Gates Open Res Gates Open Research 2572-4754 F1000 Research Limited London, UK 10.12688/gatesopenres.13667.1 Research Article Articles Who uses covertly and what is the impact on contraceptive dynamics? Evidence from a national cohort of women in Uganda

[version 1; peer review: 1 approved, 1 approved with reservations]

 Wood Shannon N. Conceptualization Formal Analysis Methodology Writing – Original Draft Preparation Writing – Review & Editing https://orcid.org/0000-0003-4389-3526 a 1 Sarnak Dana O. Formal Analysis Methodology Validation Writing – Original Draft Preparation Writing – Review & Editing 1 Kibira Simon P.S. Conceptualization Data Curation Investigation Methodology Supervision Writing – Review & Editing https://orcid.org/0000-0002-7385-423X 2 Zimmerman Linnea A. Conceptualization Funding Acquisition Methodology Supervision Writing – Review & Editing https://orcid.org/0000-0002-0118-0889 1 Karp Celia Methodology Writing – Review & Editing 1 Makumbi Fredrick Conceptualization Investigation Methodology Supervision Writing – Review & Editing 3 Moreau Caroline Conceptualization Methodology Supervision Writing – Original Draft Preparation Writing – Review & Editing 1 4 Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA Department of Community Health and Behavioral Sciences, Makerere University School of Public Health, Kampala, Uganda Department of Epidemiology and Biostatistics, Makerere University School of Public Health, Kampala, Uganda Soins et Santé Primaire, CESP Centre for Research in Epidemiology and Population Health U1018, Inserm, Villejuif, France swood@jhu.edu

No competing interests were disclosed.

 2 8 2022 2022 6 85 21 7 2022 Copyright: © 2022 Wood SN et al. 2022 This is an open access article distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Background: Little is known regarding the specific role of covert use (i.e., use of contraception without partner knowledge) in contraceptive discontinuation and switching. Among a nationally representative cohort of women in Uganda, we sought to: 1) compare characteristics of covert, overt, and non-users of contraception at baseline; 2) assess the effect of using contraception covertly on switching and discontinuation over a one-year period.

Methods: Analyses utilized PMA2020 Uganda Round 6 (April–May 2018), with longitudinal analyses incorporating data from a one-year follow-up survey (May–June 2019). Both cross-sectional (n=1,764) and longitudinal (n=616) samples included women in need of contraception. For cross-sectional analyses, multinomial regression compared risk of overt/covert use vs. non-use by user characteristics and logistic regression compared the odds of covert vs. overt use among contraceptive users. For longitudinal analyses, multinomial regression examined risk of contraceptive switching and discontinuation by baseline covert vs. overt use status.

Results: Among contraceptive users, 14.1% reported using covertly. In cross-sectional analyses, higher wealth (aRRR=1.74; 95% CI=1.19-2.54), secondary or higher education (aRRR=2.52; 95% CI=1.42-4.49), and middle parity (aRRR=1.24; 95% CI=1.00, 2.28) were associated with an increased risk of overt use, and higher wealth (aRRR=2.08; 95% CI=1.09-3.98) and polygyny (aRRR=1.60; 95% CI=1.01-2.54) with covert use, compared to non-use. Among contraceptive users, women within polygynous unions had double the odds of using covertly compared to those with monogamous partners (aOR=1.97; 95% CI=1.28-3.03). Longitudinal analyses revealed large proportions of overt and covert users switched (30% overt, 26% covert) or discontinued methods (32% overt, 37% covert) at one-year follow-up, however, neither switching nor discontinuation was significantly related to overt/covert use status at baseline.

Conclusions: Though significant differences by covert use status were not detected, approximately 33% of users discontinued over one year; these women represent important beneficiaries of family planning programming as they may remain at risk for unintended pregnancy.

 contraceptive dynamics covert use partner involvement family planning Gates Foundation OPP1163880 This work was supported, in whole or in part, by the Gates Foundation [OPP1163880]. Under the grant conditions of the Foundation, a Creative Commons Attribution 4.0 Generic License has already been assigned to the Author Accepted Manuscript version that might arise from this Submission. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Introduction

Covert use of contraception is a strategy for women to achieve their reproductive goals when faced with compromised control over reproductive decisions 1, 2 . Using contraception covertly may be risky—recent quantitative evidence from Niger indicates positive association between intimate partner violence and covert use among married adolescent girls 3 . Contextual factors may also impact women’s ability or desire to use covertly, with evidence from Nigeria revealing that covert users are more likely to live in communities with higher contraceptive prevalence and higher female employment compared to non-users; however, at the individual level, covert users were less educated and poorer than overt users 4 . Understanding who uses contraception covertly is necessary to encourage tailored family planning messaging in order to maximize women’s reproductive autonomy and safety.

Numerous studies have aimed to quantify prevalence of covert use, with estimates in sub-Saharan Africa reporting that between 15% to 77% of women use contraception without their partners’ knowledge 1, 5 . Large-scale surveys, including the Demographic and Health Surveys (DHS), previously measured covert use via one direct question, which asked the female respondent whether her partner knew of method use; however, this item was recently dropped from the majority of surveys. Another method to measure covert use is the comparison of women’s and men’s contraceptive use reports, though this approach is resource-intensive and responses differ substantially from the direct item 5, 6 . While measurement remains imperfect, continued monitoring of covert use trends and correlated contextual factors that may impact covert versus overt use are important to understand shifts in method mix 7 .

To date, little is known on the specific role of covert use in contraceptive discontinuation and switching. Qualitative research in West and East Africa suggests difficulty continuing contraception for covert users 1, 8– 10 , which may lead to switching to a more readily available or concealable contraceptive method or discontinuing method use altogether. To date, however, quantitative data have been cross-sectional in nature, with no nationally representative longitudinal studies utilized to assess this relationship over time. This study addressees this methodological gap by using longitudinal data to compare characteristics of covert, overt, and non-users of contraception and evaluate contraceptive discontinuation and switching by covert versus overt use among a national representative cohort of Ugandan women followed over a one-year period.

 Methods Study design and study population

We used data from a representative panel of reproductive age women conducted within the Performance Monitoring and Accountability 2020 (PMA2020) project in Uganda in 2018 and 2019. The baseline (PMA Uganda Round 6) was conducted from April–May 2018 and the follow up was conducted in May–June 2019. PMA2020 is a data collection platform designed to monitor key family planning indicators in 11 countries using nationally representative surveys. Additional detail on methods for PMA2020 are available elsewhere 11 ; surveys and study instruments are available at www.pmadata.org.

After providing consent, 4,227 women were interviewed at baseline. Of these women, 4,038 agreed to participate in the follow-up survey (acceptance rate=94.4%), and 2,717 women were re-interviewed one year later (follow-up rate=67.7%), while 1,258 were lost to follow-up because they moved out of the enumeration area and five women died. To address potential bias from loss-to-follow-up, an inverse propensity score was constructed by estimating the predicted probability of loss-to-follow-up according to age, parity, marital status, schooling, wealth quintile, and residence and multiplied to existing weights. Table 1 compares the responses of the full sample of women at baseline and those that were identified for follow-up, both weighted and unweighted; after adjustment, there were no differences between baseline women versus those at one-year follow-up.

Loss-to-follow-up weighting.
Unweighted Weighted
Round 6 Only (%) Round 6 Follow-Up (%) p-value Round 6 Only (%) Round 6 Follow-Up (%) p-value
Age (mean) 27.94 29.76 <0.001 27.85 27.91 0.74
Married or in-union 63.27 72.56 <0.001 63.83 64.19 0.75
Urban 27.22 20.87 <0.001 22.38 23.08 0.65
Ever given birth 73.90 82.25 <0.001 74.39 74.91 0.69
Education
   None 12.23 14.70 <0.001 9.49 9.25 0.49
   Primary 53.41 56.95 <0.001 54.77 54.46 0.76
   O-level 24.99 21.49 <0.001 26.19 26.38 0.86
   A-level + 9.38 6.86 <0.001 9.55 9.91 0.56
Delay pregnancy 2+ years 75.51 76.77 0.22 76.85 77.87 0.19
Using modern method 28.15 29.44 0.25 30.28 30.07 0.79
Overt use of contraception 78.84 81.55 <0.001 79.05 81.16 0.10

Institutional Review Board (IRB) approval was obtained at both Johns Hopkins Bloomberg School of Public Health (IRB00008436) and Makerere University School of Public Health (IRB081), as well as Uganda National Council for Science and Technology (SS3400). All eligible participants provided written informed consent; head-of-household consent with written assent was obtained for young women under age 18.

 Analytic sample

The first analytic sample focused on cross-sectional analysis of factors associated with covert, overt, and non-use of contraception at baseline. The cross-sectional analytical sample comprised 1,764 women in need of contraception (i.e., were in union and sexually active within the past year, were not pregnant, did not want to get pregnant within a year, and were not self-reported infertile) and with complete covert use data.

The second analytic sample was used to prospectively examine contraceptive discontinuation and switching using the baseline and follow-up survey data (herein referred to as longitudinal sample). From the 2,717 women who were followed up one year later, we excluded women who were not in need of contraception or who were using a sterilization method of contraception, resulting in a total longitudinal sample of 616 women. Figure 1 shows a flow chart for each analytic sample and reasons for exclusion.

Analytical Samples and Exclusion Criteria. Measures

Type of contraceptive use (non-use, overt, covert): Contraceptive use was assessed by asking women if they were doing anything to avoid a pregnancy at the time of the survey and if so, what method they were using. Covert use of contraception was defined by a single item asking female-controlled method (hormonal methods, intrauterine devices [IUD], and fertility awareness methods) users if their husband/partner knew that they were currently using a method of contraception. In this analysis, we considered a woman an overt user if she was using a male-dependent method (male condoms and withdrawal).

Contraceptive discontinuation/switching: Women’s contraceptive use at baseline and follow-up interviews was used to define a three-category outcome measure, categorized as: 1) contraceptive discontinuation (user of contraception at baseline who was no longer using contraception at follow-up); 2) contraceptive switching (using two different methods at baseline and follow-up); or 3) contraceptive continuation (user of the same contraceptive method at baseline and follow-up).

Covariates: Sociodemographic characteristics included age, parity, education, wealth, area of residence, and polygyny, which have been shown to influence contraceptive use. Small categories were combined based on bivariate distributions; specifically, wealth quintiles were dichotomized based on small distributions of lowest wealth quintiles. We further assessed multi-collinearity between covariates; given high correlation (>0.4) between age and parity, only parity was included in adjusted models, as it was postulated to theoretically influence covert use.

 Analytical approach

This analysis is structured in two parts: 1) a cross-sectional analysis of factors associated with type of contraceptive use (no use/ covert use/ overt use), and 2) a longitudinal analysis of contraceptive discontinuation or switching between baseline and follow-up, according to overt versus covert use. All analyses were conducted in STATA 16 (College Station, TX), with significance set at <0.05, incorporated survey weights, and accounted for complex survey design.

For the cross-sectional analysis, household, individual, partner, and contraceptive characteristics of women according to type of contraceptive use (covert/overt/non-use) were first examined using descriptive statistics and design-based F-statistics. Second, multinomial regressions were conducted comparing the risk of overt use and covert use versus non-use of contraception by specified characteristics. We then used logistic regression to evaluate the odds of covert use versus overt use among users of contraception according to household, individual, and partner characteristics.

For the longitudinal analysis, we conducted exploratory analysis to determine the percentage of users who discontinued or switched their method at follow-up according to whether they were using their method covertly or overtly at baseline. Bivariate and multivariable multinomial regressions were then used to evaluate the relative risk ratio (RRR) of contraceptive discontinuation and switching compared to continuation, according to covert versus overt use of contraception at baseline, after adjusting for relevant covariates.

 Results Cross-sectional analysis

Household, individual, partner, and contraceptive characteristics at baseline by contraceptive use status are provided in Table 2. Generally, women resided in rural areas (82.9%), had completed primary education or less (71.3%), and had two or more children (86.1%). Household wealth (p<0.001), polygyny (p<0.001), women’s education (p<0.001) and parity (p=0.05) differed significantly by contraceptive use status. Among users of contraception, 14.1% were classified as covert users, and method mix differed by contraceptive use status (p<0.001); the majority of covert users reported injectable use (63.2%), whereas overt users utilized a broader range of methods, namely, injectables (34.6%), implants (26.0%) and other methods (16.5%).

Characteristics of Ugandan women overall and by contraceptive use status, among Ugandan women in need of contraception <sup> <xref ref-type="other" rid="FN5">§</xref> </sup> (Cross-sectional sample 2018 n=1,764).
Baseline Characteristics Overall (n=1,764) Contraceptive Use
Non-Users (n=869) Overt Users (n=777) Covert Users (n=118) p-value
column %
Household Characteristics
Household Wealth
    Lower 65.77 74.37 58.30 59.31 <0.001
    Higher 34.23 25.63 41.70 40.69
Residence
    Urban 17.10 15.74 18.66 16.12 0.59
    Rural 82.90 84.26 81.34 83.88
Individual Characteristics
Age (Years)
    15–24 25.81 26.34 27.07 15.15 0.21
    25–34 40.63 38.81 41.63 44.96
    35+ 33.56 34.85 31.29 39.90
Highest Schooling Level
    None 12.32 16.43 8.40 11.16 <0.001
    Primary 58.97 62.31 55.09 61.62
    Secondary+ 28.71 21.26 36.51 27.22
Parity
    0–1 children 13.97 14.27 13.78 13.40 0.05
    2–4 children 43.69 39.70 48.90 36.83
    5+ children 42.35 46.03 37.31 49.77
Partner Characteristics
Polygyny
    Partner has no other wives 63.38 62.62 66.21 51.55 <0.001
    Partner has other wives 30.15 32.69 25.35 42.92
Contraceptive Characteristics
Method Mix
    Female sterilization 6.38 -- 7.10 2.11 <0.001
    Implant 25.43 -- 25.95 21.25
    IUD 2.93 -- 2.60 4.99
    Injectables 38.56 -- 34.61 63.18
    Pills 5.20 -- 5.25 4.97
    Emergency Contraception 0.15 -- 0.18 0.00
    Male Condom 6.56 -- 7.64 0.00
    Female Condom 0.13 -- 0.15 0.00
    Other 14.67 -- 16.52 3.51
Covert/overt use, among users of contraception (row %) 85.93 14.07

§In need of contraception: Women who in R6 were in union, sexually active in the past year, not currently pregnant, reported not wanting to get pregnant in the next year, and were not self-reported infertile. See Figure 1.

P-value from design-based F-statistic

We present results of unadjusted and adjusted multinomial regressions assessing factors related to covert and overt use relative to non-use in Table 3. Higher wealth was associated with an increased risk of covert use (aRRR=2.08; 95% CI=1.09-3.98) and overt use aRRR=1.74; 95% CI=1.19-3.98), compared to no contraceptive use. Women with secondary or higher education had increased risk of using contraception overtly compared to non-use (aRRR=2.52; 95% CI=1.42-4.49), as did women of middle parity (2-4 children; aRRR=1.51; 95% CI=1.00-2.28); education and parity were not similarly related to risk of covert use. Within the context of polygynous relationships, however, women displayed an increased risk of using contraception covertly (aRRR=1.60; 95% CI=1.01-2.54) compared to women in monogamous unions, once adjusted for demographic characteristics. Residence and age were not associated with overt or covert use, compared to non-use.

We further compared the characteristics of covert vs. overt users, among users of contraception, via logistic regression (data not shown). In the adjusted model, only polygyny was significantly associated with covert compared to overt use—women who reported their partners had other wives had twice the odds of using covertly than those who reported their partners were monogamous (aOR=2.01; 95% CI=1.29-3.14).

Multinomial logistic regression examining baseline characteristics for covert and overt use compared to non-use among Ugandan women in need of contraception <sup> <xref ref-type="other" rid="FN7">§</xref> </sup> at baseline (2018; n=1,764).
Baseline Characteristics Unadjusted Adjusted
Overt Users (n=777) Covert Users (n=118) Overt Users (n=777) Covert Users (n=118)
Relative Risk Ratio (RRR) (95% CI)
Household Characteristics
Household Wealth
    Lower ref ref ref ref
    Higher 2.08 *** (1.42, 3.02) 1.99 * (1.11, 3.57) 1.74 ** (1.19, 2.54) 2.08 * (1.09, 3.98)
Residence
    Urban ref ref ref ref
    Rural 0.81 (0.50, 1.33) 0.97 (0.44, 2.13) 1.31 (0.87, 1.97) 1.32 (0.57, 3.07)
Individual Characteristics
Age (Years)
    15–24 ref ref -- --
    25–34 1.04 (0.73, 1.49) 2.09 (0.85, 4.78) -- --
    35+ 0.82 (0.60, 1.13) 1.99 (0.88, 4.49) -- --
Highest Schooling Level
    None ref ref ref ref
    Primary 1.73 * (1.09, 2.76) 1.46 (0.65, 3.28) 1.58 (0.98, 2.55) 1.45 (0.63, 3.33)
    Secondary or Higher 3.36 *** (1.96, 5.78) 1.88 (0.75, 4.71) 2.52 ** (1.42, 4.49) 1.67 (0.59, 4.78)
Parity
    0–1 ref ref ref ref
    2–4 1.28 (0.86, 1.89) 0.99 (0.44, 2.23) 1.51 * (0.95, 2.29) 1.02 (0.44, 2.36)
    5+ 0.84 (0.56, 1.26) 1.15 (0.53, 2.51) 1.24 (0.83, 1.86) 1.29 (0.54, 3.06)
Partner Characteristics
Polygyny
    Partner has no other wives ref ref ref ref
    Partner has other wives 0.73 (0.53, 1.00) 1.59 * (1.04, 2.43) 0.78 (0.56, 1.07) 1.60 * (1.01, 2.54)

Adjusted for: parity, education, residence, polygyny, and wealth

*p<0.05; **p<0.01; ***p<0.001; bolded values significant at p<0.05

§ In need of contraception: Women who in R6 were in union, sexually active in the past year, not currently pregnant, reported not wanting to get pregnant in the next year, and were not self-reported infertile.

Longitudinal analysis

We then examined the relative risk of discontinuation and switching over a one-year period, compared to continued contraceptive use, by covert versus overt use at baseline (data not shown). Approximately 31.5% of overt users and 35.5% of covert users discontinued their method completely. An additional 30% of overt users (29.7%) and one-quarter of covert users (26.2%) at baseline had switched methods one year later. Neither switching nor discontinuation at one-year follow-up were significantly related to type of contraceptive use (covert versus overt use) at baseline.

 Discussion

These results highlight important scenarios by which women use contraception covertly and how their characteristics differ from non-users and overt users of contraception. Women within polygynous partnerships had double the odds of covert compared to overt use, which was the only distinguishing characteristic by contraceptive status. Moreover, in longitudinal analysis, covert versus overt use of contraception was not significantly associated with either discontinuation or switching at one-year follow-up; these null results were contrary to our hypothesis that covert users may face increased difficulty concealing method use, therefore needing to switch methods or discontinue use altogether, and warrant further research to understand high discontinuation for both covert and overt users.

There are several potential explanations for the findings indicating increased odds of covert use for women in polygynous relationships. Findings in Uganda, Niger, and South Africa highlight the importance of spousal communication in contraceptive use; however, contraceptive communication has rarely been examined within the context of polygynous partnerships 2, 12, 13 . One explanation is that women who are aware that their husbands have other partners/wives concurrently may hold less trust in the relationship and its stability. An alternative explanation is that there may be less communication about matters of reproductive health and contraceptive use in polygynous relationships, where disclosure may not be a priority and women may be granted more autonomy in decision-making. Given the male partner’s limited presence within a single relationship and additional time devoted to competing relationships, the partner may have limited involvement in couple decision-making within each individual relationship, as described by male partners within polygynous partnerships in Kano, Nigeria 14, 15 . The polygynous context of partnerships is therefore important to consider when classifying contraceptive decision-making as a “couple decision” as each individual partnership may contribute to reproductive decisions.

Approximately one-third of women had discontinued contraception within a year and another one-third had switched methods. Contrary to our expectations, and qualitative narratives of the difficulties covert users face in sustaining use of contraception secretly 1, 2 , we did not observe greater discontinuation and/or switching among covert users compared to overt users. These findings may reflect that women seeking to use contraception covertly are highly motivated to ensure method continuation. Further, results surrounding non-differential discontinuation for contraceptive use status may signal that covert use does not equate to lack of decision-making power within a relationship—rather, it likely encompasses a range of situations, including potential empowerment for women who do not feel the need to seek support from their partners for reproductive decisions 2, 15 .

There are several inherent limitations to conducting covert use research, which were similarly encountered in this study. Namely, the low prevalence of covert use limits adequate sample size for analysis, particularly for longitudinal analyses; given these small numbers, we were unable to examine uptake of covert versus overt use over a one-year period, and hope that future research utilizing larger samples and pooled analysis can address some of these issues. Further, low retention from the parent study limited sample size for longitudinal analysis. The parent study included high loss-to-follow-up as many women moved out of the enumeration areas and were thus ineligible for relocation protocols. While inverse propensity score methods limited biases and differential loss-to-follow up by covert use status was not observed, the sample size was restricted. Lastly, this study utilized the direct measure of covert use—while this measure is likely closest to the truth given reliance on women’s reports, it may be an underestimate 5, 6 . Though these limitations exist within the current research, this is the first analysis to examine the longitudinal impact of covert use on contraceptive switching and discontinuation. As future rounds of PMA collect these data utilizing a longitudinal panel design, we feel many of the current limitations can be overcome to contribute a fuller understanding of reasons for high contraceptive discontinuation and switching, likely utilizing pooled analyses across contexts.

Taken together, these results indicate that discontinuation and switching were non-differential by overt versus covert use status. Rather, discontinuation and switching were high for both covert and overt users over a one-year period—over thirty percent of both overt and covert users discontinued use while still in need of contraception, putting them at risk of unintended pregnancy. Longitudinal covert use results are largely encouraging and support the fact that covert users maybe be able to overcome obstacles to achieve their reproductive goals; however, high discontinuation rates, regardless of contraceptive status, require concerted focus on women’s priorities and circumstances to ensure method continuation if desired by the woman and aligned with her goals. Given the significant proportion of covert users, providers must continue to be aware of covert use and supportive of covert users specific needs to ensure safe, successful contraceptive utilization that maximizes women’s reproductive autonomy.

Data availability Underlying data

Quantitative survey data are available for PMA2020 Uganda Round 6 and Round 6 follow-up at the PMA website ( www.pmadata.org). Datasets are free to download and available to public, but users are required to register and provide a description of the proposed research or analysis ( https://www.pmadata.org/data/request-access-datasets). GPS coordinates are not available for ethical reasons because even after removing directly identifiable information such as names and addresses, participant identity may be difficult to fully conceal, and research locations may remain potentially identifiable, presenting a risk of deductive disclosure.

 Biddlecom AE Fapohunda BM : Covert Contraceptive Use: Prevalence, Motivations, and Consequences. Stud Fam Plann. 1998;29(4):360–72. 9919630 Kibira SPS Karp C Wood SN : Covert use of contraception in three sub-Saharan African countries: a qualitative exploration of motivations and challenges. BMC Public Health. 2020;20(1):865. 32503485 10.1186/s12889-020-08977-y 7275340 Silverman JG Challa S Boyce SC : Associations of reproductive coercion and intimate partner violence with overt and covert family planning use among married adolescent girls in Niger. EClinicalMedicine. 2020;22:100359. 32382722 10.1016/j.eclinm.2020.100359 7198910 OlaOlorun FM Anglewicz P Moreau C : From non-use to covert and overt use of contraception: Identifying community and individual factors informing Nigerian women’s degree of contraceptive empowerment. PLoS One. 2020;15(11):e0242345. 33206705 10.1371/journal.pone.0242345 7673533 Gasca NC Becker S : Using couples’ discordant reports to estimate female covert use of modern contraception in sub-Saharan Africa. J Biosoc Sci. 2018;50(3):326–46. 28720152 10.1017/S0021932017000256 Choiriyyah I Becker S : Measuring Women’s Covert Use of Modern Contraception in Cross-Sectional Surveys. Stud Fam Plann. 2018;49(2):143–57. 29845621 10.1111/sifp.12053 Jain AK Winfrey W : Contribution of Contraceptive Discontinuation to Unintended Births in 36 Developing Countries. Stud Fam Plann. 2017;48(3):269–278. 28398595 10.1111/sifp.12023 Castle S Konaté MK Ulin PR : A qualitative study of clandestine contraceptive use in urban Mali. Stud Fam Plann. 1999;30(3):231–48. 10546314 10.1111/j.1728-4465.1999.00231.x Cavallaro FL Duclos D Cresswell JA : Understanding “missed appointments” for pills and injectables: A mixed methods study in Senegal. BMJ Glob Heal. 2018;3(6):e000975. 30687521 10.1136/bmjgh-2018-000975 6326323 Alvergne A Stevens R Gurmu E : Side effects and the need for secrecy: characterising discontinuation of modern contraception and its causes in Ethiopia using mixed methods. Contracept Reprod Med. 2017;2:24. 29201429 10.1186/s40834-017-0052-7 5683325 Zimmerman L Olson H Tsui A : PMA2020: Rapid Turn-Around Survey Data to Monitor Family Planning Service and Practice in Ten Countries. Stud Fam Plann. 2017;48(3):293–303. 28885679 10.1111/sifp.12031 6084342 Kriel Y Milford C Cordero J : Male partner influence on family planning and contraceptive use: perspectives from community members and healthcare providers in KwaZulu-Natal, South Africa. Reprod Health. 2019;16(1):89. 31238960 10.1186/s12978-019-0749-y 6593556 Challa S Manu A Morhe E : Multiple levels of social influence on adolescent sexual and reproductive health decision-making and behaviors in Ghana. Women Heal. 2018;58(4):434–450. 28296626 10.1080/03630242.2017.1306607 5891210 Wood SN Karp C Tsui A : A sexual and reproductive empowerment framework to explore volitional sex in sub-Saharan Africa. Cult Heal Sex. 2020;23(6):804–821. 32242473 10.1080/13691058.2020.1733667 Karp C Wood SN Hadiza G : “I am the master key that opens and locks”: Presentation and application of a conceptual framework for women’s and girls’ empowerment in reproductive health. Soc Sci Med. 2020;258:113086. 32521413 10.1016/j.socscimed.2020.113086 7369639 10.21956/gatesopenres.14952.r33415 Reviewer response for version 1 Shekhar Chander 1 Referee https://orcid.org/0000-0002-6090-8470 International Institute for Population Sciences, Mumbai, India

Competing interests: No competing interests were disclosed.

 27 6 2023 Copyright: © 2023 Shekhar C 2023 This is an open access peer review report distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. recommendation approve

I appreciate the authors for making the best use of PMA dataset in examining covert, overt, and non-users of contraception among women in Uganda. Another important contribution to the domain knowledge is assessing the effects of covert use on discontinuation and switching over a one-year period by applying the longitudinal method. I have only a few minor queries, which the authors can easily address in the revised version. These are given below.

First of all, to my knowledge a one-year period is not good enough to dig the analysis deeper. I understand it is a trade-off between the higher retention of samples versus having sufficient duration. Any behavioral phenomenon regarding reproductive decisions in developing countries needs sufficient time. It is very much possible in these settings that first non-users get converted to covert users and then to overt users (once partners win each other's trust). If the information is available, it would be interesting to examine what proportion of covert and overt users were first-time users of contraception. 

 From the cross-sectional analysis, it is clear that the majority of covert users were mainly using two hormonal methods (implants and injectables). It implies that covert users had limited choices for switching even though they might be facing health issues with the method in use. It would have been quite useful for program purposes if a small table could be generated on the switching pattern among covert and overt users.  

Case of multi-collinearity between age and parity: The authors have considered a high correlation at 0.4. It seems too low. I would suggest if Variance Inflation Factor (VIF) >10 then only drop women's age from the adjusted models.

Table 3 shows higher wealth was significantly associated with increased relative risk of covert use, but this important result is missing from the discussion. It would be better if the implications of this finding on the family planning program could be mentioned in brief in the discussion section.

Recheck: For the polygyny background in Table 2, the percentages are not adding to 100. 

       

    

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?

Yes

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?

Yes

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

Yes

Reviewer Expertise:

Family Planning, Fertility, CAC

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.

 10.21956/gatesopenres.14952.r33665 Reviewer response for version 1 Hernandez Julie H 1 Referee https://orcid.org/0000-0002-0868-0958 Tulane University School of Public Health and Tropical Medicine, New Orleans, USA

Competing interests: No competing interests were disclosed.

 16 6 2023 Copyright: © 2023 Hernandez JH 2023 This is an open access peer review report distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. recommendation approve-with-reservations

The manuscript proposes an ambitious and complex statistical analysis of PMA datasets in Uganda and explores factors associated to covert contraceptive use as well as the possible links to discontinuation for women in need of contraception.

The analysis is overall well-presented, and the discussion raises interesting hypothesis. However, the reviewer would like to suggest several issues that could be integrated in the manuscript to strengthen its conceptual and programmatic value.

Two overarching questions are:

1) the implied approach of “covert use” as the opposite of “partner support”. Throughout the manuscript, it seems that the authors assume (as many researchers of “covert use” do) that using contraception without one’s partner knowledge means that said partner would be opposed to contraceptive use? Research on health norms in SSA suggest that in many cases, contraception is seen as “the woman’s problem” meaning that while some partners may strongly oppose (or to the contrary be very supportive of) contraceptive use, the majority simply does not care. We realize the survey is not designed to assess this distinction but it might be important to distinguish between “my partner doesn’t know THAT I’m using contraceptive (because he’d be against it”) and “my partner doesn’t know WHETHER I’m using contraceptive (because he does not care)” Would the latter still be considered “covert” use?

Sections 2 and 3 of the Introduction could introduce this nuance (not taken into account in DHS and perhaps not in the qualitative research mentioned).

2) The manuscript does not mention any changes in the supply environment/policy landscape that may have had an impact on continuation rates. Also, the discussion section could use some lines about the programmatic implications of covert use.

3) The Uganda dataset is nationally representative, but were there variations across EA/regions? Could a robustness test be performed to assess ecological effects using dummy location variables (or distance variables using the GPS coordinates of the households)?

(Again, are we assuming that all participants had access to the same range of methods throughout the study period?)

Abstract/Background: since the results regarding the role of covert use in (dis-)continuation are not significant, we suggest refocusing the Abstract on characteristics associated with covert/overt/non-use.

Perhaps shorten the main title accordingly as well.

Measures: It could be argued that fertility awareness methods are not entirely female controlled since they require male partner’s cooperation during the period of abstinence? What is the prevalence of those methods among respondents and would a different classification affect findings?

Results:

Table 2 does not report on withdrawal and fertility awareness methods, yet these may differ by contraceptive use status.

Also, the method mix distribution across covert and overt users was expected: covert users tend to use the easiest method(s) to hide (i.e. first injectable, then implants, etc…) What are the possible programmatic implications of this?

Discussion

A counter argument to the hypothesis that women in polygynous relationships may hold less trust in the relationship and its stability and therefore would be more likely to use contraception (even covertly) is that these same women might want to “stabilize”/“ground” the relationship by having more children than the other wives/female partners.

The findings from the study in Kano align with the idea that male partner may not know whether their partner uses contraception because they do not really care/consider it’s their partner’s problem to solve.

Final thought, considering that covert use requires not only motivation to “use” contraception at all, but “extra” motivation to use it covertly, it would be interesting to discuss what factors might make women that much more motivated (compared to overt users, but also to non users).

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?

I cannot comment. A qualified statistician is required.

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

Partly

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:

International family planning

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.