Thank you for allowing me to review this manuscript. The topic is certainly one that has not received much attention in the literature. I fully agree with the authors that the role of men and male engagement in sexual and reproductive health is important and requires more exploration.

I have a number of concerns with the current manuscript. First, concerning the background section:

The authors present a number of related works in their introduction; however, even after reading the manuscript, I still don’t understand what drove them to research this topic. There is no clear problem statement, other than it is something others have not examined. What is the rationale? Where is the “so what” factor? Why should we care? This isn’t to argue we should not care, but the authors should revise this section to build a logical and scientific case for why it is important and relevant to examine this topic.

Is the work clearly and accurately presented and does it cite the current literature?

Partly

If applicable, is the statistical analysis and its interpretation appropriate?

No

Are all the source data underlying the results available to ensure full reproducibility?

Yes

Is the study design appropriate and is the work technically sound?

Partly

Are the conclusions drawn adequately supported by the results?

No

Are sufficient details of methods and analysis provided to allow replication by others?

No

Reviewer Expertise:

My areas of expertise lie in health services research on the topics of sexual and reproductive health, and infectious disease, including research design and quantitative methods.

I confirm that I have read this submission and believe that I have an appropriate level of expertise to state that I do not consider it to be of an acceptable scientific standard, for reasons outlined above.

General comments: Please check spelling and grammar; there are a few typos in the article.

For full approval: Please note that one of the key hypotheses, use of contraception by males, was not proven to be true. This calls into question proposed interventions and implications of findings. Further discussion of why this might be true would significantly increase the utility of this study.

This paper examined the socio-demographic, economic and proximate predictors of age at first child’s birth among men aged 15-54 years in Uganda. This study on the age of males (fathers) at the birth of their first biological child in Uganda contributes to the body of literature on the impact of age at male/father’s first birth on male involvement/engagement in reproductive health. It is a rare study on the age of males at the birth of their first child. The study analyzes publicly available DHS data (2016 Uganda Demographic and Health Survey [UDHS] sample of 3,206 men aged 15-54 years who had a biological child) in an innovative way.

In Uganda, statistical analysis shows the median age at first birth is 22 years, most men (62.4%) became biological fathers for the first time between the ages of 18 and 24 years.

Outcome variable: male’s age at first childbirth categorized as: below 17, 18-24 and 25 years and above (25+)

Analysis: descriptive statistics, un-adjusted and adjusted multinomial regressions with significance level at 95%

Results: Median age at first child’s birth was 22 years (IQR = 20-25). The majority of men (62.4%) had fatherhood onset between 18 and 24 years. Only 5.2% had fatherhood onset at 17 years or earlier, increasing to 32.4% at 25+. Respondents whose first sexual encounter was before 18 years was 44.3% and 92.7% by 24+. Few respondents (44.1%) reported use of any contraceptive methods. Anglican religion (RRR=1.62; CI 1.06 – 2.46) or not having attended school (RRR=2.20; CI 1.02-4.71) were predictors of childbirth onset before 17 years.  Age of sex debut at 18 years or higher (RRR= 2.09, CI 1.72 – 2.54) and secondary and above education (RRR = 1.76, CI 1.42-2.18) were predictors of fatherhood onset at 25+.  Contraceptive use among men had no association with age at first child’s birth.  This is surprising. Was it possible to ascertain contraceptive use among the male’s partner?

“Conclusion: These findings are important for strategic allocation of resources to curb early onset of fatherhood among adolescent and young men under the age of 25 years. They highlight the need for gender-sensitive interventions targeting men for behavioral change, participation in Sexual and Reproductive Health Rights (SRHR) programming and improved access to services delivery.” If contraceptive use had no association, what behaviour change are you suggesting? Which interventions might work? It would be useful to be more specific here.

Good use of literature findings here. “Literature indicates that there is scarcity of evidence to demonstrate that men have been directly targeted by or are primary beneficiaries from reproductive health programs and activities (Sternberg & Hubley, 2004; Kabagenyi et al., 2014a; Onyango et al., 2010). As a consequence, male fertility in the sub-Sahara African region has remained high – two-fold times higher than female fertility (Ntozi, 1995; Schoumaker, 2017; Snow et al., 2013). The high fertility in these regions could be attributed to the male dominance in sexual relationships and marriage, high desire for large families and polygamy, little or lack of couple discussion on childbearing and disapproval of contraceptive use among men (Berhane et al., 2011; Kabagenyi et al., 2014a; Ntozi, 1995; Schoumaker, 2017; Snow et al., 2013). This paper provides an opportunity to profile the predictors of first child’s birth among men aged 15–54 years in Uganda, with the aim of enhancing knowledge and contributing to an increase in the demand and utilization of reproductive health services among men.

The literature on age at first child’s birth and the associated predictors among men has remained scarce in most developing countries in spite of numerous studies on reproductive health issues and childbearing. Existing evidence shows that most studies on first childbirths and reproductive health matters focus on women rather than men (Kabagenyi et al., 2014a; Macutkiewicz & MacBeth, 2017; Neal et al., 2015). However, a few studies in the literature which focused on men show that age at first child’s birth is not only an important predictor of fertility among men, but also it is central in influencing national and global trends of health indicators (Finer & Philbin, 2014; Martinez et al., 2012). Early age at first childbirth among men increases the risks of suffering from depression, parenting difficulties, psychological conditions such as poor mental health during late adulthood and high mortality odds.” Interesting – is there any literature indicating that the age of the biological father has an impact on the health of the infant/child?

“Benefits have been associated to delaying the age at first birth among men, and they include: enabling men to complete and attain higher education, prepare for future prospects such as engaging in income generating ventures and pursue better employment or career development during adolescence and young adulthood; reducing the risk of undesired consequences that may arise from unwanted teenage pregnancies, abortions among sexual partners and those associated with teenage fatherhood (Darroch et al., 2016; Kato-Wallace et al., 2016).”

“Specifically, the study examined the relationship between contraceptive use, age at first sex, education, financial status, place of residence, occupation, ethnicity and age at first child’s birth.”

Hypotheses:

Men with secondary and higher education levels are more likely to have a higher age at first child’s birth than those with no education.

“The findings of this study are crucial in improving male participation in reproductive health by targeting men’s behavior and social norm changes to limit teenage or early fatherhood, and to empower young couples to negotiate family planning decisions for improved contraceptive uptake freely. Second, the findings will enhance building the capacity of skills among healthcare providers in facilities to adequately engage and provide reproductive healthcare services to men. This strategy is anticipated to encourage men to take the lead as users, potential clients, and partners in accessing reproductive healthcare. Lastly, these findings will influence policymakers engaged in reproductive health programming to develop gender-sensitive policies that respond to the needs of the vulnerable young men, so that such men are targeted with efficient and effective interventions for improved male involvement and reproductive health services delivery.”

“Question on number line 211: How old were you when your (“first” applies if a respondent has had already more than one child) child was born? The response to this question was re-coded numerically in completed years of age.”

“Independent variables were grouped into categories as hypothesized to influence the dependent variable.”

“Socio-demographic and economic variables included: religion, ethnicity, education, financial status, occupation, partner-age difference, place of residence, and mass media exposure (including internet use).”

“One of the categories considered for the occupation variable was white-collar jobs, this was defined as occupations that are managerial, technical, clerical or sales based.” Was this a hypothesis?

“Proximate variables included: contraceptive use and age at sex debut. Precipitating variables, including previous exposure to parental Intimate Partner Violence (IPV) and forced sex, were included to examine their influence on age at first birth.”

“ Results”

“Precipitating factors such as exposure to mass media, forced sexual acts and exposure to parental intimate partner violence were not significantly associated with age at first childbirth among the participants. Likewise, contraceptive use as a proximate factor was not significantly associated with age at first childbirth among men. All the variables that were significantly associated with age at first childbirth were included in the adjusted multivariate analysis models.”

“ Factors associated with age at first child’s birth among men at multivariate analysis”

“Adjusted multivariate analysis results (Table 3) showed that men with no education were 2.2 times (RRR=2.2; CI: 1.02 – 4.71) more likely to have first their child by 17 than between 18–24 years compared to those with primary education, other factors remaining constant. On the contrary, men with secondary or higher education were 0.4 times less likely to have their first child (RRR=0.44; CI:0.22-0.89) by the age of 17 than 18–24 compared to those with primary education, holding other factors constant. Men with secondary or higher education were 1.8 times (RRR=1.76; CI: 1.42-2.18) more likely to have their first child by the age of 25 and above than between 18–24 years compared to those with primary education, holding other factors constant. With regards to ones’ ethnicity, Banyoro men were 0.5 times (RRR= 0.48; CI 0.30-0.78) less likely to have their first child by 25 and above than between 18–24 years compared to the Banyankore holding other factors constant. Similarly, among the Baganda men were 0.6 times (RRR=0.61; CI: 0.41-0.81) less likely to have their first child aged 25 and above than between 18–24 years compared to Banyankore holding other factors constant. Regarding religious affiliation, Anglican men were 1.6 times more likely to have their first child by 17 than between 18–24 (RRR=1.61; CI: 1.060 - 2.46) compared to Catholic men. Men were asked about their age at first sexual encounter, this variable was included in the analysis to examine its predictability to the age at which men had their first child.”

Table 3 shows men whose age at reported first sexual encounter was 18+ (18 years and above) were 0.1 times less likely (RRR: 0.06; CI:0.03 – 0.11) to have their first child by 17 than between 18–24 years compared to those who had their first sexual encounter when less than 17 years. Please add the word ‘reported’ here; otherwise it is obvious that men who did not have sex before 18 would not become biological fathers by age 17.  

“ Discussion”

“Studies on predictors of age at first child’s birth among men in Uganda are uncommon. This paper aimed at examining the socio-demographic, economic and proximate predictors of age at first child’s birth among men aged 15–54 years in Uganda. This study showed that almost three-quarters of the men had their first child as youths, before 25 years. These results are comparable with findings from a study that evaluated trends and characteristics of age at first child’s birth among adolescent girls and young women within the East African countries, which showed that Uganda was one of the countries with the highest proportion of first childbirth among adolescent girls before 20 years of age (Neal et al., 2015). This result may suggest that the determinants of age at first child may be similar between genders. Prior to this research, little has been published focusing on males spite of a high prevalence of low age at first child’s birth among both young men and women, this paper aimed to address this gap. This finding implies that interventions and policy reforms to curb early onset of childbearing among young people should target men younger than 25 years as well.”

“This study revealed that nearly all men survey had their sexual debut before 25. Both bivariate and multivariate analysis showed that age at first sex was a proximate predictor of age at first child’s birth. This finding are in agreement with another comparative study conducted among the sub-Saharan African countries where more than half of the adolescent men had sexual debut before 25 (Johnson & Gu, 2009). In many African societies behavioral maladjustment disorders, peer perceptions, negative sociocultural sex initiation values and poor parenting are direct determinants of early sex debut among adolescents (Babalola, 2004; Peltzer, 2010). This implies that interventions to ensure safer sexual behaviors have to be implemented and should aim at ensuring universal access to information about the benefits of safer practices and available contraception commodities to decrease the risk of first child’s birth among adolescent men.” Study showed no association between contraceptive use and age at first child; need to further elaborate on this. Was it consistent contraceptive use? Should better sex education be a recommendation? What methods are men using? Did you include traditional methods (withdrawal) in the mix?

“Contraceptive use was not found to be a predictor of age at first child’s birth among men. Though contraceptive use is a proximate determinant of childbirth, it is argued in the literature that willingness for contraception uptake increases mainly after the first child’s birth and with subsequent births, especially among young couples for the purposes of child spacing and limiting. Studies in Rwanda and India demonstrated that the propensity for a couple without a child to demand contraception use is often significantly reduced (Jayaraman et al., 2009; Rao & Mathada, 2016). Similar to another study conducted while comparing developing countries, it indicated that less than half of married and unmarried sexually active men used any form contraceptives (Johnson & Gu, 2009). This evidence highly suggests that the low uptake of contraceptives among men is partly the explanation for this result. There are several factors documented in the literature that may explain low contraceptive use levels among men. These include: a high prevalence of negative socio-cultural expectations and values attached to childbirth behavior and practices, misconceptions and fears about modern contraceptives, over-reliance on traditional contraceptive methods, prevalence of negative gender attitudes, limited opportunity for male discussion of family planning with health workers, and limited awareness about the role of men in fertility control to mention but a few (Kabagenyi et al., 2014a; Kabagenyi et al., 2014b; Kabagenyi et al., 2016; Johnson & Gu, 2009; MacQuarrie et al., 2015). Thus, the current relationship of contraceptive use and age at first child’s birth in this study may likely be a result of a conflict between the influences of factors that are negatively associated with contraceptive use and its low uptake among men.”

“The study also showed that education was a positive predictor of late age at first child’s birth. Previous studies conducted in the African region have consistently indicated that lack of or low education is a strong predictor of onset of teenage childbearing, especially among girls (Neal et al., 2015; Peltzer, 2010). This study has also shown similar results among men. Secondary and higher education reduce risks for not working, reverses negative socio-cultural values and norms, and other negative attitudes which are associated with early sexual debut and low contraceptive use among men (Johnson & Gu, 2009). Thus, secondary and post-secondary education improves contraceptive use and creates employment opportunities which result in delayed onset of fatherhood. This finding is consistent with the study hypothesis that men with secondary and higher education levels are more likely to have a higher age at first child’s birth than those with no education. This result implies that any interventions and programs that are aimed at curbing teenage fatherhood should prioritize second chance formal education at primary and secondary levels, address barriers of access to universal secondary education and also promote incentives for post-secondary and higher education completion among men.”

“Ethnicity was found to be a predictor of age at first child’s birth both at the bivariate and multivariate analysis levels. Possibly, cultural values, diversity in norms, and variations in the understanding of sexual roles and childbearing rewards explain the relationship between ethnicity and age at first child’s birth, as these are influenced by socio-economic factors. This finding was consistent with results from studies performed among women (Hirschman & Rindfuss, 1980; Matthews & Hamilton, 2009). However, the determinants for this relationship need to be further studied among men.”

“Religious affiliation, specifically Anglican denomination was found to be a significant predictor of early onset of fatherhood among the respondents. The relationship between religious affiliations and age at first childbirth has been observed among women in other countries such as Nigeria and Bangladesh (Fagbamigbe & Idemudia, 2016; Sarkar, 2010). However, this relationship among men has not been fully explored and this result provides a basis for further understanding of such dynamics in a Ugandan context. There is a need for more explorative research to study this phenomenological finding.”

Suggestion: Make a table of the hypotheses that the authors tested and the results. This will make them easier to track.

Hypothesis

True/False

Findings

Implications

Hypothesis: Men with secondary and higher education levels are more likely to have a higher age at first child’s birth than those with no education.

True/False: True 

Findings: Men with no education were 2.2 times (RRR=2.2; CI: 1.02 – 4.71) more likely to have first their child by 17; men with secondary or higher education were 0.4 times less likely to have their first child (RRR=0.44; CI:0.22-0.89) by the age of 17 than 18–24 compared to those with primary education.

Implications: Prioritize second chance formal education at primary and secondary levels, address barriers of access to universal secondary education and also promote incentives for post-secondary and higher education completion among men.

Hypothesis: Men who experience sexual debut after age 25 years are likely to have a higher age at first child’s birth than those with early sex debut defined as age less than 17 years.

True/False: Not proven

Findings: Nearly all men surveyed had their sexual debut before 25.

Implications:

Hypothesis: Men in rural areas have increased likelihood of having a lower age at first child’s birth than those in urban areas.

True/False: True

Findings: Men in rural areas have increased likelihood of having a lower age at first child’s birth than those in urban areas.

Implications:

Hypothesis: Men who use contraceptives are more likely to have a higher age at first child’s birth than those who don’t use.

True/False: False

Findings: No association between contraception use and age at first birth.

Implications: Promote consistent and correct use of male contraceptives; encourage dialogue between young women and young men about family planning.

Hypothesis: Men who experience sexual debut after age 25 years are likely to have a higher age at first child’s birth than those with early sex debut defined as age less than 17 years.

True/False: Not proven

Findings: Nearly all men survey had their sexual debut before 25.

Implications:

Hypothesis: Men who use contraceptives are more likely to have a higher age at first child’s birth than those who don’t use.

True/False: False

Findings: No association between contraception use and age at first birth.

Implications: Promote consistent and correct use of male contraceptives; encourage dialogue between young women and young men about family planning.

Is the work clearly and accurately presented and does it cite the current literature?

Yes

If applicable, is the statistical analysis and its interpretation appropriate?

Partly

Are all the source data underlying the results available to ensure full reproducibility?

Yes

Is the study design appropriate and is the work technically sound?

Yes

Are the conclusions drawn adequately supported by the results?

Partly

Are sufficient details of methods and analysis provided to allow replication by others?

Yes

Reviewer Expertise:

reproductive health; family planning, health systems strengthening, behavioral economics, behavioral change, health services delivery, systems thinking

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.