison e.g. FP2020: http://www.familyplanning2020.org/data-dashboard

2. Second, this goes back to my point about indicating which samples you are using – all women or ever-married women only because these estimates can differ substantially depending on the sample you use.

Authors ‘response:- Thank you very much for your comment. For this study, we include both married and unmarried women. We exclude infertile women in our analysis because it underestimates the result. We believe that all sexually active women were eligible for this study. As you mentioned some studies focus on married women. Our study focus is both married and unmarried women in the region. Our finding showed that unmarried women were high likely to use modern contraceptive utilization than married women. The reason might be unmarried women may have multiple sexual partner.

12. On the relationship between modern contraceptive utilization and health facility delivery, consider using variables – health worker talked to you about contraceptive use to elaborate on these findings. I think this may be more relevant than just a health facility delivery. In fact, across many countries- health workers teach about family planning during antenatal care and immunization of children. A hospital delivery does not necessarily mean that the woman who attended ANC and utilization of post-natal care remains low in SSA.

Authors ‘response:- Thank you very much for your comment. Yes, you write including health workers saying about family planning was better rather health facility delivery. Unfortunately, such a variable was not in the DHS dataset. we included it in the limitation part(see revised manuscript).

Reviewer #3

1. I will urge the authors to consider the most recent data set (2010 and above) and they should not forget to include the new data from Zambia. Please see below my specific comments that could further improve the manuscript.

Author’s Response: Thank you very much for your comment. We accept your comment and corrected accordingly. We included the updated Zambia dataset (2018) and excluded the Madagascar dataset (2008)(see the revised manuscript)

2. Line 31-32 should read “Therefore, this study, aimed to estimate the pooled prevalence and determinants of modern contraceptive utilization in East African Countries”

Author’s Response: Thank you very much for your comment. We accept your comment and corrected accordingly (see the revised manuscript)

3. The conclusion section of the abstract and main conclusion, Page 2 and page 18, lines 55-56 and line 390 “We found that modern contraceptive utilization in the 12 East Africa countries was low”. The authors can decide to qualify it with the word ‘relatively low’. This is because of how low is low if there is no benchmark to measure the level.

Author’s response:-Thank you very much for the comment. We accept your comment and corrected accordingly (see the revised manuscript).

4. Please specify the study period or the years you considered. E.g Surveys from 2008-2017. However, I have a concern with the authors using data that is more than a decade that is those before 2010. The authors consider only those that are a bit current. I acknowledge the fact that Madagascar’s most recent Standard DHS was conducted around 2008-2009, this is more than a decade and I am sure a lot of changes have occurred as far as contraceptive usage is concerned. The authors can decide to take this out or acknowledge it as one of their key limitations.

Author’s response:- Author’s response: Thank you very much for your comment. We accept your comment and corrected accordingly We included the updated Zambia dataset (2018) and excluded the Madagascar dataset (2008)(see the revised manuscript).

5. Line 43, Please add the confidence interval for the overall prevalence

Author’s response:- Author’s response: Thank you very much for your comment. We accept your comment and corrected accordingly (see the revised manuscript)

6. The authors can add determinants to their keywords.

Author’s Response: Thank you very much for your comment. We accept your comment and corrected accordingly (see the revised manuscript)

7. I am not too sure about PLOS one’s guidelines, but it is allowed the authors can still keep the plain English summary. If not then this section can be taken out of the manuscript. I know for BMC Reproductive health it is a requirement.

Author’s response:-Thank you very much for your comment. This is not the format of the PLOS one.

8. Please replace developing with low and middle-income countries throughout the manuscript

Author’s Response:- Thank you very much for your comment. We accept your comment and corrected accordingly (see the revised manuscript)

9. In the methods section, the authors should kindly provide the countries, the survey year, the sample size, and the numbers they excluded from their study in a table. With the data, I expect that the authors revise their analysis to consider the most recent ones. I inferred from the study period that Zambia’s current data (2018) was excluded

Author’s Response:- Thank you very much for your comment. We accept your comment and corrected accordingly (Figure 1) (see the revised manuscript)

10. Any reason why the authors considered women who have given birth 5 years preceding the survey but not sexually active women. This should be specified

Author’s Response:- Thank you very much for your comment. That was an incorrect expression and we corrected after your constrictive comments. Our Study population is both married and unmarried women and generally reproductive age women(15-49)(see the revised manuscript).

11. Line 158, please indicate the specific modern contraceptive methods you used to create modern contraceptive usage and support the categorisation with an evidence.

Author’s Response:- Thank you very much for your comment. We accept your comment and corrected accordingly (see the revised manuscript).

12. Please provide another Table and give how each of the independent variables were derived or recoded from the original dataset. This can either be in the manuscript or attached as a supplementary file.

Author’s Response:- Thank you very much for your comment. We accept your comment and corrected accordingly. We included one additional table (Table 1) in the method session that describes the original variable code in the DHS dataset and recoded variables (see the revised manuscript)

13. What informed the inclusion or selection of the independent variables?

Author’s response:- we used literature and DHS guide statistics for independent variables selection.

14. Any reason why the wealth index was collapsed into three categories instead of the original 5. This can be kept as it is due to the fact that the sample size is large enough.

Author’s response:- For ease of analysis and due to the fact that the sample size is large enough.

15. In the analysis section, although the authors have vividly explained why they used multilevel analysis they should specify the levels (i.e whether 2 level or three levels). By this, i also expect the authors to group their variables into the various levels.

Author’s Response:- Thank you very much for your comment. We accept your comment and corrected accordingly. We do have two types of variables (level one and level two). we included this in the revised manuscript Table 1 (see the revised manuscript).

16. Please specify the model equation

Author’s response:- Thank you very much for your comment. We accept your comment and corrected accordingly (see the revised manuscript page 9 line 163-170 ).

17. What informed the choice of the reference categories

Author’s response:- There are a lot of evidence to select the reference category. First using scientific evidence from the literature if the odds ratio was above one. The second method of selecting the reference category was if a specific category had high events.

Strategy 1: Use the normative category. In many cases, the most logical or important comparisons are to the most normative group. ...

Strategy 2: Use the largest category. ...

Strategy 3: Use the category whose mean is in the middle, or conversely, at one of the ends.

18. Did the authors check for multi-collinearity, the results should be provided

Author’s Response: - Thank you very much for your comment. Yes, I checked it. The VIF was less than 10. We included in the revised document (see the revised manuscript).

19. Please use the STROBE guidelines and present it as an appendix or a supplementary file

Author’s response: - Ok will submit in our revision submission.

20. The results are well presented. That notwithstanding, in the fixed effects analysis results section, the author have elaborately presented their results. I will urge them to present the key ones and make reference to the Table.

Author’s Response: - Thank you very much for your comment. We accept your comment and corrected accordingly (see the revised manuscript Table 1).

21. Table 2, please indicate as a footnote the meaning of AOR. The authors should also specify the exact p-values with different stars e.g. *p < 0.05, ** p < 0.01, *** p < 0.001

Author’s Response: - Thank you very much for your comment. We accept your comment and corrected accordingly (see the revised manuscript).

22. The authors have generally discussed their results very well. Nonetheless, it might be inappropriate to compare the pooled prevalence with country-level studies. Comparing the average prevalence of all countries found in your study to specific countries in other studies is inappropriate when your own analysis included an analysis of prevalence in individual countries. It would be more appropriate to discuss the relative differences among countries included in your own study if you wanted to have this discussion here.

Author’s Response:- Thank you very much for your comment. We accept your comment and corrected accordingly (see the revised manuscript).

23. At the strength and limitation section, line 380-388, what about the recall and social desirability biases?

Author’s Response: - Thank you very much for your comment. Yes, the biases are a problem of this study because the women asked about the use of contraceptive utilization for the last five years preceding the survey for each country survey. This bias may by affect our findings. We accept your comment and corrected accordingly (see the revised manuscript).

24. The conclusion is well presented. However, the policy implications are not well discussed. The authors can consider beefing them up.

Author’s Response:- Thank you very much for your comment. We accept your comment and corrected accordingly (see the revised manuscript).

Thank you all in advance for your constructive comments on the improvement of our manuscript!!!!!

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Submitted filename: Point by point response.docx
Revision 2

PLOS ONE

Point by point response for editors/reviewers comments

The manuscript title “Pooled prevalence and determinants of modern contraceptive utilization in East Africa: A Multi-country Analysis of recent Demographic and Health Surveys.”

Manuscript: PONE-D-20-23298R1

Dear editor/reviewer.

Dear all,

I would like to thank you for these constructive, building, and improvable comments on this manuscript that would improve the substance and content of the manuscript. We considered each comment and clarification questions of reviewers on the manuscript thoroughly. My point-by-point responses for each comment and question are described in detail on the following pages. Further, the details of changes were shown by track changes in the supplementary document attached.

Reviewer #2

1. Reviewers comment. The biggest issue for me is that I am still not convinced with the justification for the pooled analyses. Even within the East African region, countries are progressing at different rates; the context varies markedly especially in times of method mix and factors underlying non-use of modern contraceptives. Cultural factors – among the major drivers also play out differently. Therefore, it is difficult to develop a uniform approach for the entire region.

Author’s Response:- Regional studies we believe very important and informative for governmental and non-governmental organizations for implementation and decisions making. Thanks to DHS program makes life easy to do such types of a pooled analysis. There is a lot of articles that are done in such away. The DHS program uses the same sampling procedure, the same coding, and the same data collection techniques for each country in the world. Example:- antenatal care visit was coded as m14_1(0=no visit, 1=one visit….) variable in Ethiopia, Kenya, Uganda…..for all countries the had DHS data. appending this data set each and possible to have regional data and having regional estimates. We believe there is no much variation in the East Africa countries with many aspects even if they progress at different rates. Related to cultural factors we included in the limitation session after your comment(line number 372-373). We are sure it possible to append by giving a unique ID to each country and develop a single dataset that represents the region.

2. Reviewers comment. There are several places in the author’s response where they simply copy and paste comments, without necessarily addressing my comments. Rather than refer me back to the manuscript, I would appreciate it if the authors could clarify those comments and provide actual samples of the in-text revisions.

Author’s Response: - Sorry for making you uncomfortable with the previous response please accept our apology. We accept the comments and corrected them in this response.

Reviewers comment. For example, what country grouping classification was used? What are the implications of focusing on both married and unmarried women – particularly when you are comparing your findings to the existing literature that typically focuses on married women only? [see response to my query in discussion] How was the weight normalized? These details should be added to the manuscript and not simply addressed in the response to reviewers.

Author’s response:- Country grouping was based on location. The reason why included unmarried women are that they are sexually active and had recent sexual history during data collection and they are eligible for contraceptive use. If we include only married women it may overestimate the result. In addition, casual sex and cohabitation is common in developing country and therefore are eligible to contraceptive use. The weighting was done for each analysis to make the sample size representative for each country. After your comment, we included in the main text (line number 118-121)

Reviewers comment

-Not necessary to describe modern methods of contraception as the first paragraph in the introduction. Putting this in the methods section would suffice.

- Could summarize the benefits of modern contraception – not necessary to belong and paragraph is too wordy.

- Data management – still no mention of approach to create country-specific PSU ids and strata. The authors mentioned this in reviewer comments but I don’t see these details in the manuscript.

Author’s Response:- Thank you very much for your comment. We accept your comment and corrected it accordingly.

� Not necessary to describe modern methods of contraception as the first paragraph in the introduction. Putting this in the methods section would suffice.

Author’s Response: We accept and remove it from the introduction session(line number 58 ).

� Could summarize the benefits of modern contraception – not necessary to belong and paragraph is too wordy.

Author’s Response:- we accept your comment and correct it(line number 96-)

� Data management – still no mention of approach to create country-specific PSU ids and strata. The authors mentioned this in reviewer comments but I don’t see these details in the manuscript.

Author's Response:- Thank you very much for your comment. The detail about the primary sampling unit, secondary sampling unit ..etc was mentioned in the main manuscript (line number 115-122)

Reviewer #3

3. Reviewers comment

I will urge the authors to critically read through their manuscript to correct grammatical errors. And again, please do not start a sentence with numbers. E.g see page 4 line 108 ". 11 East African 109 countries (Burundi, Ethiopia, Comoros, Uganda, Rwanda, Tanzania, Mozambique, Zimbabwe, 110 Kenya, Zambia, and Malawi) were included in this study.\\

Author’s Response:- Thank you very much for your comment and we accept your comment and corrected it accordingly.

Thank you all in advance for your constructive comments on the improvement of our manuscript!!!!!

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Submitted filename: Point by point response.docx
Decision Letter - Mohammad Rifat Haider, Editor

Pooled prevalence and determinants of modern contraceptive utilization in East Africa: A Multi-country Analysis of recent Demographic and Health Surveys.

PONE-D-20-23298R2

Dear Dr. Tadesse,

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Formally Accepted
Acceptance Letter - Mohammad Rifat Haider, Editor

PONE-D-20-23298R2

Pooled prevalence and determinants of modern contraceptive utilization in East Africa: A Multi-country Analysis of recent Demographic and Health Surveys.

Dear Dr. Tessema:

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